A community study of the application of WHO ARI management guidelines in Pakistan

Credit where credit is due: Pakistan's role in reducing the global burden of reproductive, maternal, newborn, and child health (RMNCH)

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.

Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials

Pneumonia still causes around two million deaths among children annually (20% of all child deaths). Any intervention that would affect pneumonia mortality is of great public health importance. This meta-analysis provides estimates of mortality impact of the case-management approach proposed by WHO. We were able to get data from nine of ten eligible community-based studies that assessed the effects of pneumonia case-management intervention on mortality; seven studies had a concurrent control group. Standardised forms were completed by individual investigators to provide information on study description, quality scoring, follow-up, and outcome (mortality) data with three age groups (<1 month, <1 year, 0-4 years) and two mortality categories (total and pneumonia-specific). Meta-analysis found a reduction in total mortality of 27% (95% CI 18-35%), 20% (11-28%), and 24% (14-33%) among neonates, infants, and children 0-4 years of age, respectively. In the same three groups pneumonia mortality was reduced by 42% (22-57%), 36% (20-48%), and 36% (20-49%). There was no evidence of publication bias and results were unaltered by exclusion of any study. A limitation of the included studies is that they were not randomised and, because of the nature of the intervention, could not be blinded. Community-based interventions to identify and treat pneumonia have a substantial effect on neonatal, infant, and child mortality and should be incorporated into primary health care.

Clinical efficacy of co-trimoxazole versus amoxicillin twice daily for treatment of pneumonia: a randomised controlled clinical trial in Pakistan

AIMS

To compare the clinical efficacy of twice daily oral co-trimoxazole with twice daily oral amoxicillin for treatment of childhood pneumonia.

METHODS

Randomised controlled, double blind, multicentre study in outpatient departments of seven hospitals and in one community health service. A total of 1471 children (aged 2-59 months) with non-severe pneumonia were randomly assigned to 25 mg/kg amoxicillin (n = 730) or 4 mg/kg trimethoprim plus 20 mg/kg sulphamethoxazole (co-trimoxazole) (n = 741). Both medicines were given orally twice daily for five days.

RESULTS

Data from 1459 children were analysed: 725 were randomised to amoxicillin and 734 to co-trimoxazole. Treatment failure in the amoxicillin group was 16.1% compared to 18.9% in the co-trimoxazole group. Multivariate analysis showed that treatment failure was more likely in infants who had history of difficult breathing or those who had been ill for more than three days before presentation.

CONCLUSIONS

Both amoxicillin and co-trimoxazole were equally effective in non-severe pneumonia. Good follow up of patients is essential to prevent worsening of illness.

Prescription practices of public and private health care providers in Attock District of Pakistan

The irrational use of drugs is a major problem of present day medical practice and its consequences include the development of resistance to antibiotics, ineffective treatment, adverse effects and an economic burden on the patient and society. A study from Attock District of Pakistan assessed this problem in the formal allopathic health sector and compared prescribing practices of health care providers in the public and private sector. WHO recommended drug use indicators were used to study prescription practices. Prescriptions were collected from 60 public and 48 private health facilities. The mean (+/- SE) number of drugs per prescription was 4.1 +/- 0.06 for private and 2.7 +/- 0.04 for public providers (p < 0.0001). General practitioners (GPs) who represent the private sector prescribed at least one antibiotic in 62% of prescriptions compared with 54% for public sector providers. Over 48% of GP prescriptions had at least one injectable drug compared with 22.0% by public providers (p < 0.0001). Thirteen percent of GP prescriptions had two or more injections. More than 11% of GP prescriptions had an intravenous infusion compared with 1% for public providers (p < 0.001). GPs prescribed three or more oral drugs in 70% of prescriptions compared with 44% for public providers (p < 0.0001). Prescription practices were analysed for four health problems, acute respiratory infection (ARI), childhood diarrhoea (CD), fever in children and fever in adults. For these disorders, both groups prescribed antibiotics generously, however, GPs prescribed them more frequently in ARI, CD and fever in children (p < 0.01). GPs prescribed steroids more frequently, however, it was significantly higher in ARI cases (p < 0.001). For all the four health problems studied, GPs prescribed injections more frequently than public providers (p < 0.001). In CD cases GPs prescribed oral rehydration salt (ORS) less frequently (33.3%) than public providers (57.7%). GPs prescribed intravenous infusion in 12.3% cases of fever in adults compared with none by public providers (p < 0.001). A combination of non-regulatory and regulatory interventions, directed at providers as well as consumers, would need to be implemented to improve prescription practices of health care providers. Regulation alone would be ineffective unless it is supported by a well-established institutional mechanism which ensures effective implementation. The Federal Ministry of Health and the Provincial Departments of Health have to play a critical role in this respect, while the role of the Pakistan Medical Association in self-regulation of prescription practices can not be overemphasized. Improper prescription practices will not improve without consumer targeted interventions that educate and empower communities regarding the hazards of inappropriate drug use.

Circumstances of post-neonatal deaths in Ceara, Northeast Brazil: mothers' health care-seeking behaviors during their infants' fatal illness

Promotion of oral rehydration therapy (ORT) for the treatment of diarrheal diseases and the WHO case management strategy for acute respiratory infections (ARI) have contributed to significant reductions in infant mortality, but these two conditions remain the leading causes of infant deaths in most developing countries. Identification of the factors contributing to these deaths may contribute to reduce infant mortality from preventable causes. To gain insight into the circumstances and maternal and health services factors that may contribute to infant deaths we used a verbal autopsy method to interview mothers of all infants who died during the previous 12 months (June 1995-May 1996) in 11 municipalities in the State of Ceara, Northeast Brazil. Our results revealed that one-third of the deaths occurred in a hospital and two-thirds at home. Almost all the infants who died at home, however, had been examined one or more times by a doctor, and 36% of them had been hospitalized during the disease episode that resulted in death. For most (85%) of these children the causes of death were diarrhea or acute respiratory infection, and it is likely that death could have been averted if appropriate treatment had been initiated promptly. Three major groups of factors that alone or in combination appeared to contribute to most deaths were delays in seeking medical care on behalf of the parents, medical interventions reported as ineffective by mothers and delays in providing medical care to children who arrived at the hospital too late in the day to be scheduled for consultation. Our findings suggest that government efforts to further reduce infant mortality in Ceara should focus on health education interventions that address quality of home care, recognition of signs of severity and danger and importance of seeking timely medical care: and on improving the quality of care provided at community health centers and hospitals. Measures likely to improve infants' chance of survival include: ensuring prompt access to medical consultation for young children brought to health centers or hospitals with potentially life-threatening symptoms related to infections, health education to mothers on the need for continued home care after discharge and to return to the medical care facility if the child does not recover, and that they have access to medicine prescribed by hospital physicians. Further benefits could be obtained by using community health workers, now integrated into the Family Medicine Program (PSF) health teams, to provide health education, supervise home care, refer mothers to health centers and facilitate their access to hospitals.

Antibiotic medication and bacterial resistance to antibiotics: a survey of children in a Vietnamese community

OBJECTIVE

To investigate antibiotic use and antibiotic susceptibility of respiratory tract pathogens in children aged 1-5 years in Bavi, Vietnam.

METHOD

Nasopharynx and throat specimens were collected from 200 children from randomly selected households in a demographically defined population. Respiratory isolates were tested for antibiotic susceptibility according to the standard disk diffusion method. A questionnaire survey of carers elicited information on type of antibiotic used, duration of treatment, where the antibiotics had been purchased, type of treatment information retained by carers and episodes of illness preceding the study.

RESULTS

82% of the children had at least one symptom of acute respiratory tract infection (ARI) in the 4 weeks prior to the study, and of these 91% were treated with antibiotics. The most commonly used antibiotics were ampicillin (74%), penicillin (12%), amoxicillin (11%), erythromycin (5%), tetracycline (4%) and streptomycin (2%). Ampicillin was used for 3.3 days on average (SD:1.8) and penicillin for 2.6 days (SD:0.7). When deciding which antibiotic to use, 67% of the carers consulted the pharmacy seller, 11% decided themselves and 22% followed the doctor's prescription. The carrier rate of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis was 50%, 39% and 17%, respectively. Isolates from 145 children were susceptibility tested, and 74% were found to carry resistant pathogens. Of the tested isolates, 90% of S. pneumoniae, 68% of H. influenzae and 74% of M. catarrhalis were resistant to at least one antibiotic. The mean number of antibiotics (susceptible strains excluded) to which resistance was found was 2.0 (SD:1.2), 2.5 (SD:1.8) and 2.1 (SD:0.9), respectively. S. pneumoniae and H. influenzae showed high resistance to tetracycline (88% and 32%, respectively), trimethoprim/sulphonamide (32% and 44%), and chloramphenicol (25% and 24%). 23% of S. pneumoniae were erythromycin-resistant and 18% of H. influenzae isolates were resistant to ampicillin. There was a significant difference in ampicillin and penicillin resistance between the group of children previously treated with beta lactam antibiotics and the group of children who did not receive antibiotics.

CONCLUSION

As reported by the carers, children in Bavi are treated with antibiotics frequently. Most antibiotics were obtained without consulting a doctor. High levels of antibiotic resistance and high prevalence of multidrug-resistant strains were found among respiratory pathogens. The existence of a large reservoir of resistance genes among children in low-income countries represents a threat to the success of antibiotic therapy throughout the world. Multi-faceted programmes to improve rational use of antibiotics in Vietnam are urgently needed.

Antimicrobial resistance and clinical effectiveness of co-trimoxazole versus amoxycillin for pneumonia among children in Pakistan: randomised controlled trial. Pakistan Co-trimoxazole Study Group

BACKGROUND

Co-trimoxazole is widely used in treatment of paediatric pneumonia in developing countries, but drug resistance may decrease its effectiveness. We studied the effectiveness of co-trimoxazole compared with that of amoxycillin in pneumonia therapy, and assessed the clinical impact of co-trimoxazole resistance.

METHODS

We recruited 595 children, aged 2-59 months, with non-severe or severe pneumonia (WHO criteria) diagnosed in the outpatient wards of two urban Pakistan hospitals. Patients were randomly assigned on a 2:1 basis co-trimoxazole (n=398) or amoxycillin (n=197) in standard WHO doses and dosing schedules, and were monitored in study wards. The primary outcome was inpatient therapy failure (clinical criteria) or clinical evidence of pneumonia at outpatient follow-up examination.

FINDINGS

There were 92 (23%) therapy failures in the co-trimoxazole group and 30 (15%) in the amoxycillin group (p=0.03)-26 (13%) versus 12 (12%) among children with non-severe pneumonia (p=0.856) and 66 (33%) versus 18 (18%) among those with severe pneumonia (p=0.009). For patients with severe pneumonia, age under 1 year (p=0.056) and positive chest radiographs (p=0.005) also predicted therapy failure. There was no significant association between antimicrobial minimum inhibitory concentration and outcome among bacteraemic children treated with co-trimoxazole.

INTERPRETATION

Co-trimoxazole provided effective therapy in non-severe pneumonia. For severe, life-threatening pneumonia, however, co-trimoxazole is less likely than amoxycillin to be effective.

Drug prescribing practices of general practitioners and paediatricians for childhood diarrhoea in Karachi, Pakistan

Observations were made of 996 encounters between children with diarrhoea and practitioners (28 paediatricians, 62 general practitioners) in Karachi, Pakistan. Oral rehydration salt (ORS) was prescribed in more than 50% of encounters by 53% of general practitioners (GPs) and 61% of paediatricians. Sixty-six percent of GPs and 50% of paediatricians prescribed antibacterials, 60% of GPs and 28% of paediatricians prescribed antidiarrhoeals and 39% of GPs and 32% of paediatricians prescribed antiamoebics in more than 30% of their encounters. Looking at all the encounters, we observed that ORS was prescribed in 52 and 51%, antibacterials in 41 and 36%, antidiarrhoeals in 48 and 29%, and antiamoebics in 26 and 22% of encounters by GPs and paediatricians, respectively, Cotrimoxazole was the most frequently prescribed antibacterial by both types of practitioners. Antidiarrhoeals were prescribed more often by GPs than by paediatricians. In 77% of their encounters, GPs dispensed drug formulations known as "mixtures' made in their own dispensing corners. The mean duration of encounters between patients and GPs was 3 +/- 2 minutes and between patients and paediatricians was 9 +/- 4 minutes. These results indicate inadequate prescription of ORS and excessive prescription of antibacterials, antidiarrhoeals and antiamoebics. Intervention strategies need to be planned to improve the prescribing practices of both groups.