Co-carriage of respiratory tract bacterial pathogens among under-5 children with pneumococcal carriage in Peninsular Malaysia

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We therefore conducted a study to look for evidence of other respiratory bacterial pathogens and to determine the prevalence and risk factors of co-carriage status among under-5 children in Peninsular Malaysia. Methods : This retrospective case-control study is part of a paediatric pneumonia surveillance study “MY-Pneumo” (NCT04923035. Registered on June 11, 2021) in young children across three sentinel sites in Peninsular Malaysia (Kelantan, Pahang, and Kuala Lumpur). Nasopharyngeal specimens of under-5 children with positive optochin sensitive SPN isolates (n=154) were further tested for pneumococcal co-carriage status of SPN and six bacteria causing severe respiratory tract infections ( Bordetella parapertussis (BPP), B. pertussis (BP ), Chlamydophila pneumoniae (CP), Haemophilus influenzae (HI), Legionella pneumophila (LP), Mycoplasma pneumoniae (MP)) using multiplex real-time polymerase chain reaction (qPCR). Logistic regression analyses were fitted for paediatric bacterial co-carriage risk factors. Results : Co-carriage was only present between SPN and HI in 54 children (35.1%). The majority were boys (n=41, 75.9%) with a mean age of 19.26 (±14.83) months. Co-carriage of SPN and HI (SPN-HI) were significantly associated with the sentinel site location (p=0.037), gestation term (p=0.004), and household size (p=0.01). The predictors of positive co-carriage were household size of five to seven persons (aOR 3.70, 95% CI 1.43 – 9.55, p= 0.007) and more than 8 persons (aOR 3.58, 95% CI 1.06 – 12.12, p= 0.041). Conclusions: Our study revealed that co-carriage of SPN-HI was present in a significant proportion of children with pneumonia and was influenced by geographical area, and household size. Resource allocation should be targeted towards effective vaccination strategies and heightened awareness among healthcare providers to improve paediatric pneumonia interventions in the country. Pneumococcal pneumonia paediatric pneumonia co-carriage respiratory tract bacteria Streptococcus pneumoniae Haemophilus influenzae Figures Figure 1 Background Pneumonia remains a leading global cause of mortality, particularly affecting children under the age of five. In Malaysia, pneumonia contributed to 2.6% of deaths in this age group in 2023 ( 1 ). The aetiology of pneumonia is multifactorial, involving various pathogens including viruses, fungi, and bacteria. Key bacterial pathogens include Streptococcus pneumoniae (SPN) and Haemophilus influenzae (HI), with respiratory syncytial virus (RSV) also being a significant viral contributor ( 2 ). SPN is commonly found colonising the nasopharynx of young children, potentially predisposing them to disease as early colonisation of has been associated with subsequent colonisation by HI and an increased risk of childhood respiratory conditions including asthma ( 3 , 4 ). The presence of multiple microbes in the nasopharynx in the context of co-infection are often associated with more severe clinical outcomes. For instance, Mycoplasma pneumoniae (MP) and HI have been found to co-infect with viruses in children with severe, non-responsive pneumonia ( 5 – 7 ). SPN has been documented in co-infections with other bacterial pathogens such as HI, Mycoplasma pneumoniae (MP), Bordetella parapertussis (BPP), and B. pertussis (BP) ( 8 , 9 ). Therefore, monitoring and detection of co-infections of pneumococcal pneumonia through rapid molecular diagnostic assays is increasingly crucial. We therefore conducted a pneumococcal co-carriage study to assess the presence of other respiratory bacterial pathogens and to determine the prevalence and risk factors of pneumococcal co-carriage status among under-5 children in Peninsular Malaysia. Materials and methods Study population This retrospective study is part of a larger study titled "Multicentre Case-Control Study of Pneumococcal Infections among Children with Pneumonia in Peninsular Malaysia (MY-Pneumo)" ( 10 ). The study involved the recruitment of 500 children under five years old with clinical diagnosis of pneumonia, along with 500 age-matched healthy controls. Participants were selected from three university hospitals each located in Kuala Lumpur, Pahang, and Kelantan in Peninsular Malaysia. The study has been approved by the IMU Joint Committee on Research & Ethics (4.5/JCM-267/2023) and registered with ClinicalTrials.gov (NCT04923035; registered on June 11, 2021). Specimen collection Nasopharyngeal (NP) swab collection, specimen processing and storage were carried out as previously described ( 10 ). Briefly, NP swabs using FLOQswab (COPAN Diagnostics Inc., USA) were collected from subjects by trained healthcare professionals. The swabs were then placed in a transport medium consisting of skim milk, tryptone, glucose, and glycerol (STGG). Culture identification, DNA extraction and multiplex qPCR analysis A 10 µL loopful of the NP-STGG sample was streaked onto Columbia sheep blood agar (CBA) plates (Oxoid, UK) and incubated at 37°C in 5% CO 2 for 24 hours. Colonies exhibiting morphology consistent with SPN were subcultured onto fresh CBA plates and tested for optochin sensitivity using 5 µg optochin discs (HiMedia, India), followed by incubation under the same conditions. Samples that produced optochin-sensitive colonies were classified as culture-positive for SPN carriage and further tested via multiplex real-time PCR (qPCR) for co-carriage pattern analysis. Nucleic acids were extracted from all culture-positive samples using the Monarch® Genomic DNA Purification Kit (New England Biolabs, USA) directly from the original NP-STGG media following the manufacturer’s instructions. A commercial multiplex qPCR kit, Allplex™ Respiratory Panel 4 (Seegene, Korea) was used to detect seven common respiratory bacterial pathogens: Chlamydophila pneumoniae (CP), Legionella pneumophila (LP), M. pneumoniae (MP), B. pertussis (BP), B. parapertussis (BPP), SPN, and HI on the BioRad CFX96 C1000 Touch Thermal Cycler Real-Time system, according to the manufacturer’s protocol. Data analysis Data analyses were performed using IBM SPSS Statistics version 29 (Armonk, NY: IBM Corp). Pearson’s chi-square test and independent Student t-test were used to test differences in proportions and mean between pneumococcal co-carriage (single; SPN vs. multiple pathogens; SPN-HI) and socio-demographic factors, respectively. Data was presented as mean (± SD) for continuous variables and as a frequency and percentage for categorical variables. All statistical tests were two-sided, and a p-value of ≤ 0.05 was considered statistically significant. Binary logistic regression was used to model the relationship between significant risk factors associated with pneumococcal co-carriage status. Variables that were significantly associated in the univariate analysis (p ≤ 0.05) were entered into the logistic regression model to identify independent predictors. The regression models were adjusted for gender, and ethnicity to ensure accurate estimation of the independent effects of the predictors. Adjusted odds ratios (aOR) and 95% confidence intervals were calculated for significant variables. Results A total of 154 out of 1000 samples were identified as culture positive for SPN (15.4%), with equal rates among children with pneumonia and control (n = 77, 15.4% respectively). By qPCR, SPN carriage was detected in 94.8% (n = 146), of which 63.0% were SPN mono-carriage and SPN co-carriage with HI was observed in 35.1% (n = 54) samples (Fig. 1 ). Eight samples yielded no detectable pathogens via qPCR screening and were excluded from further analysis. No other respiratory pathogens (CP, MP, LP, BP, or BPP) were detected in these samples. There was no statistically significant difference between the groups of single and co-carriage among children with clinically diagnosed pneumonia and healthy controls (p = 0.894) (Table 1 ). Table 1 The pneumococcal and co-carriage distribution among children under-5 of MY-Pneumo study subjects with culture-positive for SPN (n = 154) qPCR analysis Frequency, n (%) p-value Case Control Culture positive 77 (50.0) 77 (50.0) SPN mono-carriage 47 (51.1) 45 (48.9) 0.894 SPN-HI co-carriage 26 (48.1) 28 (51.9) Negative 4 (50.0) 4 (50.0) Table 2 shows the socio-economic and demographic characteristics of subjects with SPN mono-carriage and SPN-HI co-carriage by multiplex qPCR analysis. There was no significant difference between the two groups. Table 2 Distribution of SPN carriage and SPN-HI co-carriage status against socio-demographic characteristics. Characteristics SPN mono-carriage, n (%) SPN-HI co-carriage, n (%) p-value Gender 0.176 Male 60 (65.2) 41 (75.9) Female 32 (34.8) 13 (24.1) Age, mean ± SD (months) 21.17 ± 15.25 19.26 ± 14.83 0.460 Age groups (months) 0.066 0–12 35 (38.0) 23 (42.6) 13–24 23 (25.0) 20 (37.0) 25–36 19 (20.7) 2 (3.7) 37–48 8 (8.7) 4 (7.4) 49–60 7 (7.6) 5 (9.3) Ethnicity 0.407 Malay 89 (96.7) 54 (100) Chinese 2 (2.2) 0 Bajau 1 (1.1) 0 Education level of parent 0.747 College degree or higher 50 (54.3) 26 (48.1) Secondary/Vocational/ Diploma 40 (43.5) 27 (50.0) Primary/ Unknown 2 (2.2) 1 (1.9) Prevalence of Co-carriage Patterns The highest number of SPN culture-positive samples were from the state of Kelantan (n = 86, 58.9%), while both Pahang and Kuala Lumpur contributed 24 (16.4%) and 36 (24.7%) samples, respectively. Factors that were significantly associated with pneumococcal co-carriage were sentinel site (p = 0.037), household size (p = 0.01), and gestation term (p = 0.04) (Table 3 and Table 4 ). Table 3 Demographic and environmental factors of pneumococcal co-carriage among children under-5 in MY-Pneumo study. Characteristics SPN mono-carriage, n (%) SPN-HI co-carriage, n (%) p-value Sentinel sites 0.037 Kelantan 47 (51.1) 39 (72.2) Kuantan 19 (20.6) 5 (9.3) Kuala Lumpur 26 (28.3) 10 (18.5) Day care centre 0.387 Yes 46 (50.0) 23 (42.6) No 46 (50.0) 31 (57.4) Residential area 0.797 Urban 67 (72.8) 39 (72.2) Rural 9 (9.8) 7 (13.0) Others 16 (17.4) 8 (14.8) Residential type 0.187 Landed 72 (78.3) 47 (87.0) High 20 (21.7) 7 (13.0) Rooms in residence 3.38 ± 1.7 3.6 ± 1.3 0.596 1 to 2 13 (14.1) 9 (16.7) 0.104 3 to 4 67 (72.8) 31 (57.4) More than 5 12 (13.0) 14 (25.9) Number of people in residence, mean ± SD 5.59 ± 2.5 6.41 ± 2.7 0.07 Household size 0.01 4 persons or lesser 35 (38.0) 8 (14.8) 5 to 7 persons 45 (48.9) 34 (63.0) 8 or more persons 12 (13.0) 12 (22.2) Siblings (< 5 age of years) 0.104 Yes 35 (38.0) 28 (50.9) No 57 (62.0) 26 (49.1) Exposure to tobacco smoke 0.141 Yes 25 (27.2) 21 (38.2) No/Unknown 67 (72.8) 33 (61.8) Table 4 Nutritional, clinical, and vaccination history of pneumococcal co-carriage among children under-5 in MY-Pneumo study. Variables SPN mono-carriage, n (%) SPN-HI co-carriage, n (%) p-value Feeding 0.086 Breast exclusively 16 (22.2) 4 (7.5) Mixed feeding (Breast + other) 34 (47.2) 29 (54.7) No breast milk 22 (30.6) 20 (37.7) Gestation 0.04 Post-term 3 (3.3) 2 (3.7) Term 83 (90.2) 41 (75.9) Pre-term 6 (6.5) 11 (20.4) Birth weight, mean ± SD (g) 2984 ± 529 2851 ± 540 0.147 BMI status 0.809 Underweight 11 (12.0) 5 (9.3) Normal 69 (75.0) 43 (79.6) Overweight/ obese 12 (13.0) 6 (11.1) Generally healthy 0.388 Yes 77 (83.7) 48 (88.9) No 15 (16.3) 6 (11.1) DTaP-IPV-HepB-Hib 0.130 Vaccinated 88 (95.7) 53 (98.1) Partially vaccinated 0 1 (1.9) Unvaccinated/Unknown 4 (4.3) 0 MMR 0.557 Vaccinated 65 (92.9) 38 (88.4) Partially vaccinated 1 (1.4) 2 (4.7) Unvaccinated/Unknown 4 (5.7) 3 (7.0) PCV 0.263 Vaccinated 55 (62.5) 39 (75.0) Partially vaccinated 5 (5.7) 3 (5.8) Unvaccinated/Unknown 28 (31.8) 10 (19.2) Body Mass Index (BMI) status followed WHO Child Growth Standard 2006: <fifth percentile − underweight; fifth percentile to <85th percentile − normal weight, ≥85th percentile − overweight/obese Vaccination history was classified into three categories based on the Malaysia National Immunisation Program guidelines: fully vaccinated, partially vaccinated, and unvaccinated. HepB = Hepatitis B, DTaP = diphtheria, tetanus and pertussis, Hib = Haemophilus influenzae type b, PCV = pneumococcal conjugate vaccine Based on regression analysis, the predictors of positive SPN-HI co-carriage were household size of five to seven persons (aOR 3.70, 95% CI 1.43–9.55, p = 0.007) and more than 8 persons (aOR 3.58, 95% CI 1.06–12.12, p = 0.041). The presence of pre-existing illnesses, such as immunodeficiency, sickle cell disease, asthma or other chronic illnesses, was also evaluated as a potential risk factor for co-carriage. However, no significant associations were found between pre-existing conditions and the likelihood of having single or multiple pathogen co-carriage. Vaccination records indicate that all subjects (n = 154) have received at least one vaccine under the Malaysian National Immunisation Programme (NIP). Most participants had received the hexavalent DTaP-IPV-HepB-Hib vaccine, measles, mumps, and rubella (MMR) vaccine, or the pneumococcal conjugate vaccine (PCV) according to NIP. No significant difference was found between vaccination history and both SPN-only or SPN-HI co-carriage subjects in this study. Discussion In this study, we found that SPN was detected in 94.8% of the selected MY-PNEUMO samples (n = 154) and SPN-HI in 35.1% as a co-carriage bacterial pathogen. Our findings support prior studies showing that SPN and HI frequently co-exist together in children ( 11 , 12 ), especially among those with severe pneumonia ( 13 ). Co-carriage was observed to be higher among children from Kelantan, as well as those residing in households with a larger number of occupants. These findings suggest that environmental and socio-demographic factors may play a significant role in co-carriage rates. Variables related to housing, among others, have been reported as possible factors impacting respiratory infections ( 14 , 15 ). Over-crowding will inevitably increase the likelihood of exposure to multiple pathogens and facilitate transmission among individuals in close contact. Our analysis revealed significant differences based on sentinel site and the number of residents in the household, indicating that social determinants such as crowded living conditions or non-urban environments may contribute to higher co-carriage rates. Some of these variables have been highlighted as risk factors contributing to pneumococcal disease burden ( 16 ). This aligns with a previous study done in Democratic Republic of Congo and Nepal that showed higher SPN or HI bacterial loads in rural children( 17 , 18 ) as opposed to an Indonesian study that found no significant differences between urban and semi-rural carriage and co-carriage of SPN and HI( 19 ). Interestingly, when comparing SPN-mono-carriage and SPN-HI co-carriage, no significant differences were found between clinically diagnosed pneumonia cases and healthy controls, highlighting the complex nature of pathogen interactions within the nasopharynx as not all co-existence leads to co-infection. The clinical significance of HI co-carriage in pneumococcal disease remains unclear. Studies suggest that HI colonisation can promote SPN carriage and potentially increase the risk of invasive disease ( 22 ), including by the formation of multispecies biofilms which can protect against antibiotics and promote adhesion to host tissues ( 20 ). However, we did not observe any heightened risk or severity associated with SPN-HI co-carriage. These findings underscore the need for future studies to focus on the mechanistic underpinnings of SPN-HI interactions, particularly in the context of co-carriage and its potential to impact disease severity and treatment outcomes. Our results also indicate that vaccination status, although crucial for preventing single-pathogen infections, does not appear to be a major determinant of co-carriage risk. Most subjects were fully vaccinated following the NIP including with PCV, yet we did not observe a significant difference in co-carriage rates between vaccinated and unvaccinated individuals. PCVs play a critical role in reducing pneumococcal carriage and transmission, indirectly lowering the risk of concurrent bacterial infections and consequently, disease severity and complexity ( 21 ) by decreasing colonisation with vaccine-type SPN strains ( 4 ). However, the protective effect of PCVs on overall co-infection risk remains incomplete, particularly in the context of viral respiratory infections. Such viral infections are known to predispose opportunistic bacterial colonisation by creating an environment that facilitates bacterial adherence and colonisation ( 12 , 20 , 22 ). Moreover, secondary bacterial infections have been associated with more severe clinical presentations especially in young children, immunocompromised individuals and those living in resource limited settings ( 2 , 13 ). Therefore, comprehensive strategies that address both viral and bacterial pathogens are essential to mitigate the burden of respiratory co-infections ( 2 , 11 ). Integrated approaches, combining bacterial vaccination programs with effective viral prevention measures such as influenza vaccination, improved hygiene, and early antiviral treatment, are necessary to improve respiratory infection outcomes globally ( 16 ). Our study also did not find any significant association between pre-existing illnesses and the likelihood of co-carriage, although immunocompromised children and those with underlying health conditions such as asthma or chronic respiratory diseases are known to be more vulnerable to respiratory infections ( 23 ). The methodological limitations of this study should also be considered when interpreting these results. Eight samples were negative for SPN and HI by qPCR, despite being culture-positive, which suggests the possibility of false positives due to other Streptococcus species that share similar colony morphology and optochin sensitivity. The use of bile solubility tests could improve the accuracy of SPN identification, as the zone of inhibition in optochin sensitivity tests has been shown to vary depending on agar medium and incubation conditions ( 24 , 25 ). The absence of MP, CP, and Bordetella spp. in our study contrasts with findings from other studies, which have reported low but detectable levels of these pathogens in children ( 9 , 13 , 26 – 28 ). The variability in pathogen detection could be due to differences in study populations, diagnostic methods, or sample size, and highlights the need for comprehensive surveillance to capture the full spectrum of pathogens involved in childhood pneumonia. This study was limited by the panel of bacteria in the kit, future studies should also include relevant viruses and bacteria such as RSV, Moraxella catarrhalis and Staphylococcus aureus . Conclusions In conclusion, we found that 1 in 3 children with SPN had co-carriage with HI. Geographic locations and overcrowding contribute to differences in pneumococcal carriage co-carriage status in this study. Risk of co-carriage is higher in children in Kelantan at the east coast region of Malaysia, with living conditions involving a household size of more or equal to five persons. This finding underscores the importance of continuous surveillance and targeted intervention strategies to address co-carriage, which can lead to co-infections that complicate disease management and treatment outcomes. Abbreviations aOR Adjusted odds ratio BP Bordetella pertussis BPP Bordetella parapertussis CBA Columbia agar with 5% sheep blood CDC Centers for Disease Control and Prevention CI Confidence interval CP Chlamydophila pneumoniae CRF Case report form CRP C-reactive protein CSF Cerebrospinal fluid CXR Chest radiograph DNA Deoxyribonucleic acid DTaP-IPV-HepB-Hib Diphtheria, tetanus, pertussis, inactivated poliovirus, hepatitis B and Haemophilus influenzae type b vaccine HI Haemophilus influenzae IMU-AMCRL IMU Advanced Microbiology Collaborative Research Laboratory IPD Invasive pneumococcal disease LP Legionella pneumophila MP Mycoplasma pneumoniae MMR Measles, mumps, rubella NIP National Immunisation Programme NP Nasopharyngeal NPS Nasopharyngeal swab OR Odds ratio PCV Pneumococcal conjugate vaccine PCV10 10-valent pneumococcal conjugate vaccine PCR Polymerase chain reaction PUAT Pneumococcal urine antigen test qPCR Quantitative polymerase chain reaction SPN Streptococcus pneumoniae SPN-HI Streptococcus pneumoniae - Haemophilus influenzae co-carriage STGG Skim milk, tryptone, glucose, glycerol WGS Whole-genome sequencing WHO World Health Organization Declarations Ethical approval and consent to participate This study involving human participants was reviewed and approved by the IMU Joint Committee on Research & Ethics (4.15/JCM-216/2021 and 4.5/JCM-267/2023), the Human Research Ethics Committee, Universiti Sains Malaysia (USM/JEPeM/21020190), the International Islamic University Malaysia Research Ethics Committee (IREC 2021-114), and University Malaya Medical Centre (MREC ID No: 2021128-9769). Clinical Trial ClinicalTrials.gov, NCT04923035. Registered on June 11, 2021. Consent for publication Not required because no individual identifiers have been included in the manuscript. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to privacy or ethical restrictions. Competing interests LHS acts as principal investigator for studies conducted on behalf of IMU University that are sponsored by vaccine manufacturers. No personal payments are received from them. NHR and NAJ have received financial assistance from vaccine manufacturers to attend conferences. All grants and honoraria are paid into accounts within the respective universities. All other authors have no conflicts of interest. Funding This work is funded in part by a research grant from the Investigator Initiated Studies Program of Merck Sharp & Dohme Corp (MSIP #60200). The funding body did not play any role in data collection, decision to publish, or drafting of the manuscript. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. Authors’ contributions NHR and ATCH wrote the manuscript. ATCH, SW, XQC, EEJL, XRL, AHMR, CSJT, ZZD, and NK supported the microbiological protocols. ATCH performed initial carriage analysis. AMN, MII, ZZD, AAB, and MAMH coordinated the study implementation at sentinel sites. PKL and NAJ supported the statistical analysis. LHS acquired funding, supervised the project and critically reviewed the manuscript. All authors read and approved the final manuscript version. Acknowledgements The authors thank all staff nurses and medical officers from the sentinel sites for their valuable contributions to this study. The authors also would like to thank all the parents/legal guardians and children who participated in the study. 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Low prevalence of Chlamydia pneumoniae and Mycoplasma pneumoniae among patients with symptoms of respiratory tract infections in Dutch general practices. Eur J Epidemiol. 2000;16(12). Additional Declarations Competing interest reported. LHS acts as principal investigator for studies conducted on behalf of IMU University that are sponsored by vaccine manufacturers. No personal payments are received from them. NHR and NAJ have received financial assistance from vaccine manufacturers to attend conferences. All grants and honoraria are paid into accounts within the respective universities. All other authors have no conflicts of interest. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6707646","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":473149959,"identity":"cca01b1f-894f-4ca9-837b-451a8105a224","order_by":0,"name":"Andrew Chun Hoong Tan","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Andrew","middleName":"Chun Hoong","lastName":"Tan","suffix":""},{"id":473149960,"identity":"150e0ac5-a3fb-4687-a3cf-a99e4808e4a4","order_by":1,"name":"Nurul Hanis Ramzi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYLCChw0MDGwMzAcOgHkHiNGSCNbClkCiFgYGHgMGorSYS+Q+k0jcYZfHx3/m46GbbQxyfDcSWDfz4NFiOSPdTCLxTHIxm0TuhsO5bQzGkjcS2G7j02JwI41NIrGNObFNghesJXEDkVrqE9v4zzwAaaknVsvhxDaGHAaQlgQDglrOPGO2SGw7DnRYmsHhnHMShjPPPGy7OQefluNpjDc+tlUnzu8//PhzTpmNPN/x5GM33uDRgg4kgJixgQmfw7ADxh8kaxkFo2AUjIJhDABYL1JoLc6GcwAAAABJRU5ErkJggg==","orcid":"","institution":"IMU University","correspondingAuthor":true,"prefix":"","firstName":"Nurul","middleName":"Hanis","lastName":"Ramzi","suffix":""},{"id":473149961,"identity":"70079732-6870-4f01-baa0-a92fb267e717","order_by":2,"name":"Nur Alia Johari","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Nur","middleName":"Alia","lastName":"Johari","suffix":""},{"id":473149962,"identity":"5c2dac6c-d4f5-45ef-ac88-13b10bfd6663","order_by":3,"name":"Pei Kuan Lai","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Pei","middleName":"Kuan","lastName":"Lai","suffix":""},{"id":473149963,"identity":"f7d5535a-4912-4ffc-8011-8f875032886d","order_by":4,"name":"Simone Wong","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Simone","middleName":"","lastName":"Wong","suffix":""},{"id":473149964,"identity":"1f79bfa0-c803-4b6f-b003-843c00e46e27","order_by":5,"name":"Xuan Qi Chang","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Xuan","middleName":"Qi","lastName":"Chang","suffix":""},{"id":473149965,"identity":"3dc84456-577d-44ba-b9f9-4b8f78bc89d8","order_by":6,"name":"Eileen Eng Jia Lin","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Eileen","middleName":"Eng Jia","lastName":"Lin","suffix":""},{"id":473149968,"identity":"56151d11-d259-4640-967d-09ee60678ee5","order_by":7,"name":"Xin Ru Lum","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Xin","middleName":"Ru","lastName":"Lum","suffix":""},{"id":473149970,"identity":"80746de5-3c83-455b-acac-47d116b4595b","order_by":8,"name":"Azim Haikal Md Roslan","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Azim","middleName":"Haikal Md","lastName":"Ros","suffix":"Md"},{"id":473149981,"identity":"590c71f8-ecf0-4a69-b8f9-aa3f90b42e41","order_by":9,"name":"Anna Marie Nathan","email":"","orcid":"","institution":"University of Malaya","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"Marie","lastName":"Nathan","suffix":""},{"id":473149982,"identity":"3dbb7c58-3bca-4a46-8617-c0f236ae3de6","order_by":10,"name":"Cindy Shuan Ju Teh","email":"","orcid":"","institution":"University of Malaya","correspondingAuthor":false,"prefix":"","firstName":"Cindy","middleName":"Shuan Ju","lastName":"Teh","suffix":""},{"id":473149983,"identity":"335b656a-8759-4d6c-8152-270c64a40c41","order_by":11,"name":"Mohamad Ikram Ilias","email":"","orcid":"","institution":"Universiti Sains Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Mohamad","middleName":"Ikram","lastName":"Ilias","suffix":""},{"id":473149984,"identity":"4aba9be6-fc9c-420c-ab8e-152d69bd5db4","order_by":12,"name":"Zakuan Zainy Deris","email":"","orcid":"","institution":"Universiti Sains Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Zakuan","middleName":"Zainy","lastName":"Deris","suffix":""},{"id":473149985,"identity":"eaac5c79-25f1-41fe-9c84-8c76836d0f08","order_by":13,"name":"Asrar Abu Bakar","email":"","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Asrar","middleName":"Abu","lastName":"Bakar","suffix":""},{"id":473149986,"identity":"ffc6de52-c584-4f58-adc2-b7272e6b52c1","order_by":14,"name":"Muhd Alwi Muhd Helmi","email":"","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Muhd","middleName":"Alwi Muhd","lastName":"Helmi","suffix":""},{"id":473149987,"identity":"3a9809d7-5f86-499c-be52-d8b5650c2c56","order_by":15,"name":"Norhidayah Kamarudin","email":"","orcid":"","institution":"International Islamic University Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Norhidayah","middleName":"","lastName":"Kamarudin","suffix":""},{"id":473149988,"identity":"a757cc76-c3bc-46f6-95e3-ffb6809e4f60","order_by":16,"name":"Lokman Hakim Sulaiman","email":"","orcid":"","institution":"IMU University","correspondingAuthor":false,"prefix":"","firstName":"Lokman","middleName":"Hakim","lastName":"Sulaiman","suffix":""}],"badges":[],"createdAt":"2025-05-20 12:08:52","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6707646/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6707646/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-026-12800-1","type":"published","date":"2026-02-12T15:58:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85385914,"identity":"67758568-d49f-4152-bdb9-6645ad177649","added_by":"auto","created_at":"2025-06-25 09:52:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":44568,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of real-time quantitative PCR (qPCR) analysis of respiratory bacterial pathogens in retrospective nasopharyngeal (NP) swab samples (n=1,000). All samples were subjected to culture and those yielding optochin-sensitive Streptococcus pneumoniae (SPN) were tested using Allplex™ Respiratory Panel 4 qPCR kit to determine co-carriage of respiratory pathogens. (HI = Haemophilus influenza).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6707646/v1/cf45c2559587562c01090f5b.png"},{"id":102786417,"identity":"c3020375-370c-467f-a0d0-072859dc2447","added_by":"auto","created_at":"2026-02-16 16:13:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1244282,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6707646/v1/ed695044-5cd3-4b07-8b65-413d38e9dd84.pdf"}],"financialInterests":"Competing interest reported. LHS acts as principal investigator for studies conducted on behalf of IMU University that are sponsored by vaccine manufacturers. No personal payments are received from them. NHR and NAJ have received financial assistance from vaccine manufacturers to attend conferences. All grants and honoraria are paid into accounts within the respective universities. All other authors have no conflicts of interest.","formattedTitle":"Co-carriage of respiratory tract bacterial pathogens among under-5 children with pneumococcal carriage in Peninsular Malaysia","fulltext":[{"header":"Background","content":"\u003cp\u003ePneumonia remains a leading global cause of mortality, particularly affecting children under the age of five. In Malaysia, pneumonia contributed to 2.6% of deaths in this age group in 2023 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The aetiology of pneumonia is multifactorial, involving various pathogens including viruses, fungi, and bacteria. Key bacterial pathogens include \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e (SPN) and \u003cem\u003eHaemophilus influenzae\u003c/em\u003e (HI), with respiratory syncytial virus (RSV) also being a significant viral contributor (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). SPN is commonly found colonising the nasopharynx of young children, potentially predisposing them to disease as early colonisation of has been associated with subsequent colonisation by HI and an increased risk of childhood respiratory conditions including asthma (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe presence of multiple microbes in the nasopharynx in the context of co-infection are often associated with more severe clinical outcomes. For instance, \u003cem\u003eMycoplasma pneumoniae\u003c/em\u003e (MP) and HI have been found to co-infect with viruses in children with severe, non-responsive pneumonia (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). SPN has been documented in co-infections with other bacterial pathogens such as HI, \u003cem\u003eMycoplasma pneumoniae\u003c/em\u003e (MP), \u003cem\u003eBordetella parapertussis\u003c/em\u003e (BPP), and \u003cem\u003eB. pertussis\u003c/em\u003e (BP) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Therefore, monitoring and detection of co-infections of pneumococcal pneumonia through rapid molecular diagnostic assays is increasingly crucial. We therefore conducted a pneumococcal co-carriage study to assess the presence of other respiratory bacterial pathogens and to determine the prevalence and risk factors of pneumococcal co-carriage status among under-5 children in Peninsular Malaysia.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThis retrospective study is part of a larger study titled \"Multicentre Case-Control Study of Pneumococcal Infections among Children with Pneumonia in Peninsular Malaysia (MY-Pneumo)\" (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The study involved the recruitment of 500 children under five years old with clinical diagnosis of pneumonia, along with 500 age-matched healthy controls. Participants were selected from three university hospitals each located in Kuala Lumpur, Pahang, and Kelantan in Peninsular Malaysia. The study has been approved by the IMU Joint Committee on Research \u0026amp; Ethics (4.5/JCM-267/2023) and registered with ClinicalTrials.gov (NCT04923035; registered on June 11, 2021).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSpecimen collection\u003c/h3\u003e\n\u003cp\u003eNasopharyngeal (NP) swab collection, specimen processing and storage were carried out as previously described (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Briefly, NP swabs using FLOQswab (COPAN Diagnostics Inc., USA) were collected from subjects by trained healthcare professionals. The swabs were then placed in a transport medium consisting of skim milk, tryptone, glucose, and glycerol (STGG).\u003c/p\u003e\n\u003ch3\u003eCulture identification, DNA extraction and multiplex qPCR analysis\u003c/h3\u003e\n\u003cp\u003eA 10 \u0026micro;L loopful of the NP-STGG sample was streaked onto Columbia sheep blood agar (CBA) plates (Oxoid, UK) and incubated at 37\u0026deg;C in 5% CO\u003csub\u003e2\u003c/sub\u003e for 24 hours. Colonies exhibiting morphology consistent with SPN were subcultured onto fresh CBA plates and tested for optochin sensitivity using 5 \u0026micro;g optochin discs (HiMedia, India), followed by incubation under the same conditions. Samples that produced optochin-sensitive colonies were classified as culture-positive for SPN carriage and further tested via multiplex real-time PCR (qPCR) for co-carriage pattern analysis.\u003c/p\u003e \u003cp\u003eNucleic acids were extracted from all culture-positive samples using the Monarch\u0026reg; Genomic DNA Purification Kit (New England Biolabs, USA) directly from the original NP-STGG media following the manufacturer\u0026rsquo;s instructions. A commercial multiplex qPCR kit, Allplex\u0026trade; Respiratory Panel 4 (Seegene, Korea) was used to detect seven common respiratory bacterial pathogens: \u003cem\u003eChlamydophila pneumoniae\u003c/em\u003e (CP), \u003cem\u003eLegionella pneumophila\u003c/em\u003e (LP), \u003cem\u003eM. pneumoniae\u003c/em\u003e (MP), \u003cem\u003eB. pertussis\u003c/em\u003e (BP), \u003cem\u003eB. parapertussis\u003c/em\u003e (BPP), SPN, and HI on the BioRad CFX96 C1000 Touch Thermal Cycler Real-Time system, according to the manufacturer\u0026rsquo;s protocol.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData analyses were performed using IBM SPSS Statistics version 29 (Armonk, NY: IBM Corp). Pearson\u0026rsquo;s chi-square test and independent Student t-test were used to test differences in proportions and mean between pneumococcal co-carriage (single; SPN vs. multiple pathogens; SPN-HI) and socio-demographic factors, respectively. Data was presented as mean (\u0026plusmn;\u0026thinsp;SD) for continuous variables and as a frequency and percentage for categorical variables. All statistical tests were two-sided, and a p-value of \u0026le;\u0026thinsp;0.05 was considered statistically significant. Binary logistic regression was used to model the relationship between significant risk factors associated with pneumococcal co-carriage status. Variables that were significantly associated in the univariate analysis (p\u0026thinsp;\u0026le;\u0026thinsp;0.05) were entered into the logistic regression model to identify independent predictors. The regression models were adjusted for gender, and ethnicity to ensure accurate estimation of the independent effects of the predictors. Adjusted odds ratios (aOR) and 95% confidence intervals were calculated for significant variables.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 154 out of 1000 samples were identified as culture positive for SPN (15.4%), with equal rates among children with pneumonia and control (n\u0026thinsp;=\u0026thinsp;77, 15.4% respectively). By qPCR, SPN carriage was detected in 94.8% (n\u0026thinsp;=\u0026thinsp;146), of which 63.0% were SPN mono-carriage and SPN co-carriage with HI was observed in 35.1% (n\u0026thinsp;=\u0026thinsp;54) samples (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eEight samples yielded no detectable pathogens via qPCR screening and were excluded from further analysis. No other respiratory pathogens (CP, MP, LP, BP, or BPP) were detected in these samples. There was no statistically significant difference between the groups of single and co-carriage among children with clinically diagnosed pneumonia and healthy controls (p\u0026thinsp;=\u0026thinsp;0.894) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eThe pneumococcal and co-carriage distribution among children under-5 of MY-Pneumo study subjects with culture-positive for SPN (n\u0026thinsp;=\u0026thinsp;154)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eqPCR analysis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003eFrequency, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCase\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCulture positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSPN mono-carriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (48.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.894\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSPN-HI co-carriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the socio-economic and demographic characteristics of subjects with SPN mono-carriage and SPN-HI co-carriage by multiplex qPCR analysis. There was no significant difference between the two groups.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of SPN carriage and SPN-HI co-carriage status against socio-demographic characteristics.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSPN mono-carriage, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSPN-HI co-carriage, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.176\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (24.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.17\u0026thinsp;\u0026plusmn;\u0026thinsp;15.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.26\u0026thinsp;\u0026plusmn;\u0026thinsp;14.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.460\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge groups (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u0026ndash;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (37.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u0026ndash;48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (7.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49\u0026ndash;60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (96.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBajau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level of parent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.747\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollege degree or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (54.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary/Vocational/ Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary/ Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003ePrevalence of Co-carriage Patterns\u003c/h2\u003e\n \u003cp\u003eThe highest number of SPN culture-positive samples were from the state of Kelantan (n\u0026thinsp;=\u0026thinsp;86, 58.9%), while both Pahang and Kuala Lumpur contributed 24 (16.4%) and 36 (24.7%) samples, respectively. Factors that were significantly associated with pneumococcal co-carriage were sentinel site (p\u0026thinsp;=\u0026thinsp;0.037), household size (p\u0026thinsp;=\u0026thinsp;0.01), and gestation term (p\u0026thinsp;=\u0026thinsp;0.04) (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic and environmental factors of pneumococcal co-carriage among children under-5 in MY-Pneumo study.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSPN mono-carriage, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSPN-HI co-carriage, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSentinel sites\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.037\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKelantan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (51.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKuantan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eKuala Lumpur\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDay care centre\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidential area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.797\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (17.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidential type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.187\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLanded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72 (78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47 (87.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRooms in residence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.596\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 to 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 to 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (57.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMore than 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of people in residence, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.59\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.41\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 persons or lesser\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 to 7 persons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (48.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 or more persons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSiblings (\u0026lt;\u0026thinsp;5 age of years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (38.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (50.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (62.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eExposure to tobacco smoke\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.141\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (27.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (38.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (72.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33 (61.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eNutritional, clinical, and vaccination history of pneumococcal co-carriage among children under-5 in MY-Pneumo study.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSPN mono-carriage, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSPN-HI co-carriage, n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFeeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreast exclusively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMixed feeding (Breast\u0026thinsp;+\u0026thinsp;other)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (47.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (54.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo breast milk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (30.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePost-term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTerm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83 (90.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePre-term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (g)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2984\u0026thinsp;\u0026plusmn;\u0026thinsp;529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2851\u0026thinsp;\u0026plusmn;\u0026thinsp;540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.147\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.809\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnderweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (79.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOverweight/ obese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGenerally healthy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77 (83.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (88.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (16.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDTaP-IPV-HepB-Hib\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaccinated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88 (95.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (98.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartially vaccinated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnvaccinated/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMMR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.557\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaccinated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65 (92.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (88.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartially vaccinated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnvaccinated/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePCV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.263\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVaccinated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartially vaccinated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnvaccinated/Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (31.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (19.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eBody Mass Index (BMI) status followed WHO Child Growth Standard 2006: \u0026lt;fifth percentile \u0026minus; underweight; fifth percentile to \u0026lt;85th percentile \u0026minus; normal weight, \u0026ge;85th percentile \u0026minus; overweight/obese\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003eVaccination history was classified into three categories based on the Malaysia National Immunisation Program guidelines: fully vaccinated, partially vaccinated, and unvaccinated.\u003c/p\u003e\n \u003cp\u003eHepB = Hepatitis B, DTaP = diphtheria, tetanus and pertussis, Hib = Haemophilus influenzae type b, PCV = pneumococcal conjugate vaccine\u003c/p\u003e\n \u003cp\u003eBased on regression analysis, the predictors of positive SPN-HI co-carriage were household size of five to seven persons (aOR 3.70, 95% CI 1.43\u0026ndash;9.55, p\u0026thinsp;=\u0026thinsp;0.007) and more than 8 persons (aOR 3.58, 95% CI 1.06\u0026ndash;12.12, p\u0026thinsp;=\u0026thinsp;0.041). The presence of pre-existing illnesses, such as immunodeficiency, sickle cell disease, asthma or other chronic illnesses, was also evaluated as a potential risk factor for co-carriage. However, no significant associations were found between pre-existing conditions and the likelihood of having single or multiple pathogen co-carriage.\u003c/p\u003e\n \u003cp\u003eVaccination records indicate that all subjects (n\u0026thinsp;=\u0026thinsp;154) have received at least one vaccine under the Malaysian National Immunisation Programme (NIP). Most participants had received the hexavalent DTaP-IPV-HepB-Hib vaccine, measles, mumps, and rubella (MMR) vaccine, or the pneumococcal conjugate vaccine (PCV) according to NIP. No significant difference was found between vaccination history and both SPN-only or SPN-HI co-carriage subjects in this study.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we found that SPN was detected in 94.8% of the selected MY-PNEUMO samples (n\u0026thinsp;=\u0026thinsp;154) and SPN-HI in 35.1% as a co-carriage bacterial pathogen. Our findings support prior studies showing that SPN and HI frequently co-exist together in children (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), especially among those with severe pneumonia (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Co-carriage was observed to be higher among children from Kelantan, as well as those residing in households with a larger number of occupants. These findings suggest that environmental and socio-demographic factors may play a significant role in co-carriage rates. Variables related to housing, among others, have been reported as possible factors impacting respiratory infections (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Over-crowding will inevitably increase the likelihood of exposure to multiple pathogens and facilitate transmission among individuals in close contact.\u003c/p\u003e \u003cp\u003eOur analysis revealed significant differences based on sentinel site and the number of residents in the household, indicating that social determinants such as crowded living conditions or non-urban environments may contribute to higher co-carriage rates. Some of these variables have been highlighted as risk factors contributing to pneumococcal disease burden (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This aligns with a previous study done in Democratic Republic of Congo and Nepal that showed higher SPN or HI bacterial loads in rural children(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) as opposed to an Indonesian study that found no significant differences between urban and semi-rural carriage and co-carriage of SPN and HI(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Interestingly, when comparing SPN-mono-carriage and SPN-HI co-carriage, no significant differences were found between clinically diagnosed pneumonia cases and healthy controls, highlighting the complex nature of pathogen interactions within the nasopharynx as not all co-existence leads to co-infection.\u003c/p\u003e \u003cp\u003eThe clinical significance of HI co-carriage in pneumococcal disease remains unclear. Studies suggest that HI colonisation can promote SPN carriage and potentially increase the risk of invasive disease (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), including by the formation of multispecies biofilms which can protect against antibiotics and promote adhesion to host tissues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). However, we did not observe any heightened risk or severity associated with SPN-HI co-carriage. These findings underscore the need for future studies to focus on the mechanistic underpinnings of SPN-HI interactions, particularly in the context of co-carriage and its potential to impact disease severity and treatment outcomes.\u003c/p\u003e \u003cp\u003eOur results also indicate that vaccination status, although crucial for preventing single-pathogen infections, does not appear to be a major determinant of co-carriage risk. Most subjects were fully vaccinated following the NIP including with PCV, yet we did not observe a significant difference in co-carriage rates between vaccinated and unvaccinated individuals. PCVs play a critical role in reducing pneumococcal carriage and transmission, indirectly lowering the risk of concurrent bacterial infections and consequently, disease severity and complexity (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) by decreasing colonisation with vaccine-type SPN strains (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, the protective effect of PCVs on overall co-infection risk remains incomplete, particularly in the context of viral respiratory infections. Such viral infections are known to predispose opportunistic bacterial colonisation by creating an environment that facilitates bacterial adherence and colonisation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, secondary bacterial infections have been associated with more severe clinical presentations especially in young children, immunocompromised individuals and those living in resource limited settings (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Therefore, comprehensive strategies that address both viral and bacterial pathogens are essential to mitigate the burden of respiratory co-infections (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Integrated approaches, combining bacterial vaccination programs with effective viral prevention measures such as influenza vaccination, improved hygiene, and early antiviral treatment, are necessary to improve respiratory infection outcomes globally (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Our study also did not find any significant association between pre-existing illnesses and the likelihood of co-carriage, although immunocompromised children and those with underlying health conditions such as asthma or chronic respiratory diseases are known to be more vulnerable to respiratory infections (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe methodological limitations of this study should also be considered when interpreting these results. Eight samples were negative for SPN and HI by qPCR, despite being culture-positive, which suggests the possibility of false positives due to other \u003cem\u003eStreptococcus\u003c/em\u003e species that share similar colony morphology and optochin sensitivity. The use of bile solubility tests could improve the accuracy of SPN identification, as the zone of inhibition in optochin sensitivity tests has been shown to vary depending on agar medium and incubation conditions (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The absence of MP, CP, and \u003cem\u003eBordetella spp.\u003c/em\u003e in our study contrasts with findings from other studies, which have reported low but detectable levels of these pathogens in children (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The variability in pathogen detection could be due to differences in study populations, diagnostic methods, or sample size, and highlights the need for comprehensive surveillance to capture the full spectrum of pathogens involved in childhood pneumonia. This study was limited by the panel of bacteria in the kit, future studies should also include relevant viruses and bacteria such as RSV, \u003cem\u003eMoraxella catarrhalis\u003c/em\u003e and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, we found that 1 in 3 children with SPN had co-carriage with HI. Geographic locations and overcrowding contribute to differences in pneumococcal carriage co-carriage status in this study. Risk of co-carriage is higher in children in Kelantan at the east coast region of Malaysia, with living conditions involving a household size of more or equal to five persons. This finding underscores the importance of continuous surveillance and targeted intervention strategies to address co-carriage, which can lead to co-infections that complicate disease management and treatment outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eaOR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted odds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eBordetella pertussis\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eBPP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eBordetella parapertussis\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCBA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eColumbia agar with 5% sheep blood\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCDC\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCenters for Disease Control and Prevention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eChlamydophila pneumoniae\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCRF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCase report form\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCRP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCSF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCerebrospinal fluid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCXR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eChest radiograph\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDNA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDeoxyribonucleic acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eDTaP-IPV-HepB-Hib\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiphtheria, tetanus, pertussis, inactivated poliovirus, hepatitis B and \u003cem\u003eHaemophilus influenzae\u003c/em\u003e type b vaccine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eHaemophilus influenzae\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIMU-AMCRL\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIMU Advanced Microbiology Collaborative Research Laboratory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIPD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInvasive pneumococcal disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eLP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eLegionella pneumophila\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eMycoplasma pneumoniae\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMMR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMeasles, mumps, rubella\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNIP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Immunisation Programme\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNP\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNasopharyngeal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eNPS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNasopharyngeal swab\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePCV\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePneumococcal conjugate vaccine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePCV10\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e10-valent pneumococcal conjugate vaccine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePCR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePolymerase chain reaction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePUAT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePneumococcal urine antigen test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eqPCR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eQuantitative polymerase chain reaction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPN\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPN-HI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e-\u003cem\u003eHaemophilus influenzae\u003c/em\u003e co-carriage\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSTGG\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSkim milk, tryptone, glucose, glycerol\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWGS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWhole-genome sequencing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study involving human participants was reviewed and approved by the IMU Joint Committee on Research \u0026amp; Ethics (4.15/JCM-216/2021 and 4.5/JCM-267/2023), the Human Research Ethics Committee, Universiti Sains Malaysia (USM/JEPeM/21020190), the International Islamic University Malaysia Research Ethics Committee (IREC 2021-114), and University Malaya Medical Centre (MREC ID No: 2021128-9769).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinicalTrials.gov, NCT04923035. Registered on June 11, 2021.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot required because no individual identifiers have been included in the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eLHS acts as principal investigator for studies conducted on behalf of IMU University that are sponsored by vaccine manufacturers. No personal payments are received from them. NHR and NAJ have received financial assistance from vaccine manufacturers to attend conferences. All grants and honoraria are paid into accounts within the respective universities. All other authors have no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis work is funded in part by a research grant from the Investigator Initiated Studies Program of Merck Sharp \u0026amp; Dohme Corp (MSIP #60200). The funding body did not play any role in data collection, decision to publish, or drafting of the manuscript. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp \u0026amp; Dohme Corp.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eNHR and ATCH wrote the manuscript. ATCH, SW, XQC, EEJL, XRL, AHMR, CSJT, ZZD, and NK supported the microbiological protocols. ATCH performed initial carriage analysis. AMN, MII, ZZD, AAB, and MAMH coordinated the study implementation at sentinel sites. PKL and NAJ supported the statistical analysis. LHS acquired funding, supervised the project and critically reviewed the manuscript. All authors read and approved the final manuscript version.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors thank all staff nurses and medical officers from the sentinel sites for their valuable contributions to this study. The authors also would like to thank all the parents/legal guardians and children who participated in the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDepartment of Statistics Malaysia (DOSM). Statistics on Causes of Death, Malaysia, 2024 [Internet], Putrajaya M. 2024 Oct. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://open.dosm.gov.my\u003c/span\u003e\u003cspan address=\"https://open.dosm.gov.my\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudan I, O\u0026rsquo;Brien KL, Nair H, Liu L, Theodoratou E, Qazi S et al. 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Croat Med J. 2013;54(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrauer M, Roth GA, Aravkin AY, Zheng P, Abate KH, Abate YH, et al. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990\u0026ndash;2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2024;403(10440):2162\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirindwa AM, Gonzales-Siles L, Nord\u0026eacute;n R, Geravandi S, Manegabe JT, Morisho L et al. High bacterial and viral load in the upper respiratory tract of children in the Democratic Republic of the Congo. PLoS ONE. 2020;15(10 October).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanieh S, Hamaluba M, Kelly DF, Metz JA, Wyres KL, Fisher R et al. 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Burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in the era of conjugate vaccines: global, regional, and national estimates for 2000\u0026ndash;15. Lancet Glob Health. 2018;6(7):e744\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura S, Davis KM, Weiser JN. Synergistic stimulation of type I interferons during influenza virus coinfection promotes Streptococcus pneumoniae colonization in mice. J Clin Invest. 2011;121(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardenas PA, Cooper PJ, Cox MJ, Chico M, Arias C, Moffatt MF et al. Upper Airways Microbiota in Antibiotic-Na\u0026iuml;ve Wheezing and Healthy Infants from the Tropics of Rural Ecuador. PLoS ONE. 2012;7(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurckhardt I, Panitz J, Burckhardt F, Zimmermann S. Identification of Streptococcus pneumoniae: Development of a Standardized Protocol for Optochin Susceptibility Testing Using Total Lab Automation. Biomed Res Int. 2017;2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErcibengoa M. Assessment of the optochin susceptibility test to differentiate streptococcus pneumoniae from other viridans group streptococci. Clin Lab. 2021;67(3):857\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuitunen I. Bordetella pertussis, Chlamydia pneumoniae, and Mycoplasma pneumoniae Findings in Children During COVID-19 Pandemic in Finland. SN Compr Clin Med. 2022;4(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKutty PK, Jain S, Taylor TH, Bramley AM, Diaz MH, Ampofo K, et al. Mycoplasma pneumoniae among children hospitalized with community-acquired pneumonia. Clin Infect Dis. 2019;68(1):5\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeijer A, Dagnelie CF, Jong JC, De VA, De, Bestebroer TM, Van Loon AM et al. Low prevalence of Chlamydia pneumoniae and Mycoplasma pneumoniae among patients with symptoms of respiratory tract infections in Dutch general practices. Eur J Epidemiol. 2000;16(12).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pneumococcal pneumonia, paediatric pneumonia, co-carriage, respiratory tract bacteria, Streptococcus pneumoniae, Haemophilus influenzae","lastPublishedDoi":"10.21203/rs.3.rs-6707646/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6707646/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStreptococcus pneumoniae \u003c/em\u003e(SPN) is the commonest cause of bacterial childhood pneumonia, and adverse clinical outcomes have been associated with co-infections with other bacteria causing severe respiratory disease. We therefore conducted a study to look for evidence of other respiratory bacterial pathogens and to determine the prevalence and risk factors of co-carriage status among under-5 children in Peninsular Malaysia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThis retrospective case-control study is part of a paediatric pneumonia surveillance study “MY-Pneumo” (NCT04923035. Registered on June 11, 2021) in young children across three sentinel sites in Peninsular Malaysia (Kelantan, Pahang, and Kuala Lumpur). Nasopharyngeal specimens of under-5 children with positive optochin sensitive SPN isolates (n=154) were further tested for pneumococcal co-carriage status of SPN and six bacteria causing severe respiratory tract infections (\u003cem\u003eBordetella parapertussis \u003c/em\u003e(BPP), \u003cem\u003eB. pertussis \u003c/em\u003e(BP\u003cem\u003e), Chlamydophila pneumoniae \u003c/em\u003e(CP), \u003cem\u003eHaemophilus influenzae \u003c/em\u003e(HI), \u003cem\u003eLegionella pneumophila \u003c/em\u003e(LP), \u003cem\u003eMycoplasma pneumoniae \u003c/em\u003e(MP)) using multiplex real-time polymerase chain reaction (qPCR). Logistic regression analyses were fitted for paediatric bacterial co-carriage risk factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eCo-carriage was only present between SPN and HI in 54 children (35.1%). The majority were boys (n=41, 75.9%) with a mean age of 19.26 (±14.83) months. Co-carriage of SPN and HI (SPN-HI) were significantly associated with the sentinel site location (p=0.037), gestation term (p=0.004), and household size (p=0.01). The predictors of positive co-carriage were household size of five to seven persons (aOR 3.70, 95% CI 1.43 – 9.55, p= 0.007) and more than 8 persons (aOR 3.58, 95% CI 1.06 – 12.12, p= 0.041).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study revealed that co-carriage of SPN-HI was present in a significant proportion of children with pneumonia and was influenced by geographical area, and household size. Resource allocation should be targeted towards effective vaccination strategies and heightened awareness among healthcare providers to improve paediatric pneumonia interventions in the country.\u003c/p\u003e","manuscriptTitle":"Co-carriage of respiratory tract bacterial pathogens among under-5 children with pneumococcal carriage in Peninsular Malaysia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-25 09:52:11","doi":"10.21203/rs.3.rs-6707646/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-16T05:55:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-16T01:46:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-15T09:23:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T16:34:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24911770205638133074219394324101086102","date":"2025-07-14T15:41:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-14T07:24:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-12T15:00:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T09:46:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168579938964906302082262073863786069641","date":"2025-06-26T07:32:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"257500737283673625103052920382167569968","date":"2025-06-24T10:56:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17734285202175256637150710954473897697","date":"2025-06-23T12:31:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"276776917220914539050478820119954972865","date":"2025-06-22T17:28:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100626017883898766161866334476875125095","date":"2025-06-22T15:14:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93244410575480340895865248967324201010","date":"2025-06-21T12:54:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152750825219611012997721621152683265094","date":"2025-06-20T12:18:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-18T12:12:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-27T05:24:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-26T03:28:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-26T03:24:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-05-20T12:06:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"444ac8b6-7d56-432e-92e2-88fd4bba87ac","owner":[],"postedDate":"June 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:11:43+00:00","versionOfRecord":{"articleIdentity":"rs-6707646","link":"https://doi.org/10.1186/s12879-026-12800-1","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2026-02-12 15:58:16","publishedOnDateReadable":"February 12th, 2026"},"versionCreatedAt":"2025-06-25 09:52:11","video":"","vorDoi":"10.1186/s12879-026-12800-1","vorDoiUrl":"https://doi.org/10.1186/s12879-026-12800-1","workflowStages":[]},"version":"v1","identity":"rs-6707646","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6707646","identity":"rs-6707646","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}