Development and implementation of a national programme for the management of severe and very severe pneumonia in children in Malawi.
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ABSTRACT:
SUBMITTER: Enarson PM
PROVIDER: S-EPMC2766047 | biostudies-literature | 2009 Nov
REPOSITORIES: biostudies-literature
Publications
Development and implementation of a national programme for the management of severe and very severe pneumonia in children in Malawi.
Enarson Penelope Marjorie PM Gie Robert R Enarson Donald A DA Mwansambo Charles C
PLoS medicine 20091110 11
Penelope Enarson and colleagues describe the development, scale-up, and achievements of a national pneumonia program in Malawi, which is based on a successful anti-tuberculosis service delivery model. ...[more]
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Project description:ObjectiveTo evaluate the pneumonia specific case fatality rate over time following the implementation of a Child Lung Health Programme (CLHP) within the existing government health services in Malawi to improve delivery of pneumonia case management.MethodsA prospective, nationwide public health intervention was studied to evaluate the impact on pneumonia specific case fatality rate (CFR) in infants and young children (0 to 59 months of age) following the implementation of the CLHP. The implementation was step-wise from October 1st 2000 until 31st December 2005 within paediatric inpatient wards in 24 of 25 district hospitals in Malawi. Data analysis compared recorded outcomes in the first three months of the intervention (the control period) to the period after that, looking at trend over time and variation by calendar month, age group, severity of disease and region of the country. The analysis was repeated standardizing the follow-up period by using only the first 15 months after implementation at each district hospital.FindingsFollowing implementation, 47,228 children were admitted to hospital for severe/very severe pneumonia with an overall CFR of 9.8%. In both analyses, the highest CFR was in the children 2 to 11 months, and those with very severe pneumonia. The majority (64%) of cases, 2-59 months, had severe pneumonia. In this group there was a significant effect of the intervention Odds Ratio (OR) 0.70 (95%CI: 0.50-0.98); p = 0.036), while in the same age group children treated for very severe pneumonia there was no interventional benefit (OR 0.97 (95%CI: 0.72-1.30); p = 0.8). No benefit was observed for neonates (OR 0.83 (95%CI: 0.56-1.22); p = 0.335).ConclusionsThe nationwide implementation of the CLHP significantly reduced CFR in Malawian infants and children (2-59 months) treated for severe pneumonia. Reasons for the lack of benefit for neonates, infants and children with very severe pneumonia requires further research.
| S-EPMC4106861 | biostudies-literature
Project description:Induced sputum (IS) may provide diagnostic information about the etiology of pneumonia. The safety of this procedure across a heterogeneous population with severe pneumonia in low- and middle-income countries has not been described.IS specimens were obtained as part a 7-country study of the etiology of severe and very severe pneumonia in hospitalized children <5 years of age. Rigorous clinical monitoring was done before, during, and after the procedure to record oxygen requirement, oxygen saturation, respiratory rate, consciousness level, and other evidence of clinical deterioration. Criteria for IS contraindications were predefined and serious adverse events (SAEs) were reported to ethics committees and a central safety monitor.A total of 4653 IS procedures were done among 3802 children. Thirteen SAEs were reported in relation to collection of IS, or 0.34% of children with at least 1 IS specimen collected (95% confidence interval, 0.15%-0.53%). A drop in oxygen saturation that required supplemental oxygen was the most common SAE. One child died after feeding was reinitiated 2 hours after undergoing sputum induction; this death was categorized as "possibly related" to the procedure.The overall frequency of SAEs was very low, and the nature of most SAEs was manageable, demonstrating a low-risk safety profile for IS collection even among severely ill children in low-income-country settings. Healthcare providers should monitor oxygen saturation and requirements during and after IS collection, and assess patients prior to reinitiating feeding after the IS procedure, to ensure patient safety.
| S-EPMC5447836 | biostudies-other
Project description:BackgroundResearch shows inadequate Integrated Management of Childhood Illness (IMCI)-pneumonia care in various low-income settings but evidence is largely from small-scale studies with limited evidence of patient-, provider- and facility-levels determinants of IMCI non-severe pneumonia classification and its management.MethodsThe Malawi Service Provision Assessment 2013-2014 included 3149 outpatients aged 2-59 months with completed observations, interviews and re-examinations. Mixed-effects logistic regression models quantified the influence of patient-, provider and facility-level determinants on having IMCI non-severe pneumonia and its management in observed consultations.FindingsAmong 3149 eligible outpatients, 590 (18.7%) had IMCI non-severe pneumonia classification in re-examination. 228 (38.7%) classified cases received first-line antibiotics and 159 (26.9%) received no antibiotics. 18.6% with cough or difficult breathing had 60-second respiratory rates counted during consultations, and conducting this assessment was significantly associated with IMCI training ever received (odds ratio (OR) = 2.37, 95% confidence interval (CI): 1.29-4.31) and negative rapid diagnostic test results (OR = 3.21, 95% CI: 1.45-7.13). Older children had lower odds of assessments than infants (OR = 48-59 months: 0.35, 95% CI: 0.16-0.75). Children presenting with any of the following complaints also had reduced odds of assessment: fever, diarrhea, skin problem or any danger sign. First-line antibiotic treatment for classified cases was significantly associated with high temperatures (OR = 3.26, 95% CI: 1.24-8.55) while older children had reduced odds of first-line treatment compared to infants (OR = 48-59 months: 0.29, 95% CI: 0.10-0.83). RDT-confirmed malaria was a significant predictor of no antibiotic receipt for IMCI non-severe pneumonia (OR = 10.65, 95% CI: 2.39-47.36).ConclusionsIMCI non-severe pneumonia care was sub-optimal in Malawi health facilities in 2013-2014 with inadequate assessments and prescribing practices that must be addressed to reduce this leading cause of mortality. Child's symptoms and age, malaria diagnosis and provider training were primary influences on assessment and treatment practices. Current evidence could be used to better target IMCI training and support to improve pneumonia care for sick children in Malawi facilities.
| S-EPMC5680530 | biostudies-literature
Project description:Childhood pneumonia is a major cause of childhood illness and the second leading cause of child death globally. Understanding the costs associated with the management of childhood pneumonia is essential for resource allocation and priority setting for child health.We conducted a systematic review to identify studies reporting data on the cost of management of pneumonia in children younger than 5 years old. We collected unpublished cost data on non-severe, severe and very severe pneumonia through collaboration with an international working group. We extracted data on cost per episode, duration of hospital stay and unit cost of interventions for the management of pneumonia. The mean (95% confidence interval, CI) and median (interquartile range, IQR) treatment costs were estimated and reported where appropriate.We identified 24 published studies eligible for inclusion and supplemented these with data from 10 unpublished studies. The 34 studies included in the cost analysis contained data on more than 95?000 children with pneumonia from both low- and-middle income countries (LMIC) and high-income countries (HIC) covering all 6 WHO regions. The total cost (per episode) for management of severe pneumonia was US$ 4.3 (95% CI 1.5-8.7), US$ 51.7 (95% CI 17.4-91.0) and US$ 242.7 (95% CI 153.6-341.4)-559.4 (95% CI 268.9-886.3) in community, out-patient facilities and different levels of hospital in-patient settings in LMIC. Direct medical cost for severe pneumonia in hospital inpatient settings was estimated to be 26.6%-115.8% of patients' monthly household income in LMIC. The mean direct non-medical cost and indirect cost for severe pneumonia management accounted for 0.5-31% of weekly household income. The mean length of stay (LOS) in hospital for children with severe pneumonia was 5.8 (IQR 5.3-6.4) and 7.7 (IQR 5.5-9.9) days in LMIC and HIC respectively for these children.This is the most comprehensive review to date of cost data from studies on the management of childhood pneumonia and these data should be helpful for health services planning and priority setting by national programmes and international agencies.
| S-EPMC4871066 | biostudies-literature
Project description:Program managers, investors, and evaluators need real-time information on how program strategies are being scaled up and implemented. Integrated Community Case Management (iCCM) of childhood illnesses is a strategy for increasing access to diagnosis and treatment of malaria, pneumonia, and diarrhea through community-based health workers. We collected real-time data on iCCM implementation strength through cell phone interviews with community-based health workers in Malawi and calculated indicators of implementation strength and utilization at district level using consensus definitions from the Ministry of Health (MOH) and iCCM partners. All of the iCCM implementation strength indicators varied widely within and across districts. Results show that Malawi has made substantial progress in the scale-up of iCCM since the 2008 program launch. However, there are wide differences in iCCM implementation strength by district. Districts that performed well according to the survey measures demonstrate that MOH implementation strength targets are achievable with the right combination of supportive structures. Using the survey results, specific districts can now be targeted with additional support.
| S-EPMC4596612 | biostudies-literature
Project description:Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
| S-EPMC9617073 | biostudies-literature
Project description:Pneumonia and diarrhea are leading causes of child deaths in Malawi. Guidelines to manage childhood illnesses in resource-poor settings exist, but studies have reported low health-care worker (HCW) adherence to guidelines. We conducted a health facility survey from January to March 2015 to assess HCW management of pneumonia and diarrhea in children < 5 years of age in southern Malawi, and to determine factors associated with case management quality. Descriptive statistics and multivariable logistic regression models examined patient, HCW, and health facility factors associated with recommended pneumonia and diarrhea management, using Malawi's national guidelines as the gold standard. Of 694 surveyed children 2-59 months of age at 95 health facilities, 132 (19.0%) met survey criteria for pneumonia; HCWs gave recommended antibiotic treatment to 90 (68.2%). Of 723 children < 5 years of age, 222 (30.7%) had uncomplicated diarrhea; HCWs provided recommended treatment to 94 (42.3%). In multivariable analyses, caregivers' spontaneous report of children's symptoms was associated with recommended treatment of both pneumonia (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.2-6.8, P = 0.023) and diarrhea (OR: 24.2, 95% CI: 6.0-97.0, P < 0001). Malaria diagnosis was negatively associated with recommended treatment (OR for pneumonia: 0.5, 95% CI: 0.2-1.0, P = 0.046; OR for diarrhea: 0.3, 95% CI: 0.1-0.6, P = 0.003). To improve quality of care, children should be assessed systematically, even when malaria is suspected. Renewed efforts to invigorate such a systematic approach, including HCW training, regular follow-up supervision, and monitoring HCW performance, are needed in Malawi.
| S-EPMC5417203 | biostudies-literature
Project description:BackgroundThe absolute number of pneumonia deaths in India has declined substantially since 2000. However, pneumonia remains a major cause of morbidity in children in the country. We used a risk factor-based model to estimate pneumonia and severe pneumonia morbidity in Indian states in 2000 and 2015.MethodsIn this modelling study, we estimated the burden of pneumonia and severe pneumonia in children younger than 5 years using a risk factor-based model. We did a systematic literature review to identify published data on the incidence of pneumonia from community-based longitudinal studies and calculated summary estimates. We estimated state-specific incidence rates for WHO-defined clinical pneumonia between 2000 and 2015 using Poisson regression and the prevalence of risk factors in each state was obtained from National Family Health Surveys. From clinical pneumonia studies, we identified studies reporting the proportion of clinical pneumonia cases with lower chest wall indrawing to estimate WHO-defined severe pneumonia cases. We used the estimate of the proportion of cases with lower chest wall indrawing to estimate WHO-defined severe pneumonia cases for each state.FindingsBetween 2000 and 2015, the estimated number of pneumonia cases in Indian HIV-uninfected children younger than 5 years decreased from 83·8 million cases (95% uncertainty interval [UI] 14·0-300·8) to 49·8 million cases (9·1-174·2), representing a 41% reduction in pneumonia cases. The incidence of pneumonia in children younger than 5 years in India was 657 cases per 1000 children (95% UI 110-2357) in 2000 and 403 cases per 1000 children (74-1408) in 2015. The estimated national pneumonia case fatality rate in 2015 was 0·38% (95% UI 0·11-2·10). In 2015, the estimated number of severe pneumonia cases was 8·4 million (95% UI 1·2-31·7), with an incidence of 68 cases per 1000 children (9-257) and a case fatality ratio of 2·26% (0·60-16·30). In 2015, the estimated number of pneumonia cases in HIV-uninfected children was highest in Uttar Pradesh (12·4 million [95% UI 2·1-45·0]), Bihar (7·3 million [1·3-26·1]), and Madhya Pradesh (4·6 million [0·7-17·0]). Between 2000 and 2015, the greatest reduction in pneumonia cases was observed in Kerala (82% reduction). In 2015, pneumonia incidence was greater than 500 cases per 1000 children in two states: Uttar Pradesh (565 cases per 1000 children [95% UI 94-2047]) and Madhya Pradesh (563 cases per 1000 children [88-2084]).InterpretationThe estimated number of pneumonia and severe pneumonia cases among children younger than 5 years in India decreased between 2000 and 2015. Improvements in socioeconomic indicators and specific government initiatives are likely to have contributed to declines in the prevalence of pneumonia risk factors in many states. However, pneumonia incidence in many states remains high. The introduction of new vaccines that target pneumonia pathogens and reduce risk factors will help further reduce the burden of pneumonia in the country.FundingBill & Melinda Gates Foundation.
| S-EPMC7457699 | biostudies-literature
Project description:ObjectiveTo investigate recognised co-morbidities and clinical management associated with inpatient pneumonia mortality in Malawian district hospitals.MethodsProspective cohort study, of patient records, carried out in Malawi between 1st October 2000 and 30th June 2003. The study included all children aged 0-59 months admitted to the paediatric wards in sixteen district hospitals throughout Malawi with severe and very severe pneumonia. We compared individual factors between those that survived (n = 14 076) and those that died (n = 1 633).ResultsFrom logistic regression analysis, predictors of death in hospital, adjusted for age, sex and severity grade included comorbid conditions of meningitis (OR =2.49, 95% CI 1.50-4.15), malnutrition (OR =2.37, 95% CI 1.94-2.88) and severe anaemia (OR =1.41, 95% CI 1.03-1.92). Requiring supplementary oxygen (OR =2.16, 95% CI 1.85-2.51) and intravenous fluids (OR =3.02, 95% CI 2.13-4.28) were associated with death while blood transfusion was no longer significant (OR =1.10, 95% CI 0.77-1.57) when the model included severe anaemia.ConclusionsThis study identified a number of challenges to improve outcome for Malawian infants and children hospitalised with pneumonia. These included improved assessment of co-morbidities and more rigorous application of standard case management.
| S-EPMC4523211 | biostudies-literature
Project description:BackgroundSource data verification (SDV) is a data monitoring procedure which compares the original records with the Case Report Form (CRF). Traditionally, on-site SDV relies on monitors making multiples visits to study sites requiring extensive resources. The Cooking And Pneumonia Study (CAPS) is a 24- month village-level cluster randomized controlled trial assessing the effectiveness of an advanced cook-stove intervention in preventing pneumonia in children under five in rural Malawi (www.capstudy.org). CAPS used smartphones to capture digital images of the original records on an electronic CRF (eCRF). In the present study, descriptive statistics are used to report the experience of electronic data capture with remote SDV in a challenging research setting in rural Malawi.MethodsAt three monthly intervals, fieldworkers, who were employed by CAPS, captured pneumonia data from the original records onto the eCRF. Fieldworkers also captured digital images of the original records. Once Internet connectivity was available, the data captured on the eCRF and the digital images of the original records were uploaded to a web-based SDV application. This enabled SDV to be conducted remotely from the UK. We conducted SDV of the pneumonia data (occurrence, severity, and clinical indicators) recorded in the eCRF with the data in the digital images of the original records.Result664 episodes of pneumonia were recorded after 6 months of follow-up. Of these 664 episodes, 611 (92%) had a finding of pneumonia in the original records. All digital images of the original records were clear and legible.ConclusionElectronic data capture using eCRFs on mobile technology is feasible in rural Malawi. Capturing digital images of the original records in the field allows remote SDV to be conducted efficiently and securely without requiring additional field visits. We recommend these approaches in similar settings, especially those with health endpoints.
| S-EPMC4927187 | biostudies-literature