title: Risk factors for community-acquired pneumonia in children under five years of age in the post-pneumococcal conjugate vaccine era in Brazil: a case control study.
abstract: BACKGROUND
  Pneumonia plays an important role in children's morbidity and mortality. In Brazil, epidemiological and social changes occurred concomitantly with the universal introduction of the 10-valent pneumococcal conjugate vaccine. This study identified risk factors for pneumonia following the implementation of a pneumococcal vaccination program.
  
  
  METHODS
  A hospital-based, case-control study involving incident cases of pneumonia in children aged 1-59 months was conducted between October 2010 and September 2013 at a tertiary hospital in northeastern Brazil. The diagnosis of pneumonia was based on the World Health Organization (WHO) criteria. The control group consisted of children admitted to the day-hospital ward for elective surgery. Children with comorbidities were excluded. The risk factors for pneumonia that were investigated were among those classified by the WHO as definite, likely and possible. A multivariate analysis was performed including variables that were significant at p ≤ 0.25 in the bivariate analysis.
  
  
  RESULTS
  The study evaluated 407 children in the case group and 407 children in the control group. Household crowding (OR = 2.15; 95 % CI, 1,46-3,18) and not having been vaccinated against the influenza virus (OR = 3.59; 95 % CI, 2,62-4.91) were the only factors found to increase the likelihood of pneumonia. Male gender constituted a protective factor (OR = 0.53; 95 % CI, 0,39-0,72).
  
  
  CONCLUSIONS
  Changes on risk factors for pneumonia were most likely associated with the expansion of the vaccination program and social improvements; however, these improvements were insufficient to overcome inequalities, given that household crowding remained a significant risk factor. The protection provided by the influenza vaccine must be evaluated new etiological studies. Furthermore, additional risk factors should be investigated.
authors.affiliation: Instituto de Medicina Integral Prof. Fernando Figueira(IMIP), Recife, PE, Brazil. eduardojorge@imip.org.br.|Faculdade Pernambucana de Saúde, Recife, PE, Brazil. eduardojorge@imip.org.br.
authors.forename: Eduardo Jorge da
authors.initials: EJ
authors.lastname: Fonseca Lima
authors.affiliation: Instituto de Medicina Integral Prof. Fernando Figueira(IMIP), Recife, PE, Brazil.|Faculdade Pernambucana de Saúde, Recife, PE, Brazil.
authors.forename: Maria Júlia Gonçalves
authors.initials: MJ
authors.lastname: Mello
authors.affiliation: Centro de Pesquisas Aggeu Magalhães - Fiocruz Pernambuco, Recife, PE, Brazil.
authors.forename: Maria de Fátima Pessoa Militão de
authors.initials: MF
authors.lastname: Albuquerque
authors.affiliation: Universidade Federal de Pernambuco, Recife, PE, Brazil.
authors.forename: Maria Isabella Londres
authors.initials: MI
authors.lastname: Lopes
authors.affiliation: Faculdade Pernambucana de Saúde, Recife, PE, Brazil.
authors.forename: George Henrique Cordeiro
authors.initials: GH
authors.lastname: Serra
authors.affiliation: Universidade de Pernambuco(UPE), Recife, PE, Brazil.
authors.forename: Debora Ellen Pessoa
authors.initials: DE
authors.lastname: Lima
authors.affiliation: Instituto de Medicina Integral Prof. Fernando Figueira(IMIP), Recife, PE, Brazil.|Universidade de Pernambuco(UPE), Recife, PE, Brazil.
authors.forename: Jailson Barros
authors.initials: JB
authors.lastname: Correia
keywords: Children; Influenza vaccines; Pneumococcal vaccines; Pneumonia; Risk factors