New: Childhood pneumonia
The HIFA2015/CHILD2015 Childhood Pneumonia Project is sponsored by the British Medical Association. The aim is to understand and address the information and learning needs of families and healthcare providers in relation to the diagnosis and management of childhood pneumonia in low income countries.
Overview
Pneumonia is the leading cause of death in children under 5, killing around 2 million children every year. Yet only one in five caregivers in developing countries can identify the early signs of pneumonia, and only about half of children under 5 with pneumonia are taken to an appropriate health-care provider. How can we do better to help parents and health workers to recognise the danger signs of pneumonia and to provide appropriate life-saving treatment?
‘Few caregivers can recognize pneumonia symptoms. Consequently, less than one third of children suffering from pneumonia receive antibiotics, which are available for less than US$1.’
Launch of World Pneumonia Day, November 2, 2009
What HIFA2015/CHILD2015 members say
Meeting information needs to diagnose and manage pneumonia
Case studies
Here are some real-life stories of children who survived or died from pneumonia, from the World Pneumonia Day (November 12th) and Prevent Pneumonia websites:
Nasario, Philippines (survived): A Hospital Stay Just Barely Saves a Life
Tejaswini, India (survived): The need for education about the power of vaccinations
Tarunesh, Ethiopia (survived): Community Health Workers and antibiotics save a life
Moussa, Mali (died): Use of traditional and ‘modern’ medicines, and inability to pay hospital fees
The ‘road to death’ typically includes several contributing factors, which are often sequential. For example, a child may have malnutrition associated with underlying poverty; there may be delays in recognising that the child is seriously ill; delays in reaching a health worker; delays in establishing the correct diagnosis and giving the correct treatment, or giving the wrong treatment (eg antimalalarials only or, tragically, a counterfeit medicine that says it is an antibiotic, but isn’t). Every death is the final page in a story. In many if not most cases, death could have been averted if just one detail of that story were different.
Quotes from the literature
‘More than 150 million episodes of childhood pneumonia occur every year in the developing world, accounting for more than 95% of all new cases worldwide. Between 11 and 20 million children with pneumonia will be hospitalised, and more than 2 million will die every year.’
1. Understanding information needs
‘Carers of young children need to be able to distinguish between self-limiting upper respiratory tract infections (URTI) and life-threatening pneumonia that requires treatment.’
‘Only one in five caregivers in the developing world know the two key symptoms of pneumonia - fast and difficult breathing - which indicate the child should be treated immediately. Only about half of children with pneumonia receive appropriate medical care. And, according to limited data from the early 1990s, less than 20% of children with pneumonia received antibiotics.’
‘Across much of sub-Saharan Africa communities confront an epidemiological minefield without the benefits of basic health or education. They blame demons and witchcraft when children have fevers brought on by pneumonia… In Junju, some whispered that researchers used blood samples from Junju’s children to feed these demons.’
‘There was mistreatment with antimalarials, delays in seeking care and likely low quality of care for children with fatal pneumonia [in rural Uganda].’
‘The crucial first step in tackling childhood pneumonia is being able to diagnose it accurately…. the bulk of childhood pneumonia deaths occur in community settings where there are relatively few skilled health workers… success will depend on the availability and application of robust diagnostic algorithms by health workers with only basic training or even lay people.’
‘Many small hospitals in the developing world have unacceptably high case-fatality rates for childhood pneumonia, often as high as 15-20%. Most of these deaths are avoidable with adequate care… Access to a poorly functioning facility may be equivalent to no access or, in some cases, worse than no access at all. In such cases, everything might appear to go as it should. When a child develops pneumonia, the signs of pneumonia are recognized by his educated mother and he is taken promptly to a health facility. However, at the facility he receives either no treatment or inappropriate treatment and subsequently dies.’
‘A survey of 21 hospitals in seven less-developed countries found inadequate knowledge and practice for managing pneumonia among 56% of doctors and nurses.’
‘Inappropriate knowledge on causes of pneumonia and signs of non-severe pneumonia are likely to interfere with compliance with home care messages.’
‘GPs in Multan [Pakistan] were not familiar with national Acute Respiratory Illness control programme and rational drug use guidelines. They rarely asked about symptoms describing severity of disease while taking patient histories and did not look for signs of severe pneumonia during physical examinations. Most patients diagnosed as URTI (upper respiratory tract infection) received oral antibiotics and those with pneumonia received injectable antibiotics. Other drugs prescribed included cough syrups, antihistamines and antipyretics. The average number of drugs prescribed per patient was 3-4.’
Iqbal I et al 1997 (not available online)
‘Health workers overwhelmingly disagreed with the IMCI recommendation that all severely ill children be referred… Despite 5% mortality and a death rate equivalent to or greater than the in-hospital mortality recently documented in comparable settings in Kenya and the United Republic of Tanzania, health workers expressed confidence in their capacity to safely manage most cases of severe malaria and severe pneumonia without referral.’
‘To ensure that every child with severe pneumonia has rapid access to treatment with an effective antibiotic, treatment in the community by workers with limited training is necessary in many developing country situations and is essential in ensuring equity in access to treatment.’
2. Undertaking and publishing research on childhood pneumonia
‘Pneumonia, the world’s most important cause of child death, has attracted remarkably little attention over the past decade. There has been very little research on the disease, apart from trials of pneumococcal and Haemophilus influenzae type b (Hib) vaccines, which included evaluations of the impact on these vaccines on pneumonia, and some studies on the case management of pneumonia.’
3. Synthesizing knowledge
‘Local adaptation of the IMCI guidelines [increased use of local oral amoxicillin vs referral to hospital], with appropriate training and supervision, could allow safe and effective management of severe pneumonia, especially if compliance with referral is difficult because of geographical, financial or cultural barriers.’
‘Although national adaptation of WHO guidelines [for treatment of childhood pneumonia] to take into account the local epidemiology of disease is recommended, few countries have the data to allow for adaptation and the tendency is to follow the generic WHO advice…’
‘To address the low literacy level of some Female Community Health Volunteers, extensive effort was given to developing pictorial training manuals, educational materials and reporting booklets… Other countries should accept the existing evidence that clearly demonstrates that community-based workers can effectively manage pneumonia.’
Dawson P et al 2008
‘Two key questions are whether current algorithms for clinical diagnosis of pneumonia are robust, and if so, are current antibiotic regimens adequate for the treatment of pneumonia in primary care settings?’
Bhutta Z 2007
4. Making knowledge available
‘Community-based approaches to managing childhood pneumonia have proven successful; but expanding this approach has been met with resistance. Concerns have been raised about lower-level health workers, such as community health workers, administering antibiotics to children with pneumonia, and with fears that these activities could exacerbate antibiotic resistance. But community health workers can appropriately administer antibiotics consistent with guidelines.’
‘Health professionals in many developing countries believe that only health professionals at a health facility should treat pneumonia. A common reason for caution is concern about CHWs’ possible misuse of antimicrobials and increased drug resistance. However, Community Case Management of pneumonia, which uses IMCI algorithms, could reduce both the improper use of antibiotics for cough and cold and increase their proper use for algorithm-positive pneumonia provided that supervision reinforces CHW performance.’
5. Impact of knowledge
‘It is especially important for countries with limited resources to scale up training of health workers on a local level to assess and diagnose cases of pneumonia. “Children in rural areas and those living in the poorest households are less likely to receive appropriate care,” noted Dr. Young [UNICEF Senior Health Specialist]. “That is one of the reasons why UNICEF is promoting community-based case management, providing community health workers with the knowledge, skills and essential medicines to manage pneumonia closer to the home, and increase access to appropriate care.”
UNICEF 2009
‘Under current WHO recommendations for treating children with severe pneumonia, they should be referred to a health facility and given injectable antibiotics. We have plenty of data to show that when a health worker tells parents that their child is very sick and should be taken to a health facility, many children are not taken to the health facility and die at home.’
Hazir T 2008
‘Case management by community health workers has a significant impact on both overall and pneumonia-specific under-five mortality. A recent meta-analysis of community-based pneumonia case management studies estimated a 20 per cent reduction in all-cause under-one mortality, and a 24 per cent reduction in all-cause under-five mortality.’
WHO/UNICEF 2004
‘From October 2000 to December 2005, 312 health workers (approximately one-quarter of all nurses, clinical officers, and medical assistants working in government hospitals [in Malawi]) participated in 5-d training courses. The 22 district and three central hospitals reported 48,702 cases between 1 October 2000 and 31 December 2005… The proportion of children dying of pneumonia fell from 18.6% to 8.4%, a reduction of 54.8% over the baseline.’
Enarson P at al 2009
References
Alsop Z. Malaria vaccine researchers face cultural challenges. Lancet 2009;374:104-5 (free access)
Bhutta Z. Childhood pneumonia in developing countries. BMJ 2006;333:612-613 (free access)
Iqbal I et al. Management of children with acute respiratory infections (ARI) by general practitioners in Multan - an observational study. Journal of the Pakistan Medical Association 1997;47(1):24-8 (not available online)
UNICEF. 2009. UNICEF and WHO release comprehensive plan to tackle leading killer of young children.
Wardlaw T et al. Pneumonia: the leading killer of children. Lancet 2006;368:1048-50 (free access)
WHO/UNICEF Joint Statement. 2004. Management of pneumonia in community settings.
