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Shi H, Wang T, Zhao Z, Norback D, Wang X, Li Y, Deng Q, Lu C, Zhang X, Zheng X, Qian H, Zhang L, Yu W, Shi Y, Chen T, Yu H, Qi H, Yang Y, Jiang L, Lin Y, Yao J, Lu J, Yan Q. Prevalence, risk factors, impact and management of pneumonia among preschool children in Chinese seven cities: a cross-sectional study with interrupted time series analysis. BMC Med 2023; 21:227. [PMID: 37365601 DOI: 10.1186/s12916-023-02951-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/19/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Pneumonia is a common disease worldwide in preschool children. Despite its large population size, China has had no comprehensive study of the national prevalence, risk factors, and management of pneumonia among preschool children. We therefore investigated the prevalence of pneumonia among preschool children in Chinese seven representative cities, and explore the possible risk factors of pneumonia on children, with a view to calling the world's attention to childhood pneumonia to reduce the prevalence of childhood pneumonia. METHODS Two group samples of 63,663 and 52,812 preschool children were recruited from 2011 and 2019 surveys, respectively. Which were derived from the cross-sectional China, Children, Homes, Health (CCHH) study using a multi-stage stratified sampling method. This survey was conducted in kindergartens in seven representative cities. Exclusion criteria were younger than 2 years old or older than 8 years old, non-permanent population, basic information such as gender, date of birth and breast feeding is incomplete. Pneumonia was determined on the basis of parents reported history of clearly diagnosed by the physician. All participants were assessed with a standard questionnaire. Risk factors for pneumonia, and association between pneumonia and other respiratory diseases were examined by multivariable-adjusted analyses done in all participants for whom data on the variables of interest were available. Disease management was evaluated by the parents' reported history of physician diagnosis, longitudinal comparison of risk factors in 2011 and 2019. RESULTS In 2011 and 2019, 31,277 (16,152 boys and 15,125 girls) and 32,016 (16,621 boys and 15,395 girls) preschool children aged at 2-8 of permanent population completed the questionnaire, respectively, and were thus included in the final analysis. The findings showed that the age-adjusted prevalence of pneumonia in children was 32.7% in 2011 and 26.4% in 2019. In 2011, girls (odds ratio [OR] 0.91, 95%CI [confidence interval]0.87-0.96; p = 0.0002), rural (0.85, 0.73-0.99; p = 0.0387), duration of breastfeeding ≥ 6 months(0.83, 0.79-0.88; p < 0.0001), birth weight (g) ≥ 4000 (0.88, 0.80-0.97; p = 0.0125), frequency of putting bedding to sunshine (Often) (0.82, 0.71-0.94; p = 0.0049), cooking fuel type (electricity) (0.87, 0.80-0.94; p = 0.0005), indoor use air-conditioning (0.85, 0.80-0.90; p < 0.0001) were associated with a reduced risk of childhood pneumonia. Age (4-6) (1.11, 1.03-1.20; p = 0.0052), parental smoking (one) (1.12, 1.07-1.18; p < 0.0001), used antibiotics (2.71, 2.52-2.90; p < 0.0001), history of parental allergy (one and two) (1.21, 1.12-1.32; p < 0.0001 and 1.33, 1.04-1.69; p = 0.0203), indoor dampness (1.24, 1.15-1.33; p < 0.0001), home interior decoration (1.11, 1.04-1.19; p = 0.0013), Wall painting materials (Paint) (1.16, 1.04-1.29; p = 0.0084), flooring materials (Laminate / Composite wood) (1.08, 1.02-1.16; p = 0.0126), indoor heating mode(Central heating)(1.18, 1.07-1.30, p = 0.0090), asthma (2.38, 2.17-2.61; p < 0.0001), allergic rhinitis (1.36, 1.25-1.47; p < 0.0001), wheezing (1.64, 1.55-1.74; p < 0.0001) were associated with an elevated risk of childhood pneumonia; pneumonia was associated with an elevated risk of childhood asthma (2.53, 2.31-2.78; p < 0.0001), allergic rhinitis (1.41, 1.29-1.53; p < 0.0001) and wheezing (1.64, 1.55-1.74; p < 0.0001). In 2019, girls (0.92, 0.87-0.97; p = 0.0019), duration of breastfeeding ≥ 6 months (0.92, 0.87-0.97; p = 0.0031), used antibiotics (0.22, 0.21-0.24; p < 0.0001), cooking fuel type (Other) (0.40, 0.23-0.63; p = 0.0003), indoor use air-conditioning (0.89, 0.83-0.95; p = 0.0009) were associated with a reduced risk of childhood pneumonia. Urbanisation (Suburb) (1.10, 1.02-1.18; p = 0.0093), premature birth (1.29, 1.08-1.55; p = 0.0051), birth weight (g) < 2500 (1.17, 1.02-1.35; p = 0.0284), parental smoking (1.30, 1.23-1.38; p < 0.0001), history of parental asthma (One) (1.23, 1.03-1.46; p = 0.0202), history of parental allergy (one and two) (1.20, 1.13-1.27; p < 0.0001 and 1.22, 1.08-1.37; p = 0.0014), cooking fuel type (Coal) (1.58, 1.02-2.52; p = 0.0356), indoor dampness (1.16, 1.08-1.24; p < 0.0001), asthma (1.88, 1.64-2.15; p < 0.0001), allergic rhinitis (1.57, 1.45-1.69; p < 0.0001), wheezing (2.43, 2.20-2.68; p < 0.0001) were associated with an elevated risk of childhood pneumonia; pneumonia was associated with an elevated risk of childhood asthma (1.96, 1.72-2.25; p < 0.0001), allergic rhinitis (1.60, 1.48-1.73; p < 0.0001) and wheezing (2.49, 2.25-2.75; p < 0.0001). CONCLUSIONS Pneumonia is prevalent among preschool children in China, and it affects other childhood respiratory diseases. Although the prevalence of pneumonia in Chinese children shows a decreasing trend in 2019 compared to 2011, a well-established management system is still needed to further reduce the prevalence of pneumonia and reduce the burden of disease in children.
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Affiliation(s)
- Haonan Shi
- School of Nursing & Health Management, Shanghai University of Medicine & Health Sciences, No.279, Zhouzhu Highway, Pudong New District, Shanghai, 201318, China
| | - Tingting Wang
- School of Nursing & Health Management, Shanghai University of Medicine & Health Sciences, No.279, Zhouzhu Highway, Pudong New District, Shanghai, 201318, China.
| | - Zhuohui Zhao
- Department of Environmental Health, School of Public Health, Fudan University, Shanghai, 200433, China
- Key Lab of Public Health Safety of the Ministry of Education, NHC Key Lab of Health Technology Assessment (Fudan University), Shanghai, 200433, China
| | - Dan Norback
- Department of Medical Sciences, Occupational and Environmental Medicine, Uppsala University, SE-751, Uppsala, Sweden
| | - Xiaowei Wang
- Department of Operation and Security, Zhoupu Hospital Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, 201318, China
| | - Yongsheng Li
- Department of Preventive Medicine, Medical College, Shihezi University, Shihezi, 832002, China
| | - Qihong Deng
- School of Public Health, Central South University, Changsha, 410083, China
| | - Chan Lu
- School of Public Health, Central South University, Changsha, 410083, China
| | - Xin Zhang
- Research Center for Environmental Science and Engineering, Shanxi University, Taiyuan, 237016, China
| | - Xiaohong Zheng
- School of Energy and Environment, Southeast University, Nanjing, 214135, China
| | - Hua Qian
- School of Energy and Environment, Southeast University, Nanjing, 214135, China
| | - Ling Zhang
- Wuhan University of Science and Technology, Wuhan, 430081, China
| | - Wei Yu
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, 400044, China
- National Centre for International Research of Low-Carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, 400044, China
| | - Yuqing Shi
- Wuhan University of Science and Technology, Wuhan, 430081, China
| | - Tianyi Chen
- Department of Environmental Health, School of Public Health, Fudan University, Shanghai, 200433, China
| | - Huaijiang Yu
- People's Hospital of Bayingguoleng Mongolian Autonomous Prefecture, Kuerle, 841099, China
| | - Huizhen Qi
- Department of Neurology, The Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, China
| | - Ye Yang
- Department of No.1 Cadres, The Second Affiliated Hospital of Xinjiang Medical University, Urumqi, 830063, China
| | - Lan Jiang
- Department of Laboratory Medicine, Xinjiang Uyghur Autonomous Region Maternal and Child Health Hospital, Urumqi, 830001, China
| | - Yuting Lin
- Department of Laboratory Medicine, Xinjiang Uyghur Autonomous Region Maternal and Child Health Hospital, Urumqi, 830001, China
| | - Jian Yao
- School of Public Health, Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Special Environment and Health Research, Urumqi, 830054, China
| | - Junwen Lu
- School of Public Health, Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Special Environment and Health Research, Urumqi, 830054, China
| | - Qi Yan
- School of Public Health, Xinjiang Medical University, Urumqi, 830054, China
- Xinjiang Key Laboratory of Special Environment and Health Research, Urumqi, 830054, China
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Established and Novel Risk Factors for 30-Day Readmission Following Total Knee Arthroplasty: A Modified Delphi and Focus Group Study to Identify Clinically Important Predictors. J Clin Med 2023; 12:jcm12030747. [PMID: 36769396 PMCID: PMC9917714 DOI: 10.3390/jcm12030747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/03/2023] [Accepted: 01/14/2023] [Indexed: 01/20/2023] Open
Abstract
Thirty-day readmission following total knee arthroplasty (TKA) is an important outcome influencing the quality of patient care and health system efficiency. The aims of this study were (1) to ascertain the clinical importance of established risk factors for 30-day readmission risk and give clinicians the opportunity to suggest and discuss novel risk factors and (2) to evaluate consensus on the importance of these risk factors. This study was conducted in two stages: a modified Delphi survey followed by a focus group. Orthopaedic surgeons and anaesthetists involved in the care of TKA patients completed an anonymous survey to judge the clinical importance of risk factors selected from a systematic review and meta-analysis and to suggest other clinically meaningful risk factors, which were then discussed in a focus group designed using elements of nominal group technique. Eleven risk factors received a majority (≥50%) vote of high importance in the Delphi survey overall, and six risk factors received a majority vote of high importance in the focus group overall. Lack of consensus highlighted the fact that this is a highly complex problem which is challenging to predict and which depends heavily on risk factors which may be open to interpretation, difficult to capture, and dependent upon personal clinical experience, which must be tailored to the individual patient.
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Mvalo T, Smith AG, Eckerle M, Hosseinipour MC, Kondowe D, Vaidya D, Liu Y, Corbett K, Nansongole D, Mtimaukanena TA, Lufesi N, McCollum ED. Antibiotic treatment failure in children aged 1 to 59 months with World Health Organization-defined severe pneumonia in Malawi: A CPAP IMPACT trial secondary analysis. PLoS One 2022; 17:e0278938. [PMID: 36516197 PMCID: PMC9750006 DOI: 10.1371/journal.pone.0278938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Pneumonia is a leading cause of mortality in children <5 years globally. Early identification of hospitalized children with pneumonia who may fail antibiotics could improve outcomes. We conducted a secondary analysis from the Malawi CPAP IMPACT trial evaluating risk factors for antibiotic failure among children hospitalized with pneumonia. METHODS Participants were 1-59 months old with World Health Organization-defined severe pneumonia and hypoxemia, severe malnutrition, and/or HIV exposure/infection. All participants received intravenous antibiotics per standard care. First-line antibiotics were benzylpenicillin and gentamicin for five days. Study staff assessed patients for first-line antibiotic failure daily between days 3-6. When identified, patients failing antibiotics were switched to second-line ceftriaxone. Analyses excluded children receiving ceftriaxone and/or deceased by hospital day two. We compared characteristics between patients with and without treatment failure and fit multivariable logistic regression models to evaluate associations between treatment failure and admission characteristics. RESULTS From June 2015-March 2018, 644 children were enrolled and 538 analyzed. Antibiotic failure was identified in 251 (46.7%) participants, and 19/251 (7.6%) died. Treatment failure occurred more frequently with severe malnutrition (50.2% (126/251) vs 28.2% (81/287), p<0.001) and amongst those dwelling ≥10km from a health facility (22.3% (56/251) vs 15.3% (44/287), p = 0.026). Severe malnutrition occurred more frequently among children living ≥10km from a health facility than those living <10km (49.0% (49/100) vs 35.7% (275/428), p = 0.014). Children with severe malnutrition (adjusted odds ratio (aOR) 2.2 (95% CI 1.52, 3.24), p<0.001) and pre-hospital antibiotics ((aOR 1.47, 95% CI 1.01, 2.14), p = 0.043) had an elevated aOR for antibiotic treatment failure. CONCLUSION Severe malnutrition and pre-hospital antibiotic use predicted antibiotic treatment failure in this high-risk severe pneumonia pediatric population in Malawi. Our findings suggest addressing complex sociomedical conditions like severe malnutrition and improving pneumonia etiology diagnostics will be key for better targeting interventions to improve childhood pneumonia outcomes.
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Affiliation(s)
- Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- * E-mail:
| | - Andrew G. Smith
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States of America
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
- Division of Pediatric Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, United States of America
| | - Mina C. Hosseinipour
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Division of Infectious Disease, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Davie Kondowe
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Dhananjay Vaidya
- Department of Medicine, Epidemiology and the BEAD Core, Johns Hopkins University, Baltimore, MD, United States of America
| | - Yisi Liu
- Department of Pediatrics and the BEAD Core, Johns Hopkins University, Baltimore, MD, United States of America
| | - Kelly Corbett
- Department of Pediatrics, Section of Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America
| | - Dan Nansongole
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | | | - Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Global Program for Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
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Baker K, Petzold M, Mucunguzi A, Wharton-Smith A, Dantzer E, Habte T, Matata L, Nanyumba D, Okwir M, Posada M, Sebsibe A, Nicholson J, Marasciulo M, Izadnegahdar R, Alfvén T, Källander K. Performance of five pulse oximeters to detect hypoxaemia as an indicator of severe illness in children under five by frontline health workers in low resource settings - A prospective, multicentre, single-blinded, trial in Cambodia, Ethiopia, South Sudan, and Uganda. EClinicalMedicine 2021; 38:101040. [PMID: 34368660 PMCID: PMC8326731 DOI: 10.1016/j.eclinm.2021.101040] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/30/2021] [Accepted: 07/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Low blood oxygen saturation (SpO2), or hypoxaemia, is an indicator of severe illness in children. Pulse oximetry is a globally accepted, non-invasive method to identify hypoxaemia, but rarely available outside higher-level facilities in resource-constrained countries. This study aims to evaluate the performance of different types of pulse oximeters amongst frontline health workers in Cambodia, Ethiopia, South Sudan, and Uganda. METHODS Five pulse oximeters (POx) which passed laboratory testing, out of an initial 32 potential pulse oximeters, were evaluated by frontline health workers for performance, defined as agreement between the SpO2 measurements of the test device and the reference standard. The study protocol is registered with the Australia New Zealand Clinical Trials Registry (Ref: ACTRrn12615000348550). FINDINGS Two finger-tip pulse oximeters (Contec and Devon), two handheld pulse oximeters (Lifebox and Utech), and one phone pulse oximeter (Masimo) passed the laboratory testing. They were evaluated for performance on 1,313 children under five years old by 207 frontline health workers between February and May 2015. Phone and handheld pulse oximeters had greater overall agreement with the reference standard (56%; 95% CI 0.52 - 0.60 to 68%; 95% CI 0.65 - 0.71) than the finger-tip POx (31%; 95% CI 0.26 to 0.36 and 47%; 95% CI 0.42 to 0.52). Fingertip POx performance was substantially lower in the 0-2 month olds; having just 17% and 25% agreement. The finger-tip devices more often underreported SpO2 readings (mean difference -7.9%; 95%CI -8.6,-7.2 and -3.9%; 95%CI -4.4,-3.4), and therefore over diagnosed hypoxaemia in the children assessed. INTERPRETATION While the Masimo phone pulse oximeter performed best, all handheld POx with age-specific probes performed well in the hands of frontline health workers, further highlighting their suitability as a screening tool of severe illness. The poor performance of the fingertip POx suggests they should not be used in children under five by frontline health workers. It is essential that POx are performance tested on children in routine settings (in vivo), not only in laboratories or controlled settings (in vitro), before being introduced at scale. FUNDING Bill & Melinda Gates Foundation [OPP1054367].
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Affiliation(s)
- Kevin Baker
- Malaria Consortium, London, United Kingdom
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Corresponding author at: Kevin Baker, Malaria Consortium, The Green House, 244-254 Cambridge Heath Road, London, E2 9DA
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | | | | | | | | | | | | | | | | | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Sachs’ Children and Youth Hospital, Stockholm, Sweden
| | - Karin Källander
- Malaria Consortium, London, United Kingdom
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Programme Division, Health Section, UNICEF, New York, United States
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5
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Crocker ME, Hossen S, Goodman D, Simkovich SM, Kirby M, Thompson LM, Rosa G, Garg SS, Thangavel G, McCollum ED, Peel J, Clasen T, Checkley W. Effects of high altitude on respiratory rate and oxygen saturation reference values in healthy infants and children younger than 2 years in four countries: a cross-sectional study. Lancet Glob Health 2020; 8:e362-e373. [PMID: 32087173 PMCID: PMC7034060 DOI: 10.1016/s2214-109x(19)30543-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/10/2019] [Accepted: 12/16/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND In resource-limited settings, pneumonia diagnosis and management are based on thresholds for respiratory rate (RR) and oxyhaemoglobin saturation (SpO2) recommended by WHO. However, as RR increases and SpO2 decreases with elevation, these thresholds might not be applicable at all altitudes. We sought to determine upper thresholds for RR and lower thresholds for SpO2 by age and altitude at four sites, with altitudes ranging from sea level to 4348 m. METHODS In this cross-sectional study, we enrolled healthy children aged 0-23 months who lived within the study areas in India, Guatemala, Rwanda, and Peru. Participants were excluded if they had been born prematurely (<37 weeks gestation); had a congenital heart defect; had history in the past 2 weeks of overnight admission to a health facility, diagnosis of pneumonia, antibiotic use, or respiratory or gastrointestinal signs; history in the past 24 h of difficulty breathing, fast breathing, runny nose, or nasal congestion; and current runny nose, nasal congestion, fever, chest indrawing, or cyanosis. We measured RR either automatically with the Masimo Rad-97, manually, or both, and measured SpO2 with the Rad-97. Trained staff measured RR in duplicate and SpO2 in triplicate in children who had no respiratory symptoms or signs in the past 2 weeks. We estimated smooth percentiles for RR and SpO2 that varied by age and site using generalised additive models for location, shape, and scale. We compared these data with WHO RR and SpO2 thresholds for tachypnoea and hypoxaemia to determine agreement. FINDINGS Between Nov 24, 2017, and Oct 10, 2018, we screened 2027 children for eligibility. 335 were ineligible, leaving 1692 eligible participants. 30 children were excluded because of missing values and 92 were excluded because of measurement or data entry errors, leaving 1570 children in the final analysis. 404 participants were from India (altitude 1-919 m), 389 were from Guatemala (1036-2017 m), 341 from Rwanda (1449-1644 m), and 436 from Peru (3827-4348 m). Mean age was 7·2 months (SD 7·2) and 796 (50·7%) of 1570 participants were female. Although average age was mostly similar between settings, the average participant age in Rwanda was noticeably younger, at 5·5 months (5·9). In the 1570 children included in the analysis, mean RR was 31·9 breaths per min (SD 7·1) in India, 41·5 breaths per min in Guatemala (8·4), 44·0 breaths per min in Rwanda (10·8), and 48·0 breaths per min in Peru (9·4). Mean SpO2 was 98·3% in India (SD 1·5), 97·3% in Guatemala (2·4), 96·2% in Rwanda (2·6), and 89·7% in Peru (3·5). Compared to India, mean RR was 9·6 breaths per min higher in Guatemala, 12·1 breaths per min higher in Rwanda, and 16·1 breaths per min higher in Peru (likelihood ratio test p<0·0001). Smooth percentiles for RR and SpO2 varied by site and age. When we compared age-specific and site-specific 95th percentiles for RR and 5th percentiles for SpO2 against the WHO cutoffs, we found that the proportion of false positives for tachypnoea increased with altitude: 0% in India (95% CI 0-0), 7·3% in Guatemala (4·1-10·4), 16·8% in Rwanda (12·9-21·1), and 28·9% in Peru (23·7-33·0). We also found a high proportion of false positives for hypoxaemia in Peru (11·6%, 95% CI 7·0-14·7). INTERPRETATION WHO cutoffs for fast breathing and hypoxaemia overlap with RR and SpO2 values that are normal for children in different altitudes. Use of WHO definitions for fast breathing could result in misclassification of pneumonia in many children who live at moderate to high altitudes and show acute respiratory signs. The 5th percentile for SpO2 was in reasonable agreement with the WHO definition of hypoxaemia in all regions except for Peru (the highest altitude site). Misclassifications could result in inappropriate management of paediatric respiratory illness and misdirection of potentially scarce resources such as antibiotics and supplemental oxygen. Future studies at various altitudes are needed to validate our findings and recommend a revision to current guidelines. Substantiating research in sick children is still needed. FUNDING US National Institutes of Health, Bill & Melinda Gates Foundation.
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Affiliation(s)
- Mary E Crocker
- Department of Paediatrics, School of Medicine, University of Washington, Seattle, WA, USA; Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Shakir Hossen
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dina Goodman
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suzanne M Simkovich
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miles Kirby
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Lisa M Thompson
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Ghislaine Rosa
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarada S Garg
- Department of Environmental Health Engineering, ICMR Centre for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Gurusamy Thangavel
- Department of Environmental Health Engineering, ICMR Centre for Advanced Research on Air Quality, Climate and Health, Sri Ramachandra Institute of Higher Education and Research (SRIHER), Chennai, India
| | - Eric D McCollum
- Eudowood Division of Paediatric Respiratory Sciences, Department of Paediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Peel
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - 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 School of Medicine, Baltimore, MD, USA; Centre for Global Non-Communicable Disease Research and Training, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Marangu D, Zar HJ. Childhood pneumonia in low-and-middle-income countries: An update. Paediatr Respir Rev 2019; 32:3-9. [PMID: 31422032 PMCID: PMC6990397 DOI: 10.1016/j.prrv.2019.06.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To review epidemiology, aetiology and management of childhood pneumonia in low-and-middle-income countries. DESIGN Review of published English literature between 2013 and 2019. RESULTS Pneumonia remains a major cause of morbidity and mortality. Risk factors include young age, malnutrition, immunosuppression, tobacco smoke or air pollution exposure. Better methods for specimen collection and molecular diagnostics have improved microbiological diagnosis, indicating that pneumonia results from several organisms interacting. Induced sputum increases microbiologic yield for Bordetella pertussis or Mycobacterium tuberculosis, which has been associated with pneumonia in high TB prevalence areas. The proportion of cases due to Streptococcus pneumoniae and Haemophilus influenzae b has declined with new conjugate vaccines; Staphylococcus aureus and H. influenzae non-type b are the commonest bacterial pathogens; viruses are the most common pathogens. Effective interventions comprise antibiotics, oxygen and non-invasive ventilation. New vaccines have reduced severity and incidence of disease, but disparities exist in uptake. CONCLUSION Morbidity and mortality from childhood pneumonia has decreased but a considerable preventable burden remains. Widespread implementation of available, effective interventions and development of novel strategies are needed.
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MESH Headings
- Age Factors
- Air Pollution/statistics & numerical data
- Anti-Bacterial Agents/therapeutic use
- Child Nutrition Disorders/epidemiology
- Child, Preschool
- Developing Countries
- Haemophilus Infections/epidemiology
- Haemophilus Infections/microbiology
- Haemophilus Infections/prevention & control
- Haemophilus Infections/therapy
- Humans
- Infant
- Infant, Newborn
- Noninvasive Ventilation/methods
- Oxygen Inhalation Therapy/methods
- Pneumonia/epidemiology
- Pneumonia/microbiology
- Pneumonia/prevention & control
- Pneumonia/therapy
- Pneumonia, Pneumococcal/epidemiology
- Pneumonia, Pneumococcal/microbiology
- Pneumonia, Pneumococcal/prevention & control
- Pneumonia, Pneumococcal/therapy
- Pneumonia, Staphylococcal/epidemiology
- Pneumonia, Staphylococcal/microbiology
- Pneumonia, Staphylococcal/therapy
- Risk Factors
- Tobacco Smoke Pollution/statistics & numerical data
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Pulmonary/microbiology
- Tuberculosis, Pulmonary/prevention & control
- Tuberculosis, Pulmonary/therapy
- Vaccines/therapeutic use
- Whooping Cough/epidemiology
- Whooping Cough/microbiology
- Whooping Cough/prevention & control
- Whooping Cough/therapy
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Affiliation(s)
- Diana Marangu
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya; Department of Paediatrics and Child Health and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health and SA Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa.
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7
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McCollum ED, Brown SP, Nkwopara E, Mvalo T, May S, Ginsburg AS. Development of a prognostic risk score to aid antibiotic decision-making for children aged 2-59 months with World Health Organization fast breathing pneumonia in Malawi: An Innovative Treatments in Pneumonia (ITIP) secondary analysis. PLoS One 2019; 14:e0214583. [PMID: 31220085 PMCID: PMC6586284 DOI: 10.1371/journal.pone.0214583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 03/14/2019] [Indexed: 01/19/2023] Open
Abstract
Background Due to increasing antimicrobial resistance in low-resource settings, strategies to rationalize antibiotic treatment of children unlikely to have a bacterial infection are needed. This study’s objective was to utilize a database of placebo treated Malawian children with World Health Organization (WHO) fast breathing pneumonia to develop a prognostic risk score that could aid antibiotic decision making. Methods We conducted a secondary analysis of children randomized to the placebo group of the Innovative Treatments in Pneumonia (ITIP) fast breathing randomized, controlled, noninferiority trial. Participants were low-risk HIV-uninfected children 2–59 months old with WHO fast breathing pneumonia in Lilongwe, Malawi. Study endpoints were treatment failure, defined as either disease progression at any time on or before Day 4 of treatment or disease persistence on Day 4, or relapse, considered as the recurrence of pneumonia or severe disease among previously cured children between Days 5 and 14. We utilized multivariable linear regression and stepwise model selection to develop a model to predict the probability of treatment failure or relapse. Results Treatment failure or relapse occurred in 11.5% (61/526) of children included in this analysis. The final model incorporated the following predictors: heart rate terms, mid-upper arm circumference, malaria status, water source, family income, and whether or not a sibling or other child in the household received childcare outside the home. The model’s area under the receiver operating characteristic score was 0.712 (95% confidence interval 0.66, 0.78) and it explained 6.1% of the variability in predicting treatment failure or relapse (R2, 0.061). For the model to categorize all children with treatment failure or relapse correctly, 77% of children without treatment failure or relapse would require antibiotics. Conclusion The model had inadequate discrimination to be appropriate for clinical application. Different strategies will likely be required for models to perform accurately among similar pediatric populations.
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Affiliation(s)
- Eric D. McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- * E-mail:
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle, Washington, United States of America
| | | | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Susanne May
- Department of Biostatistics, University of Washington Clinical Trial Center, Seattle, Washington, United States of America
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8
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Adaji EE, Ekezie W, Clifford M, Phalkey R. Understanding the effect of indoor air pollution on pneumonia in children under 5 in low- and middle-income countries: a systematic review of evidence. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2019; 26:3208-3225. [PMID: 30569352 PMCID: PMC6513791 DOI: 10.1007/s11356-018-3769-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 11/15/2018] [Indexed: 04/12/2023]
Abstract
Exposure to indoor air pollution increases the risk of pneumonia in children, accounting for about a million deaths globally. This study investigates the individual effect of solid fuel, carbon monoxide (CO), black carbon (BC) and particulate matter (PM)2.5 on pneumonia in children under 5 in low- and middle-income countries. A systematic review was conducted to identify peer-reviewed and grey full-text documents without restrictions to study design, language or year of publication using nine databases (Embase, PubMed, EBSCO/CINAHL, Scopus, Web of Knowledge, WHO Library Database (WHOLIS), Integrated Regional Information Networks (IRIN), the World Meteorological Organization (WMO)-WHO and Intergovernmental Panel on Climate Change (IPCC). Exposure to solid fuel use showed a significant association to childhood pneumonia. Exposure to CO showed no association to childhood pneumonia. PM2.5 did not show any association when physically measured, whilst eight studies that used solid fuel as a proxy for PM2.5 all reported significant associations. This review highlights the need to standardise measurement of exposure and outcome variables when investigating the effect of air pollution on pneumonia in children under 5. Future studies should account for BC, PM1 and the interaction between indoor and outdoor pollution and its cumulative impact on childhood pneumonia.
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Affiliation(s)
- Enemona Emmanuel Adaji
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham City Hospital, Clinical Sciences Building, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - Winifred Ekezie
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham City Hospital, Clinical Sciences Building, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Michael Clifford
- Faculty of Engineering, University of Nottingham, Nottingham, UK
| | - Revati Phalkey
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham City Hospital, Clinical Sciences Building, Hucknall Road, Nottingham, NG5 1PB, UK
- Climate Change and Human Health Group, Institute for Public Health, University of Heidelberg, Heidelberg, Germany
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9
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King C, Nightingale R, Phiri T, Zadutsa B, Kainja E, Makwenda C, Colbourn T, Stevenson F. Non-adherence to oral antibiotics for community paediatric pneumonia treatment in Malawi - A qualitative investigation. PLoS One 2018; 13:e0206404. [PMID: 30379968 PMCID: PMC6209296 DOI: 10.1371/journal.pone.0206404] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/14/2018] [Indexed: 11/24/2022] Open
Abstract
Background Pneumonia remains the leading cause of paediatric infectious mortality globally. Treatment failure, which can result from non-adherence to oral antibiotics, can lead to poor outcomes and therefore improving adherence could be a strategy to reduce pneumonia related morbidity and mortality. However, there is little published evidence from low-resource settings for the drivers of non-adherence to oral antibiotics in children. Objective We aimed to investigate reasons for adherence and non-adherence in children diagnosed and treated in the community with fast-breathing pneumonia in rural Malawi. Methods We conducted focus group discussions (FGDs) with caregivers of children known to have been diagnosed and treated with oral antibiotics for fast-breathing pneumonia in the community and key informant interviews with community healthcare workers (CHW). FGDs and interviews were conducted within communities in Chichewa, the local language. We used a framework approach to analyze the transcripts. Results We conducted 4 FGDs with caregivers and 10 interviews with CHWs. We identified four themes, which were common across caregivers and CHWs: knowledge and understanding, effort, medication perceptions and community influences. Caregivers and CHWs demonstrated good knowledge of pneumonia and types of treatment, but caregivers showed confusion around dosing and treatment durations. Effort was needed to seek care, prepare medication and understand regimens, acting as a barrier to adherence. Perceptions of how well the treatment was working influenced adherence, with both quick recovery and slow recovery leading to non-adherence. Community influences were both supportive, with transport assistance for referrals and home visits to improve adherence, and detrimental, with pressure to share treatments. Conclusion Adherence to oral antibiotic treatment for fast-breathing pneumonia was understood to be important, however considerable barriers we described within this rural low-resource setting, such as the effort preparing and administering medication, community pressures to share drugs and potential complexity of regimens.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, United Kingdom
- * E-mail:
| | | | - Tambosi Phiri
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | - Esther Kainja
- Parent and Child Health Initiative, Lilongwe, Malawi
| | | | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - Fiona Stevenson
- Research Department of Primary Care and Population Health, University College London, London, United Kingdom
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10
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Spence H, Baker K, Wharton-Smith A, Mucunguzi A, Matata L, Habte T, Nanyumba D, Sebsibe A, Thany T, Källander K. Childhood pneumonia diagnostics: community health workers' and national stakeholders' differing perspectives of new and existing aids. Glob Health Action 2018; 10:1290340. [PMID: 28485694 PMCID: PMC5496071 DOI: 10.1080/16549716.2017.1290340] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Pneumonia heavily contributes to global under-five mortality. Many countries use community case management to detect and treat childhood pneumonia. Community health workers (CHWs) have limited tools to help them assess signs of pneumonia. New respiratory rate (RR) counting devices and pulse oximeters are being considered for this purpose. Objective: To explore perspectives of CHWs and national stakeholders regarding the potential usability and scalability of seven devices to aid community assessment of pneumonia signs. Design: Pile sorting was conducted to rate the usability and scalability of 7 different RR counting aids and pulse oximeters amongst 16 groups of participants. Following each pile-sorting session, a focus group discussion (FGD) explored participants’ sorting rationale. Purposive sampling was used to select CHWs and national stakeholders with experience in childhood pneumonia and integrated community case management (iCCM) in Cambodia, Ethiopia, Uganda and South Sudan. Pile-sorting data were aggregated for countries and participant groups. FGDs were audio recorded and transcribed verbatim. Translated FGDs transcripts were coded in NVivo 10 and analysed using thematic content analysis. Comparative analysis was performed between countries and groups to identify thematic patterns. Results: CHWs and national stakeholders across the four countries perceived the acute respiratory infection (ARI) timer and fingertip pulse oximeter as highly scalable and easy for CHWs to use. National stakeholders were less receptive to new technologies. CHWs placed greater priority on device acceptability to caregivers and children. Both groups felt that heavy reliance on electricity reduced potential scalability and usability in rural areas. Device simplicity, affordability and sustainability were universally valued. Conclusions: CHWs and national stakeholders prioritise different device characteristics according to their specific focus of work. The views of all relevant stakeholders, including health workers, policy makers, children and parents, should be considered in future policy decisions, research and development regarding suitable pneumonia diagnostic aids for community use.
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Affiliation(s)
- Hollie Spence
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Kevin Baker
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,b Malaria Consortium , London , UK
| | | | | | | | | | | | | | - Thol Thany
- c Malaria Consortium , Phnom Penh , Cambodia
| | - Karin Källander
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,b Malaria Consortium , London , UK
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11
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Mathur S, Fuchs A, Bielicki J, Van Den Anker J, Sharland M. Antibiotic use for community-acquired pneumonia in neonates and children: WHO evidence review. Paediatr Int Child Health 2018; 38:S66-S75. [PMID: 29790844 PMCID: PMC6176769 DOI: 10.1080/20469047.2017.1409455] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Pneumonia is the most common cause of death in children worldwide, accounting for 15% of all deaths of children under 5 years of age. This review summarises the evidence for the empirical antibiotic treatment of community-acquired pneumonia in neonates and children and puts emphasis on publications since the release of the previous WHO Evidence Summary report published in 2014. Methods A systematic search for systematic reviews and meta-analyses of antibiotic therapy for community-acquired pneumonia was conducted between 1 January 2013 and 10 November 2016. Results The optimal dosing recommendation for amoxicillin remains unclear with limited pharmacological and clinical evidence. There is limited evidence from surveillance to indicate whether amoxicillin or broader spectrum antibiotics (e.g. third-generation cephalosporins) are being used most commonly for paediatric CAP in different WHO regions. Data are lacking on clinical efficacy in the context of pneumococcal, staphylococcal and mycoplasma disease and the relative contributions of varying first-line and step-down options to the selection of such resistance. Conclusion Further pragmatic trials are required to optimise management of hospitalised children with severe and very severe pneumonia.
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Key Words
- AAD, antibiotic-associated diarrhoea
- BNFc, British National Formulary for Children
- BTS, British Thoracic Society
- CAP, community-acquired pneumonia
- CPS, Canadian Paediatric Society
- EARS-Net, European Antimicrobial Resistance Surveillance Network
- ESPID, European Society for Paediatric Infectious Diseases
- GRADE, Grading of Recommendations Assessment, Development and Evaluation
- IDSA, Infectious Diseases Society of America
- IMCI, integrated management of childhood illness
- PCV, pneumococcal conjugate vaccine
- PIDS, Pediatric Infectious Diseases Society
- Pneumonia
- RCPCH, Royal College of Paediatrics and Child Health
- WHO, World Health Organization
- antimicrobial resistance
- bacterial
- community-acquired pneumonia
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Affiliation(s)
- Shrey Mathur
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK,Corresponding author.
| | - Aline Fuchs
- Paediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, Basel, Switzerland
| | - Julia Bielicki
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK,Paediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, Basel, Switzerland
| | - Johannes Van Den Anker
- Paediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, Basel, Switzerland,Division of Clinical Pharmacology, Children’s National Health System, Washington, DC, USA
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
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12
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Update on Prevention Efforts for Pneumonia Attributed Deaths in Children Under 5 Years of Age. CURRENT TROPICAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40475-018-0138-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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McCollum ED, King C, Hammitt LL, Ginsburg AS, Colbourn T, Baqui AH, O'Brien KL. Reduction of childhood pneumonia mortality in the Sustainable Development era. THE LANCET. RESPIRATORY MEDICINE 2016; 4:932-933. [PMID: 27843130 PMCID: PMC5495600 DOI: 10.1016/s2213-2600(16)30371-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 10/12/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, MA, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA.
| | - Carina King
- Institute for Global Health, University College London, London, UK
| | - Laura L Hammitt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA; Kenya Medical Research Institute, Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Katherine L O'Brien
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
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14
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Nightingale R, Colbourn T, Mukanga D, Mankhambo L, Lufesi N, McCollum ED, King C. Non-adherence to community oral-antibiotic treatment in children with fast-breathing pneumonia in Malawi- secondary analysis of a prospective cohort study. Pneumonia (Nathan) 2016; 8:21. [PMID: 28702300 PMCID: PMC5471995 DOI: 10.1186/s41479-016-0024-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/03/2016] [Indexed: 11/13/2022] Open
Abstract
Background Despite significant progress, pneumonia is still the leading cause of infectious deaths in children under five years of age. Poor adherence to antibiotics has been associated with treatment failure in World Health Organisation (WHO) defined clinical pneumonia; therefore, improving adherence could improve outcomes in children with fast-breathing pneumonia. We examined clinical factors that may affect adherence to oral antibiotics in children in the community setting in Malawi. Methods We conducted a sub-analysis of a prospective cohort of children aged 2–59 months diagnosed by community health workers (CHW) in rural Malawi with WHO fast-breathing pneumonia. Clinical factors identified during CHW diagnosis were investigated using multivariate logistic regression for association with non-adherence, including concurrent diagnoses and treatments. Adherence was measured at both 80% and 100% completion of prescribed oral antibiotics. Results Eight hundred thirty-four children were included in our analysis, of which 9.5% and 20.0% were non-adherent at 80% and 100% of treatment completion, respectively. A concurrent infectious diagnosis (OR: 1.76, 95% CI: 0.84–2.96/OR: 1.81, 95% CI: 1.21–2.71) and an illness duration of >24 h prior to diagnosis (OR: 2.14, 95% CI: 1.27–3.60/OR: 1.88, 95% CI: 1.29–2.73) had higher odds of non-adherence when measured at both 80% and 100%. Older age was associated with lower odds of non-adherence when measured at 80% (OR: 0.41, 95% CI: 0.21–0.78). Conclusion Non-adherence to oral antibiotics was not uncommon in this rural sub-Saharan African setting. As multiple diagnoses by the CHW and longer illness were important factors, this provides an opportunity for further investigation into targeted interventions and refinement of referral guidelines at the community level. Further research into the behavioural drivers of non-adherence within this setting is needed.
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Affiliation(s)
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - David Mukanga
- Science and Health Impact Group (SHI), Kampala, Uganda
| | | | - Norman Lufesi
- Acute Respiratory Infection Unit, Ministry of Health, Lilongwe, Malawi
| | - Eric D McCollum
- Department of Pediatrics, Division of Pulmonology, Johns Hopkins School of Medicine, Baltimore, USA
| | - Carina King
- Institute for Global Health, University College London, London, UK
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15
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McCollum ED, King C, Deula R, Zadutsa B, Mankhambo L, Nambiar B, Makwenda C, Masache G, Lufesi N, Mwansambo C, Costello A, Colbourn T. Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi. Bull World Health Organ 2016; 94:893-902. [PMID: 27994282 PMCID: PMC5153930 DOI: 10.2471/blt.16.173401] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/13/2016] [Accepted: 08/15/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate implementation of outpatient pulse oximetry among children with pneumonia, in Malawi. METHODS In 2011, 72 health-care providers at 18 rural health centres and 38 community health workers received training in the use of pulse oximetry to measure haemoglobin oxygen saturations. Data collected, between 1 January 2012 and 30 June 2014 by the trained individuals, on children aged 2-59 months with clinically diagnosed pneumonia were analysed. FINDINGS Of the 14 092 children included in the analysis, 13 266 (94.1%) were successfully checked by oximetry. Among the children with chest indrawing and/or danger signs, those with a measured oxygen saturation below 90% were more than twice as likely to have been referred as those with higher saturations (84.3% [385/457] vs 41.5% [871/2099]; P < 0.001). The availability of oximetry appeared to have increased the referral rate for severely hypoxaemic children without chest indrawing or danger signs from 0% to 27.2% (P < 0.001). In the absence of oximetry, if the relevant World Health Organization (WHO) guidelines published in 2014 had been applied, 390/568 (68.7%) severely hypoxaemic children at study health centres and 52/84 (61.9%) severely hypoxaemic children seen by community health workers would have been considered ineligible for referral. CONCLUSION Implementation of pulse oximetry by our trainees substantially increased the referrals of Malawian children with severe hypoxaemic pneumonia. When data from oximetry were excluded, retrospective application of the guidelines published by WHO in 2014 failed to identify a considerable proportion of severely hypoxaemic children eligible only via oximetry.
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Affiliation(s)
- Eric D McCollum
- Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Rubenstein Building, 200 North Wolfe Street, Baltimore, MD 21287, United States of America
| | - Carina King
- Institute for Global Health, University College London, London, England
| | - Rashid Deula
- Parent and Child Health Initiative Trust, Lilongwe, Malawi
| | | | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, England
| | | | - Gibson Masache
- Parent and Child Health Initiative Trust, Lilongwe, Malawi
| | | | | | - Anthony Costello
- Institute for Global Health, University College London, London, England
| | - Tim Colbourn
- Institute for Global Health, University College London, London, England
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16
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King C, McCollum ED, Mankhambo L, Colbourn T, Beard J, Hay Burgess DC, Costello A, Izadnegahdar R, Lufesi N, Masache G, Mwansambo C, Nambiar B, Johnson E, Platt R, Mukanga D. Can We Predict Oral Antibiotic Treatment Failure in Children with Fast-Breathing Pneumonia Managed at the Community Level? A Prospective Cohort Study in Malawi. PLoS One 2015; 10:e0136839. [PMID: 26313752 PMCID: PMC4551481 DOI: 10.1371/journal.pone.0136839] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 08/10/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pneumonia is the leading cause of infectious death amongst children globally, with the highest burden in Africa. Early identification of children at risk of treatment failure in the community and prompt referral could lower mortality. A number of clinical markers have been independently associated with oral antibiotic failure in childhood pneumonia. This study aimed to develop a prognostic model for fast-breathing pneumonia treatment failure in sub-Saharan Africa. METHOD We prospectively followed a cohort of children (2-59 months), diagnosed by community health workers with fast-breathing pneumonia using World Health Organisation (WHO) integrated community case management guidelines. Cases were followed at days 5 and 14 by study data collectors, who assessed a range of pre-determined clinical features for treatment outcome. We built the prognostic model using eight pre-defined parameters, using multivariable logistic regression, validated through bootstrapping. RESULTS We assessed 1,542 cases of which 769 were included (32% ineligible; 19% defaulted). The treatment failure rate was 15% at day 5 and relapse was 4% at day 14. Concurrent malaria diagnosis (OR: 1.62; 95% CI: 1.06, 2.47) and moderate malnutrition (OR: 1.88; 95% CI: 1.09, 3.26) were associated with treatment failure. The model demonstrated poor calibration and discrimination (c-statistic: 0.56). CONCLUSION This study suggests that it may be difficult to create a pragmatic community-level prognostic child pneumonia tool based solely on clinical markers and pulse oximetry in an HIV and malaria endemic setting. Further work is needed to identify more accurate and reliable referral algorithms that remain feasible for use by community health workers.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, United Kingdom
| | - Eric D. McCollum
- Institute for Global Health, University College London, London, United Kingdom
- Department of Pediatrics, Division of Pulmonology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | | | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | - James Beard
- Institute for Global Health, University College London, London, United Kingdom
| | | | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom
| | - Raza Izadnegahdar
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Norman Lufesi
- Acute Respiratory Infection Unit, Ministry of Health, Lilongwe, Malawi
| | | | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, United Kingdom
| | - Eric Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | | | - David Mukanga
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
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