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Sultana M, Watts JJ, Alam NH, Faruque ASG, Fuchs GJ, Gyr N, Ali N, Chisti MJ, Ahmed T, Abimanyi-Ochom J, Gold L. Cost of childhood severe pneumonia management in selected public inpatient care facilities in Bangladesh: a provider perspective. Arch Dis Child 2024; 109:622-627. [PMID: 38621857 DOI: 10.1136/archdischild-2022-325222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/08/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE To estimate inpatient care costs of childhood severe pneumonia and its urban-rural cost variation, and to predict cost drivers. DESIGN The study was nested within a cluster randomised trial of childhood severe pneumonia management. Cost per episode of severe pneumonia was estimated from a healthcare provider perspective for children who received care from public inpatient facilities. A bottom-up micro-costing approach was applied and data collected using structured questionnaire and review of the patient record. Multivariate regression analysis determined cost predictors and sensitivity analysis explored robustness of cost parameters. SETTING Eight public inpatient care facilities from two districts of Bangladesh covering urban and rural areas. PATIENTS Children aged 2-59 months with WHO-classified severe pneumonia. RESULTS Data on 1252 enrolled children were analysed; 795 (64%) were male, 787 (63%) were infants and 59% from urban areas. Average length of stay (LoS) was 4.8 days (SD ±2.5) and mean cost per patient was US$48 (95% CI: US$46, US$49). Mean cost per patient was significantly greater for urban tertiary-level facilities compared with rural primary-secondary facilities (mean difference US$43; 95% CI: US$40, US$45). No cost variation was found relative to age, sex, malnutrition or hypoxaemia. Type of facility was the most important cost predictor. LoS and personnel costs were the most sensitive cost parameters. CONCLUSION Healthcare provider cost of childhood severe pneumonia was substantial for urban located public health facilities that provided tertiary-level care. Thus, treatment availability at a lower-level facility at a rural location may help to reduce overall treatment costs.
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Affiliation(s)
- Marufa Sultana
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Jennifer J Watts
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Nur H Alam
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - A S G Faruque
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - George J Fuchs
- Department of Paediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Niklaus Gyr
- Department of Internal Medicine, University of Basel, Basel, Switzerland
| | - Nausad Ali
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Md Jobayer Chisti
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Julie Abimanyi-Ochom
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Lisa Gold
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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Alam NH, Faruque AS, Ashraf H, Chisti MJ, Ahmed T, Sultana M, Khalequzzaman M, Ali S, Ahmed S, Nasrin S, Tariqujjaman M, Haque KE, Amin R, Mollah AH, Kabir L, Shahidullah M, Khanam W, Islam K, Kim M, Vandenent M, Duke T, Gyr N, Fuchs GJ. Effectiveness, safety and economic viability of daycare versus usual hospital care management of severe pneumonia with or without malnutrition in children using the existing health system of Bangladesh: a cluster randomised controlled trial. EClinicalMedicine 2023; 60:102023. [PMID: 37304498 PMCID: PMC10250158 DOI: 10.1016/j.eclinm.2023.102023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Background We aimed to define clinical and cost-effectiveness of a Day Care Approach (DCA) alternative to Usual Care (UC, comparison group) within the Bangladesh health system to manage severe childhood pneumonia. Methods This was a cluster randomised controlled trial in urban Dhaka and rural Bangladesh between November 1, 2015 and March 23, 2019. Children aged 2-59 months with severe pneumonia with or without malnutrition received DCA or UC. The DCA treatment settings comprised of urban primary health care clinics run by NGO under Dhaka South City Corporation and in rural Union health and family welfare centres under the Ministry of Health and Family welfare Services. The UC treatment settings were hospitals in these respective areas. Primary outcome was treatment failure (persistence of pneumonia symptoms, referral or death). We performed both intention-to-treat and per-protocol analysis for treatment failure. Registered at www.ClinicalTrials.gov, NCT02669654. Findings In total 3211 children were enrolled, 1739 in DCA and 1472 in UC; primary outcome data were available in 1682 and 1357 in DCA and UC, respectively. Treatment failure rate was 9.6% among children in DCA (167 of 1739) and 13.5% in the UC (198 of 1472) (group difference, -3.9 percentage point; 95% confidence interval (CI), -4.8 to -1.5, p = 0.165). Treatment success within the health care systems [DCA plus referral vs. UC plus referral, 1587/1739 (91.3%) vs. 1283/1472 (87.2%), group difference 4.1 percentage point, 95% CI, 3.7 to 4.1, p = 0.160)] was better in DCA. One child each in UC of both urban and rural sites died within day 6 after admission. Average cost of treatment per child was US$94.2 (95% CI, 92.2 to 96.3) and US$184.8 (95% CI, 178.6 to 190.9) for DCA and UC, respectively. Interpretation In our population of children with severe pneumonia with or without malnutrition, >90% were successfully treated at Day care Clinics at 50% lower cost. A modest investment to upgrade Day care facilities may provide a cost-effective, accessible alternative to hospital management. Funding UNICEF, Botnar Foundation, UBS Optimus Foundation, and EAGLE Foundation, Switzerland.
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Affiliation(s)
- Nur H. Alam
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Abu S. Faruque
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Hasan Ashraf
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Marufa Sultana
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Shahjahan Ali
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Shahnawaz Ahmed
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Sabiha Nasrin
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | - Md Tariqujjaman
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh
| | | | - Ruhul Amin
- Dhaka Shishu Hospital, Dhaka, Bangladesh
| | | | - Lutful Kabir
- Sir Salimullah Medical College Hospital, Dhaka, Bangladesh
| | | | - Wahida Khanam
- Institute of Child and Mother Health, Matuail, Dhaka, Bangladesh
| | - Khaleda Islam
- Primary Health Care, Ministry of Health and Family Planning, Government of Bangladesh, Bangladesh
| | | | | | - Trevor Duke
- Melbourne Children Hospital, Melbourne, Australia
| | | | - George J. Fuchs
- College of Medicine and College of Public Health, University of Kentucky, USA
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Rahman AE, Hossain AT, Nair H, Chisti MJ, Dockrell D, Arifeen SE, Campbell H. Prevalence of hypoxaemia in children with pneumonia in low-income and middle-income countries: a systematic review and meta-analysis. THE LANCET GLOBAL HEALTH 2022; 10:e348-e359. [PMID: 35180418 PMCID: PMC8864303 DOI: 10.1016/s2214-109x(21)00586-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/31/2021] [Accepted: 12/07/2021] [Indexed: 12/23/2022] Open
Abstract
Background Pneumonia accounts for around 15% of all deaths of children younger than 5 years globally. Most happen in resource-constrained settings and are potentially preventable. Hypoxaemia is one of the strongest predictors of these deaths. We present an updated estimate of hypoxaemia prevalence among children with pneumonia in low-income and middle-income countries. Methods We conducted a systematic review using the following key concepts “children under five years of age” AND “pneumonia” AND “hypoxaemia” AND “low- and middle-income countries” by searching in 11 bibliographic databases and citation indices. We included all articles published between Nov 1, 2008, and Oct 8, 2021, based on observational studies and control arms of randomised and non-randomised controlled trials. We excluded protocol papers, articles reporting hypoxaemia prevalence based on less than 100 pneumonia cases, and articles published before 2008 from the review. Quality appraisal was done with the Joanna Briggs Institute tools. We reported pooled prevalence of hypoxaemia (SpO2 <90%) by classification of clinical severity and by clinical settings by use of the random-effects meta-analysis models. We combined our estimate of the pooled prevalence of pneumonia with a previously published estimate of the number of children admitted to hospital due to pneumonia annually to calculate the total annual number of children admitted to hospital with hypoxaemic pneumonia. Findings We identified 2825 unique records from the databases, of which 57 studies met the eligibility criteria: 26 from Africa, 23 from Asia, five from South America, and four from multiple continents. The prevalence of hypoxaemia was 31% (95% CI 26–36; 101 775 children) among all children with WHO-classified pneumonia, 41% (33–49; 30 483 children) among those with very severe or severe pneumonia, and 8% (3–16; 2395 children) among those with non-severe pneumonia. The prevalence was much higher in studies conducted in emergency and inpatient settings than in studies conducted in outpatient settings. In 2019, we estimated that over 7 million children (95% CI 5–8 million) were admitted to hospital with hypoxaemic pneumonia. The studies included in this systematic review had high τ2 (ie, 0·17), indicating a high level of heterogeneity between studies, and a high I2 value (ie, 99·6%), indicating that the heterogeneity was not due to chance. This study is registered with PROSPERO, CRD42019126207. Interpretation The high prevalence of hypoxaemia among children with severe pneumonia, particularly among children who have been admitted to hospital, emphasises the importance of overall oxygen security within the health systems of low-income and middle-income countries, particularly in the context of the COVID-19 pandemic. Even among children with non-severe pneumonia that is managed in outpatient and community settings, the high prevalence emphasises the importance of rapid identification of hypoxaemia at the first point of contact and referral for appropriate oxygen therapy. Funding UK National Institute for Health Research (Global Health Research Unit on Respiratory Health [RESPIRE]; 16/136/109).
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Affiliation(s)
- Ahmed Ehsanur Rahman
- The University of Edinburgh, Edinburgh, UK; International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
| | - Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Sultana M, Alam NH, Ali N, Faruque ASG, Fuchs GJ, Gyr N, Chisti MJ, Ahmed T, Gold L. Household economic burden of childhood severe pneumonia in Bangladesh: a cost-of-illness study. Arch Dis Child 2021; 106:539-546. [PMID: 33906852 PMCID: PMC8142430 DOI: 10.1136/archdischild-2020-320834] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh. DESIGN An incidence-based COI study was performed for one episode of childhood severe pneumonia from a household perspective. Face-to-face interviews collected data on socioeconomic, resource use and cost from caregivers. A micro-costing bottom-up approach was applied to calculate medical, non-medical and time costs. Multiple regression analysis was applied to explore the factors associated with COI. Sensitivity analysis explored the robustness of cost parameters. SETTING Four urban and rural study sites from two districts in Bangladesh. PATIENTS Children aged 2-59 months with severe pneumonia. RESULTS 1472 children with severe pneumonia were enrolled between November 2015 and March 2019. The mean age of children was 12 months (SD ±10.2) and 64% were male. The mean household cost per episode was US$147 (95% CI 141.1 to 152.7). Indirect costs were the main cost drivers (65%, US$96). Household costs for the poorest income quintile were lower in absolute terms, but formed a higher proportion of monthly income. COI was significantly higher if treatment was received from urban health facilities compared with rural health facilities (difference US$84.9, 95% CI 73.3 to 96.3). Child age, household income, healthcare facility and hospital length of stay (LoS) were significant predictors of household COI. Costs were most sensitive to hospital LoS and productivity loss. CONCLUSIONS Severe pneumonia in young children is associated with high household economic burden and cost varies significantly across socioeconomic parameters. Management strategies with improved accessibility are needed particularly for the poor to make treatment affordable in order to reduce household economic burden.
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Affiliation(s)
- Marufa Sultana
- Nutrition and Clinical Services Division, icddr,b, Dhaka, Bangladesh .,Deakin Health Economics, School of Health and Social Development, Deakin University, Geelong, Victoria, Australia
| | - Nur H Alam
- Nutrition and Clinical Services Division, icddr, b, Dhaka, Bangladesh,Clinical Sciences Division (CSD), Centre for Nutrition and Food Security (CNFS), Dhaka, Bangladesh
| | - Nausad Ali
- Nutrition and Clinical Services Division, icddr, b, Dhaka, Bangladesh
| | - A S G Faruque
- Nutrition and Clinical Services Division, icddr, b, Dhaka, Bangladesh
| | - George J Fuchs
- Department of Paediatrics, University of Kentucky College of Medicine and Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Niklaus Gyr
- Department of Internal Medicine, University of Basel, Basel, Switzerland
| | - Md Jobayer Chisti
- Nutrition and Clinical Services Division, icddr, b, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr, b, Dhaka, Bangladesh
| | - Lisa Gold
- Deakin Health Economics, School of Health and Social Development, Deakin University, Geelong, Victoria, Australia
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de Broucker G, Ahmed S, Hasan MZ, Mehdi GG, Martin Del Campo J, Ali MW, Uddin MJ, Constenla D, Patenaude B. The economic burden of measles in children under five in Bangladesh. BMC Health Serv Res 2020; 20:1026. [PMID: 33172442 PMCID: PMC7653835 DOI: 10.1186/s12913-020-05880-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/30/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND This study estimated the economic cost of treating measles in children under-5 in Bangladesh from the caregiver, government, and societal perspectives. METHOD We conducted an incidence-based study using an ingredient-based approach. We surveyed the administrative staff and the healthcare professionals at the facilities, recording their estimates supported by administrative data from the healthcare perspective. We conducted 100 face-to-face caregiver interviews at discharge and phone interviews 7 to 14 days post-discharge to capture all expenses, including time costs related to measles. All costs are in 2018 USD ($). RESULTS From a societal perspective, a hospitalized and ambulatory case of measles cost $159 and $18, respectively. On average, the government spent $22 per hospitalized case of measles. At the same time, caregivers incurred $131 and $182 in economic costs, including $48 and $83 in out-of-pocket expenses in public and private not-for-profit facilities, respectively. Seventy-eight percent of the poorest caregivers faced catastrophic health expenditures compared to 21% of the richest. In 2018, 2263 cases of measles were confirmed, totaling $348,073 in economic costs to Bangladeshi society, with $121,842 in out-of-pocket payments for households. CONCLUSION The resurgence of measles outbreaks is a substantial cost for society, requiring significant short-term public expenditures, putting households into a precarious financial situation. Improving vaccination coverage in areas where it is deficient (Sylhet division in our study) would likely alleviate most of this burden.
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Affiliation(s)
- Gatien de Broucker
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA.
| | - Sayem Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Liverpool School of Tropical Disease (LSTM), Liverpool, UK
| | - Md Zahid Hasan
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Gazi Golam Mehdi
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jorge Martin Del Campo
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA
| | - Md Wazed Ali
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Jasim Uddin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Dagna Constenla
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA
- GlaxoSmithKline Plc, Panama City, Panama
| | - Bryan Patenaude
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, #530, Baltimore, MD, 21231, USA
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Shahrin L, Chisti MJ, Shahid ASMSB, Rahman ASMMH, Islam MZ, Afroze F, Huq S, Ahmed T. Injectable Amoxicillin Versus Injectable Ampicillin Plus Gentamicin in the Treatment of Severe Pneumonia in Children Aged 2 to 59 Months: Protocol for an Open-Label Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e17735. [PMID: 33136058 PMCID: PMC7669443 DOI: 10.2196/17735] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Pneumonia causes about 0.9 million deaths worldwide each year. The World Health Organization (WHO) guidelines for the standard management of severe pneumonia requires parenteral ampicillin every 6 hours and once-daily parenteral gentamicin for 5 to 7 days. Although this treatment has contributed to the reduction of mortality, it requires nursing interventions every 6 hours for 7 days. Further intervention trials should be conducted to search for alternate antibiotics with better adherence, reduced cost, and reduced hospital stay. Parenteral amoxicillin is an effective alternative to ampicillin, as it has a longer half-life and broader coverage. OBJECTIVE The aim of this clinical trial is to compare the efficacy of a dose of injectable amoxicillin every 12 hours plus a once-daily dose of injectable gentamicin with a dose of injectable ampicillin every 6 hours plus a once-daily dose of injectable gentamicin in children hospitalized for severe pneumonia. METHODS This randomized, controlled, open-label, noninferiority trial is being conducted in Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh. A sample size of 308 children with severe pneumonia will give adequate power to this study. Children aged 2 to 59 months are randomized to either intravenous ampicillin or intravenous amoxicillin, plus intravenous gentamicin in both study arms. The monitoring of the patients is carried out according to the WHO protocol for the treatment of severe pneumonia. The primary objective is the rate of treatment failure, defined by the persistence of danger signs of severe pneumonia beyond 48 hours or deterioration within 24 hours of initiation of the therapy. The secondary objectives are (1) improvement in or the resolution of danger signs since enrollment, (2) length of hospital stay, (3) death during hospitalization, and (4) rate of nosocomial infections. RESULTS Enrollment in the study started on January 1, 2018, and ended on October 31, 2019. Data entry and analysis are in progress. Findings from the study are expected to be disseminated in October 2020. CONCLUSIONS Our study's findings will improve compliance with the use of antibiotics that require less frequent doses for the treatment of severe pneumonia. TRIAL REGISTRATION ClinicalTrials.gov NCT03369093; https://clinicaltrials.gov/ct2/show/NCT03369093. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17735.
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Affiliation(s)
- Lubaba Shahrin
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | | | | | - Md Zahidul Islam
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Farzana Afroze
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sayeeda Huq
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
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de Broucker G, Sim SY, Brenzel L, Gross M, Patenaude B, Constenla DO. Cost of Nine Pediatric Infectious Illnesses in Low- and Middle-Income Countries: A Systematic Review of Cost-of-Illness Studies. PHARMACOECONOMICS 2020; 38:1071-1094. [PMID: 32748334 PMCID: PMC7578143 DOI: 10.1007/s40273-020-00940-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Cost-of-illness data from empirical studies provide insights into the use of healthcare resources including both expenditures and the opportunity cost related to receiving treatment. OBJECTIVE The objective of this systematic review was to gather cost data and relevant parameters for hepatitis B, pneumonia, meningitis, encephalitis caused by Japanese encephalitis, rubella, yellow fever, measles, influenza, and acute gastroenteritis in children in low- and middle-income countries. DATA SOURCES Peer-reviewed studies published in public health, medical, and economic journals indexed in PubMed (MEDLINE), Embase, and EconLit. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS Studies must (1) be peer reviewed, (2) be published in 2000-2016, (3) provide cost data for one of the nine diseases in children aged under 5 years in low- and middle-income countries, and (4) generated from primary data collection. LIMITATIONS We cannot exclude missing a few articles in our review. Measures were taken to reduce this risk. Several articles published since 2016 are omitted from the systematic review results, these articles are included in the discussion. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The review yielded 37 articles and 267 sets of cost estimates. We found no cost-of-illness studies with cost estimates for hepatitis B, measles, rubella, or yellow fever from primary data. Most estimates were from countries in Gavi preparatory (28%) and accelerated (28%) transition, followed by those who are initiating self-financing (22%) and those not eligible for Gavi support (19%). Thirteen articles compared household expenses to manage illnesses with income and two articles with other household expenses, such as food, clothing, and rent. An episode of illness represented 1-75% of the household's monthly income or 10-83% of its monthly expenses. Articles that presented both household and government perspectives showed that most often governments incurred greater costs than households, including non-medical and indirect costs, across countries of all income statuses, with a few notable exceptions. Although limited for low- and middle-income country settings, cost estimates generated from primary data collection provided a 'real-world' estimate of the economic burden of vaccine-preventable diseases. Additional information on whether common situations preventing the application of official clinical guidelines (such as medication stock-outs) occurred would help reveal deficiencies in the health system. Improving the availability of cost-of-illness evidence can inform the public policy agenda about healthcare priorities and can help to operationalize the healthcare budget in local health systems to respond adequately to the burden of illness in the community.
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Affiliation(s)
- Gatien de Broucker
- International Vaccine Access Center, 415 North Washington Street, Suite #530, Baltimore, MD, 21231, USA.
| | - So Yoon Sim
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Margaret Gross
- Welch Medical Library, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Bryan Patenaude
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dagna O Constenla
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- GlaxoSmithKline Plc, Panama City, Panama
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Ashraf H, Alam NH, Sultana M, Jahan SA, Begum N, Farzana S, Chisti MJ, Kamal M, Shamsuzzaman A, Ahmed T, Khan JAM, Fuchs GJ, Duke T, Gyr N. Day clinic vs. hospital care of pneumonia and severe malnutrition in children under five: a randomised trial. Trop Med Int Health 2019; 24:922-931. [PMID: 31046165 DOI: 10.1111/tmi.13242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To evaluate the clinical outcomes and costs of managing pneumonia and severe malnutrition in a day clinic (DC) management model (outpatient) vs. hospital care (inpatient). METHODS Randomised clinical trial where children aged 2 months to 5 years with pneumonia and severe malnutrition were randomly allocated to DC or inpatient hospital care. We used block randomisation of variable length from 8 to 20 and produced computer-generated random numbers that were assigned to one of the two interventions. Successful management was defined as resolution of clinical signs of pneumonia and being discharged from the model of care (DC or hospital) without need for referral to a hospital (DC), or referral to another hospital. All the children in both DC and hospital received intramuscular ceftriaxone, daily nutrition support and micronutrients. RESULTS Four hundred and seventy children were randomly assigned to either DC or hospital care. Successful management was achieved for 184 of 235 (78.3%) by DC alone, vs. 201 of 235 (85.5%) by hospital inpatient care [RR (95% CI) = 0.79 (0.65-0.97), P = 0.02]. During 6 months of follow-up, 30/235 (12.8%) in the DC group and 36/235 (15.3%) required readmission to hospital in the hospital care group [RR (95% CI) = 0.89 (0.67-1.18), P = 0.21]. The average overall healthcare and societal cost was 34% lower in DC (US$ 188 ± 11.7) than in hospital (US$ 285 ± 13.6) (P < 0.001), and costs for households were 33% lower. CONCLUSIONS There was a 7% greater probability of successful management of pneumonia and severe malnutrition when inpatient hospital care rather than the outpatient day clinic care was the initial method of care. However, where timely referral mechanisms were in place, 94% of children with pneumonia and severe malnutrition were successfully managed initially in a day clinic, and costs were substantially lower than with hospital admission.
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Affiliation(s)
- Hasan Ashraf
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Nur H Alam
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Marufa Sultana
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Selina A Jahan
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Nurshad Begum
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Sharmin Farzana
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Mohammod J Chisti
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Mohiuddin Kamal
- Radda Maternal and Child Health Family Planning Centre, Dhaka, Bangladesh
| | - Abu Shamsuzzaman
- Institute of Child Health and Shishu, Sasthya Foundation Hospital, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh
| | - Jahangir A M Khan
- icddr,b, International Centre for Diarrhoeal Disease Research, Bangladesh.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, UK
| | - George J Fuchs
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, Melbourne, Australia
| | - Niklaus Gyr
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Jahan Y, Rahman A. A case report on management of severe childhood pneumonia in low resource settings. Respir Med Case Rep 2018; 25:192-195. [PMID: 30211000 PMCID: PMC6129689 DOI: 10.1016/j.rmcr.2018.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/18/2022] Open
Abstract
Pneumonia is a major cause of child mortality among children under five years, worldwide. Pneumonia infection may be caused by bacteria, viruses, or fungi in single or in both lungs. According to recent criteria developed by World Health Organization (WHO) in September (2013), pneumonia can be classified into severe pneumonia, pneumonia and no pneumonia. Most of the deaths occur from severe pneumonia and management of severe childhood pneumonia requires early identification, prompt referral and the availability of intensive quality of care. This case study aimed to represent the actual scenario of severe childhood pneumonia case management at community clinic. Considering that circumstances, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) developed an innovative day care management approach as safe, effective and less expensive alternative to hospital management of severe childhood pneumonia. A twenty-seven months old boy came to the Health & Family Welfare Centre (HFWC) with severe breathing difficulty, cough, history of fever. The management described below was continued daily until there was clinical improvement; no fever, no fast breathing, no lower chest wall indrawing, no danger signs, no rales on auscultation and no hypoxemia. Considering the WHO case management protocol for severe pneumonia, day care management approach on community clinic recommends that diagnosis of severe pneumonia should be based primarily on visible clinical parameters. On that basis, severe childhood pneumonia can be successfully managed at community clinics including for children with hypoxemia who is required prolong (4–6 hours) oxygen therapy.
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Affiliation(s)
- Yasmin Jahan
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Japan
- Corresponding author.
| | - Atiqur Rahman
- School of Health, University of New England, Australia
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Jahan Y, Rahman SA, Chowdhury AS, Moshiur Rahman M. Management of severe childhood pneumonia by day care approach in developing countries. Health Promot Perspect 2018; 8:88-91. [PMID: 29423367 PMCID: PMC5797313 DOI: 10.15171/hpp.2018.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/01/2017] [Indexed: 11/29/2022] Open
Abstract
Background: Pneumonia is a major cause of child mortality among children under 5 years, worldwide. Pneumonia infection may be caused by bacteria, viruses, or fungi in single or in both lungs. According to recent criteria developed by the World Health Organization(WHO) in September (2013), pneumonia can be classified into severe pneumonia, pneumonia and no pneumonia. Most of the deaths occur from severe pneumonia. Methods: Disease management of severe childhood pneumonia requires early identification,prompt referral and the availability of intensive quality care. Under 5 years old children with severe pneumonia should receive day care, with antibiotic treatment, feeding, and supportive care with similar 24-hour hospital treatment. Results: Considering that difficulties, International Centre for Diarrheal Disease Research,Bangladesh (ICDDR, B) initiated Day Care Approach (DCA) model, as an innovative, safe,effective and less expensive alternative to hospital management of severe childhood pneumonia.A 24 months old girl came to the health care center with severe breathing difficulty, cough,history of fever and head nodding. The management described below was continued daily until there was clinical improvement; no fever, no fast breathing, no lower chest wall in drawing, no danger signs, no rales on auscultation, and no hypoxemia. Conclusion: Considering the WHO case management protocol for severe pneumonia, DCA recommends that diagnosis of severe pneumonia should be based primarily on visible clinical parameters. On that basis, severe childhood pneumonia can be successfully managed at daycare clinics including for children with hypoxemia who is required prolong (4-6 hours) oxygen therapy.
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Affiliation(s)
- Yasmin Jahan
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Japan
| | | | | | - Md Moshiur Rahman
- Graduate School of Biomedical & Health Sciences, Hiroshima University, Japan
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Zhang S, Sammon PM, King I, Andrade AL, Toscano CM, Araujo SN, Sinha A, Madhi SA, Khandaker G, Yin JK, Booy R, Huda TM, Rahman QS, El Arifeen S, Gentile A, Giglio N, Bhuiyan MU, Sturm-Ramirez K, Gessner BD, Nadjib M, Carosone-Link PJ, Simões EA, Child JA, Ahmed I, Bhutta ZA, Soofi SB, Khan RJ, Campbell H, Nair H. Cost of management of severe pneumonia in young children: systematic analysis. J Glob Health 2018; 6:010408. [PMID: 27231544 PMCID: PMC4871066 DOI: 10.7189/jogh.06.010408] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Childhood pneumonia is a major cause of childhood illness and the second leading cause of child death globally. Understanding the costs associated with the management of childhood pneumonia is essential for resource allocation and priority setting for child health. METHODS We conducted a systematic review to identify studies reporting data on the cost of management of pneumonia in children younger than 5 years old. We collected unpublished cost data on non-severe, severe and very severe pneumonia through collaboration with an international working group. We extracted data on cost per episode, duration of hospital stay and unit cost of interventions for the management of pneumonia. The mean (95% confidence interval, CI) and median (interquartile range, IQR) treatment costs were estimated and reported where appropriate. RESULTS We identified 24 published studies eligible for inclusion and supplemented these with data from 10 unpublished studies. The 34 studies included in the cost analysis contained data on more than 95 000 children with pneumonia from both low- and-middle income countries (LMIC) and high-income countries (HIC) covering all 6 WHO regions. The total cost (per episode) for management of severe pneumonia was US$ 4.3 (95% CI 1.5-8.7), US$ 51.7 (95% CI 17.4-91.0) and US$ 242.7 (95% CI 153.6-341.4)-559.4 (95% CI 268.9-886.3) in community, out-patient facilities and different levels of hospital in-patient settings in LMIC. Direct medical cost for severe pneumonia in hospital inpatient settings was estimated to be 26.6%-115.8% of patients' monthly household income in LMIC. The mean direct non-medical cost and indirect cost for severe pneumonia management accounted for 0.5-31% of weekly household income. The mean length of stay (LOS) in hospital for children with severe pneumonia was 5.8 (IQR 5.3-6.4) and 7.7 (IQR 5.5-9.9) days in LMIC and HIC respectively for these children. CONCLUSION This is the most comprehensive review to date of cost data from studies on the management of childhood pneumonia and these data should be helpful for health services planning and priority setting by national programmes and international agencies.
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Affiliation(s)
- Shanshan Zhang
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK; Department of Preventive Dentistry, Peking University, School and Hospital of Stomatology, Beijing, PR China
| | - Peter M Sammon
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Isobel King
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK; NHS Grampian, UK
| | | | | | - Sheila N Araujo
- Department of Community Health, Federal University of Goias, Brazil; State University of Maranhăo, Brazil
| | - Anushua Sinha
- New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey USA
| | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Gulam Khandaker
- National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, NSW, Australia; Sydney School of Public Health, Faculty of Medicine, The University of Sydney, NSW, Australia
| | - Jiehui Kevin Yin
- National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, NSW, Australia; Sydney School of Public Health, Faculty of Medicine, The University of Sydney, NSW, Australia
| | - Robert Booy
- National Centre for Immunisation Research and Surveillance, The Children's Hospital at Westmead, NSW, Australia; Sydney School of Public Health, Faculty of Medicine, The University of Sydney, NSW, Australia
| | - Tanvir M Huda
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh; School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Qazi S Rahman
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - Shams El Arifeen
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - Angela Gentile
- Epidemiology Department, Ricardo Gutierrez Children Hospital, University of Buenos Aires, Argentina
| | - Norberto Giglio
- Epidemiology Department, Ricardo Gutierrez Children Hospital, University of Buenos Aires, Argentina
| | | | - Katharine Sturm-Ramirez
- Centre for Communicable Diseases, icddr,b, Dhaka, Bangladesh; Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Mardiati Nadjib
- Faculty of Public Health, University of Indonesia, Jakarta, Indonesia
| | - Phyllis J Carosone-Link
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado Denver School of Medicine, Denver, CO, USA
| | - Eric Af Simões
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado Denver School of Medicine, Denver, CO, USA; Center for Global Health and Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Jason A Child
- Pharmacy Department, Children's Hospital Colorado, Aurora, CO, USA
| | - Imran Ahmed
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Sajid B Soofi
- Department of Paediatrics & Child Health, The Aga Khan University, Karachi, Pakistan
| | - Rumana J Khan
- James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Harry Campbell
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Harish Nair
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK; Public Health Foundation of India, New Delhi, India
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Howie SR, Hamer DH, Graham SM. Pneumonia. INTERNATIONAL ENCYCLOPEDIA OF PUBLIC HEALTH 2017. [PMCID: PMC7171906 DOI: 10.1016/b978-0-12-803678-5.00334-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Pneumonia is an important cause of morbidity and mortality globally. It is the leading cause of death in infants and young children with the majority of these deaths occurring in low income countries. Risk factors affecting incidence and outcome include extremes of age, poor nutrition, immunosuppression, environmental exposures and socioeconomic determinants. Pneumonia can be caused by a wide range of pathogens including bacteria, viruses and fungi, and the etiology varies by epidemiological setting, comorbidities and whether the pneumonia is community-acquired or hospital-acquired. Streptococcus pneumoniae is the major cause of community-acquired bacterial pneumonia while Gram negative bacteria, often resistant to multiple antibiotics, are common causes of hospital-acquired pneumonia and pneumonia in immunosuppressed individuals. Diagnosis is generally clinical and management is based mainly on knowledge of likely causative pathogens as well as clinical severity and presence of known risk factors. Timely and effective antibiotic treatment and oxygen therapy if hypoxemic are critical to patient outcomes. Preventive measures range from improved nutrition and hygiene to specific vaccines that target common causes in children and adults such as the pneumococcal or influenza vaccines.
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Kissoon N, Carapetis J. Pediatric sepsis in the developing world. J Infect 2015; 71 Suppl 1:S21-6. [DOI: 10.1016/j.jinf.2015.04.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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Ortiz JR, Jacob ST, West TE. Clinical care for severe influenza and other severe illness in resource-limited settings: the need for evidence and guidelines. Influenza Other Respir Viruses 2014; 7 Suppl 2:87-92. [PMID: 24034491 PMCID: PMC5909399 DOI: 10.1111/irv.12086] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The 2009 influenza A (H1N1) pandemic highlighted the importance of quality hospital care of the severely ill, yet there is evidence that the impact of the 2009 pandemic was highest in low‐ and middle‐income countries with fewer resources. Recent data indicate that death and suffering from seasonal influenza and severe illness in general are increased in resource‐limited settings. However, there are limited clinical data and guidelines for the management of influenza and other severe illness in these settings. Life‐saving supportive care through syndromic case management is used successfully in high‐resource intensive care units and in global programs such as the Integrated Management of Childhood Illness (IMCI). While there are a variety of challenges to the management of the severely ill in resource‐limited settings, several new international initiatives have begun to develop syndromic management strategies for these environments, including the World Health Organization's Integrated Management of Adult and Adolescent Illness Program. These standardized clinical guidelines emphasize syndromic case management and do not require high‐resource intensive care units. These efforts must be enhanced by quality clinical research to provide missing evidence and to refine recommendations, which must be carefully integrated into existing healthcare systems. Realizing a sustainable, global impact on death and suffering due to severe influenza and other severe illness necessitates an ongoing and concerted international effort to iteratively generate, implement, and evaluate best‐practice management guidelines for use in resource‐limited settings.
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Affiliation(s)
- Justin R Ortiz
- International Respiratory and Severe Illness Center (INTERSECT), University of Washington, Seattle, WA, USA
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Pericás JM, Aibar J, Soler N, López-Soto A, Sanclemente-Ansó C, Bosch X. Should alternatives to conventional hospitalisation be promoted in an era of financial constraint? Eur J Clin Invest 2013; 43:602-15. [PMID: 23590593 DOI: 10.1111/eci.12087] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/10/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Because the current economic crisis has led to austerity in health policies, with severe restrictions on public health care, avoiding unnecessary admissions and shortening hospital stays is rapidly becoming an urgent priority. Alternatives to hospitalisation replace or shorten hospital processes, including diagnosis, monitoring, treatment and follow-up. This review aims to present the available evidence on alternatives to conventional hospitalisation for medical disorders; options for surgery, psychiatry and palliative care are largely excluded. MATERIALS AND METHODS Narrative review. RESULTS The main alternatives to conventional hospitalisation include day centres (DC), quick diagnosis units (QDU), hospital at home (HaH) and, in some circumstances, telemonitoring. DC increase patient comfort, reduce costs and can improve efficiency. In generally healthy patients with suspected severe disease, QDU may be a good alternative to hospitalisation for diagnostic procedures. However, their cost-effectiveness remains to be clearly proven. Randomised controlled trials have shown that hospital-at-home (HaH) can lead to earlier hospital discharges, improve outcomes and reduce costs in patients with prevalent chronic diseases. Although telemonitoring seems to be promising and its use is increasing, methodologically sounder studies with a higher level of evidence are needed to assess its clinical effectiveness. CONCLUSIONS Factors such as ageing, the need for an earlier diagnosis of suspected severe disease, the increasing complexity of medical care and the increasing costs of hospitalisation mean that, whenever possible, giving priority to less expensive alternatives to hospital admission, such as QDU, DC, HaH and telemedicine, is an urgent task in the current economic crisis.
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Affiliation(s)
- Juan M Pericás
- Department of Internal Medicine, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Ashraf H, Alam NH, Chisti MJ, Salam MA, Ahmed T, Gyr N. Observational follow-up study following two cohorts of children with severe pneumonia after discharge from day care clinic/hospital in Dhaka, Bangladesh. BMJ Open 2012; 2:bmjopen-2012-000961. [PMID: 22842561 PMCID: PMC4400608 DOI: 10.1136/bmjopen-2012-000961] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To compare the features of relapse, morbidity, mortality and re-hospitalisation following successful discharge after severe pneumonia in children between a day care group and a hospital group and to explore the predictors of failures during 3 months of follow-up. DESIGN An observational study following two cohorts of children with severe pneumonia for 3 months after discharge from hospital/clinic. SETTING Day care was provided at the Radda Clinic and hospital care at a hospital in Dhaka, Bangladesh. PARTICIPANTS Children aged 2-59 months with severe pneumonia attending the clinic/hospital who survived to discharge. INTERVENTION No intervention was done except providing some medications for minor illnesses, if indicated. PRIMARY OUTCOME MEASURES The primary outcome measures were the proportion of successes and failures of day care at follow-up visits as determined by estimating the OR with 95% CI in comparison to hospital care. RESULTS The authors enrolled 360 children with a mean (SD) age of 8 (7) months, 81% were infants and 61% were men. The follow-up compliance dropped from 95% at first to 85% at sixth visit. The common morbidities during the follow-up period included cough (28%), fever (17%), diarrhoea (9%) and rapid breathing (7%). During the follow-up period, significantly more day care children (n=22 (OR 12.2 (95% CI 8.2-17.8))) required re-hospitalisation after completion of initial day care compared with initial hospital care group (n=11 (OR 6.1 (95% CI 3.4-10.6))). The predictors for failure were associated with tachycardia, tachypnoea and hypoxaemia on admission and prolonged duration of stay. CONCLUSIONS There are considerable morbidities in children discharged following treatment of severe pneumonia like cough, fever, rapid breathing and diarrhoea during 3-month period. The findings indicate the importance of follow-up for early detection of medical problems and their management to reduce the risk of death. Establishment of an effective community follow-up would be ideal to address the problem of 'non-compliance with follow-up'. TRIAL REGISTRATION The original randomised control trial comparing day care with hospital care was registered at http://www.clinicaltrials.gov (identifier NCT00455468).
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Affiliation(s)
- Hasan Ashraf
- Centre for Nutrition and Food Security (CNFS), International Centre for
Diarrhoeal Disease Research, Bangladesh (icddr,b)
| | - Nur H Alam
- Centre for Nutrition and Food Security (CNFS), International Centre for
Diarrhoeal Disease Research, Bangladesh (icddr,b)
| | - Mohammod Jobayer Chisti
- Centre for Nutrition and Food Security (CNFS), International Centre for
Diarrhoeal Disease Research, Bangladesh (icddr,b)
| | - Mohammed Abdus Salam
- Centre for Nutrition and Food Security (CNFS), International Centre for
Diarrhoeal Disease Research, Bangladesh (icddr,b)
| | - Tahmeed Ahmed
- Centre for Nutrition and Food Security (CNFS), International Centre for
Diarrhoeal Disease Research, Bangladesh (icddr,b)
| | - Niklaus Gyr
- Department of Internal Medicine, University of Basel, Basel,
Switzerland
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Acute respiratory infection and pneumonia in India: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr 2011; 48:191-218. [PMID: 21478555 DOI: 10.1007/s13312-011-0051-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Scaling up of evidence based management of childhood acute respiratory infection/pneumonia, is a public health priority in India, and necessitates robust literature review, for advocacy and action. OBJECTIVE To identify, synthesize and summarize current evidence to guide scaling up of management of childhood acute respiratory infection/pneumonia in India, and identify existing knowledge gaps. METHODS A set of ten questions pertaining to the management (prevention, treatment, and control) of childhood ARI/pneumonia was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. RESULTS Childhood ARI/pneumonia is a significant public health problem in India, although robust epidemiological data is not available on its incidence. Mortality due to pneumonia accounts for approximately one-fourth of the total deaths in under five children, in India. Pneumonia affects children irrespective of socioeconomic status; with higher risk among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use. There is lack of robust nation-wide data on etiology; bacteria (including Pneumococcus, H. influenzae, S. aureus and Gram negative bacilli), viruses (especially RSV) and Mycoplasma, are the common organisms identified. In-vitro resistance to cotrimoxazole is high. Wheezing is commonly associated with ARI/pneumonia in children, but difficult to appreciate without auscultation. The current WHO guidelines as modified by IndiaCLEN Task force on Penumonia (2010), are sufficient for case-management of childhood pneumonia. Other important interventions to prevent mortality are oxygen therapy for those with severe or very severe pneumonia and measles vaccination for all infants. There is insufficient evidence for protective or curative effect of vitamin A; zinc supplementation could be beneficial to prevent pneumonia, although it has no therapeutic benefit. There is insufficient evidence on potential effectiveness and cost-effectiveness of Hib and Pneumococcal vaccines on reduction of ARI specific mortality. Case-finding and community-based management are effective management strategies, but have low coverage in India due to policy and programmatic barriers. There is a significant gap in the utilization of existing services, provider practices as well as family practices in seeking care. CONCLUSION The systematic review summarizes current evidence on childhood ARI and pneumonia management and provides evidence to inform child health programs in India.
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