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Chest radiograph reading panel performance in a Bangladesh pneumococcal vaccine effectiveness study
  1. Eric D McCollum1,2,3,
  2. Salahuddin Ahmed4,
  3. Nabidul H Chowdhury4,
  4. Syed J R Rizvi4,
  5. Ahad M Khan4,
  6. Arun D Roy4,
  7. Abu AM Hanif4,
  8. Farhan Pervaiz5,6,7,
  9. ASM Nawshad U Ahmed8,9,
  10. Ehteshamul H Farrukee10,
  11. Mahmuda Monowara11,
  12. Mohammad M Hossain11,
  13. Fatema Doza12,
  14. Bidoura Tanim13,
  15. Farzana Alam14,
  16. Nicole Simmons3,
  17. Megan E Reller15,16,17,
  18. Meagan Harrison3,
  19. Holly B Schuh3,
  20. Abdul Quaiyum18,
  21. Samir K Saha9,
  22. Nazma Begum4,
  23. Mathuram Santosham3,
  24. Lawrence H Moulton5,
  25. William Checkley5,6,7 and
  26. Abdullah H Baqui3
  1. 1Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
  2. 2Global Program in Respiratory Sciences, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
  3. 3Health Systems, Department of International Health, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
  4. 4Johns Hopkins University – Bangladesh, Dhaka, Bangladesh
  5. 5Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
  6. 6Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
  7. 7Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
  8. 8Department of Pediatrics, Dhaka Shishu Hospital, Dhaka, Bangladesh
  9. 9Child Health Research Foundation, Dhaka, Bangladesh
  10. 10Department of Radiology and Imaging, LabAid Cardiac Hospital, Dhaka, Bangladesh
  11. 11Department of Radiology and Imaging, Dhaka Shishu Hospital, Dhaka, Bangladesh
  12. 12Department of Radiology and Imaging, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh
  13. 13Department of Radiology and Imaging, National Institute of Ophthalmology, Dhaka, Bangladesh
  14. 14Department of Radiology and Imaging, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
  15. 15Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
  16. 16Duke Hubert-Yeargan Center for Global Health, Durham, North Carolina, USA
  17. 17Duke Global Health Institute, Durham, North Carolina, USA
  18. 18Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
  1. Correspondence to Dr Eric D McCollum; emccoll3{at}


Introduction To evaluate WHO chest radiograph interpretation processes during a pneumococcal vaccine effectiveness study of children aged 3–35 months with suspected pneumonia in Sylhet, Bangladesh.

Methods Eight physicians masked to all data were standardised to WHO methodology and interpreted chest radiographs between 2015 and 2017. Each radiograph was randomly assigned to two primary readers. If the primary readers were discordant for image interpretability or the presence or absence of primary endpoint pneumonia (PEP), then another randomly selected, masked reader adjudicated the image (arbitrator). If the arbitrator disagreed with both primary readers, or concluded no PEP, then a masked expert reader finalised the interpretation. The expert reader also conducted blinded quality control (QC) for 20% of randomly selected images. We evaluated agreement between primary readers and between the expert QC reading and the final panel interpretation using per cent agreement, unadjusted Cohen’s kappa, and a prevalence and bias-adjusted kappa.

Results Among 9723 images, the panel classified 21.3% as PEP, 77.6% no PEP and 1.1% uninterpretable. Two primary readers agreed on interpretability for 98% of images (kappa, 0.25; prevalence and bias-adjusted kappa, 0.97). Among interpretable radiographs, primary readers agreed on the presence or absence of PEP in 79% of images (kappa, 0.35; adjusted kappa, 0.57). Expert QC readings agreed with final panel conclusions on the presence or absence of PEP for 92.9% of 1652 interpretable images (kappa, 0.75; adjusted kappa, 0.85).

Conclusion Primary reader performance and QC results suggest the panel effectively applied the WHO chest radiograph criteria for pneumonia.

  • Asia
  • developing countries
  • respiratory tract diseases
  • child
  • infant
  • pneumococcal vaccines

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  • Contributors Funding acquisition: AHB and EDM. Conceptualisation and design: EDM and AHB. Data curation: EDM, AHB, NHC and SJR. Data collection: EDM, SA, AMK, ADR, AAH, ANUA, EHF, MM, MMH, FD, BT and FA. Data analysis: EDM, NHC, SJR, HBS, NS and LHM. Data interpretation: EDM, AHB, FP, NS, MER, MH, HBS, MS, LHM and WC. Writing—original draft: EDM. Writing—review & editing: EDM, AHB, WC, LHM, MS, SA, NB, SKS, AQ, HBS, MH, MER, NS, FA, BT, FD, MMH, MM, EHF, ANUA, FP, AAH, ADR, AMK, AJR and NHC.

  • Funding This study is funded by the Bill & Melinda Gates Foundation [OPP1084286, OPP1117483] and GlaxoSmithKline [90063241]. EDM was also supported by the Fogarty International Center of the National Institutes of Health under Award Number K01TW009988 for the research reported in this publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Bill & Melinda Gates Foundation, GlaxoSmithKline or the National Institutes of Health.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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