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Wilkes C, Bava M, Graham HR, Duke T. What are the risk factors for death among children with pneumonia in low- and middle-income countries? A systematic review. J Glob Health 2023; 13:05003. [PMID: 36825608 PMCID: PMC9951126 DOI: 10.7189/jogh.13.05003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background Knowledge of the risk factors for and causes of treatment failure and mortality in childhood pneumonia is important for prevention, diagnosis, and treatment at an individual and population level. This review aimed to identify the most important risk factors for mortality among children aged under ten years with pneumonia. Methods We systematically searched MEDLINE, EMBASE, and PubMed for observational and interventional studies reporting risk factors for mortality in children (aged two months to nine years) in low- and middle-income countries (LMICs). We screened articles according to specified inclusion and exclusion criteria, assessed risk of bias using the EPHPP framework, and extracted data on demographic, clinical, and laboratory risk factors for death. We synthesized data descriptively and using Forest plots and did not attempt meta-analysis due to the heterogeneity in study design, definitions, and populations. Findings We included 143 studies in this review. Hypoxaemia (low blood oxygen level), decreased conscious state, severe acute malnutrition, and the presence of an underlying chronic condition were the risk factors most strongly and consistently associated with increased mortality in children with pneumonia. Additional important clinical factors that were associated with mortality in the majority of studies included particular clinical signs (cyanosis, pallor, tachypnoea, chest indrawing, convulsions, diarrhoea), chronic comorbidities (anaemia, HIV infection, congenital heart disease, heart failure), as well as other non-severe forms of malnutrition. Important demographic factors associated with mortality in the majority of studies included age <12 months and inadequate immunisation. Important laboratory and investigation findings associated with mortality in the majority of studies included: confirmed Pneumocystis jirovecii pneumonia (PJP), consolidation on chest x-ray, pleural effusion on chest x-ray, and leukopenia. Several other demographic, clinical and laboratory findings were associated with mortality less consistently or in a small numbers of studies. Conclusions Risk assessment for children with pneumonia should include routine evaluation for hypoxaemia (pulse oximetry), decreased conscious state (e.g. AVPU), malnutrition (severe, moderate, and stunting), and the presence of an underlying chronic condition as these are strongly and consistently associated with increased mortality. Other potentially useful risk factors include the presence of pallor or anaemia, chest indrawing, young age (<12 months), inadequate immunisation, and leukopenia.
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Affiliation(s)
- Chris Wilkes
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Mohamed Bava
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Hamish R Graham
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia,Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Trevor Duke
- Murdoch Children’s Research Institution, Royal Children’s Hospital, Parkville, Victoria, Australia,Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, Australia
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Jambo A, Gashaw T, Mohammed AS, Edessa D. Treatment outcomes and its associated factors among pneumonia patients admitted to public hospitals in Harar, eastern Ethiopia: a retrospective follow-up study. BMJ Open 2023; 13:e065071. [PMID: 36792331 PMCID: PMC9933768 DOI: 10.1136/bmjopen-2022-065071] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 02/01/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE Although there is a high risk of drug resistance, empiric treatment is a common approach for pneumonia management. In this respect, it is relevant to know treatment outcomes of patients with pneumonia. This study aimed to assess treatment outcomes and its associated factors among pneumonia patients treated at two public hospitals in Harar, eastern Ethiopia. DESIGN Retrospective follow-up study. SETTING Jugal General Hospital and Hiwot Fana Specialised University Hospital in Harar, eastern Ethiopia. PARTICIPANTS Patients admitted and treated for pneumonia in the two public hospitals in eastern Ethiopia between April 2020 and April 2021. PRIMARY OUTCOME The primary outcome was unfavourable treatment outcome (died or transferred to intensive care unit) for pneumonia patients. RESULTS A total of 693 patients with pneumonia were included in the study. 88 (12.7%) of these patients had an unfavourable treatment outcome, which included 14 (2%) transfers to the intensive care unit and 74 (10.7%) deaths. Patients with comorbidity (adjusted OR, AOR=2.96; 95% CI: 1.47 to 5.97) and with clinical features including abnormal body temperature (AOR=4.03; 95% CI: 2.14 to 7.58), tachycardia (AOR=2.57; 95% CI: 1.45 to 4.55), bradypnoea or tachypnoea (AOR=3.92; 95% CI:1.94 to 7.92), oxygen saturation below 90% (AOR=2.52; 95% CI:1.37 to 4.64) and leucocytosis (AOR=2.78, 95%, CI:1.38 to 5.58) had a significantly increased unfavourable treatment outcome. CONCLUSION We found that nearly one out of eight patients with pneumonia had unfavourable treatment outcomes. It was considerably high among patients with comorbidities and apparent abnormal clinical conditions. Therefore, taking into account regionally adaptable intervention and paying close attention to pneumonia patients admitted with comorbidity and other superimposed abnormal conditions might help improve the treatment outcomes of these populations.
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Affiliation(s)
- Abera Jambo
- Clinical Pharmacy Department, Haramaya University, Dire Dawa, Ethiopia
| | - Tigist Gashaw
- Department of Pharmacology and Toxicology, Haramaya University, Dire Dawa, Ethiopia
| | | | - Dumessa Edessa
- Clinical Pharmacy Department, Haramaya University, Dire Dawa, Ethiopia
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Hakizimana B, Kalimba E, Ndatinya A, Saint G, van Miert C, Cartledge PT. Field testing two existing, standardized respiratory severity scores (LIBSS and ReSViNET) in infants presenting with acute respiratory illness to tertiary hospitals in Rwanda - a validation and inter-rater reliability study. PLoS One 2021; 16:e0258882. [PMID: 34735488 PMCID: PMC8568200 DOI: 10.1371/journal.pone.0258882] [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] [Received: 07/13/2020] [Accepted: 10/07/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION There is a substantial burden of respiratory disease in infants in the sub-Saharan Africa region. Many health care providers (HCPs) that initially receive infants with respiratory distress may not be adequately skilled to differentiate between mild, moderate and severe respiratory symptoms, which may contribute to poor management and outcome. Therefore, respiratory severity scores have the potential to contributing to address this gap. OBJECTIVES to field-test the use of two existing standardized bronchiolitis severity scores (LIBSS and ReSViNET) in a population of Rwandan infants (1-12 months) presenting with respiratory illnesses to urban, tertiary, pediatric hospitals and to assess the severity of respiratory distress in these infants and the treatments used. METHODS A cross-sectional, validation study, was conducted in four tertiary hospitals in Rwanda. Infants presenting with difficulty in breathing were included. The LIBSS and ReSViNET scores were independently employed by nurses and residents to assess the severity of disease in each infant. RESULTS 100 infants were recruited with a mean age of seven months. Infants presented with pneumonia (n = 51), bronchiolitis (n = 36) and other infectious respiratory illnesses (n = 13). Thirty-three infants had severe disease and survival was 94% using nurse applied LIBSS. Regarding inter-rater reliability, the intra-class correlation coefficient (ICC) for LIBSS and ReSViNET between nurses and residents was 0.985 (95% CI: 0.98-0.99) and 0.980 (0.97-0.99). The convergent validity (Pearson's correlation) between LIBSS and ReSViNET for nurses and residents was R = 0.836 (p<0.001) and R = 0.815 (p<0.001). The area under the Receiver Operator Curve (aROC) for admission to PICU or HDU was 0.956 (CI: 0.92-0.99, p<0.001) and 0.880 (CI: 0.80-0.96, p<0.001) for nurse completed LIBSS and ReSViNET respectively. CONCLUSION LIBSS and ReSViNET were designed for infants with bronchiolitis in resource-rich settings. Both LIBSS and ReSViNET demonstrated good reliability and validity results, in this cohort of patients presenting to tertiary level hospitals. This early data demonstrate that these two scores have the potential to be used in conjunction with clinical reasoning to identify infants at increased risk of clinical deterioration and allow timely admission, treatment escalation and therefore support resource allocation in Rwanda.
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Affiliation(s)
- Boniface Hakizimana
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- Department of Pediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Edgar Kalimba
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- King Faisal Hospital, Kigali, Rwanda
| | | | - Gemma Saint
- Institute of Child Health, University of Liverpool, Liverpool, United Kingdom
- Department of Respiratory Pediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Clare van Miert
- School of Nursing and Allied Health Liverpool John Moores University, Liverpool, United Kingdom
| | - Peter Thomas Cartledge
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, United States of America
- Rwanda Human Resources for Health (HRH) Program, Ministry of Health, Kigali, Rwanda
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Ginsburg AS, Mvalo T, Hwang J, Phiri M, McCollum ED, Maliwichi M, Schmicker R, Phiri A, Lufesi N, May S. Malawian children with fast-breathing pneumonia with and without comorbidities. Pneumonia (Nathan) 2021; 13:3. [PMID: 33627192 PMCID: PMC7905626 DOI: 10.1186/s41479-021-00081-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/15/2021] [Indexed: 01/03/2023] Open
Abstract
Background Due to high risk of mortality, children with comorbidities are typically excluded from trials evaluating pneumonia treatment. Understanding heterogeneity of outcomes among children with pneumonia and comorbidities is critical to ensuring appropriate treatment. Methods We explored whether the percentage of children with fast-breathing pneumonia cured at Day 14 was lower among those with selected comorbidities enrolled in a prospective observational study than among those enrolled in a concurrent randomized controlled trial evaluating treatment with amoxicillin in Lilongwe, Malawi. Results Among 79 children with fast-breathing pneumonia in the prospective observational cohort, 57 (72.2%) had HIV infection/exposure, 20 (25.3%) had malaria, 2 (2.5%) had severe acute malnutrition, and 17 (21.5%) had anemia. Treatment failure rate was slightly (not significantly) lower in children with comorbidities (4.1%, 3/73) compared to those without comorbidities (4.5%, 25/552) similarly treated. There was no significant difference in clinical cure rates by Day 14 (95.8% with vs 96.7% without comorbidity). Conclusions Children with fast-breathing pneumonia excluded from a concurrent clinical trial due to comorbidities did not fare worse. Children at higher risk whose caregivers seek care early and who receive appropriate risk assessment (e.g., pulse oximetry, hemoglobin, HIV/malaria testing) and treatment, can achieve clinical cure by Day 14. Trial registration ClinicalTrials.govNCT02960919; registered November 8, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s41479-021-00081-y.
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Affiliation(s)
- Amy Sarah Ginsburg
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA.
| | - Tisungane Mvalo
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Jun Hwang
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA
| | - Melda Phiri
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | | | - Madalitso Maliwichi
- University of North Carolina Project, Lilongwe Medical Relief Fund Trust, Lilongwe, Malawi
| | - Robert Schmicker
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA
| | - Ajib Phiri
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Susanne May
- University of Washington Clinical Trial Center, Building 29, Suite 250, 6200 NE 74th Street, Seattle, WA, 98115, USA
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Hakizimana B, Saint G, van Miert C, Cartledge P. Can a Respiratory Severity Score Accurately Assess Respiratory Distress in Children with Bronchiolitis in a Resource-Limited Setting? J Trop Pediatr 2020; 66:234-243. [PMID: 32236471 DOI: 10.1093/tropej/fmz055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Boniface Hakizimana
- Department of Pediatrics, University of Rwanda, Kigali, Rwanda.,Department of Pediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Gemma Saint
- Department of Child Health, Institute of Translational Medicine, University of Liverpool, Liverpool
| | - Clare van Miert
- Liverpool John Moores University, Liverpool.,Alder Hey Children's NHS Foundation Trust, Liverpool
| | - Peter Cartledge
- Department of Pediatrics, University of Rwanda, Kigali, Rwanda.,Department of Pediatrics, Yale University, Rwanda Human Resources for Health (HRH) Program, Kigali, Rwanda
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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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7
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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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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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Pneumonia Risk Stratification Scores for Children in Low-Resource Settings: A Systematic Literature Review. Pediatr Infect Dis J 2018; 37:743-748. [PMID: 29278608 PMCID: PMC6014863 DOI: 10.1097/inf.0000000000001883] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pneumonia is the leading infectious cause of death among children less than 5 years of age. Predictive tools, commonly referred to as risk scores, can be employed to identify high-risk children early for targeted management to prevent adverse outcomes. This systematic review was conducted to identify pediatric pneumonia risk scores developed, validated and implemented in low-resource settings. METHODS We searched CAB Direct, Cochrane Reviews, Embase, PubMed, Scopus and Web of Science for studies that developed formal risk scores to predict treatment failure or mortality among children less than 5 years of age diagnosed with a respiratory infection or pneumonia in low-resource settings. Data abstracted from articles included location and study design, sample size, age, diagnosis, score features and model discrimination. RESULTS Three pediatric pneumonia risk scores predicted mortality specifically, and 2 treatment failure. Scores developed using World Health Organization-recommended variables for pneumonia assessment demonstrated better predictive fit than scores developed using alternative features. Scores developed using routinely collected healthcare data performed similarly well as those developed using clinical trial data. No score has been implemented in low-resource settings. CONCLUSIONS While pediatric pneumonia-specific risk scores have been developed and validated, it is yet unclear if implementation is feasible, what impact, if any, implemented scores may have on child outcomes, or how broadly scores may be generalized. To increase the feasibility of implementation, future research should focus on developing scores based on routinely collected data.
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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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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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King C, Colbourn T, Mankhambo L, Beard J, Hay Burgess DC, Costello A, Izadnegahdar R, Lufesi N, Mwansambo C, Nambiar B, Johnson ES, Platt RW, Mukanga D, McCollum ED. Non-treatment of children with community health worker-diagnosed fast-breathing pneumonia in rural Malawi: exploratory subanalysis of a prospective cohort study. BMJ Open 2016; 6:e011636. [PMID: 27852705 PMCID: PMC5128900 DOI: 10.1136/bmjopen-2016-011636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite recent progress, pneumonia remains the largest infectious killer of children globally. This paper describes outcomes of not treating community-diagnosed fast-breathing pneumonia on patient recovery. METHODS We conducted an exploratory subanalysis of an observational prospective cohort study in Malawi. We recruited children (2-59 months) diagnosed by community health workers with fast-breathing pneumonia using WHO integrated community case management (iCCM) guidelines. Children were followed at days 5 and 14 with a clinical assessment of recovery. We conducted bivariate and multivariable logistic regression for the association between treatment of fast-breathing pneumonia and recovery, adjusting for potential confounders. RESULTS We followed up 847 children, of whom 78 (9%) had not been given antibiotics (non-treatment). Non-treatment cases had higher baseline rates of diarrhoea, non-severe hypoxaemia and fever. Non-recovery (persistence or worsening of symptoms) was 13% and 23% at day 5 in those who did receive and those who did not receive co-trimoxazole. Non-recovery, when defined as worsening of symptoms only, at day 5 was 7% in treatment and 10% in non-treatment cases. For both definitions, combined co-trimoxazole and lumefantrine-artemether (LA) treatment trended towards protection (adjusted OR (aOR) 0.28; 95% CI 0.12 to 0.68/aOR 0.29; 95% CI 0.08 to 1.01). CONCLUSION We found that children who did not receive co-trimoxazole treatment had worse clinical outcomes; malaria co-diagnosis and treatment also play a significant role in non-recovery. Further research into non-treatment of fast-breathing pneumonia, using a pragmatic approach with consideration for malaria co-diagnosis and HIV status is needed to guide refinement of community treatment algorithms in this region.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, UK
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | | | - James Beard
- Institute for Global Health, University College London, London, UK
| | | | - Anthony Costello
- Institute for Global Health, University College London, London, UK
| | | | - Norman Lufesi
- Acute Respiratory Infection Unit, Ministry of Health, Lilongwe, Malawi
| | - Charles Mwansambo
- Parent and Child Health Initiative, Lilongwe, Malawi
- Ministry of Health, Lilongwe, Malawi
| | - Bejoy Nambiar
- Institute for Global Health, University College London, London, UK
| | - Eric S Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | | | - David Mukanga
- Science and Health Impact Group (SHI), Kampala, Uganda
| | - Eric D McCollum
- Institute for Global Health, University College London, London, UK
- Division of Pulmonology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Correction: 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:e0139295. [PMID: 26402716 PMCID: PMC4581694 DOI: 10.1371/journal.pone.0139295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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