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Gallagher KE, Awori JO, Knoll MD, Rhodes J, Higdon MM, Hammitt LL, Prosperi C, Baggett HC, Brooks WA, Fancourt N, Feikin DR, Howie SRC, Kotloff KL, Tapia MD, Levine OS, Madhi SA, Murdoch DR, O’Brien KL, Thea DM, Baillie VL, Ebruke BE, Kamau A, Moore DP, Mwananyanda L, Olutunde EO, Seidenberg P, Sow SO, Thamthitiwat S, Scott JAG. Factors predicting mortality in hospitalised HIV-negative children with lower-chest-wall indrawing pneumonia and implications for management. PLoS One 2024; 19:e0297159. [PMID: 38466696 PMCID: PMC10927117 DOI: 10.1371/journal.pone.0297159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 12/29/2023] [Indexed: 03/13/2024] Open
Abstract
INTRODUCTION In 2012, the World Health Organization revised treatment guidelines for childhood pneumonia with lower chest wall indrawing (LCWI) but no 'danger signs', to recommend home-based treatment. We analysed data from children hospitalized with LCWI pneumonia in the Pneumonia Etiology Research for Child Health (PERCH) study to identify sub-groups with high odds of mortality, who might continue to benefit from hospital management but may not be admitted by staff implementing the 2012 guidelines. We compare the proportion of deaths identified using the criteria in the 2012 guidelines, and the proportion of deaths identified using an alternative set of criteria from our model. METHODS PERCH enrolled a cohort of 2189 HIV-negative children aged 2-59 months who were admitted to hospital with LCWI pneumonia (without obvious cyanosis, inability to feed, vomiting, convulsions, lethargy or head nodding) between 2011-2014 in Kenya, Zambia, South Africa, Mali, The Gambia, Bangladesh, and Thailand. We analysed risk factors for mortality among these cases using predictive logistic regression. Malnutrition was defined as mid-upper-arm circumference <125mm or weight-for-age z-score <-2. RESULTS Among 2189 cases, 76 (3·6%) died. Mortality was associated with oxygen saturation <92% (aOR 3·33, 1·99-5·99), HIV negative but exposed status (4·59, 1·81-11·7), moderate or severe malnutrition (6·85, 3·22-14·6) and younger age (infants compared to children 12-59 months old, OR 2·03, 95%CI 1·05-3·93). At least one of three risk factors: hypoxaemia, HIV exposure, or malnutrition identified 807 children in this population, 40% of LCWI pneumonia cases and identified 86% of the children who died in hospital (65/76). Risk factors identified using the 2012 WHO treatment guidelines identified 66% of the children who died in hospital (n = 50/76). CONCLUSIONS Although it focuses on treatment failure in hospital, this study supports the proposal for better risk stratification of children with LCWI pneumonia. Those who have hypoxaemia, any malnutrition or those who were born to HIV positive mothers, experience poorer outcomes than other children with LCWI pneumonia. Consistent identification of these risk factors should be prioritised and children with at least one of these risk factors should not be managed in the community.
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Affiliation(s)
- Katherine E. Gallagher
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Juliet O. Awori
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Maria D. Knoll
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Julia Rhodes
- Global Disease Detection Center, Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Melissa M. Higdon
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Laura L. Hammitt
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Christine Prosperi
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Henry C. Baggett
- Global Disease Detection Center, Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - W. Abdullah Brooks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka and Matlab, Bangladesh
| | - Nicholas Fancourt
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Daniel R. Feikin
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Viral Diseases, National Center for Immunizations and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Stephen R. C. Howie
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Basse, The Gambia
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Karen L. Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Milagritos D. Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Orin S. Levine
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shabir A. Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - David R. Murdoch
- Department of Pathology and Biomedical Sciences, University of Otago, Christchurch, New Zealand
- Microbiology Unit, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Katherine L. O’Brien
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Donald M. Thea
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Vicky L. Baillie
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Bernard E. Ebruke
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Basse, The Gambia
| | - Alice Kamau
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - David P. Moore
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Paediatrics & Child Health, Chris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Mwananyanda
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Right to Care-Zambia, Lusaka, Zambia
| | - Emmanuel O. Olutunde
- Medical Research Council Unit The Gambia at London School of Hygiene & Tropical Medicine, Basse, The Gambia
| | - Phil Seidenberg
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Samba O. Sow
- Centre pour le Développement des Vaccins (CVD-Mali), Bamako, Mali
| | - Somsak Thamthitiwat
- Global Disease Detection Center, Thailand Ministry of Public Health–US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - J. Anthony G. Scott
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
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Alam NH, Faruque AS, Ashraf H, Chisti MJ, Ahmed T, Sultana M, Khalequzzaman M, Ali S, Ahmed S, Nasrin S, Tariqujjaman M, Haque KE, Amin R, Mollah AH, Kabir L, Shahidullah M, Khanam W, Islam K, Kim M, Vandenent M, Duke T, Gyr N, Fuchs GJ. Effectiveness, safety and economic viability of daycare versus usual hospital care management of severe pneumonia with or without malnutrition in children using the existing health system of Bangladesh: a cluster randomised controlled trial. EClinicalMedicine 2023; 60:102023. [PMID: 37304498 PMCID: PMC10250158 DOI: 10.1016/j.eclinm.2023.102023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Background We aimed to define clinical and cost-effectiveness of a Day Care Approach (DCA) alternative to Usual Care (UC, comparison group) within the Bangladesh health system to manage severe childhood pneumonia. Methods This was a cluster randomised controlled trial in urban Dhaka and rural Bangladesh between November 1, 2015 and March 23, 2019. Children aged 2-59 months with severe pneumonia with or without malnutrition received DCA or UC. The DCA treatment settings comprised of urban primary health care clinics run by NGO under Dhaka South City Corporation and in rural Union health and family welfare centres under the Ministry of Health and Family welfare Services. The UC treatment settings were hospitals in these respective areas. Primary outcome was treatment failure (persistence of pneumonia symptoms, referral or death). We performed both intention-to-treat and per-protocol analysis for treatment failure. Registered at www.ClinicalTrials.gov, NCT02669654. Findings In total 3211 children were enrolled, 1739 in DCA and 1472 in UC; primary outcome data were available in 1682 and 1357 in DCA and UC, respectively. Treatment failure rate was 9.6% among children in DCA (167 of 1739) and 13.5% in the UC (198 of 1472) (group difference, -3.9 percentage point; 95% confidence interval (CI), -4.8 to -1.5, p = 0.165). Treatment success within the health care systems [DCA plus referral vs. UC plus referral, 1587/1739 (91.3%) vs. 1283/1472 (87.2%), group difference 4.1 percentage point, 95% CI, 3.7 to 4.1, p = 0.160)] was better in DCA. One child each in UC of both urban and rural sites died within day 6 after admission. Average cost of treatment per child was US$94.2 (95% CI, 92.2 to 96.3) and US$184.8 (95% CI, 178.6 to 190.9) for DCA and UC, respectively. Interpretation In our population of children with severe pneumonia with or without malnutrition, >90% were successfully treated at Day care Clinics at 50% lower cost. A modest investment to upgrade Day care facilities may provide a cost-effective, accessible alternative to hospital management. Funding UNICEF, Botnar Foundation, UBS Optimus Foundation, and EAGLE Foundation, Switzerland.
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Affiliation(s)
- Nur H. Alam
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Abu S. Faruque
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Hasan Ashraf
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Marufa Sultana
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Shahjahan Ali
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Shahnawaz Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Sabiha Nasrin
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Md Tariqujjaman
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Ruhul Amin
- Dhaka Shishu Hospital, Dhaka, Bangladesh
| | | | - Lutful Kabir
- Sir Salimullah Medical College Hospital, Dhaka, Bangladesh
| | | | - Wahida Khanam
- Institute of Child and Mother Health, Matuail, Dhaka, Bangladesh
| | - Khaleda Islam
- Primary Health Care, Ministry of Health and Family Planning, Government of Bangladesh, Bangladesh
| | | | | | - Trevor Duke
- Melbourne Children Hospital, Melbourne, Australia
| | | | - George J. Fuchs
- College of Medicine and College of Public Health, University of Kentucky, USA
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3
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Hooli S, King C, McCollum ED, Colbourn T, Lufesi N, Mwansambo C, Gregory CJ, Thamthitiwat S, Cutland C, Madhi SA, Nunes MC, Gessner BD, Hazir T, Mathew JL, Addo-Yobo E, Chisaka N, Hassan M, Hibberd PL, Jeena P, Lozano JM, MacLeod WB, Patel A, Thea DM, Nguyen NTV, Zaman SM, Ruvinsky RO, Lucero M, Kartasasmita CB, Turner C, Asghar R, Banajeh S, Iqbal I, Maulen-Radovan I, Mino-Leon G, Saha SK, Santosham M, Singhi S, Awasthi S, Bavdekar A, Chou M, Nymadawa P, Pape JW, Paranhos-Baccala G, Picot VS, Rakoto-Andrianarivelo M, Rouzier V, Russomando G, Sylla M, Vanhems P, Wang J, Basnet S, Strand TA, Neuman MI, Arroyo LM, Echavarria M, Bhatnagar S, Wadhwa N, Lodha R, Aneja S, Gentile A, Chadha M, Hirve S, O'Grady KAF, Clara AW, Rees CA, Campbell H, Nair H, Falconer J, Williams LJ, Horne M, Qazi SA, Nisar YB. In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset. Int J Infect Dis 2023; 129:240-250. [PMID: 36805325 PMCID: PMC10017350 DOI: 10.1016/j.ijid.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. METHODS We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. RESULTS Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). CONCLUSION Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.
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Affiliation(s)
- Shubhada Hooli
- Division of Pediatric Emergency Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, United States of America
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden and Institute for Global Health, University College London, London, United Kingdom
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, United States of America and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Christopher J Gregory
- Division of Vector-Borne Diseases, US Centers for Disease Control and Prevention, Fort Collins, United States of America
| | - Somsak Thamthitiwat
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Clare Cutland
- African Leadership in Vaccinology Expertise (Alive), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir Ahmed Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Marta C Nunes
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Tabish Hazir
- The Children's Hospital, (Retired), Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Emmanuel Addo-Yobo
- Kwame Nkrumah University of Science & Technology/Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Noel Chisaka
- World Bank, Washington DC, United States of America
| | - Mumtaz Hassan
- The Children's Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Juan M Lozano
- Florida International University, Miami, United States of America
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur and Datta Meghe Institute of Medical Sciences, Sawangi, India
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Syed Ma Zaman
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Raul O Ruvinsky
- Dirección de Control de Enfermedades Inmunoprevenibles, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - Marilla Lucero
- Research Institute for Tropical Medicine, Manila, Philippines
| | - Cissy B Kartasasmita
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Rai Asghar
- Rawalpindi Medical College, Rawalpindi, Pakistan
| | | | - Imran Iqbal
- Combined Military Hospital Institute of Medical Sciences, Multan, Pakistan
| | - Irene Maulen-Radovan
- Instituto Nacional de Pediatria Division de Investigacion Insurgentes, Mexico City, Mexico
| | - Greta Mino-Leon
- Children's Hospital Dr Francisco de Ycaza Bustamante, Head of Department, Infectious diseases, Guayaquil, Ecuador
| | - Samir K Saha
- Child Health Research Foundation and Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Mathuram Santosham
- International Vaccine Access Center (IVAC), Department of International Health, Johns Hopkins University, Baltimore, United States of America
| | | | - Shally Awasthi
- King George's Medical University, Department of Pediatrics, Lucknow, India
| | | | - Monidarin Chou
- University of Health Sciences, Rodolph Mérieux Laboratory & Ministry of Environment, Phom Phen, Cambodia
| | - Pagbajabyn Nymadawa
- Mongolian Academy of Sciences, Academy of Medical Sciences, Ulaanbaatar, Mongolia
| | | | | | | | | | | | - Graciela Russomando
- Universidad Nacional de Asuncion, Departamento de Biología Molecular y Genética, Instituto de Investigaciones en Ciencias de la Salud, Asuncion, Paraguay
| | - Mariam Sylla
- Gabriel Touré Hospital, Department of Pediatrics, Bamako, Mali
| | - Philippe Vanhems
- Unité d'Hygiène, Epidémiologie, Infectiovigilance et Prévention, Hospices Civils de Lyon, Lyon, France and Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jianwei Wang
- Chinese Academy of Medical Sciences & Peking Union, Medical College Institute of Pathogen Biology, MOH Key Laboratory of Systems Biology of Pathogens and Dr Christophe Mérieux Laboratory, Beijing, China
| | - Sudha Basnet
- Center for Intervention Science in Maternal and Child Health, University of Bergen, Norway and Department of Pediatrics, Tribhuvan University Institute of Medicine, Nepal
| | - Tor A Strand
- Research Department, Innlandet Hospital Trust, Lillehammer, Norway
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, United States of America
| | | | - Marcela Echavarria
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas, Mar del Plata, Argentina
| | | | - Nitya Wadhwa
- Translational Health Science and Technology Institute, Faridabad, India
| | - Rakesh Lodha
- All India Institute of Medical Sciences, New Delhi, India
| | - Satinder Aneja
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | - Angela Gentile
- Department of Epidemiology, "R. Gutiérrez" Children's Hospital, Buenos Aires, Argentina
| | - Mandeep Chadha
- Former Scientist G, ICMR National Institute of Virology, Pune, India
| | | | - Kerry-Ann F O'Grady
- Australian Centre for Health Services Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - Alexey W Clara
- Centers for Disease Control, Central American Region, Guatemala City, Guatemala
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, United States of America
| | - Harry Campbell
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Harish Nair
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Jennifer Falconer
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Linda J Williams
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Margaret Horne
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child, and Adolescent Health (Retired), World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child, and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland.
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Ahmed S, Ariff S, Muhammed S, Rizvi A, Ahmed I, Soofi SB, Bhutta ZA. Community case management of fast-breathing pneumonia with 3 days oral amoxicillin vs 5 days cotrimoxazole in children 2-59 months of age in rural Pakistan: A cluster randomized trial. J Glob Health 2022; 12:04097. [PMID: 36579494 PMCID: PMC9798244 DOI: 10.7189/jogh.12.04097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Pneumonia is the leading cause of mortality in under-five children and most of these deaths occur in South-East Asia and Africa. Fast breathing pneumonia if not treated can progress to lower chest indrawing pneumonia. Treatment recommendation by the World Health Organization (WHO) for fast-breathing pneumonia includes oral amoxicillin and cotrimoxazole (as an alternative). Due to limited access to health care facilities and skilled health care workers, many children are unable to receive antibiotics. Algorithm-based community case management of pneumonia through trained community health workers has resulted in a decline in morbidity and mortality in low- and middle-income countries (LMIC). Methods It was a cluster-randomized, unblinded, community-based trial conducted in the Matiari district of Sindh province, Pakistan. Lady Health Workers (LHWs) were trained in assessing, classifying, and managing fast-breathing pneumonia cases (Respiratory rate of >50 breaths/min) at home with oral amoxicillin for three days and with co-trimoxazole for five days in the intervention and control arms respectively. Children with fast-breathing pneumonia were screened by LHWs and were validated by the study by Community Health Workers (CHWs) within 48 hours. They were followed by the LHWs on days 2, 4, and 14 in intervention and on days 2, 6, and 14 in the control arm. Primary treatment failure was assessed on day 4 in intervention and day 6 in the control arm. A severe pneumonia trial was registered with ClinicalTrials.gov, number NCT01192789. Results From February 2008 to March 2010, a total of 5876 children were enrolled by Lady Health Workers as fast breathing pneumonia. On validation visits of the CHWs, 728 (12%) children were excluded. A total of 4984 children were analysed as per protocol: 2480 in intervention and 2504 in control. There were 72 (2.9%) primary treatment failures in the intervention arm as compared to 102 (4%) in the control arm with a risk difference of -0.94 (-2.84%, 0.96%). Secondary treatment failures were almost equal in both arms (4 vs 7 cases). No deaths or serious adverse events were recorded. Conclusions This study shows that amoxicillin can be as effective as cotrimoxazole to treat fast-breathing pneumonia cases at the domiciliary level. Registration NCT01192789.
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Affiliation(s)
- Sheraz Ahmed
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Shabina Ariff
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Sajid Muhammed
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Arjumand Rizvi
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Imran Ahmed
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Sajid Bashir Soofi
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan,Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Sindh, Pakistan,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
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Wilkes C, Graham H, Walker P, Duke T. Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries. J Glob Health 2022; 12:10008. [PMID: 36040992 PMCID: PMC9428503 DOI: 10.7189/jogh.12.10008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background WHO pneumonia guidelines recommend that children (aged 2-59 months) with chest indrawing pneumonia and without any “general danger sign” can be treated with oral amoxicillin without hospital admission. This recommendation was based on trial data from limited contexts whose generalisability is unclear. This review aimed to identify which children with chest-indrawing pneumonia in low- and middle-income countries can be safely treated at home, and under what conditions is it safe to do so. Methods We searched MEDLINE, EMBASE, and PubMed for observational and interventional studies of home-based management of children (aged 28 days to four years) with chest-indrawing pneumonia in low- or middle-income countries. Results We included 14 studies, including seven randomised trials, from a variety of urban and rural contexts in 11 countries. Two community-based and two hospital-based trials in Pakistan and India found that home treatment of chest-indrawing pneumonia was associated with similar or superior treatment outcomes to hospital admission. Evidence from trials (n = 3) and observational (n = 6) studies in these and other countries confirms the acceptability and feasibility of home management of chest-indrawing pneumonia in low-risk cases, so long as safeguards are in place. Risk assessment includes clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia, or HIV. Pulse oximetry is a critical risk-assessment tool that is currently not widely available and can identify severely ill patients with hypoxaemia otherwise possibly missed by clinical assessment alone. Additional safeguards include caregiver understanding and ability to return for review. Conclusions Home treatment of chest-indrawing pneumonia can be safe but should only be recommended for children confirmed to be low-risk and in contexts where appropriate care and safety measures are in place.
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Mukherjee A, Jat KR, Lodha R, Goyal JP, Bhatt JI, Das RR, Ratageri V, Vyas B, Kabra SK. Feasibility of establishing acute respiratory infection treatment units (ATU) for improvement of care of children with acute respiratory infection. BMC Pediatr 2022; 22:189. [PMID: 35395777 PMCID: PMC8991474 DOI: 10.1186/s12887-022-03240-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Background Acute respiratory infections (ARI) are the leading cause of morbidity and mortality in children below 5 years of age. Methods This multisite prospective observational study was carried out in the Pediatrics’ out-patient departments of 5 medical colleges across India with an objective to assess the feasibility of establishing Acute Respiratory Infection Treatment Unit (ATU) in urban medical college hospitals. ATU (staffed with a nurse and a medical officer) was established in the out-patient areas at study sites. Children, aged 2–59 months, with cough and/ breathing difficulty for < 14 days were screened by study nurse in the ATU for pneumonia, severe pneumonia or no pneumonia. Diagnosis was verified by study doctor. Children were managed as per the World Health Organization (WHO) guidelines. The key outcomes were successful establishment of ATUs, antibiotic usage, treatment outcomes. Results ATUs were successfully established at the 5 study sites. Of 18,159 under-five children screened, 7026 (39%) children were assessed to have ARI. Using the WHO criteria, 938 were diagnosed as pneumonia (13.4%) and of these, 347 (36.9%) had severe pneumonia. Ambulatory home-based management was done in 6341 (90%) children with ARI; of these, 16 (0.25%) required admission because of non-response or deterioration on follow-up. Case-fatality rate in severe pneumonia was 2%. Nearly 12% of children with ‘no pneumonia’ received antibiotics. Conclusions Setting up of ATUs dedicated to management of ARI in children was feasible in urban medical colleges. The observed case fatality, and rate of unnecessary use of antibiotics were lower than that reported in literature.
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Affiliation(s)
- Aparna Mukherjee
- Epidemiology and Communicable Diseases Division, Indian Council of Medical Research, New Delhi, India
| | - K R Jat
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Jagdish Prasad Goyal
- Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Javeed Iqbal Bhatt
- Pediatrics, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Vinod Ratageri
- Department of Pediatrics, Karnataka Institute of Medical Sciences, Hubbali, Karnataka, India
| | - Bhadresh Vyas
- Department of Pediatrics, MP Saha Medical College, Jam Nagar, Gujrat, India
| | - S K Kabra
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
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7
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Innovative, enhanced community management of non-hypoxaemic chest-indrawing pneumonia in 2-59-month-old children: a cluster-randomised trial in Africa and Asia. BMJ Glob Health 2022; 7:bmjgh-2021-006405. [PMID: 34987033 PMCID: PMC8734014 DOI: 10.1136/bmjgh-2021-006405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/09/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction The WHO recommends oral amoxicillin for 2–59-month-old children with chest-indrawing pneumonia presenting at the health facility. Community-level health workers (CLHWs) are not allowed to treat these children when presented at the community level. This study aimed to evaluate whether CLHWs can safely and effectively treat children 2–59 months-old with chest indrawing with a 5-day course of oral amoxicillin in a few selected countries in Africa and Asia, especially when a referral is not feasible. Methods We conducted a prospective multicountry cluster-randomised, open-label, non-inferiority trial in rural areas of four countries (Bangladesh, Ethiopia, India and Malawi) from September 2016 to December 2018. Children aged 2–59 months having parents/caregivers reported cough and/or difficult breathing presenting to a CLHW were screened for enrolment. CLHWs in the intervention clusters assessed children for hypoxaemia and treated non-hypoxaemic chest-indrawing pneumonia with two times per day oral amoxicillin (50 mg/kg body weight per dose) for 5 days at the community level. CLHWs in the control clusters identified chest indrawing and referred them to a referral-level health facility for treatment. Study supervisors performed pulse oximetry in the control clusters except in Bangladesh. Children were assessed for the primary outcome (clinical treatment failure) up to day 14 after enrolment. The accuracy and impact of pulse oximetry by CLHWs in the intervention clusters were also assessed. Results In 208 clusters, 1688 CLHWs assessed 62 363 children with cough and/or difficulty breathing. Of these, 4013 non-hypoxaemic 2–59-month-old children with chest-indrawing pneumonia were enrolled. We excluded 116 children from analysis, leaving 3897 for intention-to-treat analysis. In the intervention clusters, 4.3% (90/2081) failed treatment, including five deaths, while in the control clusters, 4.4% (79/1816) failed treatment, including five deaths. The adjusted risk difference was -0.01 (95% CI −1.5% to 1.5%), which satisfied the prespecified non-inferiority criterion. CLHWs correctly performed pulse oximetry in 91.1% (2001/2196) of cases in the intervention clusters. Conclusions The community treatment of non-hypoxaemic children with chest-indrawing pneumonia with 5-day oral amoxicillin by trained, equipped and supervised CLHWs is non-inferior to currently recommended facility-based treatment. These findings encourage a review of the existing strategy of community-based management of pneumonia. Trial registration ACTRN12617000857303; The Australian New Zealand Clinical Trials Registry.
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8
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LeFevre AE, Mir F, Mitra DK, Ariff S, Mohan D, Ahmed I, Sultana S, Winch PJ, Shakoor S, Connor NE, Islam MS, El-Arifeen S, Quaiyum MA, Baqui AH, Gravett MG, Santosham M, Bhutta ZA, Zaidi A, Saha SK, Ahmed S, Soofi S, Bartlett LA. Validation of community health worker identification of maternal puerperal sepsis using a clinical diagnostic algorithm in Bangladesh and Pakistan. J Glob Health 2021; 11:04039. [PMID: 34912547 PMCID: PMC8645220 DOI: 10.7189/jogh.11.04039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Puerperal sepsis (PP sepsis) is a leading cause of maternal mortality globally. The majority of maternal sepsis cases and deaths occur at home and remain undiagnosed and under-reported. In this paper, we present findings from a nested case-control study in Bangladesh and Pakistan which sought to assess the validity of community health worker (CHW) identification of PP sepsis using a clinical diagnostic algorithm with physician assessment and classification used as the gold standard. Methods Up to 300 postpartum women were enrolled in each of the 3 sites 1) Sylhet, Bangladesh (n = 278), 2) Karachi, Pakistan (n = 278) and 3) Matiari, Pakistan (n = 300). Index cases were women with suspected PP Sepsis as diagnosed by CHWs clinical assessment of one or more of the following signs and symptoms: temperature (recorded fever ≥38.1°C, reported history of fever, lower abdominal or pelvic pain, and abnormal or foul-smelling discharge. Each case was matched with 3 control women who were diagnosed by CHWs to have no infection. Cases and controls were assessed by trained physicians using the same algorithm implemented by the CHWs. Using physician assessment as the gold standard, Kappa statistics for reliability and diagnostic validity (sensitivity and specificity) are presented with 95% CI. Sensitivity and specificity were adjusted for verification bias. Results The adjusted sensitivity and specificity of CHW identification of PP sepsis across all sites was 82% (Karachi: 78%, Matiari: 78%, Sylhet: 95%) and 90% (Karachi: 95%, Matiari: 85%, Sylhet: 90%) respectively. CHW-Physician agreement was highest for moderate and high fever (range across sites: K = 0.84-0.97) and lowest for lower abdominal pain (K = 0.30-0.34). The clinical signs and symptoms for other conditions were reported infrequently, however, the CHW-physician agreement was high for all symptoms except severe headache/ blurred vision (K = 0.13-0.38) and reported "lower abdominal pain without fever" (K = 0.39-0.57). Conclusion In all sites, CHWs with limited training were able to identify signs and symptoms and to classify cases of PP sepsis with high validity. Integrating postpartum infection screening into existing community-based platforms and post-natal visits is a promising strategy to monitor women for PP sepsis - improving delivery of cohesive maternal and child health care in low resource settings.
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Affiliation(s)
- Amnesty E LeFevre
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Fatima Mir
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Dipak K Mitra
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Public Health, North South University, Dhaka, Bangladesh
| | - Shabina Ariff
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Imran Ahmed
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Shazia Sultana
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sadia Shakoor
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Nicholas E Connor
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh.,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mohammad Shahidul Islam
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Shams El-Arifeen
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - M A Quaiyum
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Michael G Gravett
- University of Washington, Departments of Obstetrics & Gynecology and of Global Health, Seattle, Washington, USA
| | - Mathuram Santosham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Anita Zaidi
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Samir K Saha
- The Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sajid Soofi
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Linda A Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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9
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Mir F, Ali Nathwani A, Chanar S, Hussain A, Rizvi A, Ahmed I, Memon ZA, Habib A, Soofi S, Bhutta ZA. Impact of pulse oximetry on hospital referral acceptance in children under 5 with severe pneumonia in rural Pakistan (district Jamshoro): protocol for a cluster randomised trial. BMJ Open 2021; 11:e046158. [PMID: 34535473 PMCID: PMC8451312 DOI: 10.1136/bmjopen-2020-046158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pneumonia is a leading cause of death among children under 5 specifically in South Asia and sub-Saharan Africa. Hypoxaemia is a life-threatening complication among children under 5 with pneumonia. Hypoxaemia increases risk of mortality by 4.3 times in children with pneumonia than those without hypoxaemia. Prevalence of hypoxaemia varies with geography, altitude and severity (9%-39% Asia, 3%-10% African countries). In this protocol paper, we describe research methods for assessing impact of Lady Health Workers (LHWs) identifying hypoxaemia in children with signs of pneumonia during household visits on acceptance of hospital referral in district Jamshoro, Sindh. METHODS AND ANALYSIS A cluster randomised controlled trial using pulse oximetry as intervention for children with severe pneumonia will be conducted in community settings. Children aged 0-59 months with signs of severe pneumonia will be recruited by LHWs during routine visits in both intervention and control arms after consent. Severe pneumonia will be defined as fast breathing and/or chest in-drawing, and, one or more danger sign and/or hypoxaemia (Sa02 <92%) in PO (intervention) group and fast breathing and/or chest in-drawing and one or more danger sign in clinical signs (control) group. Recruits in both groups will receive a stat dose of oral amoxicillin and referral to designated tertiary health facility. Analysis of variance will be used to compare baseline referral acceptance in both groups with that at end of study. ETHICS AND DISSEMINATION Ethical approval was granted by the Ethics Review Committee of the Aga Khan University (4722-Ped-ERC-17), Karachi. Study results will be shared with relevant government and non-governmental organisations, presented at national and international research conferences and published in international peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER NCT03588377.
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Affiliation(s)
- Fatima Mir
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Apsara Ali Nathwani
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Suhail Chanar
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Amjad Hussain
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Imran Ahmed
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Zahid Ali Memon
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Atif Habib
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
| | - Sajid Soofi
- Department of Paediatrics & Child Health, Aga Khan University, Karachi, Sindh, Pakistan
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10
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Effectiveness of management of severe acute malnutrition (SAM) through community health workers as compared to a traditional facility-based model: a cluster randomized controlled trial. Eur J Nutr 2021; 60:3853-3860. [PMID: 33880645 DOI: 10.1007/s00394-021-02550-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We compared the impact of management of severe acute malnutrition (SAM) by lady health workers (LHWs) at a community level with the standard CMAM program provided at the health facility. METHODS A two-arm cluster randomised controlled trial was conducted in a rural district in sindh Pakistan. The primary outcome was recovery from SAM and secondary outcomes were relapse, defaulter and mortality rate. RESULTS A total of 829 children were recruited in the trial (430 in intervention and 399 in control groups). No significant difference was noted in recovery rate between the intervention and control groups (79.2% vs 85.6%, p = 0.276). Similarly, no significant differences were noted in relapse (p = 0.757), weight gain (p = 0.609), deaths (p = 0.775) and defaulter rate (p = 0.324) across the groups. Compliance of RUTF was significantly higher in the control group (93%) than in the intervention group (87%), p < 0.000. CONCLUSION Our results showed no impact of SAM treatment on performance indicators of CMAM (recovery, relapse, death and default) between the standard CMAM programme performed at the health facility by the government and NGO staff and the programme performed at health house level by the LHWs in Pakistan. We recommend further robust trials in other settings to confirm our results.
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11
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Counihan H, Baba E, Oresanya O, Adesoro O, Hamzat Y, Marks S, Ward C, Gimba P, Qazi SA, Källander K. One-arm safety intervention study on community case management of chest indrawing pneumonia in children in Nigeria - a study protocol. Glob Health Action 2021; 13:1775368. [PMID: 32856569 PMCID: PMC7480438 DOI: 10.1080/16549716.2020.1775368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Current recommendations within integrated community case management (iCCM) programmes advise community health workers (CHWs) to refer cases of chest indrawing pneumonia to health facilities for treatment, but many children die due to delays or non-compliance with referral advice. Recent revision of World Health Organization (WHO) pneumonia guidelines and integrated management of childhood illness chart booklet recommend oral amoxicillin for treatment of lower chest indrawing (LCI) pneumonia on an outpatient basis. However, these guidelines did not recommend its use by CHWs as part of iCCM, due to insufficient evidence regarding safety. We present a protocol for a one-arm safety intervention study aimed at increasing access to treatment of pneumonia by training CHWs, locally referred to as Community Oriented Resource Persons (CORPs) in Nigeria. The primary objective was to assess if CORPs could safely and appropriately manage LCI pneumonia in 2-59 month old children, and refer children with danger signs. The primary outcomes were the proportion of children 2-59 months with LCI pneumonia who were managed appropriately by CORPs and the clinical treatment failure within 6 days of LCI pneumonia. Secondary outcomes included proportion of children with LCI followed up by CORPs on day 3; caregiver adherence to treatment for chest indrawing, acceptability and satisfaction of both CORP and caregivers on the mode of treatment, including caregiver adherence to treatment; and clinical relapse of pneumonia between day 7 to 14 among children whose signs of pneumonia disappeared by day 6. Approximately 308 children 2-59 months of age with LCI pneumonia would be needed for this safety intervention study.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation , Geneva, Switzerland
| | - Karin Källander
- Malaria Consortium , London, UK.,Department of Public Health Sciences, Karolinska Institutet , Stockholm, Sweden
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12
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Hoang VT, Dao TL, Minodier P, Nguyen DC, Hoang NT, Dang VN, Gautret P. Risk Factors for Severe Pneumonia According to WHO 2005 Criteria Definition Among Children <5 Years of Age in Thai Binh, Vietnam: A Case-Control Study. J Epidemiol Glob Health 2020; 9:274-280. [PMID: 31854169 PMCID: PMC7310799 DOI: 10.2991/jegh.k.191009.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/07/2019] [Indexed: 11/21/2022] Open
Abstract
Vietnam is one of the 15 countries where the prevalence of child pneumonia is highest. It is a major cause of admission in pediatric hospitals. However, little is known on the burden of severe pneumonia and their risk factors in children <5 years of age in Vietnam. A case–control study was conducted among children aged 2–59 months presenting with pneumonia at the Pediatric Provincial Hospital of Thai Binh. Cases were children with severe pneumonia while controls included those with non-severe pneumonia as defined by the World Health Organization (WHO) classification of 2005. Eighty-three cases and 83 controls were included. Sex ratio was 2.19. Children with severe pneumonia were significantly less likely to receive antibiotics preadmission compared to children with non-severe pneumonia [odds ratio (OR) = 0.16, 95% confidence interval (CI) = 0.06–0.42]. The main risk factors of severe pneumonia were a lack of immunization (OR = 4.77, 95% CI = 1.80–12.65), an exposure to cigarette smoke (OR = 3.87, 95% CI = 1.62–9.23), and having a mother with a low level of education. Children with severe pneumonia were 25 times more likely to present with associated measles with p < 0.0001 and five times more likely to present with diarrhea than children with non-severe pneumonia (p < 0.0001). Improving immunization coverage, educating parents about the risks of passive smoking and the recognition of respiratory distress signs, and facilitating early antibiotic access for infants with acute pulmonary disease should reduce the burden of such illnesses. To implement a national, multicenter study about pneumonia in children, more precise inclusion criteria should be chosen, including radiological and/or biological assessment.
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Affiliation(s)
- Van Thuan Hoang
- IRD, AP-HM, SSA, VITROME, Aix-Marseille Université, Marseille, France.,IHU - Méditerranée Infection, Marseille, France.,Thai Binh University of Medicine and Pharmacy, Thai Binh, Viet Nam
| | - Thi Loi Dao
- IRD, AP-HM, SSA, VITROME, Aix-Marseille Université, Marseille, France.,IHU - Méditerranée Infection, Marseille, France.,Thai Binh University of Medicine and Pharmacy, Thai Binh, Viet Nam
| | - Philippe Minodier
- Department of Pediatric Emergency, Centre Hospitalier Universitaire Nord, Marseille, France.,Groupe de Pathologie Infectieuse Pédiatrique, Paris, France
| | - Duy Cuong Nguyen
- Thai Binh University of Medicine and Pharmacy, Thai Binh, Viet Nam
| | - Nang Trong Hoang
- Thai Binh University of Medicine and Pharmacy, Thai Binh, Viet Nam
| | - Van Nghiem Dang
- Thai Binh University of Medicine and Pharmacy, Thai Binh, Viet Nam
| | - Philippe Gautret
- IRD, AP-HM, SSA, VITROME, Aix-Marseille Université, Marseille, France.,IHU - Méditerranée Infection, Marseille, France
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13
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Qureshi RN, Sheikh S, Hoodbhoy Z, Sharma S, Vidler M, Payne BA, Ahmed I, Mark Ansermino J, Bone J, Dunsmuir DT, Lee T, Li J, Nathan HL, Shennan AH, Singer J, Tu DK, Wong H, Magee LA, von Dadelszen P, Bhutta ZA. Community-level interventions for pre-eclampsia (CLIP) in Pakistan: A cluster randomised controlled trial. Pregnancy Hypertens 2020; 22:109-118. [PMID: 32777710 PMCID: PMC7694879 DOI: 10.1016/j.preghy.2020.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/15/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022]
Abstract
Task-sharing activities to detect and manage pregnancy hypertension can be achieved by CHWs. Intervention effects may have been masked by incomplete implementation or weak in-facility care. Contact intensity analyses support the WHO eight contact antenatal care model. Condition-focused community-based interventions without facility strengthening are inadequate.
Objectives To reduce all-cause maternal and perinatal mortality and major morbidity through Lady Health Worker (LHW)-facilitated community engagement and early diagnosis, stabilization and referral of women with preeclampsia, an important contributor to adverse maternal and perinatal outcomes given delays in early detection and initial management. Study design In the Pakistan Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494), LHWs engaged the community, recruited pregnant women from 20 union councils (clusters), undertook mobile health-guided clinical assessment for preeclampsia, and referral to facilities after stabilization. Main outcome measures The primary outcome was a composite of maternal, fetal and newborn mortality and major morbidity. Findings We recruited 39,446 women in intervention (N = 20,264) and control clusters (N = 19,182) with minimal loss to follow-up (3∙7% vs. 4∙5%, respectively). The primary outcome did not differ between intervention (26·6%) and control (21·9%) clusters (adjusted odds ratio, aOR, 1∙20 [95% confidence interval 0∙84-1∙72]; p = 0∙31). There was reduction in stillbirths (0·89 [0·81-0·99]; p = 0·03), but no impact on maternal death (1·08 [0·69, 1·71]; p = 0·74) or morbidity (1·12 [0·57, 2·16]; p = 0·77); early (0·95 [0·82-1·09]; p = 0·46) or late neonatal deaths (1·23 [0·97-1·55]; p = 0·09); or neonatal morbidity (1·22 [0·77, 1·96]; p = 0·40). Improvements in outcome rates were observed with 4–7 (p = 0·015) and ≥8 (p < 0·001) (vs. 0) CLIP contacts. Interpretation The CLIP intervention was well accepted by the community and implemented by LHWs. Lack of effects on adverse outcomes could relate to quality care for mothers with pre-eclampsia in health facilities. Future strategies for community outreach must also be accompanied by health facility strengthening. Funding The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).
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Affiliation(s)
- Rahat N Qureshi
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - Sana Sheikh
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - Zahra Hoodbhoy
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Centre for International Child Health, University of British Columbia, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Beth A Payne
- Centre for International Child Health, University of British Columbia, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Imran Ahmed
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan
| | - J Mark Ansermino
- Centre for International Child Health, University of British Columbia, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Dustin T Dunsmuir
- Centre for International Child Health, University of British Columbia, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Tang Lee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Jing Li
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Palace Road, London SE1 7EH, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Palace Road, London SE1 7EH, UK
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z 1Y6, Canada
| | - Domena K Tu
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Hubert Wong
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver, BC V6Z 1Y6, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Palace Road, London SE1 7EH, UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Palace Road, London SE1 7EH, UK
| | - Zulfiqar A Bhutta
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Stadium Road, P. O. Box 3500, Karachi 74800, Pakistan; Centre for Global Child Health, Hospital for Sick Children, 525 University Avenue, Suite 702, Toronto, ON M5G 2L3, Canada.
| | -
- the CLIP Pakistan Trial Working Group (Table S1)
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14
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Memon ZA, Muhammad S, Soofi S, Khan N, Akseer N, Habib A, Bhutta Z. Effect and feasibility of district level scale up of maternal, newborn and child health interventions in Pakistan: a quasi-experimental study. BMJ Open 2020; 10:e036293. [PMID: 32665387 PMCID: PMC7365487 DOI: 10.1136/bmjopen-2019-036293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Pakistan has a high burden of maternal, newborn and child morbidity and mortality. Several factors including weak scale-up of evidence-based interventions within the existing health system; lack of community awareness regarding health conditions; and poverty contribute to poor outcomes. Deaths and morbidity are largely preventable if a combination of community and facility-based interventions are rolled out at scale. METHODS AND ANALYSIS Umeed-e-Nau (UeN) (New Hope) project aims is to improve maternal, newborn and child health (MNCH) in eight high-burden districts of Pakistan by scaling up of evidence-based interventions. The project will assess interventions focused on, first, improving the quality of MNCH care at primary level and secondary level. Second, interventions targeting demand generation such as community mobilisation, creating awareness of healthy practices and expanding coverage of outreach services will be evaluated. Third, we will also evaluate interventions targeting the improvement in quality of routine health information and promotion of use of the data for decision-making. Hypothesis of the project is that roll out of evidence-based interventions at scale will lead to at least 20% reduction in perinatal mortality and 30% decrease in diarrhoea and pneumonia case fatality in the target districts whereas two intervention groups will serve as internal controls. Monitoring and evaluation of the programme will be undertaken through conducting periodical population level surveys and quality of care assessments. Descriptive and multivariate analytical methods will be used for assessing the association between different factors, and difference in difference estimates will be used to assess the impact of the intervention on outcomes. ETHICS AND DISSEMINATION The ethics approval was obtained from the Aga Khan University Ethics Review Committee. The findings of the project will be shared with relevant stakeholders and disseminated through open access peer-reviewed journal articles. TRIAL REGISTRATION NUMBER NCT04184544; Pre-results.
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Affiliation(s)
- Zahid Ali Memon
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shah Muhammad
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Soofi
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Nimra Khan
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Atif Habib
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
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15
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Ginsburg AS, Mvalo T, Nkwopara E, McCollum ED, Phiri M, Schmicker R, Hwang J, Ndamala CB, Phiri A, Lufesi N, Izadnegahdar R, May S. Amoxicillin for 3 or 5 Days for Chest-Indrawing Pneumonia in Malawian Children. N Engl J Med 2020; 383:13-23. [PMID: 32609979 PMCID: PMC7233470 DOI: 10.1056/nejmoa1912400] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Evidence regarding the appropriate duration of treatment with antibiotic agents in children with pneumonia in low-resource settings in Africa is lacking. METHODS We conducted a double-blind, randomized, controlled, noninferiority trial in Lilongwe, Malawi, to determine whether treatment with amoxicillin for 3 days is less effective than treatment for 5 days in children with chest-indrawing pneumonia (cough lasting <14 days or difficulty breathing, along with visible indrawing of the chest wall with or without fast breathing for age). Children not infected with human immunodeficiency virus (HIV) who were 2 to 59 months of age and had chest-indrawing pneumonia were randomly assigned to receive amoxicillin twice daily for either 3 days or 5 days. Children were followed for 14 days. The primary outcome was treatment failure by day 6; noninferiority of the 3-day regimen to the 5-day regimen would be shown if the percentage of children with treatment failure in the 3-day group was no more than 1.5 times that in the 5-day group. Prespecified secondary analyses included assessment of treatment failure or relapse by day 14. RESULTS From March 29, 2016, to April 1, 2019, a total of 3000 children underwent randomization: 1497 children were assigned to the 3-day group, and 1503 to the 5-day group. Among children with day 6 data available, treatment failure had occurred in 5.9% in the 3-day group (85 of 1442 children) and in 5.2% (75 of 1456) in the 5-day group (adjusted difference, 0.7 percentage points; 95% confidence interval [CI], -0.9 to 2.4) - a result that satisfied the criterion for noninferiority of the 3-day regimen to the 5-day regimen. Among children with day 14 data available, 176 of 1411 children (12.5%) in the 3-day group and 154 of 1429 (10.8%) in the 5-day group had had treatment failure by day 6 or relapse by day 14 (between-group difference, 1.7 percentage points; 95% CI, -0.7 to 4.1). The percentage of children with serious adverse events was similar in the two groups (9.8% in the 3-day group and 8.8% in the 5-day group). CONCLUSIONS In HIV-uninfected Malawian children, treatment with amoxicillin for chest-indrawing pneumonia for 3 days was noninferior to treatment for 5 days. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT02678195.).
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Affiliation(s)
| | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical
Relief Fund Trust, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | | | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences,
Department of Pediatrics, Johns Hopkins School of Medicine and Department of International
Health, Johns Hopkins Bloomberg School of Public Health, 200 N Wolfe Street, Baltimore,
MD, 21287, USA
| | - Melda Phiri
- University of North Carolina Project, Lilongwe Medical
Relief Fund Trust, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Robert Schmicker
- Department of Biostatistics, University of Washington
Clinical Trial Center, Building 29, Suite 250, 6200 NE 74 Street, Seattle,
WA, 98115, USA
| | - Jun Hwang
- Department of Biostatistics, University of Washington
Clinical Trial Center, Building 29, Suite 250, 6200 NE 74 Street, Seattle,
WA, 98115, USA
| | - Chifundo B. Ndamala
- University of North Carolina Project, Lilongwe Medical
Relief Fund Trust, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Ajib Phiri
- Department of Pediatrics and Child Health, College of
Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre, Malawi
| | - Norman Lufesi
- Acute Respiratory Infection and Emergency Triage
Assessment and Treatment, Malawi Ministry of Health, Private Bag 65, Lilongwe,
Malawi
| | - Rasa Izadnegahdar
- Bill & Melinda Gates Foundation, 500 Fifth Avenue
N, Seattle, WA, 98109, USA
| | - Susanne May
- Department of Biostatistics, University of Washington
Clinical Trial Center, Building 29, Suite 250, 6200 NE 74 Street, Seattle,
WA, 98115, USA
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16
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Evolutionary Algorithms for Community Detection in Continental-Scale High-Voltage Transmission Grids. Symmetry (Basel) 2019. [DOI: 10.3390/sym11121472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Symmetry is a key concept in the study of power systems, not only because the admittance and Jacobian matrices used in power flow analysis are symmetrical, but because some previous studies have shown that in some real-world power grids there are complex symmetries. In order to investigate the topological characteristics of power grids, this paper proposes the use of evolutionary algorithms for community detection using modularity density measures on networks representing supergrids in order to discover densely connected structures. Two evolutionary approaches (generational genetic algorithm, GGA+, and modularity and improved genetic algorithm, MIGA) were applied. The results obtained in two large networks representing supergrids (European grid and North American grid) provide insights on both the structure of the supergrid and the topological differences between different regions. Numerical and graphical results show how these evolutionary approaches clearly outperform to the well-known Louvain modularity method. In particular, the average value of modularity obtained by GGA+ in the European grid was 0.815, while an average of 0.827 was reached in the North American grid. These results outperform those obtained by MIGA and Louvain methods (0.801 and 0.766 in the European grid and 0.813 and 0.798 in the North American grid, respectively).
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17
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Goodman D, Crocker ME, Pervaiz F, McCollum ED, Steenland K, Simkovich SM, Miele CH, Hammitt LL, Herrera P, Zar HJ, Campbell H, Lanata CF, McCracken JP, Thompson LM, Rosa G, Kirby MA, Garg S, Thangavel G, Thanasekaraan V, Balakrishnan K, King C, Clasen T, Checkley W. Challenges in the diagnosis of paediatric pneumonia in intervention field trials: recommendations from a pneumonia field trial working group. THE LANCET. RESPIRATORY MEDICINE 2019; 7:1068-1083. [PMID: 31591066 PMCID: PMC7164819 DOI: 10.1016/s2213-2600(19)30249-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/27/2019] [Accepted: 07/03/2019] [Indexed: 12/14/2022]
Abstract
Pneumonia is a leading killer of children younger than 5 years despite high vaccination coverage, improved nutrition, and widespread implementation of the Integrated Management of Childhood Illnesses algorithm. Assessing the effect of interventions on childhood pneumonia is challenging because the choice of case definition and surveillance approach can affect the identification of pneumonia substantially. In anticipation of an intervention trial aimed to reduce childhood pneumonia by lowering household air pollution, we created a working group to provide recommendations regarding study design and implementation. We suggest to, first, select a standard case definition that combines acute (≤14 days) respiratory symptoms and signs and general danger signs with ancillary tests (such as chest imaging and pulse oximetry) to improve pneumonia identification; second, to prioritise active hospital-based pneumonia surveillance over passive case finding or home-based surveillance to reduce the risk of non-differential misclassification of pneumonia and, as a result, a reduced effect size in a randomised trial; and, lastly, to consider longitudinal follow-up of children younger than 1 year, as this age group has the highest incidence of severe pneumonia.
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Affiliation(s)
- Dina Goodman
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Mary E Crocker
- Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; Division of Pediatric Pulmonology, School of Medicine, University of Washington, Seattle, WA, USA
| | - Farhan Pervaiz
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kyle Steenland
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Catherine H Miele
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Laura L Hammitt
- School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Phabiola Herrera
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA
| | - Heather J Zar
- Department of Pediatrics and Child Health, SA-MRC Unit on Child & Adolescent Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Claudio F Lanata
- Instituto de Investigación Nutricional, Lima, Peru; Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - Lisa M Thompson
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ghislaine Rosa
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Miles A Kirby
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sarada Garg
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Vijayalakshmi Thanasekaraan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Kalpana Balakrishnan
- Department of Environmental Health Engineering, ICMR Center for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Medical College & Research Institute (Deemed University), Chennai, India
| | - Carina King
- Institute for Global Health, University College London, London, UK
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - William Checkley
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, Johns Hopkins University, Baltimore, MD, USA; School of Medicine, and Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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18
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Duke T. CPAP and high-flow oxygen to address high mortality of very severe pneumonia in low-income countries - keeping it in perspective. Paediatr Int Child Health 2019; 39:155-159. [PMID: 31241014 DOI: 10.1080/20469047.2019.1613782] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Trevor Duke
- a Paediatric Intensive Care Unit , Royal Children's Hospital , Melbourne , Australia.,b Centre for International Child Health , University of Melbourne , Australia.,c School of Medicine and Health Sciences , University of Papua New Guinea , Port Moresby , Papua New Guinea
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19
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Samuel A, Osendarp SJM, Ferguson E, Borgonjen K, Alvarado BM, Neufeld LM, Adish A, Kebede A, Brouwer ID. Identifying Dietary Strategies to Improve Nutrient Adequacy among Ethiopian Infants and Young Children Using Linear Modelling. Nutrients 2019; 11:E1416. [PMID: 31238506 PMCID: PMC6627485 DOI: 10.3390/nu11061416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 11/30/2022] Open
Abstract
Nutrient adequacy of young children's diet and best possible strategies to improve nutrient adequacy were assessed. Data from the Ethiopian National Food Consumption Survey were analysed using Optifood (software for linear programming) to identify nutrient gaps in diets for children (6-8, 9-11 and 12-23 months), and to formulate feasible Food-Based Dietary Recommendations (FBDRs) in four regions which differ in culture and food practices. Alternative interventions including a local complementary food, micronutrient powders (MNPs), Small quantity Lipid-based Nutrient Supplement (Sq-LNS) and combinations of these were modelled in combination with the formulated FBDRs to compare their relative contributions. Risk of inadequate and excess nutrient intakes was simulated using the Estimated Average Requirement cut-point method and the full probability approach. Optimized local diets did not provide adequate zinc in all regions and age groups, iron for infants <12 months of age in all regions, and calcium, niacin, thiamine, folate, vitamin B12 and B6 in some regions and age-groups. The set of regional FBDRs, considerably different for four regions, increased nutrient adequacy but some nutrients remained sub-optimal. Combination of regional FBDRs with daily MNP supplementation for 6-12 months of age and every other day for 12-23 months of age, closed the identified nutrient gaps without leading to a substantial increase in the risk of excess intakes.
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Affiliation(s)
- Aregash Samuel
- Ethiopian Public Health Institute (EPHI), Gulele Sub City, Addis Ababa, Ethiopia.
- Division of Human Nutrition and Health, Wageningen University and Research, 6700 AA Wageningen, The Netherlands.
| | - Saskia J M Osendarp
- Division of Human Nutrition and Health, Wageningen University and Research, 6700 AA Wageningen, The Netherlands.
- Nutrition International (NI), Ottawa, ON K2P2K3, Canada.
| | - Elaine Ferguson
- London School of Hygiene and Tropical Medicine (LSHTM), London WC1E 7HT, UK.
| | - Karin Borgonjen
- Division of Human Nutrition and Health, Wageningen University and Research, 6700 AA Wageningen, The Netherlands.
| | - Brenda M Alvarado
- Division of Human Nutrition and Health, Wageningen University and Research, 6700 AA Wageningen, The Netherlands.
| | - Lynnette M Neufeld
- Global Alliance for Improved Nutrition (GAIN), 1202 Geneva, Switzerland.
| | - Abdulaziz Adish
- Nutrition International (NI), Nifas Silk Lafto Sub City, Kebele 04, Addis Ababa, Ethiopia.
| | - Amha Kebede
- Ethiopian Public Health Institute (EPHI), Gulele Sub City, Addis Ababa, Ethiopia.
| | - Inge D Brouwer
- Division of Human Nutrition and Health, Wageningen University and Research, 6700 AA Wageningen, The Netherlands.
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20
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Morre R, Sobi K, Pameh W, Ripa P, Vince JD, Duke T. Safety, Effectiveness and Feasibility of Outpatient Management of Children with Pneumonia with Chest Indrawing at Port Moresby General Hospital, Papua New Guinea. J Trop Pediatr 2019; 65:71-77. [PMID: 29660106 PMCID: PMC6366396 DOI: 10.1093/tropej/fmy013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Implementing the World Health Organization (WHO) recommendations on home-based management of pneumonia with chest indrawing is challenging in many settings. In Papua New Guinea, 120 children presenting with the WHO definition of pneumonia were screened for danger signs, comorbidities and hypoxaemia using pulse oximetry; 117 were appropriate for home care. We taught mothers about danger signs and when to return, using structured teaching materials and a video. The children were given a single dose of intramuscular benzylpenicillin, then sent home on oral amoxicillin for 5 days, with follow-up at Days 2 and 6. During the course of treatment, five (4%) of the 117 children were admitted and 15 (13%) were lost to follow-up. There were no deaths. Treating children with pneumonia with chest indrawing but no danger signs is feasible as long as safeguards are in place-excluding high-risk patients, checking for danger signs and hypoxemia and providing education for mothers and follow-up.
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Affiliation(s)
- Rose Morre
- Department of Paediatrics, Port Moresby General Hospital, Port Moresby, NCD, Papua New Guinea.,Mt Hagen General Hospital, Mt Hagen, WHP, Papua New Guinea
| | - Kone Sobi
- Department of Paediatrics, Port Moresby General Hospital, Port Moresby, NCD, Papua New Guinea
| | - Wendy Pameh
- Child Health Discipline, School of Medicine and Health Sciences, University of PNG, Taurama Campus, Port Moresby, NCD, Papua New Guinea
| | - Paulus Ripa
- Mt Hagen General Hospital, Mt Hagen, WHP, Papua New Guinea
| | - John D Vince
- Child Health Discipline, School of Medicine and Health Sciences, University of PNG, Taurama Campus, Port Moresby, NCD, Papua New Guinea
| | - Trevor Duke
- Child Health Discipline, School of Medicine and Health Sciences, University of PNG, Taurama Campus, Port Moresby, NCD, Papua New Guinea.,Centre for International Child Health, University of Melbourne, MCRI, Parkville, Victoria, Australia
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21
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Correa M, Zimic M, Barrientos F, Barrientos R, Román-Gonzalez A, Pajuelo MJ, Anticona C, Mayta H, Alva A, Solis-Vasquez L, Figueroa DA, Chavez MA, Lavarello R, Castañeda B, Paz-Soldán VA, Checkley W, Gilman RH, Oberhelman R. Automatic classification of pediatric pneumonia based on lung ultrasound pattern recognition. PLoS One 2018; 13:e0206410. [PMID: 30517102 PMCID: PMC6281243 DOI: 10.1371/journal.pone.0206410] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/12/2018] [Indexed: 11/19/2022] Open
Abstract
Pneumonia is one of the major causes of child mortality, yet with a timely diagnosis, it is usually curable with antibiotic therapy. In many developing regions, diagnosing pneumonia remains a challenge, due to shortages of medical resources. Lung ultrasound has proved to be a useful tool to detect lung consolidation as evidence of pneumonia. However, diagnosis of pneumonia by ultrasound has limitations: it is operator-dependent, and it needs to be carried out and interpreted by trained personnel. Pattern recognition and image analysis is a potential tool to enable automatic diagnosis of pneumonia consolidation without requiring an expert analyst. This paper presents a method for automatic classification of pneumonia using ultrasound imaging of the lungs and pattern recognition. The approach presented here is based on the analysis of brightness distribution patterns present in rectangular segments (here called “characteristic vectors“) from the ultrasound digital images. In a first step we identified and eliminated the skin and subcutaneous tissue (fat and muscle) in lung ultrasound frames, and the “characteristic vectors”were analyzed using standard neural networks using artificial intelligence methods. We analyzed 60 lung ultrasound frames corresponding to 21 children under age 5 years (15 children with confirmed pneumonia by clinical examination and X-rays, and 6 children with no pulmonary disease) from a hospital based population in Lima, Peru. Lung ultrasound images were obtained using an Ultrasonix ultrasound device. A total of 1450 positive (pneumonia) and 1605 negative (normal lung) vectors were analyzed with standard neural networks, and used to create an algorithm to differentiate lung infiltrates from healthy lung. A neural network was trained using the algorithm and it was able to correctly identify pneumonia infiltrates, with 90.9% sensitivity and 100% specificity. This approach may be used to develop operator-independent computer algorithms for pneumonia diagnosis using ultrasound in young children.
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Affiliation(s)
- Malena Correa
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
- * E-mail:
| | - Mirko Zimic
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Franklin Barrientos
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ronald Barrientos
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Avid Román-Gonzalez
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
- Research and Development Laboratory, Science and Philosophy Faculty, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Mónica J. Pajuelo
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Cynthia Anticona
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Holger Mayta
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- Infectious Diseases Research Laboratory, Department of Cellular and Molecular Sciences, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Alicia Alva
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Leonardo Solis-Vasquez
- Bioinformatics and Molecular Biology Laboratory, Department of Cellular and Molecular Sciences, Faculty of Science, Universidad Peruana Cayetano Heredia, Lima, Peru
- Research and Development Laboratory, Science and Philosophy Faculty, Universidad Peruana Cayetano Heredia, Lima, Perú
| | | | - Miguel A. Chavez
- Biomedical Research Unit, Asociación Benéfica Prisma, Lima, Peru
| | - Roberto Lavarello
- Laboratorio de Imágenes Médicas, Sección Electricidad y Electrónica, Departamento de Ingeniería Pontificia Universidad Católica del Perú, San Miguel, Lima, Perú
| | - Benjamín Castañeda
- Laboratorio de Imágenes Médicas, Sección Electricidad y Electrónica, Departamento de Ingeniería Pontificia Universidad Católica del Perú, San Miguel, Lima, Perú
| | - Valerie A. Paz-Soldán
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
| | - William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Maryland, United States of America
- Program in Global Disease Epidemiology and Control, Bloombeg School of Public Health, Johns Hopkins University, Maryland, United States of America
| | - Robert H. Gilman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Richard Oberhelman
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
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22
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Onono M, Abdi M, Mutai K, Asadhi E, Nyamai R, Okoth P, Qazi SA. Community case management of lower chest indrawing pneumonia with oral amoxicillin in children in Kenya. Acta Paediatr 2018; 107 Suppl 471:44-52. [PMID: 30570795 DOI: 10.1111/apa.14405] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/30/2018] [Accepted: 05/14/2018] [Indexed: 11/30/2022]
Abstract
AIM To determine the accuracy and effectiveness of community health workers (CHWs) when compared to trained nurses for management of pneumonia in Kenyan children. METHODS In Homabay County in western Kenya, children 2-59 months of age with lower chest indrawing pneumonia were identified, classified and treated by CHWs with oral amoxicillin (90 mg/kg per day) for five days at home. Trained nurses visited the child within 24 hours to verify diagnosis; and on day 4 and 14 to assess treatment outcomes. RESULTS CHWs identified 1906 children with lower chest indrawing pneumonia. There was an 88.7% concordance in classification and treatment for lower chest indrawing pneumonia by CHWs compared to nurses. Children with moderate malnutrition (OR 1.68; 95% CI: 1.22-2.30), comorbidities such as diarrhoea or malaria (OR 1.55; 95% CI: 1.32-1.81) or an additional day of delay in care seeking (OR 1.06; 95% CI: 1.02-1.10) were more likely to have an incorrect classification of lower chest indrawing by the CHW. Comorbidity (OR 1.66; 95% CI: 1.12-2.48) and fast breathing (OR 4.66; 95% CI: 1.26-17.27) were significantly associated with treatment failure on day 14. CONCLUSION CHWs can correctly manage lower chest indrawing pneumonia even in high-mortality settings, such as western Kenya, in sub-Saharan Africa.
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Affiliation(s)
| | | | | | | | - Rachel Nyamai
- Maternal, Newborn, Child and Adolescent Health Unit; Ministry of Health Kenya; Nairobi Kenya
| | | | - Shamim Ahmad Qazi
- Department of Maternal, Newborn, Child and Adolescent Health; World Health Organization; Geneva Switzerland
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Oral Ondansetron Administration to Nondehydrated Children With Diarrhea and Associated Vomiting in Emergency Departments in Pakistan: A Randomized Controlled Trial. Ann Emerg Med 2018; 73:255-265. [PMID: 30392735 PMCID: PMC6390170 DOI: 10.1016/j.annemergmed.2018.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/04/2018] [Accepted: 09/10/2018] [Indexed: 12/20/2022]
Abstract
Study objective We determine whether single-dose oral ondansetron administration to children with vomiting as a result of acute gastroenteritis without dehydration reduces administration of intravenous fluid rehydration. Methods In this 2-hospital, double-blind, placebo-controlled, emergency department–based, randomized trial conducted in Karachi Pakistan, we recruited children aged 0.5 to 5.0 years, without dehydration, who had diarrhea and greater than or equal to 1 episode of vomiting within 4 hours of arrival. Patients were randomly assigned (1:1), through an Internet-based randomization service using a stratified variable-block randomization scheme, to single-dose oral ondansetron or placebo. The primary endpoint was intravenous rehydration (administration of ≥20 mL/kg of an isotonic fluid during 4 hours) within 72 hours of randomization. Results Participant median age was 15 months (interquartile range 10 to 26) and 59.4% (372/626) were male patients. Intravenous rehydration use was 12.1% (38/314) and 11.9% (37/312) in the placebo and ondansetron groups, respectively (odds ratio 0.98; 95% confidence interval [CI] 0.60 to 1.61; difference 0.2%; 95% CI of the difference –4.9% to 5.4%). Bolus fluid administration occurred within 72 hours of randomization in 10.8% (34/314) and 10.3% (27/312) of children administered placebo and ondansetron, respectively (odds ratio 0.95; 95% CI 0.56 to 1.59). A multivariable regression model fitted with treatment group and adjusted for antiemetic administration, antibiotics, zinc prerandomization, and vomiting frequency prerandomization yielded similar results (odds ratio 0.91; 95% CI 0.55 to 1.53). There was no interaction between treatment group and age, greater than or equal to 3 stools in the preceding 24 hours, or greater than or equal to 3 vomiting episodes in the preceding 24 hours. Conclusion Oral administration of a single dose of ondansetron did not result in a reduction in intravenous rehydration use. In children without dehydration, ondansetron does not improve clinical outcomes.
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24
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Pérez MC, Minoyan N, Ridde V, Sylvestre MP, Johri M. Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review. Trials 2018; 19:410. [PMID: 30064484 PMCID: PMC6069979 DOI: 10.1186/s13063-018-2796-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 07/09/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cluster randomised trials (CRTs) are a key instrument to evaluate public health interventions. Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned. Evaluation of implementation fidelity (IF) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions conducted in low- and middle-income countries (LMICs). However, current CRT reporting guidelines offer no guidance on IF assessment. The objective of this review was to study current practices concerning the assessment of IF in CRTs of public health interventions in LMICs. METHODS CRTs of public health interventions in LMICs that planned or reported IF assessment in either the trial protocol or the main trial report were included. The MEDLINE/PubMed, CINAHL and EMBASE databases were queried from January 2012 to May 2016. To ensure availability of a study protocol, CRTs reporting a registration number in the abstract were included. Relevant data were extracted from each study protocol and trial report by two researchers using a predefined screening sheet. Risk of bias for individual studies was assessed. RESULTS We identified 90 CRTs of public health interventions in LMICs with a study protocol in a publicly available trial registry published from January 2012 to May 2016. Among these 90 studies, 25 (28%) did not plan or report assessing IF; the remaining 65 studies (72%) addressed at least one IF dimension. IF assessment was planned in 40% (36/90) of trial protocols and reported in 71.1% (64/90) of trial reports. The proportion of overall agreement between the trial protocol and trial report concerning occurrence of IF assessment was 66.7% (60/90). Most studies had low to moderate risk of bias. CONCLUSIONS IF assessment is not currently a systematic practice in CRTs of public health interventions carried out in LMICs. In the absence of IF assessment, it may be difficult to determine if CRT results are due to the intervention design, to its implementation, or to unknown or external factors that may influence results. CRT reporting guidelines should promote IF assessment. TRIAL REGISTRATION Protocol published and available at: https://doi.org/10.1186/s13643-016-0351-0.
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Affiliation(s)
- Myriam Cielo Pérez
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis, Pavillon R, Tour Saint-Antoine Porte S03.414, Montréal, Québec, H2X 0A9, Canada.,Département de médicine sociale et préventive, École de santé publique (ESPUM), Université de Montréal, 7101, avenue du Parc, 3e étage, Montréal, Québec, H3N 1X9, Canada
| | - Nanor Minoyan
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis, Pavillon R, Tour Saint-Antoine Porte S03.414, Montréal, Québec, H2X 0A9, Canada.,Département de médicine sociale et préventive, École de santé publique (ESPUM), Université de Montréal, 7101, avenue du Parc, 3e étage, Montréal, Québec, H3N 1X9, Canada
| | - Valéry Ridde
- Institut de Recherche en Santé Publique Université de Montréal (IRSPUM), Pavillon 7101 Avenue du Parc, P.O. Box 6128, Centre-ville Station, Montréal, Québec, H3C 3J7, Canada.,Institut de Recherche Pour le Développement (IRD), Le Sextant 44, bd de Dunkerque, CS 90009 13572, Cedex 02, Marseille, France
| | - Marie-Pierre Sylvestre
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis, Pavillon R, Tour Saint-Antoine Porte S03.414, Montréal, Québec, H2X 0A9, Canada.,Département de médicine sociale et préventive, École de santé publique (ESPUM), Université de Montréal, 7101, avenue du Parc, 3e étage, Montréal, Québec, H3N 1X9, Canada
| | - Mira Johri
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), 900, rue Saint-Denis, Pavillon R, Tour Saint-Antoine Porte S03.414, Montréal, Québec, H2X 0A9, Canada. .,Département de gestion, d'évaluation, et de politique de santé, École de santé publique, Université de Montréal, 7101, avenue du Parc, 3e étage, Montréal, Québec, H3N 1X9, Canada.
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Tramper-Stranders GA. Childhood community-acquired pneumonia: A review of etiology- and antimicrobial treatment studies. Paediatr Respir Rev 2018; 26:41-48. [PMID: 28844414 PMCID: PMC7106165 DOI: 10.1016/j.prrv.2017.06.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 06/16/2017] [Accepted: 06/21/2017] [Indexed: 11/15/2022]
Abstract
Community acquired pneumonia (CAP) is a leading cause of childhood morbidity worldwide. Because of the rising antimicrobial resistance rates and adverse effects of childhood antibiotic use on the developing microbiome, rational prescribing of antibiotics for CAP is important. This review summarizes and critically reflects on the available evidence for the epidemiology, etiology and antimicrobial management of childhood CAP. Larger prospective studies on antimicrobial management derive mostly from low- or middle-income countries as they have the highest burden of CAP. Optimal antimicrobial management depends on the etiology, age, local vaccination policies and resistance patterns. As long as non-rapid surrogate markers are used to distinguish viral- from bacterial pneumonia, the management is probably suboptimal. For a young child with signs of non-severe pneumonia (with or without wheezing), watchful waiting is recommended because of probable viral etiology. For children with more severe CAP with fever, a five-day oral amoxicillin course would be the first choice therapy and dosage will depend on local resistance rates. There is no clear evidence yet for superiority of a macrolide-based regimen for all ages. For cases with CAP requiring hospitalization, several studies have shown that narrow-spectrum IV beta-lactam therapy is as effective as a broad-spectrum cephalosporin therapy. For most severe disease, broad-spectrum therapy with or without a macrolide is suggested. In case of empyema, rapid IV-to-oral switch seems to be equivalent to prolonged IV treatment.
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Affiliation(s)
- Gerdien A Tramper-Stranders
- Department of Pediatrics, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands; Department of Neonatology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
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26
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Soofi S, Cousens S, Turab A, Wasan Y, Mohammed S, Ariff S, Bhatti Z, Ahmed I, Wall S, Bhutta ZA. Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural Pakistan. LANCET GLOBAL HEALTH 2018; 5:e796-e806. [PMID: 28716351 PMCID: PMC5762815 DOI: 10.1016/s2214-109x(17)30248-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 06/01/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although the effectiveness of community mobilisation and promotive care delivered by community health workers in reducing perinatal and neonatal mortality is well established, evidence in support of home-based neonatal resuscitation and infection management is mixed. We assessed the effectiveness of adding training in neonatal bag and mask resuscitation and oral antibiotic therapy for suspected neonatal infections to a basic preventive and promotive interventions package delivered by public sector community-based lady health workers (LHWs) in rural Pakistan. METHODS We did a cluster-randomised controlled trial in two subdistricts of Naushahro Feroze in rural Sindh, Pakistan, between April 15, 2009, and Dec 10, 2012. LHWs, trained in basic newborn resuscitation and in recognition and treatment (with oral amoxicillin) of suspected neonatal respiratory infections, were linked with traditional birth attendants and encouraged to attend home births. Control clusters received routine care through the existing national programme. The primary outcome was all-cause neonatal mortality. Independent data collection teams recorded data for all pregnancies and their outcomes, morbidity, mortality, and household practices related to maternal and newborn care. FINDINGS Of the 27 randomised clusters with functional LHW programmes, 13 were allocated to the intervention group (n=242 749) and 14 to the control group (n=256 985). In the intervention group, LHWs did 80% of the planned community mobilisation sessions, but were able to attend only 1184 (14%) of 8425 deliveries and 4318 (25%) of 17 288 neonatal visits within 72 h of birth (p<0·0001 for both variables compared with the control group). The neonatal mortality rate was 42 deaths per 1000 livebirths in intervention clusters compared with 55 per 1000 in the control group (risk ratio 0·80, 95% CI 0·68-0·93; p=0·005). INTERPRETATION The reduction in neonatal mortality in intervention clusters occurred against a background of improvements in domiciliary practices for maternal and newborn care. However, the poor reach of LHWs in accessing newborn infants at birth and in the early postnatal period underscores the limitations of tasking community health workers in public sector programmes working in similar circumstances with such complex interventions. Such community-based interventions in health systems should be accompanied by concerted efforts to improve quality of care in facilities and referral systems. FUNDING Saving Newborn Lives, Save the Children USA.
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Affiliation(s)
- Sajid Soofi
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Simon Cousens
- London School of Hygiene & Tropical Medicine, London, UK
| | - Ali Turab
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Yaqub Wasan
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shah Mohammed
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shabina Ariff
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zaid Bhatti
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Imran Ahmed
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Steve Wall
- Saving Newborn Lives Program, Save the Children, Washington, DC, USA
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.
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Improving Access to Child Health Care in Indonesia Through Community Case Management. Matern Child Health J 2017; 20:2254-2260. [PMID: 27449650 DOI: 10.1007/s10995-016-2149-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objectives In order to reduce infant mortality in Indonesia, community case management (CCM) was introduced. CCM is a community-based service delivery model to improve children's wellness and longevity, involving the delivery of lifesaving, curative interventions to address common childhood illnesses, particularly where there are limited facility-based services. This paper reports the findings of a qualitative study that investigated the implementation of CCM in the Kutai Timur district, East Kalimantan Indonesia from the perspective of mothers who received care. Methods Seven mothers and health workers were observed during a consultation and these mothers were interviewed in their home weeks after delivery. Field notes and the interview transcriptions were analysed thematically. Findings Mothers reported that their access to care had improved, along with an increase in their knowledge of infant danger signs and when to seek care. Family compliance with care plans was also found to have improved. Mothers expressed satisfaction with the care provided under the CCM model. The mothers expressed a need for a nurse or midwife to be posted in each village, preferably someone from that village. However two mothers did not wish their children to receive health interventions as they did not believe these to be culturally appropriate. Conclusion CCM is seen by rural Indonesian mothers to be a helpful model of care in terms of increasing access to health care and the uptake of lifesaving interventions for sick children. However there is a need to modify the program to demonstrate cultural sensitivity and meet cultural needs of the target population. While CCM is a potentially effective model of care, further integrative strategies are required to embed this model into maternal and child health service delivery.
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28
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Altaras R, Montague M, Graham K, Strachan CE, Senyonjo L, King R, Counihan H, Mubiru D, Källander K, Meek S, Tibenderana J. Integrated community case management in a peri-urban setting: a qualitative evaluation in Wakiso District, Uganda. BMC Health Serv Res 2017; 17:785. [PMID: 29183312 PMCID: PMC5706411 DOI: 10.1186/s12913-017-2723-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/10/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas, but there is little evidence to support iCCM as an appropriate strategy in non-rural contexts. This study aimed to inform future iCCM implementation by exploring caregiver and VHT member perceptions of the value and effectiveness of iCCM in peri-urban settings in Uganda. METHODS A qualitative evaluation was conducted in seven villages in Wakiso district, a rapidly urbanising area in central Uganda. Villages were purposively selected, spanning a range of peri-urban settlements experiencing rapid population change. In each village, rapid appraisal activities were undertaken separately with purposively selected caregivers (n = 85) and all iCCM-trained VHT members (n = 14), providing platforms for group discussions. Fifteen key informant interviews were also conducted with community leaders and VHT members. Thematic analysis was based on the 'Health Access Livelihoods Framework'. RESULTS iCCM was perceived to facilitate timely treatment access and improve child health in peri-urban settings, often supplanting private clinics and traditional healers as first point of care. Relative to other health service providers, caregivers valued VHTs' free, proximal services, caring attitudes, perceived treatment quality, perceived competency and protocol use, and follow-up and referral services. VHT effectiveness was perceived to be restricted by inadequate diagnostics, limited newborn care, drug stockouts and VHT member absence - factors which drove utilisation of alternative providers. Low community engagement in VHT selection, lack of referral transport and poor availability of referral services also diminished perceived effectiveness. The iCCM strategy was widely perceived to result in economic savings and other livelihood benefits. CONCLUSIONS In peri-urban areas, iCCM was perceived as an effective, well-utilised strategy, reflecting both VHT attributes and gaps in existing health services. Depending on health system resources and organisation, iCCM may be a useful transitional service delivery approach. Implementation in peri-urban areas should consider tailored community engagement strategies, adapted selection criteria, and assessment of population density to ensure sufficient coverage.
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Affiliation(s)
- Robin Altaras
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Mark Montague
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Kirstie Graham
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK
| | - Clare E Strachan
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda.,London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Laura Senyonjo
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Rebecca King
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Helen Counihan
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK.
| | - Denis Mubiru
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Karin Källander
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK.,Karolinska Institutet, Tomtebodavägen 18A, 17177, Stockholm, Sweden
| | - Sylvia Meek
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK
| | - James Tibenderana
- Malaria Consortium Africa, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
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Mathew JL. Does Routine Antibiotic Therapy Benefit Children With Severe Acute Malnutrition?: Evidence-based Medicine Viewpoint. Indian Pediatr 2017; 53:329-32. [PMID: 27156547 DOI: 10.1007/s13312-016-0846-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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30
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Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: a systematic analysis for the Global Burden of Disease Study 2015. THE LANCET. INFECTIOUS DISEASES 2017; 17:1133-1161. [PMID: 28843578 PMCID: PMC5666185 DOI: 10.1016/s1473-3099(17)30396-1] [Citation(s) in RCA: 472] [Impact Index Per Article: 67.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 06/14/2017] [Accepted: 06/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2015 provides an up-to-date analysis of the burden of lower respiratory tract infections (LRIs) in 195 countries. This study assesses cases, deaths, and aetiologies spanning the past 25 years and shows how the burden of LRI has changed in people of all ages. METHODS We estimated LRI mortality by age, sex, geography, and year using a modelling platform shared across most causes of death in the GBD 2015 study called the Cause of Death Ensemble model. We modelled LRI morbidity, including incidence and prevalence, using a meta-regression platform called DisMod-MR. We estimated aetiologies for LRI using two different counterfactual approaches, the first for viral pathogens, which incorporates the aetiology-specific risk of LRI and the prevalence of the aetiology in LRI episodes, and the second for bacterial pathogens, which uses a vaccine-probe approach. We used the Socio-demographic Index, which is a summary indicator derived from measures of income per capita, educational attainment, and fertility, to assess trends in LRI-related mortality. The two leading risk factors for LRI disability-adjusted life-years (DALYs), childhood undernutrition and air pollution, were used in a decomposition analysis to establish the relative contribution of changes in LRI DALYs. FINDINGS In 2015, we estimated that LRIs caused 2·74 million deaths (95% uncertainty interval [UI] 2·50 million to 2·86 million) and 103·0 million DALYs (95% UI 96·1 million to 109·1 million). LRIs have a disproportionate effect on children younger than 5 years, responsible for 704 000 deaths (95% UI 651 000-763 000) and 60.6 million DALYs (95ÙI 56·0-65·6). Between 2005 and 2015, the number of deaths due to LRI decreased by 36·9% (95% UI 31·6 to 42·0) in children younger than 5 years, and by 3·2% (95% UI -0·4 to 6·9) in all ages. Pneumococcal pneumonia caused 55·4% of LRI deaths in all ages, totalling 1 517 388 deaths (95% UI 857 940-2 183 791). Between 2005 and 2015, improvements in air pollution exposure were responsible for a 4·3% reduction in LRI DALYs and improvements in childhood undernutrition were responsible for an 8·9% reduction. INTERPRETATION LRIs are the leading infectious cause of death and the fifth-leading cause of death overall; they are the second-leading cause of DALYs. At the global level, the burden of LRIs has decreased dramatically in the last 10 years in children younger than 5 years, although the burden in people older than 70 years has increased in many regions. LRI remains a largely preventable disease and cause of death, and continued efforts to decrease indoor and ambient air pollution, improve childhood nutrition, and scale up the use of the pneumococcal conjugate vaccine in children and adults will be essential in reducing the global burden of LRI. FUNDING Bill & Melinda Gates Foundation.
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Lunze K, Biemba G, Lawrence JJ, MacLeod WB, Yeboah-Antwi K, Musokotwane K, Ajayi T, Mutembo S, Puta C, Earle D, Steketee R, Hamer DH. Clinical management of children with fever: a cross-sectional study of quality of care in rural Zambia. Bull World Health Organ 2017; 95:333-342. [PMID: 28479634 PMCID: PMC5418822 DOI: 10.2471/blt.16.170092] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate current practices and standards of evaluation and treatment of childhood febrile illness in Southern Province, Zambia. METHODS From November to December 2013, we conducted a cross-sectional survey of facilities and health workers and we observed the health workers' interactions with febrile children and their caregivers. The facility survey recorded level of staffing, health services provided by the facility, availability and adequacy of medical equipment, availability of basic drugs and supplies and availability of treatment charts and guidelines. The health worker survey assessed respondents' training, length of service, access to national guidelines and job aids for managing illnesses, and their practice and knowledge on management of neonatal and child illnesses. We also conducted exit interviews with caregivers to collect information on demographic characteristics, chief complaints, counselling and drug dispensing practices. FINDINGS This study included 24 health facilities, 53 health workers and 161 children presenting with fever. Facilities were insufficiently staffed, stocked and equipped to adequately manage childhood fever. Children most commonly presented with upper respiratory tract infections (46%; 69), diarrhoea (31%; 27) and malaria (10%; 16). Health workers insufficiently evaluated children for danger signs, and less than half (47%; 9/19) of children with pneumonia received appropriate antibiotic treatment. Only 57% (92/161) were tested for malaria using either rapid diagnostic tests or microscopy. CONCLUSION Various health system challenges resulted in a substantial proportion of children receiving insufficient management and treatment of febrile illness. Interventions are needed including strengthening the availability of commodities and improving diagnosis and treatment of febrile illness.
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Affiliation(s)
- Karsten Lunze
- Department of Medicine, Boston University Medical School, 801 Massachusetts Ave, Boston MA 02119, United States of America (USA)
| | - Godfrey Biemba
- Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
| | - J Joseph Lawrence
- Global Health Corps Fellowship, Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
| | - William B MacLeod
- Center for Global Health and Development, Boston University School of Public Health, Boston, USA
| | - Kojo Yeboah-Antwi
- Center for Global Health and Development, Boston University School of Public Health, Boston, USA
| | | | | | - Simon Mutembo
- Southern Provincial Medical Office, Ministry of Health, Choma, Zambia
| | | | | | - Rick Steketee
- Malaria Control and Elimination Partnership in Africa Program, PATH, Seattle, USA
| | - Davidson H Hamer
- Center for Global Health and Development, Boston University School of Public Health, Boston, USA
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Poddar B. Vitamin D in Critical Illness: Not a Panacea for All Ills! Indian Pediatr 2017; 53:475-6. [PMID: 27376599 DOI: 10.1007/s13312-016-0875-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India.
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Nguyen TKP, Tran TH, Roberts CL, Graham SM, Marais BJ. Child pneumonia - focus on the Western Pacific Region. Paediatr Respir Rev 2017; 21:102-110. [PMID: 27569107 PMCID: PMC7106312 DOI: 10.1016/j.prrv.2016.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/12/2016] [Indexed: 01/09/2023]
Abstract
Worldwide, pneumonia is the leading cause of death in infants and young children (aged <5 years). We provide an overview of the global pneumonia disease burden, as well as the aetiology and management practices in different parts of the world, with a specific focus on the WHO Western Pacific Region. In 2011, the Western Pacific region had an estimated 0.11 pneumonia episodes per child-year with 61,900 pneumonia-related deaths in children less than 5 years of age. The majority (>75%) of pneumonia deaths occurred in six countries; Cambodia, China, Laos, Papua New Guinea, the Philippines and Viet Nam. Historically Streptococcus pneumoniae and Haemophilus influenzae were the commonest causes of severe pneumonia and pneumonia-related deaths in young children, but this is changing with the introduction of highly effective conjugate vaccines and socio-economic development. The relative contribution of viruses and atypical bacteria appear to be increasing and traditional case management approaches may require revision to accommodate increased uptake of conjugated vaccines in the Western Pacific region. Careful consideration should be given to risk reduction strategies, enhanced vaccination coverage, improved management of hypoxaemia and antibiotic stewardship.
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MESH Headings
- Anti-Bacterial Agents/therapeutic use
- Asia, Southeastern/epidemiology
- Child
- Child, Preschool
- Asia, Eastern/epidemiology
- Global Health
- Haemophilus Infections/drug therapy
- Haemophilus Infections/epidemiology
- Haemophilus Infections/mortality
- Haemophilus Infections/prevention & control
- Haemophilus Vaccines/therapeutic use
- Haemophilus influenzae
- Humans
- Hypoxia/therapy
- Infant
- Influenza Vaccines/therapeutic use
- Influenza, Human/epidemiology
- Influenza, Human/mortality
- Influenza, Human/prevention & control
- Influenza, Human/therapy
- Pneumococcal Vaccines/therapeutic use
- Pneumonia/drug therapy
- Pneumonia/epidemiology
- Pneumonia/mortality
- Pneumonia/prevention & control
- Pneumonia, Mycoplasma/drug therapy
- Pneumonia, Mycoplasma/epidemiology
- Pneumonia, Mycoplasma/mortality
- Pneumonia, Pneumococcal/drug therapy
- Pneumonia, Pneumococcal/epidemiology
- Pneumonia, Pneumococcal/mortality
- Pneumonia, Pneumococcal/prevention & control
- Respiratory Syncytial Virus Infections/epidemiology
- Respiratory Syncytial Virus Infections/mortality
- Respiratory Syncytial Virus Infections/therapy
- Streptococcus pneumoniae
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/mortality
- World Health Organization
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Affiliation(s)
- T K P Nguyen
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, The University of Sydney, Australia; Da Nang Hospital for Women and Children, Da Nang, Viet Nam.
| | - T H Tran
- Da Nang Hospital for Women and Children, Da Nang, Viet Nam
| | - C L Roberts
- Clinical and Population Perinatal Health Research, Kolling Institute, Northern Sydney Local Health District, Sydney, Australia; Sydney Medical School Northern, The University of Sydney, Australia
| | - S M Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Australia
| | - B J Marais
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, The University of Sydney, Australia
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Salam RA, Qureshi RN, Sheikh S, Khowaja AR, Sawchuck D, Vidler M, von Dadelszen P, Zaidi S, Bhutta Z. Potential for task-sharing to Lady Health Workers for identification and emergency management of pre-eclampsia at community level in Pakistan. Reprod Health 2016; 13:107. [PMID: 27719680 PMCID: PMC5056493 DOI: 10.1186/s12978-016-0214-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background An estimated 276 Pakistani women die for every 100,000 live births; with eclampsia accounting for about 10 % of these deaths. Community health workers contribute to the existing health system in Pakistan under the banner of the Lady Health Worker (LHW) Programme and are responsible to provide a comprehensive package of antenatal services. However, there is a need to increase focus on early identification and prompt diagnosis of pre-eclampsia in community settings, since women with mild pre-eclampsia often present without symptoms. This study aims to explore the potential for task-sharing to LHWs for the community-level management of pre-eclampsia and eclampsia in Pakistan. Methods A qualitative exploratory study was undertaken February-July 2012 in two districts, Hyderabad and Matiari, in the southern province of Sindh, Pakistan. Altogether 33 focus group discussions (FGDs) were conducted and the LHW curriculum and training materials were also reviewed. The data was audio-recorded, then transcribed verbatim for thematic analysis using QSR NVivo-version10. Results Findings from the review of the LHW curriculum and training program describe that in the existing community delivery system, LHWs are responsible for identification of pregnant women, screening women for danger signs and referrals for antenatal care. They are the first point of contact for women in pregnancy and provide nutritional counselling along with distribution of iron and folic acid supplements. Findings from FGDs suggest that LHWs do not carry a blood pressure device or antihypertensive medications; they refer to the nearest public facility in the event of a pregnancy complication. Currently, they provide tetanus toxoid in pregnancy. The health advice provided by lady health workers is highly valued and accepted by pregnant women and their families. Many Supervisors of LHWs recognized the need for increased training regarding pre-eclampsia and eclampsia, with a focus on identifying women at high risk. The entire budget of the existing lady health worker Programme is provided by the Government of Pakistan, indicating a strong support by policy makers and the government for the tasks undertaken by these providers. Conclusion There is a potential for training and task-sharing to LHWs for providing comprehensive antenatal care; specifically for the identification and management of pre-eclampsia in Pakistan. However, the implementation needs to be combined with appropriate training, equipment availability and supervision. Trial registration ClinicalTrial.gov, NCT01911494 Electronic supplementary material The online version of this article (doi:10.1186/s12978-016-0214-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rehana A Salam
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan
| | - Rahat Najam Qureshi
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan. .,Department of Obstetrics and Gynaecology, Aga Khan University, Stadium Road, Karachi, Pakistan.
| | - Sana Sheikh
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan
| | - Asif Raza Khowaja
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan
| | - Diane Sawchuck
- Department of Research, Vancouver Island Health Authority, Victoria, V8R1J8, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, and the Child and Family Research Unit, University of British Columbia, Vancouver, V5Z 4H4, Canada
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, St George's, University of London, London, SW17 0RE, UK
| | - Shujaat Zaidi
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Bhutta
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, M5G 2L3, Canada
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Folgori L, Bielicki J, Ruiz B, Turner MA, Bradley JS, Benjamin DK, Zaoutis TE, Lutsar I, Giaquinto C, Rossi P, Sharland M. Harmonisation in study design and outcomes in paediatric antibiotic clinical trials: a systematic review. THE LANCET. INFECTIOUS DISEASES 2016; 16:e178-e189. [PMID: 27375212 DOI: 10.1016/s1473-3099(16)00069-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 01/15/2016] [Accepted: 01/28/2016] [Indexed: 10/21/2022]
Abstract
There is no global consensus on the conduct of clinical trials in children and neonates with complicated clinical infection syndromes. No comprehensive regulatory guidance exists for the design of antibiotic clinical trials in neonates and children. We did a systematic review of antibiotic clinical trials in complicated clinical infection syndromes (including bloodstream infections and community-acquired pneumonia) in children and neonates (0-18 years) to assess whether standardised European Medicines Agency (EMA) and US Food and Drug Administration (FDA) guidance for adults was used in paediatrics, and whether paediatric clinical trials applied consistent definitions for eligibility and outcomes. We searched MEDLINE, Cochrane CENTRAL databases, and ClinicalTrials.gov between Jan 1, 2000, and Nov 18, 2015. 82 individual studies met our inclusion criteria. The published studies reported on an average of 66% of CONSORT items. Study design, inclusion and exclusion criteria, and endpoints varied substantially across included studies. The comparison between paediatric clinical trials and adult EMA and FDA guidance highlighted that regulatory definitions are only variably applicable and used at present. Absence of consensus for paediatric antibiotic clinical trials is a major barrier to harmonisation in research and translation into clinical practice. To improve comparison of therapies and strategies, international collaboration among all relevant stakeholders leading to harmonised case definitions and outcome measures is needed.
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Affiliation(s)
- Laura Folgori
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Julia Bielicki
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK; Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
| | - Beatriz Ruiz
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Mark A Turner
- University of Liverpool, Institute of Translational Medicine, Department of Women's and Children's Health, Crown Street, Liverpool, UK
| | - John S Bradley
- Department of Pediatrics, University of California San Diego, San Diego, CA, USA; Rady Children's Hospital San Diego, San Diego, CA, USA
| | | | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA; Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Tartu, Estonia
| | - Carlo Giaquinto
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Paolo Rossi
- University Department of Pediatrics (DPUO), Bambino Gesù Children's Hospital, Rome, Italy
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George's University of London, London, UK.
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Lodha R, Randev S, Kabra SK. Oral antibiotics for community–acquired pneumonia with chest-indrawing in children aged below five years: A Systematic Review. Indian Pediatr 2016; 53:489-95. [DOI: 10.1007/s13312-016-0878-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
BACKGROUND The Aetiology of Neonatal Infection in South Asia (ANISA) study is a population-based study with sites in Bangladesh, India and Pakistan. It aims to determine community-acquired incidence, etiology and associated risk factors for neonatal infections. Matiari, a rural site in Pakistan, was chosen for the study due to its high neonatal mortality rate and the presence of an established pregnancy and birth surveillance system. This article summarizes various challenges, remedial measures taken and lessons learned during the implementation of the ANISA study protocol in the unique rural setting of Matiari where the majority of births take place at home and accessibility to health care is limited. CHALLENGES Achieving and maintaining project targets of early registration of birth and collection of biological specimens in households have been challenging in Matiari. Capturing births of study subjects that occur outside the catchment areas and those taking place during public holidays and acquiring parental consent for specimen collection from healthy controls require extensive community mobilization. Contamination and power outages that affect the laboratory equipment are 2 of the major logistic challenges faced. We keep track of pregnancy outcomes through mobile phones and reimburse the costs for birth notifications to the caller. We created separate dedicated mobile teams that visit newborns outside the catchment area and carry out possible serious bacterial infection assessments. We also formed mobile teams for specimen collection from residences of newborns as there is no facility for specimen collection at this site. Our study personnel work on holidays and weekends to improve the study's performance. We nurture strong community liaison by employing staff from within the community. We train the study physicians on communication and counseling skills required for overcoming refusal for referral and specimen collection. The contamination rate is controlled by repeated training and supervision and extensive monitoring of phlebotomy activities. The majority of phlebotomy procedures are recorded on video in the field to provide feedback to phlebotomists for improving their performance. CONCLUSION The contextual challenges faced in field implementation of the ANISA protocol in the rural setting of Matiari are unique. These challenges are being successfully addressed through hard work, strict monitoring and improvisation. This experience can be used for improving study performance in similar settings elsewhere.
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Mendelson M, Røttingen JA, Gopinathan U, Hamer DH, Wertheim H, Basnyat B, Butler C, Tomson G, Balasegaram M. Maximising access to achieve appropriate human antimicrobial use in low-income and middle-income countries. Lancet 2016; 387:188-98. [PMID: 26603919 DOI: 10.1016/s0140-6736(15)00547-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Access to quality-assured antimicrobials is regarded as part of the human right to health, yet universal access is often undermined in low-income and middle-income countries. Lack of access to the instruments necessary to make the correct diagnosis and prescribe antimicrobials appropriately, in addition to weak health systems, heightens the challenge faced by prescribers. Evidence-based interventions in community and health-care settings can increase access to appropriately prescribed antimicrobials. The key global enablers of sustainable financing, governance, and leadership will be necessary to achieve access while preventing excess antimicrobial use.
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Affiliation(s)
- Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - John-Arne Røttingen
- Norwegian Institute of Public Health, Oslo, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Unni Gopinathan
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Davidson H Hamer
- Zambia Center for Applied Health Research and Development, Lusaka, Zambia; Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA; Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Heiman Wertheim
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, National Hospital for Tropical Diseases, Hanoi, Vietnam; Nuffield Department of Clinical Medicine, Centre for Tropical Diseases, Oxford, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Kathmandu, Nepal
| | - Christopher Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Göran Tomson
- Departments of Learning, Informatics, Management, Ethics and Public Health Sciences, Karolinska Institute, Stockholm, Sweden
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Current therapeutics and prophylactic approaches to treat pneumonia. THE MICROBIOLOGY OF RESPIRATORY SYSTEM INFECTIONS 2016. [PMCID: PMC7150263 DOI: 10.1016/b978-0-12-804543-5.00017-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Bacterial pneumonia caused by Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Mycoplasma pneumoniae, and Klebsiella pneumoniae represents a frequent cause of mortality worldwide. The increased incidence of pneumococcal diseases in both developed and developing countries is alarmingly high, affecting infants and aged adult populations. The growing rate of antibiotic resistance and biofilm formation on medical device surfaces poses a greater challenge for treating respiratory infections. Over recent years, a better understanding of bacterial growth, metabolism, and virulence has offered several potential targets for developing therapeutics against bacterial pneumonia. This chapter will discuss the current and developing trends in treating bacterial pneumonia.
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Credit where credit is due: Pakistan's role in reducing the global burden of reproductive, maternal, newborn, and child health (RMNCH). Health Res Policy Syst 2015; 13 Suppl 1:48. [PMID: 26791944 PMCID: PMC4895729 DOI: 10.1186/s12961-015-0035-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Factors contributing to Pakistan’s poor progress in reducing reproductive, maternal, newborn, and child health (RMNCH) include its low level of female literacy, gender inequity, political challenges, and extremism along with its associated relentless violence; further, less than 1% of Pakistan’s GDP is allocated to the health sector. However, despite these disadvantages, Pakistani researchers have been able to achieve positive contributions towards RMNCH-related global knowledge and evidence base, in some cases leading to the formulation of WHO guidelines, for which they should feel proud. Nevertheless, in order to improve the health of its own women and children, greater investments in human and health resources are required to facilitate the generation and use of policy-relevant knowledge. To accomplish this, fair incentives for research production need to be introduced, policy and decision-makers’ capacity to demand and use evidence needs to be increased, and strong support from development partners and the global health community must be secured.
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Sadruddin S, Shehzad S, Bari A, Khan A, Khan A, Qazi S. Household costs for treatment of severe pneumonia in Pakistan. Am J Trop Med Hyg 2015; 87:137-143. [PMID: 23136289 PMCID: PMC3748514 DOI: 10.4269/ajtmh.2012.12-0242] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Current World Health Organization (WHO) guidelines for severe pneumonia treatment of under-5 children recommend hospital referral. However, high treatment cost is a major barrier for communities. We compared household costs for referred cases with management by lady health workers (LHWs) using oral antibiotics. This study was nested within a cluster randomized trial in Haripur, Pakistan. Data on direct and indirect costs were collected through interviews and record reviews in the 14 intervention and 14 control clusters. The average household cost/case for a LHW managed case was $1.46 compared with $7.60 for referred cases. When the cost of antibiotics provided by the LHW program was excluded from the estimates, the cost/case came to $0.25 and $7.51 for the community managed and referred cases, respectively, a 30-fold difference. Expanding severe pneumonia treatment with oral amoxicillin to community level could significantly reduce household costs and improve access to the underprivileged population, preventing many child deaths.
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Affiliation(s)
- Salim Sadruddin
- *Address correspondence to Salim Sadruddin, Department of Health and Nutrition, Save the Children, 54 Wilton Street, Westport, CT 06880. E-mail:
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Nascimento-Carvalho CM, Andrade DC, Vilas-Boas AL. An update on antimicrobial options for childhood community-acquired pneumonia: a critical appraisal of available evidence. Expert Opin Pharmacother 2015; 17:53-78. [PMID: 26549167 DOI: 10.1517/14656566.2016.1109633] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) is a leading cause of death and a major cause of morbidity in children under the age of 5. Appropriate antimicrobial use is one crucial tool in controlling childhood CAP mortality and suffering. AREAS COVERED Structured search of current literature. PubMed was consulted for published trials conducted in children with CAP. We aimed to provide a comprehensive evaluation of antimicrobials used to treat childhood CAP, including a critical appraisal of the methodological aspects of these clinical trials. EXPERT OPINION Amoxicillin is the preferred option to treat non-severe non-complicated CAP among children aged ≥2 months. Amoxicillin may be used to treat children in this age group with severe CAP if they do not require hospital assistance. If the patient warrants hospitalization, intravenous penicillin is the chosen option. Heterogeneity was high in the included trials, in regard to clinical inclusion criteria, use of radiological inclusion criteria, placebo use and masking. Higher quality evidence was found in the studies which included amoxicillin. There is a clear dearth of randomized, placebo-controlled, well-performed clinical trials evaluating children with CAP aged under 2 months, or aged 2 months and above with very severe or complicated CAP, or in specific age groups like teenagers.
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Affiliation(s)
| | - Dafne C Andrade
- b Postgraduate Program in Health Sciences , Federal University of Bahia School of Medicine , Salvador CEP 40025-010 , Brazil
| | - Ana-Luisa Vilas-Boas
- b Postgraduate Program in Health Sciences , Federal University of Bahia School of Medicine , Salvador CEP 40025-010 , Brazil
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Zinc for Acute Diarrhea and Amoxicillin for Pneumonia, Do They Work? : Delivered at the AIIMS, IJP Excellence Award for the year 2013 on 7th September 2014. Indian J Pediatr 2015; 82:703-6. [PMID: 25731896 DOI: 10.1007/s12098-015-1712-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/21/2015] [Indexed: 11/27/2022]
Abstract
Acute diarrhea and pneumonia are the two largest killers of under-five children in the world. Zinc, used in management of acute diarrhea and Amoxicillin, used in community acquired pneumonia, feature in the list of 13 Life Saving Commodities for Women's and Children Health by the UN Commission. Zinc has caught wide scientific attention for the conceptual promise it has to offer for prevention, control and treatment of acute diarrhea. This presentation focuses on author's research on the mechanisms by which zinc might contribute to the pathogenesis of acute diarrhea and the degree of success achieved in diarrhea control and treatment by zinc supplementation including its impact on mortality. However, emerging evidence in terms of controlled studies in humans beckons a more complete understanding of the mechanistic basis for zinc supplementation. Current evidence indicates that studies specifically addressing the variability in response to zinc supplementation need to be undertaken to better comprehend these mechanisms. Similarly, the author presented her research that examined the role of oral amoxicillin in community management of severe pneumonia in children and the need to assess its universal efficacy in all children with severe pneumonia.
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New Algorithm for Managing Childhood Illness Using Mobile Technology (ALMANACH): A Controlled Non-Inferiority Study on Clinical Outcome and Antibiotic Use in Tanzania. PLoS One 2015; 10:e0132316. [PMID: 26161535 PMCID: PMC4498627 DOI: 10.1371/journal.pone.0132316] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 02/24/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction The decline of malaria and scale-up of rapid diagnostic tests calls for a revision of IMCI. A new algorithm (ALMANACH) running on mobile technology was developed based on the latest evidence. The objective was to ensure that ALMANACH was safe, while keeping a low rate of antibiotic prescription. Methods Consecutive children aged 2–59 months with acute illness were managed using ALMANACH (2 intervention facilities), or standard practice (2 control facilities) in Tanzania. Primary outcomes were proportion of children cured at day 7 and who received antibiotics on day 0. Results 130/842 (15∙4%) in ALMANACH and 241/623 (38∙7%) in control arm were diagnosed with an infection in need for antibiotic, while 3∙8% and 9∙6% had malaria. 815/838 (97∙3%;96∙1–98.4%) were cured at D7 using ALMANACH versus 573/623 (92∙0%;89∙8–94∙1%) using standard practice (p<0∙001). Of 23 children not cured at D7 using ALMANACH, 44% had skin problems, 30% pneumonia, 26% upper respiratory infection and 13% likely viral infection at D0. Secondary hospitalization occurred for one child using ALMANACH and one who eventually died using standard practice. At D0, antibiotics were prescribed to 15∙4% (12∙9–17∙9%) using ALMANACH versus 84∙3% (81∙4–87∙1%) using standard practice (p<0∙001). 2∙3% (1∙3–3.3) versus 3∙2% (1∙8–4∙6%) received an antibiotic secondarily. Conclusion Management of children using ALMANACH improve clinical outcome and reduce antibiotic prescription by 80%. This was achieved through more accurate diagnoses and hence better identification of children in need of antibiotic treatment or not. The building on mobile technology allows easy access and rapid update of the decision chart. Trial Registration Pan African Clinical Trials Registry PACTR201011000262218
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McCollum ED, King C, Hollowell R, Zhou J, Colbourn T, Nambiar B, Mukanga D, Burgess DCH. Predictors of treatment failure for non-severe childhood pneumonia in developing countries--systematic literature review and expert survey--the first step towards a community focused mHealth risk-assessment tool? BMC Pediatr 2015; 15:74. [PMID: 26156710 PMCID: PMC4496936 DOI: 10.1186/s12887-015-0392-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 06/24/2015] [Indexed: 11/30/2022] Open
Abstract
Background Improved referral algorithms for children with non-severe pneumonia at the community level are desirable. We sought to identify predictors of oral antibiotic failure in children who fulfill the case definition of World Health Organization (WHO) non-severe pneumonia. Predictors of greatest interest were those not currently utilized in referral algorithms and feasible to obtain at the community level. Methods We systematically reviewed prospective studies reporting independent predictors of oral antibiotic failure for children 2–59 months of age in resource-limited settings with WHO non-severe pneumonia (either fast breathing for age and/or lower chest wall indrawing without danger signs), with an emphasis on predictors not currently utilized for referral and reasonable for community health workers. We searched PubMed, Cochrane, and Embase and qualitatively analyzed publications from 1997–2014. To supplement the limited published evidence in this subject area we also surveyed respiratory experts. Results Nine studies met criteria, seven of which were performed in south Asia. One eligible study occurred exclusively at the community level. Overall, oral antibiotic failure rates ranged between 7.8-22.9 %. Six studies found excess age-adjusted respiratory rate (either WHO-defined very fast breathing for age or 10–15 breaths/min faster than normal WHO age-adjusted thresholds) and four reported young age as predictive for oral antibiotic failure. Of the seven predictors identified by the expert panel, abnormal oxygen saturation and malnutrition were most highly favored per the panel’s rankings and comments. Conclusions This review identified several candidate predictors of oral antibiotic failure not currently utilized in childhood pneumonia referral algorithms; excess age-specific respiratory rate, young age, abnormal oxygen saturation, and moderate malnutrition. However, the data was limited and there are clear evidence gaps; research in rural, low-resource settings with community health workers is needed. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0392-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Eric D McCollum
- Department of Pediatrics, Division of Pulmonology, Johns Hopkins School of Medicine, Baltimore, USA. .,Institute for Global Health, University College London, London, UK.
| | - Carina King
- Institute for Global Health, University College London, London, UK.
| | | | - Janet Zhou
- Bill & Melinda Gates Foundation, Seattle, USA.
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK.
| | - Bejoy Nambiar
- Institute for Global Health, University College London, London, UK.
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Acácio S, Verani JR, Lanaspa M, Fairlie TA, Nhampossa T, Ruperez M, Aide P, Plikaytis BD, Sacoor C, Macete E, Alonso P, Sigaúque B. Under treatment of pneumonia among children under 5 years of age in a malaria-endemic area: population-based surveillance study conducted in Manhica district- rural, Mozambique. Int J Infect Dis 2015; 36:39-45. [PMID: 25980619 DOI: 10.1016/j.ijid.2015.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 04/27/2015] [Accepted: 05/04/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Integrated Management of Childhood Illness (IMCI) guidelines were developed to decrease morbidity and mortality, yet implementation varies across settings. Factors associated with poor adherence are not well understood. METHODS We used data from Manhiça District Hospital outpatient department and five peripheral health centers to examine pneumonia management for children <5 years old from January 2008 to June 2011. Episodes of IMCI-defined pneumonia (cough or difficult breathing plus tachypnea), severe pneumonia (pneumonia plus chest wall in-drawing), and/or clinician-diagnosed pneumonia (based on discharge diagnosis) were included. RESULTS Among severe pneumonia episodes, 96.2% (2,918/3,032) attended in the outpatient department and 70.0% (291/416) attended in health centers were appropriately referred to the emergency department. Age<1 year, malnutrition and various physical exam findings were associated with referral. For non-severe pneumonia episodes, antibiotics were prescribed in 45.7% (16,094/35,224). Factors associated with antibiotic prescription included age <1 year, abnormal auscultatory findings, and clinical diagnosis of pneumonia; diagnosis of malaria or gastroenteritis and pallor were negatively associated with antibiotic prescription. CONCLUSION Adherence to recommended management of severe pneumonia was high in a hospital outpatient department, but suboptimal in health centers. Antibiotics were prescribed in fewer than half of non-severe pneumonia episodes, and diagnosis of malaria was the strongest risk factor for incorrect management.
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Affiliation(s)
- Sozinho Acácio
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique.
| | - Jennifer R Verani
- Centers for Disease Control and Prevention - 1600 Clifton Road, Atlanta, GA 30329 USA.
| | - Miguel Lanaspa
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Centre de Recerca en Salut Internacional de Barcelona, Hospital Clínic, Universitat de Barcelona - Rosselló 132, 08036, Barcelona, Spain.
| | - Tarayn A Fairlie
- Centers for Disease Control and Prevention - 1600 Clifton Road, Atlanta, GA 30329 USA.
| | - Tacilta Nhampossa
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique.
| | - Maria Ruperez
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Centre de Recerca en Salut Internacional de Barcelona, Hospital Clínic, Universitat de Barcelona - Rosselló 132, 08036, Barcelona, Spain.
| | - Pedro Aide
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique.
| | - Brian D Plikaytis
- Centers for Disease Control and Prevention - 1600 Clifton Road, Atlanta, GA 30329 USA.
| | - Charfudin Sacoor
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique.
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique.
| | - Pedro Alonso
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Centre de Recerca en Salut Internacional de Barcelona, Hospital Clínic, Universitat de Barcelona - Rosselló 132, 08036, Barcelona, Spain.
| | - Betuel Sigaúque
- Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique.
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Wu J, Jin YU, Li H, Xie Z, Li J, Ao Y, Duan Z. Evaluation and significance of C-reactive protein in the clinical diagnosis of severe pneumonia. Exp Ther Med 2015; 10:175-180. [PMID: 26170931 DOI: 10.3892/etm.2015.2491] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 12/12/2014] [Indexed: 12/11/2022] Open
Abstract
Severe pneumonia is a major cause of mortality in children. The present study evaluated the diagnostic value of serum C-reactive protein (CRP) levels for cases of severe pneumonia. A total of 862 children, hospitalized for acute respiratory tract infections, were evaluated between September 2008 and February 2011; the serum levels of CRP were measured in all the children. Bacterial identification was performed, while polymerase chain reaction was used to detect the 12 respiratory viruses. Multivariate logistic regression analysis was performed with independent [CRP, proportion of neutrophils (NEUT), body temperature, sputum production, age and dyspnea] and dependent (severe and mild pneumonia) variables for clinical diagnosis, which produced three new variables that represented an individual's predictive value: Pre-1, Pre-2 and Pre-3. A receiver operating characteristic (ROC) curve was generated using the new variables to assess their predictive value for severe pneumonia. Of the 862 patients, 108 individuals were diagnosed with severe pneumonia and 754 individuals had mild pneumonia. Increased levels of CRP were associated with severe pneumonia and bacterial infection (P<0.05). Multivariate logistic regression analysis found that severe pneumonia was associated with the levels of CRP, body temperature, expectoration, age, NEUT and dyspnea (P<0.05). The ROC curve of the regression diagnostics model sequentially presented CRP, CRP and the other five correlative variables (NEUT + body temperature + sputum production + age + dyspnea) and the other five correlative variables used to diagnose severe pneumonia. The area under curve values were determined as 0.550 for Pre-1 [95% confidence interval (CI), 0.490-0.609], 0.897 for Pre-2 (95% CI, 0.861-0.932) and 0.893 for Pre-3 (95% CI, 0.855-0.931). The results revealed that the six correlative variables had improved accuracy in the diagnosis of severe pneumonia. The serum levels of CRP were strongly associated with bacterial infection and severe pneumonia. Therefore, the CRP level, along with other parameters, may be used as early indicators of severe pneumonia development. However, the efficiency of the CRP level alone to diagnose severe pneumonia was found to be limited.
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Affiliation(s)
- Jianjun Wu
- Gansu Traditional Chinese Medical University, Lanzhou, Gansu 730000, P.R. China ; School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu 730000, P.R. China
| | - Y U Jin
- School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu 730000, P.R. China ; Nanjing Children's Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210008, P.R. China
| | - Hailong Li
- Gansu Traditional Chinese Medical University, Lanzhou, Gansu 730000, P.R. China
| | - Zhiping Xie
- National Institute for Viral Disease Control and Prevention, China CDC, Beijing 100052, P.R. China
| | - Jinsong Li
- National Institute for Viral Disease Control and Prevention, China CDC, Beijing 100052, P.R. China
| | - Yuanyun Ao
- National Institute for Viral Disease Control and Prevention, China CDC, Beijing 100052, P.R. China
| | - Zhaojun Duan
- National Institute for Viral Disease Control and Prevention, China CDC, Beijing 100052, P.R. China
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Fox MP, Baqui AH, Hibberd PL, Black RE, Santosham M, Bhutta Z, Thea DM. Antibiotic trials for community-acquired pneumonia. THE LANCET RESPIRATORY MEDICINE 2015; 3:e4-5. [PMID: 25773214 DOI: 10.1016/s2213-2600(15)00044-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 12/30/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA; Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Abdullah H Baqui
- Department of International Health, International Center for Maternal and Newborn Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Patricia L Hibberd
- Division of Global Health, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert E Black
- Department of International Health, International Center for Maternal and Newborn Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mathuram Santosham
- Department of International Health, International Center for Maternal and Newborn Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Department of Pediatrics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Zulfiqar Bhutta
- Department of Nutritional Sciences, The Hospital for Sick Children, Research Centre for Global Child Health, University of Toronto, Toronto, ON, Canada
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
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Kok MC, Kane SS, Tulloch O, Ormel H, Theobald S, Dieleman M, Taegtmeyer M, Broerse JEW, de Koning KAM. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Res Policy Syst 2015; 13:13. [PMID: 25890229 PMCID: PMC4358881 DOI: 10.1186/s12961-015-0001-3] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 02/02/2015] [Indexed: 11/18/2022] Open
Abstract
Background Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors intersect to influence CHW performance. A systematic review with a narrative analysis was conducted to identify contextual factors influencing performance of CHWs. Methods We searched six databases for quantitative, qualitative, and mixed-methods studies that included CHWs working in promotional, preventive or curative primary health care services in LMICs. We differentiated CHW performance outcome measures at two levels: CHW level and end-user level. Ninety-four studies met the inclusion criteria and were double read to extract data relevant to the context of CHW programmes. Thematic coding was conducted and evidence on five main categories of contextual factors influencing CHW performance was synthesized. Results Few studies had the influence of contextual factors on CHW performance as their primary research focus. Contextual factors related to community (most prominently), economy, environment, and health system policy and practice were found to influence CHW performance. Socio-cultural factors (including gender norms and values and disease related stigma), safety and security and education and knowledge level of the target group were community factors that influenced CHW performance. Existence of a CHW policy, human resource policy legislation related to CHWs and political commitment were found to be influencing factors within the health system policy context. Health system practice factors included health service functionality, human resources provisions, level of decision-making, costs of health services, and the governance and coordination structure. All contextual factors can interact to shape CHW performance and affect the performance of CHW interventions or programmes. Conclusions Research on CHW programmes often does not capture or explicitly discuss the context in which CHW interventions take place. This synthesis situates and discusses the influence of context on CHW and programme performance. Future health policy and systems research should better address the complexity of contextual influences on programmes. This insight can help policy makers and programme managers to develop CHW interventions that adequately address and respond to context to optimise performance. Electronic supplementary material The online version of this article (doi:10.1186/s12961-015-0001-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maryse C Kok
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands. .,VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan, 1081 HV, Amsterdam, The Netherlands.
| | - Sumit S Kane
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Olivia Tulloch
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Hermen Ormel
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Marjolein Dieleman
- Royal Tropical Institute, P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Jacqueline E W Broerse
- VU University Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, De Boelelaan, 1081 HV, Amsterdam, The Netherlands.
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50
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Awor P, Miller J, Peterson S. Systematic literature review of integrated community case management and the private sector in Africa: Relevant experiences and potential next steps. J Glob Health 2014; 4:020414. [PMID: 25520804 PMCID: PMC4267082 DOI: 10.7189/jogh.04.020414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Despite substantial investments made over the past 40 years in low income countries, governments cannot be viewed as the principal health care provider in many countries. Evidence on the role of the private sector in the delivery of health services is becoming increasingly available. In this study, we set out to determine the extent to which the private sector has been utilized in providing integrated care for sick children under 5 years of age with community–acquired malaria, pneumonia or diarrhoea. Methods We reviewed the published literature for integrated community case management (iCCM) related experiences within both the public and private sector. We searched PubMed and Google/Google Scholar for all relevant literature until July 2014. The search terms used were “malaria”, “pneumonia”, “diarrhoea”, “private sector” and “community case management”. Results A total of 383 articles referred to malaria, pneumonia or diarrhoea in the private sector. The large majority of these studies (290) were only malaria related. Most of the iCCM–related studies evaluated introduction of only malaria drugs and/or diagnostics into the private sector. Only one study evaluated the introduction of drugs and diagnostics for malaria, pneumonia and diarrhoea in the private sector. In contrast, most iCCM–related studies in the public sector directly reported on community case management of 2 or more of the illnesses. Conclusions While the private sector is an important source of care for children in low income countries, little has been done to harness the potential of this sector in improving access to care for non–malaria–associated fever in children within the community. It would be logical for iCCM programs to expand their activities to include the private sector to achieve higher population coverage. An implementation research agenda for private sector integrated care of febrile childhood illness needs to be developed and implemented in conjunction with private sector intervention programs.
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Affiliation(s)
- Phyllis Awor
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda ; Centre for International Health, Global Public Health and Primary Care, University of Bergen, Norway
| | - Jane Miller
- Malaria and Child Survival Department, Population Services International, Nairobi, Kenya
| | - Stefan Peterson
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda ; Global Health, Karolinska Institutet, Stockholm, Sweden ; International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden
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