1
|
Hooli S, King C, McCollum ED, Colbourn T, Lufesi N, Mwansambo C, Gregory CJ, Thamthitiwat S, Cutland C, Madhi SA, Nunes MC, Gessner BD, Hazir T, Mathew JL, Addo-Yobo E, Chisaka N, Hassan M, Hibberd PL, Jeena P, Lozano JM, MacLeod WB, Patel A, Thea DM, Nguyen NTV, Zaman SM, Ruvinsky RO, Lucero M, Kartasasmita CB, Turner C, Asghar R, Banajeh S, Iqbal I, Maulen-Radovan I, Mino-Leon G, Saha SK, Santosham M, Singhi S, Awasthi S, Bavdekar A, Chou M, Nymadawa P, Pape JW, Paranhos-Baccala G, Picot VS, Rakoto-Andrianarivelo M, Rouzier V, Russomando G, Sylla M, Vanhems P, Wang J, Basnet S, Strand TA, Neuman MI, Arroyo LM, Echavarria M, Bhatnagar S, Wadhwa N, Lodha R, Aneja S, Gentile A, Chadha M, Hirve S, O'Grady KAF, Clara AW, Rees CA, Campbell H, Nair H, Falconer J, Williams LJ, Horne M, Qazi SA, Nisar YB. In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset. Int J Infect Dis 2023; 129:240-250. [PMID: 36805325 PMCID: PMC10017350 DOI: 10.1016/j.ijid.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVES We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. METHODS We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. RESULTS Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). CONCLUSION Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.
Collapse
Affiliation(s)
- Shubhada Hooli
- Division of Pediatric Emergency Medicine, Texas Children's Hospital/Baylor College of Medicine, Houston, United States of America
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden and Institute for Global Health, University College London, London, United Kingdom
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, United States of America and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Tim Colbourn
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Christopher J Gregory
- Division of Vector-Borne Diseases, US Centers for Disease Control and Prevention, Fort Collins, United States of America
| | - Somsak Thamthitiwat
- Division of Global Health Protection, Thailand Ministry of Public Health-US Centers for Disease Control and Prevention Collaboration, Nonthaburi, Thailand
| | - Clare Cutland
- African Leadership in Vaccinology Expertise (Alive), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Shabir Ahmed Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Marta C Nunes
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Tabish Hazir
- The Children's Hospital, (Retired), Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Joseph L Mathew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Emmanuel Addo-Yobo
- Kwame Nkrumah University of Science & Technology/Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Noel Chisaka
- World Bank, Washington DC, United States of America
| | - Mumtaz Hassan
- The Children's Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan (deceased)
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Juan M Lozano
- Florida International University, Miami, United States of America
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur and Datta Meghe Institute of Medical Sciences, Sawangi, India
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, United States of America
| | | | - Syed Ma Zaman
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Raul O Ruvinsky
- Dirección de Control de Enfermedades Inmunoprevenibles, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | - Marilla Lucero
- Research Institute for Tropical Medicine, Manila, Philippines
| | - Cissy B Kartasasmita
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Rai Asghar
- Rawalpindi Medical College, Rawalpindi, Pakistan
| | | | - Imran Iqbal
- Combined Military Hospital Institute of Medical Sciences, Multan, Pakistan
| | - Irene Maulen-Radovan
- Instituto Nacional de Pediatria Division de Investigacion Insurgentes, Mexico City, Mexico
| | - Greta Mino-Leon
- Children's Hospital Dr Francisco de Ycaza Bustamante, Head of Department, Infectious diseases, Guayaquil, Ecuador
| | - Samir K Saha
- Child Health Research Foundation and Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Mathuram Santosham
- International Vaccine Access Center (IVAC), Department of International Health, Johns Hopkins University, Baltimore, United States of America
| | | | - Shally Awasthi
- King George's Medical University, Department of Pediatrics, Lucknow, India
| | | | - Monidarin Chou
- University of Health Sciences, Rodolph Mérieux Laboratory & Ministry of Environment, Phom Phen, Cambodia
| | - Pagbajabyn Nymadawa
- Mongolian Academy of Sciences, Academy of Medical Sciences, Ulaanbaatar, Mongolia
| | | | | | | | | | | | - Graciela Russomando
- Universidad Nacional de Asuncion, Departamento de Biología Molecular y Genética, Instituto de Investigaciones en Ciencias de la Salud, Asuncion, Paraguay
| | - Mariam Sylla
- Gabriel Touré Hospital, Department of Pediatrics, Bamako, Mali
| | - Philippe Vanhems
- Unité d'Hygiène, Epidémiologie, Infectiovigilance et Prévention, Hospices Civils de Lyon, Lyon, France and Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Jianwei Wang
- Chinese Academy of Medical Sciences & Peking Union, Medical College Institute of Pathogen Biology, MOH Key Laboratory of Systems Biology of Pathogens and Dr Christophe Mérieux Laboratory, Beijing, China
| | - Sudha Basnet
- Center for Intervention Science in Maternal and Child Health, University of Bergen, Norway and Department of Pediatrics, Tribhuvan University Institute of Medicine, Nepal
| | - Tor A Strand
- Research Department, Innlandet Hospital Trust, Lillehammer, Norway
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, United States of America
| | | | - Marcela Echavarria
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas, Mar del Plata, Argentina
| | | | - Nitya Wadhwa
- Translational Health Science and Technology Institute, Faridabad, India
| | - Rakesh Lodha
- All India Institute of Medical Sciences, New Delhi, India
| | - Satinder Aneja
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | - Angela Gentile
- Department of Epidemiology, "R. Gutiérrez" Children's Hospital, Buenos Aires, Argentina
| | - Mandeep Chadha
- Former Scientist G, ICMR National Institute of Virology, Pune, India
| | | | - Kerry-Ann F O'Grady
- Australian Centre for Health Services Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - Alexey W Clara
- Centers for Disease Control, Central American Region, Guatemala City, Guatemala
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, United States of America
| | - Harry Campbell
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Harish Nair
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Jennifer Falconer
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Linda J Williams
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Margaret Horne
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child, and Adolescent Health (Retired), World Health Organization, Geneva, Switzerland
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child, and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland.
| | | |
Collapse
|
2
|
Williams PCM, Qazi SA, Agarwal R, Velaphi S, Bielicki JA, Nambiar S, Giaquinto C, Bradley J, Noel GJ, Ellis S, O’Brien S, Balasegaram M, Sharland M. Antibiotics needed to treat multidrug-resistant infections in neonates. Bull World Health Organ 2022; 100:797-807. [PMCID: PMC9706347 DOI: 10.2471/blt.22.288623] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/14/2022] [Accepted: 08/20/2022] [Indexed: 12/04/2022] Open
Abstract
Infections remain a leading cause of death in neonates. The sparse antibiotic development pipeline and challenges in conducting neonatal research have resulted in few effective antibiotics being adequately studied to treat multidrug-resistant (MDR) infections in neonates, despite the increasing global mortality burden caused by antimicrobial resistance. Of 40 antibiotics approved for use in adults since 2000, only four have included dosing information for neonates in their labelling. Currently, 43 adult antibiotic clinical trials are recruiting patients, compared with only six trials recruiting neonates. We review the World Health Organization (WHO) priority pathogens list relevant to neonatal sepsis and propose a WHO multiexpert stakeholder meeting to promote the development of a neonatal priority antibiotic development list. The goal is to develop international, interdisciplinary consensus for an accelerated neonatal antibiotic development programme. This programme would enable focused research on identified priority antibiotics for neonates to reduce the excess morbidity and mortality caused by MDR infections in this vulnerable population.
Collapse
Affiliation(s)
- Phoebe CM Williams
- School of Public Health, Faculty of Medicine, Edward Ford Building, The University of Sydney, Camperdown, NSW, 2006, Australia
| | | | - Ramesh Agarwal
- Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sithembiso Velaphi
- Department of Paediatrics, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Julia A Bielicki
- Institute of Infection and Immunity, University of London, London, England
| | - Sumathi Nambiar
- Johnson & Johnson, Rockville, United States of America (USA)
| | - Carlo Giaquinto
- Department of Women and Children’s Health, University of Padua, Padua, Italy
| | - John Bradley
- Department of Pediatric Infectious Diseases, University of California San Diego School of Medicine, San Diego, USA
| | - Gary J Noel
- Institute for Advanced Clinical Trials for Children, Weill Cornell Medical College, Rockville, USA
| | - Sally Ellis
- Global Antibiotic Research and Development Project, Geneva, Switzerland
| | - Seamus O’Brien
- Global Antibiotic Research and Development Project, Geneva, Switzerland
| | | | - Michael Sharland
- Institute of Infection and Immunity, University of London, London, England
| |
Collapse
|
3
|
Connor NE, Islam MS, Mullany LC, Shang N, Bhutta ZA, Zaidi AKM, Soofi S, Nisar I, Panigrahi P, Panigrahi K, Satpathy R, Bose A, Isaac R, Baqui AH, Mitra DK, Sadeq-ur Rahman Q, Hossain T, Schrag SJ, Winchell JM, Arvay ML, Diaz MH, Waller JL, Weber MW, Hamer DH, Hibberd P, Nawshad Uddin Ahmed ASM, Islam M, Hossain MB, Qazi SA, El Arifeen S, Darmstadt GL, Saha SK. Risk factors for community-acquired bacterial infection among young infants in South Asia: a longitudinal cohort study with nested case-control analysis. BMJ Glob Health 2022; 7:bmjgh-2022-009706. [PMID: 36319031 PMCID: PMC9628539 DOI: 10.1136/bmjgh-2022-009706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/24/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Risk factors predisposing infants to community-acquired bacterial infections during the first 2 months of life are poorly understood in South Asia. Identifying risk factors for infection could lead to improved preventive measures and antibiotic stewardship. METHODS Five sites in Bangladesh, India and Pakistan enrolled mother-child pairs via population-based pregnancy surveillance by community health workers. Medical, sociodemographic and epidemiological risk factor data were collected. Young infants aged 0-59 days with signs of possible serious bacterial infection (pSBI) and age-matched controls provided blood and respiratory specimens that were analysed by blood culture and real-time PCR. These tests were used to build a Bayesian partial latent class model (PLCM) capable of attributing the probable cause of each infant's infection in the ANISA study. The collected risk factors from all mother-child pairs were classified and analysed against the PLCM using bivariate and stepwise logistic multivariable regression modelling to determine risk factors of probable bacterial infection. RESULTS Among 63 114 infants born, 14 655 were assessed and 6022 had signs of pSBI; of these, 81% (4859) provided blood samples for culture, 71% (4216) provided blood samples for quantitative PCR (qPCR) and 86% (5209) provided respiratory qPCR samples. Risk factors associated with bacterial-attributed infections included: low (relative risk (RR) 1.73, 95% credible interval (CrI) 1.42 to 2.11) and very low birth weight (RR 5.77, 95% CrI 3.73 to 8.94), male sex (RR 1.27, 95% CrI 1.07 to 1.52), breathing problems at birth (RR 2.50, 95% CrI 1.96 to 3.18), premature rupture of membranes (PROMs) (RR 1.27, 95% CrI 1.03 to 1.58) and being in the lowest three socioeconomic status quintiles (first RR 1.52, 95% CrI 1.07 to 2.16; second RR 1.41, 95% CrI 1.00 to 1.97; third RR 1.42, 95% CrI 1.01 to 1.99). CONCLUSION Distinct risk factors: birth weight, male sex, breathing problems at birth and PROM were significantly associated with the development of bacterial sepsis across South Asian community settings, supporting refined clinical discernment and targeted use of antimicrobials.
Collapse
Affiliation(s)
- Nicholas E Connor
- Department of Microbiology, Child Health Research Foundation, Dhaka, Bangladesh,Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Luke C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nong Shang
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan
| | - Anita K M Zaidi
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Sajid Soofi
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Imran Nisar
- Department of Pediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Pinaki Panigrahi
- Department of Pediatrics, Georgetown University Medical Center, Washington, DC, USA
| | | | | | | | - Rita Isaac
- Christian Medical College, Vellore, India
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Dipak K Mitra
- Department of Public Health, North South University, Dhaka, Bangladesh
| | - Qazi Sadeq-ur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tanvir Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Stephanie J Schrag
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jonas M Winchell
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa L Arvay
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maureen H Diaz
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessica L Waller
- Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Martin W Weber
- Child and Adolescent Health and Development Division, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Patricia Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Maksuda Islam
- Department of Microbiology, Child Health Research Foundation, Dhaka, Bangladesh
| | | | - Shamim A Qazi
- Consultant and Researcher, (Retired WHO staff), Geneva, Switzerland
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Samir K Saha
- Department of Microbiology, Child Health Research Foundation, Dhaka, Bangladesh
| |
Collapse
|
4
|
Arvay ML, Shang N, Qazi SA, Darmstadt GL, Islam MS, Roth DE, Liu A, Connor NE, Hossain B, Sadeq-ur Rahman Q, El Arifeen S, Mullany LC, Zaidi AKM, Bhutta ZA, Soofi SB, Shafiq Y, Baqui AH, Mitra DK, Panigrahi P, Panigrahi K, Bose A, Isaac R, Westreich D, Meshnick SR, Saha SK, Schrag SJ. Infectious aetiologies of neonatal illness in south Asia classified using WHO definitions: a primary analysis of the ANISA study. The Lancet Global Health 2022; 10:e1289-e1297. [PMID: 35961352 PMCID: PMC9380253 DOI: 10.1016/s2214-109x(22)00244-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background Globally, neonatal mortality accounts for almost half of all deaths in children younger than 5 years. Aetiological agents of neonatal infection are difficult to identify because the clinical signs are non-specific. Using data from the Aetiology of Neonatal Infections in south Asia (ANISA) cohort, we aimed to describe the spectrum of infectious aetiologies of acute neonatal illness categorised post-hoc using the 2015 WHO case definitions of critical illness, clinical severe infection, and fast breathing only. Methods Eligible infants were aged 0–59 days with possible serious bacterial infection and healthy infants enrolled in the ANISA study in Bangladesh, India, and Pakistan. We applied a partial latent class Bayesian model to estimate the prevalence of 27 pathogens detectable on PCR, pathogens detected by blood culture only, and illness not attributed to any infectious aetiology. Infants with at least one clinical specimen available were included in the analysis. We assessed the prevalence of these aetiologies according to WHO's case definitions of critically ill, clinical severe infection, and infants with late onset, isolated fast breathing. For the clinical severe definition, we compared the prevalence of signs by bacterial versus viral aetiology. Findings There were 934 infants (992 episodes) in the critically ill category, 3769 (4000 episodes) in the clinical severe infection category, and 738 (771 episodes) in the late-onset isolated fast breathing category. We estimated the proportion of illness attributable to bacterial infection was 32·7% in infants in the critically ill group, 15·6% in the clinical severe infection group, and 8·8% among infants with late-onset isolated fast breathing group. An infectious aetiology was not identified in 58–82% of infants in these categories. Among 4000 episodes of clinical severe infection, those with bacterial versus viral attribution had higher proportions of hypothermia, movement only when stimulated, convulsions, and poor feeding. Interpretation Our modelled results generally support the revised WHO case definitions, although a revision of the most severe case definition could be considered. Clinical criteria do not clearly differentiate between young infants with and without infectious aetiologies. Our results highlight the need for improved point-of-care diagnostics, and further study into neonatal deaths and episodes with no identified aetiology, to ensure antibiotic stewardship and targeted interventions. Funding The Bill and Melinda Gates Foundation.
Collapse
|
5
|
Rees CA, Colbourn T, Hooli S, King C, Lufesi N, McCollum ED, Mwansambo C, Cutland C, Madhi SA, Nunes M, Matthew JL, Addo-Yobo E, Chisaka N, Hassan M, Hibberd PL, Jeena PM, Lozano JM, MacLeod WB, Patel A, Thea DM, Nguyen NTV, Kartasasmita CB, Lucero M, Awasthi S, Bavdekar A, Chou M, Nymadawa P, Pape JW, Paranhos-Baccala G, Picot VS, Rakoto-Andrianarivelo M, Rouzier V, Russomando G, Sylla M, Vanhems P, Wang J, Asghar R, Banajeh S, Iqbal I, Maulen-Radovan I, Mino-Leon G, Saha SK, Santosham M, Singhi S, Basnet S, Strand TA, Bhatnagar S, Wadhwa N, Lodha R, Aneja S, Clara AW, Campbell H, Nair H, Falconer J, Qazi SA, Nisar YB, Neuman MI. Derivation and validation of a novel risk assessment tool to identify children aged 2–59 months at risk of hospitalised pneumonia-related mortality in 20 countries. BMJ Glob Health 2022; 7:bmjgh-2021-008143. [PMID: 35428680 PMCID: PMC9014031 DOI: 10.1136/bmjgh-2021-008143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/20/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Existing risk assessment tools to identify children at risk of hospitalised pneumonia-related mortality have shown suboptimal discriminatory value during external validation. Our objective was to derive and validate a novel risk assessment tool to identify children aged 2–59 months at risk of hospitalised pneumonia-related mortality across various settings. Methods We used primary, baseline, patient-level data from 11 studies, including children evaluated for pneumonia in 20 low-income and middle-income countries. Patients with complete data were included in a logistic regression model to assess the association of candidate variables with the outcome hospitalised pneumonia-related mortality. Adjusted log coefficients were calculated for each candidate variable and assigned weighted points to derive the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) risk assessment tool. We used bootstrapped selection with 200 repetitions to internally validate the PREPARE risk assessment tool. Results A total of 27 388 children were included in the analysis (mean age 14.0 months, pneumonia-related case fatality ratio 3.1%). The PREPARE risk assessment tool included patient age, sex, weight-for-age z-score, body temperature, respiratory rate, unconsciousness or decreased level of consciousness, convulsions, cyanosis and hypoxaemia at baseline. The PREPARE risk assessment tool had good discriminatory value when internally validated (area under the curve 0.83, 95% CI 0.81 to 0.84). Conclusions The PREPARE risk assessment tool had good discriminatory ability for identifying children at risk of hospitalised pneumonia-related mortality in a large, geographically diverse dataset. After external validation, this tool may be implemented in various settings to identify children at risk of hospitalised pneumonia-related mortality.
Collapse
Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Shubhada Hooli
- Section of Pediatric Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Norman Lufesi
- Acute Respiratory Illness Unit, Government of Malawi Ministry of Health, Lilongwe, Malawi
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Charles Mwansambo
- Acute Respiratory Illness Unit, Government of Malawi Ministry of Health, Lilongwe, Malawi
| | - Clare Cutland
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Shabir Ahmed Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Marta Nunes
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | - Joseph L Matthew
- Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Noel Chisaka
- World Bank, World Bank, Washington, District of Columbia, USA
| | - Mumtaz Hassan
- Department of Pediatrics, Children's Hospital, Islamabad, Pakistan
| | - Patricia L Hibberd
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Prakash M Jeena
- Department of Paediatrics and Child Health, University of KwaZulu-Natal Nelson R Mandela School of Medicine, Durban, South Africa
| | - Juan M Lozano
- Division of Medical and Population Health Science Education and Research, Florida International University, Miami, Florida, USA
| | - William B MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Archana Patel
- Lata Medical Research Foundation, Nagpur and Datta Meghe Institute of Medical Sciences, Sawangi, India
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | | | - Cissy B Kartasasmita
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Marilla Lucero
- Department of Pediatrics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Shally Awasthi
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, India
| | | | - Monidarin Chou
- Rodolph Mérieux Laboratory, Faculty of Medicine, University of Health Sciences, Phnom Penh, Cambodia
| | - Pagbajabyn Nymadawa
- Department of Pediatrics, Mongolian Academy of Sciences, Ulaanbaatar, Mongolia
| | | | | | | | | | | | - Graciela Russomando
- Departamento de Biología Molecular y Genética, Instituto de Investigaciones en Ciencias de la Salud, Asuncion, Paraguay
| | - Mariam Sylla
- Department of Pediatrics, Gabriel Touré University Hospital Center, Bamako, Mali
| | - Philippe Vanhems
- Unité d'Hygiène, Epidémiologie, Infectiovigilance et Prévention, Hospices Civils de Lyon, Lyon, France
| | - Jianwei Wang
- MOH Key Laboratory of Systems Biology of Pathogens and Dr Christophe Mérieux Laboratory, Chinese Academy of Medical Sciences & Peking Union, Beijing, China
| | - Rai Asghar
- Department of Paediatrics, Rawalpindi Medical College, Rawalpindi, Pakistan
| | - Salem Banajeh
- Department of Pediatrics, Sana'a University, Sana'a, Yemen
| | - Imran Iqbal
- Department of Pediatrics, Nishtar Medical College, Multan, Pakistan
| | - Irene Maulen-Radovan
- Division de Investigacion Insurgentes, Instituto Nactional de Pediatria, Mexico City, Mexico
| | - Greta Mino-Leon
- Infectious Diseases, Children's Hospital Dr Francisco de Ycaza Bustamante, Guayaquil, Ecuador
| | - Samir K Saha
- Child Health Research Foundation, Dhaka Shishu Hosp, Dhaka, Bangladesh
| | - Mathuram Santosham
- International Vaccine Access Center (IVAC), Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sunit Singhi
- Department of Pediatrics, Medanta, The Medicity, Gurgaon, India
| | - Sudha Basnet
- Department of Pediatrics, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Tor A Strand
- Department of Research, Innlandet Hospital Trust, Lillehammer, Norway
| | - Shinjini Bhatnagar
- Department of Maternal and Child Health, Translational Health Science and Technology Institute, Faridabad, India
| | - Nitya Wadhwa
- Department of Maternal and Child Health, Translational Health Science and Technology Institute, Faridabad, India
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Satinder Aneja
- Department of Pediatrics, Sharda University School of Medical Sciences and Research, Greater Noida, Uttar Pradesh, India
| | - Alexey W Clara
- Central American Region, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Harry Campbell
- Population Health Sciences and Informati, The University of Edinburgh, Edinburgh, UK
| | - Harish Nair
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Jennifer Falconer
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child, and Adolescent Health (Retired), World Health Organization, Geneva, Switzerland
| | - Yasir B Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
King C, Baker K, Richardson S, Wharton-Smith A, Bakare AA, Jehan F, Chisti MJ, Zar H, Awasthi S, Smith H, Greenslade L, Qazi SA. Paediatric pneumonia research priorities in the context of COVID-19: A eDelphi study. J Glob Health 2022; 12:05007. [PMID: 35265331 PMCID: PMC8877807 DOI: 10.7189/jogh.12.05007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Pneumonia remains the leading cause of infectious deaths in children under-five globally. We update the research priorities for childhood pneumonia in the context of the COVID-19 pandemic and explore whether previous priorities have been addressed. Methods We conducted an eDelphi study from November 2019 to June 2021. Experts were invited to take part, targeting balance by: gender, profession, and high (HIC) and low- and middle-income countries (LMIC). We followed a three-stage approach: 1. Collating questions, using a list published in 2011 and adding newly posed topics; 2. Narrowing down, through participant scoring on importance and whether they had been answered; 3. Ranking of retained topics. Topics were categorized into: prevent and protect, diagnosis, treatment and cross-cutting. Results Overall 379 experts were identified, and 108 took part. We started with 83 topics, and 81 further general and 40 COVID-19 specific topics were proposed. In the final ranking 101 topics were retained, and the highest ranked was to "explore interventions to prevent neonatal pneumonia". Among the top 20 topics, epidemiological research and intervention evaluation was commonly prioritized, followed by the operational and implementation research. Two COVID-19 related questions were ranked within the top 20. There were clear differences in priorities between HIC and LMIC respondents, and academics vs non-academics. Conclusions Operational research on health system capacities, and evaluating optimized delivery of existing treatments, diagnostics and case management approaches are needed. This list should act as a catalyst for collaborative research, especially to meet the top priority in preventing neonatal pneumonia, and encourage multi-disciplinary partnerships.
Collapse
Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Institute for Global Health, University College London, London, UK
| | - Kevin Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Malaria Consortium, London, UK
| | | | | | - Ayobami A Bakare
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Fyezah Jehan
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Heather Zar
- Department of Paediatrics and Child Health and SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Shally Awasthi
- Department of Paediatrics, King George's Medical University, Lucknow, India
| | - Helen Smith
- Malaria Consortium, London, UK
- Consultant, International Health Consulting Services Ltd, UK
| | | | - Shamim A Qazi
- Consultant, Retired staff World Health Organization, Geneva, Switzerland
| |
Collapse
|
7
|
King C, Baker K, Richardson S, Wharton-Smith A, Bakare AA, Jehan F, Chisti MJ, Zar H, Awasthi S, Smith H, Greenslade L, Qazi SA. Paediatric pneumonia research priorities in the context of COVID-19: An eDelphi study. J Glob Health 2022; 12:09001. [PMID: 35265333 PMCID: PMC8874896 DOI: 10.7189/jogh.12.09001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Pneumonia remains the leading cause of infectious deaths in children under-five globally. We update the research priorities for childhood pneumonia in the context of the COVID-19 pandemic and explore whether previous priorities have been addressed. Methods We conducted an eDelphi study from November 2019 to June 2021. Experts were invited to take part, targeting balance by: gender, profession, and high (HIC) and low- and middle-income countries (LMIC). We followed a three-stage approach: 1. Collating questions, using a list published in 2011 and adding newly posed topics; 2. Narrowing down, through participant scoring on importance and whether they had been answered; 3. Ranking of retained topics. Topics were categorized into: prevent and protect, diagnosis, treatment and cross-cutting. Results Overall 379 experts were identified, and 108 took part. We started with 83 topics, and 81 further general and 40 COVID-19 specific topics were proposed. In the final ranking 101 topics were retained, and the highest ranked was to “explore interventions to prevent neonatal pneumonia”. Among the top 20 topics, epidemiological research and intervention evaluation was commonly prioritized, followed by the operational and implementation research. Two COVID-19 related questions were ranked within the top 20. There were clear differences in priorities between HIC and LMIC respondents, and academics vs non-academics. Conclusions Operational research on health system capacities, and evaluating optimized delivery of existing treatments, diagnostics and case management approaches are needed. This list should act as a catalyst for collaborative research, especially to meet the top priority in preventing neonatal pneumonia, and encourage multi-disciplinary partnerships.
Collapse
Affiliation(s)
- Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Institute for Global Health, University College London, London, UK
| | - Kevin Baker
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Malaria Consortium, London, UK
| | | | | | - Ayobami A Bakare
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Community Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Fyezah Jehan
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Heather Zar
- Department of Paediatrics and Child Health and SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Shally Awasthi
- Department of Paediatrics, King George’s Medical University, Lucknow, India
| | - Helen Smith
- Malaria Consortium, London, UK
- Consultant, International Health Consulting Services Ltd, UK
| | | | - Shamim A Qazi
- Consultant, Retired staff World Health Organization, Geneva, Switzerland
| |
Collapse
|
8
|
Qureshi M, Inam O, Qazi SA, Aslam I, Omer H. Tangent vector-based gradient method with l 12-regularization: Iterative half thresholding algorithm for CS-MRI. J Magn Reson 2021; 333:107080. [PMID: 34689098 DOI: 10.1016/j.jmr.2021.107080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECT This paper presents a new method using tangent vector-based l12-regularization for compressed sensing MR image reconstruction. MATERIALS AND METHODS The proposed method with l12-regularization is tested on four datasets: (i) 1-D sparse signal (ii) numerical cardiac phantom, (iii & iv) two sets of in-vivo cardiac MRI datasets acquired using 30 receiver coil elements with Cartesian and radial trajectories on 3T scanner. The results are compared with standard CS reconstruction, which utilizes l1-regularization. The experiments were also conducted for two different types of samplings: (i) cartesian sub-sampling and (ii) 2D random Gaussian sub-sampling. RESULTS The quality of the reconstructed images is validated through Root Mean Square Error (RMSE) and Peak Signal-to-Noise Ratio (PSNR). The results show that the proposed method outperforms the standard CS reconstructions in our experiments with an improvement of 54.8% in RMSE and 14.3% in terms of PSNR. Moreover, the Gaussian random sub-sampling-based image reconstruction results are better than the Cartesian sub-sampling-based reconstruction results. CONCLUSION The results show that the proposed method yields a good sparse signal approximation and superior convergence behavior, which implies a promising technique for the reconstruction of cardiac MR images as compared to the conventional CS algorithm.
Collapse
Affiliation(s)
- M Qureshi
- Medical Image Processing Research Group (MIPRG), Department of Electrical & Computer Engineering, COMSATS University Islamabad, Pakistan.
| | - O Inam
- Medical Image Processing Research Group (MIPRG), Department of Electrical & Computer Engineering, COMSATS University Islamabad, Pakistan.
| | - S A Qazi
- Medical Image Processing Research Group (MIPRG), Department of Electrical & Computer Engineering, COMSATS University Islamabad, Pakistan.
| | - I Aslam
- Medical Image Processing Research Group (MIPRG), Department of Electrical & Computer Engineering, COMSATS University Islamabad, Pakistan; Department of Radiology & Medical Informatics, Faculties of Medicine & Life Sciences University of Geneva, Switzerland.
| | - H Omer
- Medical Image Processing Research Group (MIPRG), Department of Electrical & Computer Engineering, COMSATS University Islamabad, Pakistan.
| |
Collapse
|
9
|
Rees CA, Hooli S, King C, McCollum ED, Colbourn T, Lufesi N, Mwansambo C, Lazzerini M, Madhi SA, Cutland C, Nunes M, Gessner BD, Basnet S, Kartasasmita CB, Mathew JL, Zaman SMAU, Paranhos-Baccala G, Bhatnagar S, Wadhwa N, Lodha R, Aneja S, Santosham M, Picot VS, Sylla M, Awasthi S, Bavdekar A, Pape JW, Rouzier V, Chou M, Rakoto-Andrianarivelo M, Wang J, Nymadawa P, Vanhems P, Russomando G, Asghar R, Banajeh S, Iqbal I, MacLeod W, Maulen-Radovan I, Mino G, Saha S, Singhi S, Thea DM, Clara AW, Campbell H, Nair H, Falconer J, Williams LJ, Horne M, Strand T, Qazi SA, Nisar YB, Neuman MI. External validation of the RISC, RISC-Malawi, and PERCH clinical prediction rules to identify risk of death in children hospitalized with pneumonia. J Glob Health 2021; 11:04062. [PMID: 34737862 PMCID: PMC8542381 DOI: 10.7189/jogh.11.04062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Existing scores to identify children at risk of hospitalized pneumonia-related mortality lack broad external validation. Our objective was to externally validate three such risk scores. METHODS We applied the Respiratory Index of Severity in Children (RISC) for HIV-negative children, the RISC-Malawi, and the Pneumonia Etiology Research for Child Health (PERCH) scores to hospitalized children in the Pneumonia REsearch Partnerships to Assess WHO REcommendations (PREPARE) data set. The PREPARE data set includes pooled data from 41 studies on pediatric pneumonia from across the world. We calculated test characteristics and the area under the curve (AUC) for each of these clinical prediction rules. RESULTS The RISC score for HIV-negative children was applied to 3574 children 0-24 months and demonstrated poor discriminatory ability (AUC = 0.66, 95% confidence interval (CI) = 0.58-0.73) in the identification of children at risk of hospitalized pneumonia-related mortality. The RISC-Malawi score had fair discriminatory value (AUC = 0.75, 95% CI = 0.74-0.77) among 17 864 children 2-59 months. The PERCH score was applied to 732 children 1-59 months and also demonstrated poor discriminatory value (AUC = 0.55, 95% CI = 0.37-0.73). CONCLUSIONS In a large external application of the RISC, RISC-Malawi, and PERCH scores, a substantial number of children were misclassified for their risk of hospitalized pneumonia-related mortality. Although pneumonia risk scores have performed well among the cohorts in which they were derived, their performance diminished when externally applied. A generalizable risk assessment tool with higher sensitivity and specificity to identify children at risk of hospitalized pneumonia-related mortality may be needed. Such a generalizable risk assessment tool would need context-specific validation prior to implementation in that setting.
Collapse
Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Shubhada Hooli
- Section of Pediatric Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden and Institute for Global Health, University College London, London, UK
| | - Eric D McCollum
- Global Program in Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, USA and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | | | | | - Marzia Lazzerini
- WHO Collaborating Centre for Maternal and Child Health, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Shabir Ahmed Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Clare Cutland
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Marta Nunes
- South African Medical Research Council: Vaccines and Infectious Diseases Analytics Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases Unit, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Sudha Basnet
- Center for Intervention Science in Maternal and Child Health, University of Bergen, Norway
| | - Cissy B Kartasasmita
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Joseph L Mathew
- Pediatric Pulmonology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | - Nitya Wadhwa
- Translational Health Science and Technology Institute, Faridabad, India
| | - Rakesh Lodha
- All India Institute of Medical Sciences, New Delhi, India
| | - Satinder Aneja
- School of Medical Sciences & Research, Sharda University, Greater Noida, India
| | - Mathuram Santosham
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Mariam Sylla
- Gabriel Touré Hospital, Department of Pediatrics, Bamako, Mali
| | - Shally Awasthi
- King George's Medical University, UP, Department of Pediatrics, Lucknow, India
| | | | | | | | - Monidarin Chou
- University of Health Sciences Faculty of Medicine, Rodolph Mérieux Laboratory, Phom Phen, Cambodia
| | | | - Jianwei Wang
- Chinese Academy of Medical Sciences & Peking Union, Medical College Institute of Pathogen Biology, MOH Key Laboratory of Systems Biology of Pathogens and Dr Christophe Mérieux Laboratory, Beijing, China
| | - Pagbajabyn Nymadawa
- Mongolian Academy of Sciences, Academy of Medical Sciences, Ulaanbaatar, Mongolia
| | - Philippe Vanhems
- Hospices Civils de Lyon, Infection Control Unit; CIRI, Centre International de Recherche en Infectiologie, (Team PHE3ID), Université Claude Bernard Lyon, Lyon, France
| | - Graciela Russomando
- Universidad Nacional de Asuncion, Instituto de Investigaciones en Ciencias de la Salud, San Lorenzo, Paraguay
| | - Rai Asghar
- Rawalpindi Medical College, Rawalpindi, Pakistan
| | | | | | - William MacLeod
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Irene Maulen-Radovan
- Instituto Nactional de Pediatria Division de Investigacion Insurgentes, Mexico City, Mexico
| | - Greta Mino
- Children's Hospital Dr Francisco de Ycaza Bustamante, Head of Department, Infectious diseases, Guayaquil, Ecuador
| | - Samir Saha
- Dhaka Shishu Hospital, Dhaka, Bangladesh
| | | | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alexey W Clara
- US Centers for Disease Control, Central American Region, Guatemala City, Guatemala
| | - Harry Campbell
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Harish Nair
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Jennifer Falconer
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland
| | - Linda J Williams
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Margaret Horne
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Tor Strand
- Research Department, Innlandet Hospital Trust, Lillehammer, Norway
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health (Retired), World Health Organization, Geneva, Switzerland
| | - Yasir B Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
10
|
Rees CA, Basnet S, Gentile A, Gessner BD, Kartasasmita CB, Lucero M, Martinez L, O'Grady KAF, Ruvinsky RO, Turner C, Campbell H, Nair H, Falconer J, Williams LJ, Horne M, Strand T, Nisar YB, Qazi SA, Neuman MI. An analysis of clinical predictive values for radiographic pneumonia in children. BMJ Glob Health 2021; 5:bmjgh-2020-002708. [PMID: 32792409 PMCID: PMC7430338 DOI: 10.1136/bmjgh-2020-002708] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/09/2020] [Accepted: 06/24/2020] [Indexed: 11/04/2022] Open
Abstract
Introduction Healthcare providers in resource-limited settings rely on the presence of tachypnoea and chest indrawing to establish a diagnosis of pneumonia in children. We aimed to determine the test characteristics of commonly assessed signs and symptoms for the radiographic diagnosis of pneumonia in children 0–59 months of age. Methods We conducted an analysis using patient-level pooled data from 41 shared datasets of paediatric pneumonia. We included hospital-based studies in which >80% of children had chest radiography performed. Primary endpoint pneumonia (presence of dense opacity occupying a portion or entire lobe of the lung or presence of pleural effusion on chest radiograph) was used as the reference criterion radiographic standard. We assessed the sensitivity, specificity, and likelihood ratios for clinical findings, and combinations of findings, for the diagnosis of primary endpoint pneumonia among children 0–59 months of age. Results Ten studies met inclusion criteria comprising 15 029 children; 24.9% (n=3743) had radiographic pneumonia. The presence of age-based tachypnoea demonstrated a sensitivity of 0.92 and a specificity of 0.22 while lower chest indrawing revealed a sensitivity of 0.74 and specificity of 0.15 for the diagnosis of radiographic pneumonia. The sensitivity and specificity for oxygen saturation <90% was 0.40 and 0.67, respectively, and was 0.17 and 0.88 for oxygen saturation <85%. Specificity was improved when individual clinical factors such as tachypnoea, fever and hypoxaemia were combined, however, the sensitivity was lower. Conclusions No single sign or symptom was strongly associated with radiographic primary end point pneumonia in children. Performance characteristics were improved by combining individual signs and symptoms.
Collapse
Affiliation(s)
- Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sudha Basnet
- Center for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
| | - Angela Gentile
- Department of Epidemiology, "R. Gutiérrez" Children's Hospital, Buenos Aires, Argentina
| | | | - Cissy B Kartasasmita
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Marilla Lucero
- Research Institute for Tropical Medicine, Manila, Philippines
| | | | - Kerry-Ann F O'Grady
- Institute of Health & Biomedical Innovation @ Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Queensland, Australia
| | - Raul O Ruvinsky
- Dirección de Control de Enfermedades Inmunoprevenibles, Ministerio de Salud de la Nación, Buenos Aires, Argentina
| | | | - Harry Campbell
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Harish Nair
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Jennifer Falconer
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland
| | - Linda J Williams
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Margaret Horne
- Centre for Global Health, Usher Institute, The University of Edinburgh, Edinburgh, Scotland
| | - Tor Strand
- Research Department, Innlandet Hospital Trust, Lillehammer, Norway
| | - Yasir B Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health (Retired), World Health Organization, Geneva, Switzerland
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
11
|
Rahman AE, Hossain AT, Zaman SB, Salim N, K C A, Day LT, Ameen S, Ruysen H, Kija E, Peven K, Tahsina T, Ahmed A, Rahman QSU, Khan J, Kong S, Campbell H, Hailegebriel TD, Ram PK, Qazi SA, El Arifeen S, Lawn JE. Antibiotic use for inpatient newborn care with suspected infection: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth 2021; 21:229. [PMID: 33765948 PMCID: PMC7995687 DOI: 10.1186/s12884-020-03424-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia. METHODS EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017-July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes (sepsis, meningitis, and pneumonia), excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women's report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis. RESULTS A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (n = 910), 98.8% (95% CI: 97.8-99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1-64.5%) reported their baby's diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture. CONCLUSIONS Women's report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records.
Collapse
Affiliation(s)
- Ahmed Ehsanur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh.
| | - Aniqa Tasnim Hossain
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Sojib Bin Zaman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Nahya Salim
- Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam, Tanzania
| | - Ashish K C
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Louise T Day
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Shafiqul Ameen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Harriet Ruysen
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Edward Kija
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences (MUHAS), Dar Es Salaam, Tanzania
| | - Kimberly Peven
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Tazeen Tahsina
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Anisuddin Ahmed
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Qazi Sadeq-Ur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Jasmin Khan
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Stefanie Kong
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | | | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahid Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
12
|
Graham H, Bakare AA, Ayede AI, Oyewole OB, Gray A, Neal E, Qazi SA, Duke T, Falade AG. Diagnosis of pneumonia and malaria in Nigerian hospitals: A prospective cohort study. Pediatr Pulmonol 2020; 55 Suppl 1:S37-S50. [PMID: 32074408 PMCID: PMC7318580 DOI: 10.1002/ppul.24691] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pneumonia and malaria are the leading causes of global childhood mortality. We describe the clinical presentation of children diagnosed with pneumonia and/or malaria, and identify possible missed cases and diagnostic predictors. METHODS Prospective cohort study involving children (aged 28 days to 15 years) admitted to 12 secondary-level hospitals in south-west Nigeria, from November 2015 to October 2017. We described children diagnosed with malaria and/or pneumonia on admission and identified potential missed cases using WHO criteria. We used logistic regression models to identify associations between clinical features and severe pneumonia and malaria diagnoses. RESULTS Of 16 432 admitted children, 16 184 (98.5%) had adequate data for analysis. Two-thirds (10 561, 65.4%) of children were diagnosed with malaria and/or pneumonia by the admitting doctor; 31.5% (567/1799) of those with pneumonia were also diagnosed with malaria. Of 1345 (8.3%) children who met WHO severe pneumonia criteria, 557 (41.4%) lacked a pneumonia diagnosis. Compared with "potential missed" diagnoses of severe pneumonia, children with "detected" severe pneumonia were more likely to receive antibiotics (odds ratio [OR], 4.03; 2.63-6.16, P < .001), and less likely to die (OR, 0.72; 0.51-1.02, P = .067). Of 2299 (14.2%) children who met WHO severe malaria criteria, 365 (15.9%) lacked a malaria diagnosis. Compared with "potential missed" diagnoses of severe malaria, children with "detected" severe malaria were less likely to die (OR, 0.59; 0.38-0.91, P = 0.017), with no observed difference in antimalarial administration (OR, 0.29; 0.87-1.93, P = .374). We identified predictors of severe pneumonia and malaria diagnosis. CONCLUSION Pneumonia should be considered in all severely unwell children with respiratory signs, regardless of treatment for malaria or other conditions.
Collapse
Affiliation(s)
- Hamish Graham
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A Bakare
- Department of Community Medicine, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Oladapo B Oyewole
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Amy Gray
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Eleanor Neal
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia.,Infection & Immunity, MCRI, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Trevor Duke
- Centre for International Child Health, MCRI, Royal Children's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Adegoke G Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria.,Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| |
Collapse
|
13
|
Graham HR, Bakare AA, Ayede AI, Gray AZ, McPake B, Peel D, Olatinwo O, Oyewole OB, Neal EFG, Nguyen CD, Qazi SA, Izadnegahdar R, Carlin JB, Falade AG, Duke T. Oxygen systems to improve clinical care and outcomes for children and neonates: A stepped-wedge cluster-randomised trial in Nigeria. PLoS Med 2019; 16:e1002951. [PMID: 31710601 PMCID: PMC6844455 DOI: 10.1371/journal.pmed.1002951] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/11/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Improving oxygen systems may improve clinical outcomes for hospitalised children with acute lower respiratory infection (ALRI). This paper reports the effects of an improved oxygen system on mortality and clinical practices in 12 general, paediatric, and maternity hospitals in southwest Nigeria. METHODS AND FINDINGS We conducted an unblinded stepped-wedge cluster-randomised trial comparing three study periods: baseline (usual care), pulse oximetry introduction, and stepped introduction of a multifaceted oxygen system. We collected data from clinical records of all admitted neonates (<28 days old) and children (28 days to 14 years old). Primary analysis compared the full oxygen system period to the pulse oximetry period and evaluated odds of death for children, children with ALRI, neonates, and preterm neonates using mixed-effects logistic regression. Secondary analyses included the baseline period (enabling evaluation of pulse oximetry introduction) and evaluated mortality and practice outcomes on additional subgroups. Three hospitals received the oxygen system intervention at 4-month intervals. Primary analysis included 7,716 neonates and 17,143 children admitted during the 2-year stepped crossover period (November 2015 to October 2017). Compared to the pulse oximetry period, the full oxygen system had no association with death for children (adjusted odds ratio [aOR] 1.06; 95% confidence interval [CI] 0.77-1.46; p = 0.721) or children with ALRI (aOR 1.09; 95% CI 0.50-2.41; p = 0.824) and was associated with an increased risk of death for neonates overall (aOR 1.45; 95% CI 1.04-2.00; p = 0.026) but not preterm/low-birth-weight neonates (aOR 1.30; 95% CI 0.76-2.23; p = 0.366). Secondary analyses suggested that the introduction of pulse oximetry improved oxygen practices prior to implementation of the full oxygen system and was associated with lower odds of death for children with ALRI (aOR 0.33; 95% CI 0.12-0.92; p = 0.035) but not for children, preterm neonates, or neonates overall (aOR 0.97, 95% CI 0.60-1.58, p = 0.913; aOR 1.12, 95% CI 0.56-2.26, p = 0.762; aOR 0.90, 95% CI 0.57-1.43, p = 0.651). Limitations of our study are a lower-than-anticipated power to detect change in mortality outcomes (low event rates, low participant numbers, high intracluster correlation) and major contextual changes related to the 2016-2017 Nigerian economic recession that influenced care-seeking and hospital function during the study period, potentially confounding mortality outcomes. CONCLUSIONS We observed no mortality benefit for children and a possible higher risk of neonatal death following the introduction of a multifaceted oxygen system compared to introducing pulse oximetry alone. Where some oxygen is available, pulse oximetry may improve oxygen usage and clinical outcomes for children with ALRI. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12617000341325.
Collapse
Affiliation(s)
- Hamish R. Graham
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Amy Z. Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Parkville, Australia
| | | | - Olatayo Olatinwo
- Biomedical Services, University College Hospital, Ibadan, Nigeria
| | | | - Eleanor F. G. Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
- Asia-Pacific Health, New Vaccines, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Cattram D. Nguyen
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
- Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Australia
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Rasa Izadnegahdar
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - John B. Carlin
- Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia
| |
Collapse
|
14
|
Graham H, Bakare AA, Ayede AI, Oyewole OB, Gray A, Peel D, McPake B, Neal E, Qazi SA, Izadnegahdar R, Duke T, Falade AG. Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals. EClinicalMedicine 2019; 16:51-63. [PMID: 31832620 PMCID: PMC6890969 DOI: 10.1016/j.eclinm.2019.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 10/15/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Hypoxaemia is a common complication of pneumonia and a major risk factor for death, but less is known about hypoxaemia in other common conditions. We evaluated the epidemiology of hypoxaemia and oxygen use in hospitalised neonates and children in Nigeria. METHODS We conducted a prospective cohort study among neonates and children (<15 years of age) admitted to 12 secondary-level hospitals in southwest Nigeria (November 2015-November 2017) using data extracted from clinical records (documented during routine care). We report summary statistics on hypoxaemia prevalence, oxygen use, and clinical predictors of hypoxaemia. We used generalised linear mixed-models to calculate relative odds of death (hypoxaemia vs not). FINDINGS Participating hospitals admitted 23,926 neonates and children during the study period. Pooled hypoxaemia prevalence was 22.2% (95%CI 21.2-23.2) for neonates and 10.2% (9.7-10.8) for children. Hypoxaemia was common among children with acute lower respiratory infection (28.0%), asthma (20.4%), meningitis/encephalitis (17.4%), malnutrition (16.3%), acute febrile encephalopathy (15.4%), sepsis (8.7%) and malaria (8.5%), and neonates with neonatal encephalopathy (33.4%), prematurity (26.6%), and sepsis (21.0%). Hypoxaemia increased the adjusted odds of death 6-fold in neonates and 7-fold in children. Clinical signs predicted hypoxaemia poorly, and their predictive ability varied across ages and conditions. Hypoxaemic children received oxygen for a median of 2-3 days, consuming ∼3500 L of oxygen per admission. INTERPRETATION Hypoxaemia is common in respiratory and non-respiratory acute childhood illness and increases the risk of death substantially. Given the limitations of clinical signs, pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine assessment of all hospitalised neonates and children.
Collapse
Affiliation(s)
- Hamish Graham
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Corresponding author at: Centre for International Child Health, Department of Paediatrics, Level 2 East, 50 Flemington Road, Parkville, VIC 3052, Australia.
| | - Ayobami A. Bakare
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
| | - Adejumoke I. Ayede
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| | | | - Amy Gray
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | | | - Barbara McPake
- Nossal Institute of Global Health, University of Melbourne, Parkville, Australia
| | - Eleanor Neal
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
- Pneumococcal Research, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Trevor Duke
- Centre for International Child Health, University of Melbourne, MCRI, Royal Children's Hospital, Parkville, Australia
| | - Adegoke G. Falade
- Department of Paediatrics, University College Hospital, Ibadan, Nigeria
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria
| |
Collapse
|
15
|
Modi D, Dholakia N, Gopalan R, Venkatraman S, Dave K, Shah S, Desai G, Qazi SA, Sinha A, Pandey RM, Anand A, Desai S, Shah P. mHealth intervention "ImTeCHO" to improve delivery of maternal, neonatal, and child care services-A cluster-randomized trial in tribal areas of Gujarat, India. PLoS Med 2019; 16:e1002939. [PMID: 31647821 PMCID: PMC6812744 DOI: 10.1371/journal.pmed.1002939] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 09/12/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The coverage of community-based maternal, neonatal, and child health (MNCH) services remains low, especially in hard-to-reach areas. We evaluated the effectiveness of a mobile-phone-and web-based application, Innovative Mobile-phone Technology for Community Health Operations (ImTeCHO), as a job aid to the government's Accredited Social Health Activists (ASHAs) and Primary Health Center (PHC) staff to improve coverage of MNCH services in rural tribal communities of Gujarat, India. METHODS AND FINDINGS This open cluster-randomized trial was conducted in 22 PHCs in six tribal blocks of Bharuch and Narmada districts in India. The ImTeCHO mobile-phone-and web-based application included various technology-based job aids to facilitate scheduling of home visits, screening for complications, counseling during home visits, and supportive supervision by PHC staff. Primary outcome indicators were a composite index calculated based on coverage of important MNCH services and coverage of at least two home visitations by ASHA within the first week of birth. Primary analysis was intention to treat (ITT). Generalized Estimating Equation (GEE) was used to account for clustering. Eleven PHCs each were randomly allocated to the intervention (280 ASHAs, population: 234,134) and control (281 ASHAs, population: 242,809) arms. The intervention was implemented from February, 2016 to January, 2017. At the end of the implementation, 6,493 mothers were surveyed. Most of the surveyed women were tribal (5,571, 85.8%), and reported having a government-issued certificate for living below poverty line (4,916, 75.7%). The coverage of at least two home visits within first week of birth was 32.4% in the intervention clusters compared to 22.9% in the control clusters (adjusted effect size 10.2 [95% CI: 6.4, 14.0], p < 0.001). Mean number of home visits within first week of birth was 1.11 and 0.80 for intervention and control clusters, respectively (adjusted effect size 0.34 [95% CI: 0.23, 0.45], p < 0.001). The composite coverage index was 43.0% in the intervention clusters compared to 38.5% (adjusted effect size 4.9 [95% CI: 0.2, 9.5], p = 0.03) in the control clusters. There were substantial improvements in coverage home visits by ASHAs during antenatal period (adjusted effect size 15.7 [95% CI: 11.0, 20.4], p < 0.001), postnatal period (adjusted effect size 6.4, [95% CI: 3.2, 9.6], p <0.001), early initiation of breastfeeding (adjusted effect size 7.8 [95% CI: 4.2, 11.4], p < 0.001), and exclusive breastfeeding (adjusted effect size 13.4 [95% CI: 8.9, 17.9], p < 0.001). Number of infant and neonatal deaths was similar in the two arms in the ITT analysis. The limitations of the study include potential risk of inaccuracies in reporting events that occurred during pregnancy by the mothers and the duration of intervention being 12 months, which might be considered short. CONCLUSIONS In this study, we found that use of ImTeCHO mobile- and web-based application as a job aid by government ASHAs and PHC staff improved coverage and quality of MNCH services in hard-to-reach areas. Supportive supervision, change management, and timely resolution of technology-related issues were critical implementation considerations to ensure adherence to the intervention. TRIAL REGISTRATION Study was registered at the Clinical Trial Registry of India (www.ctri.nic.in). Trial number: CTRI/2015/06/005847. The trial was registered (prospective) on 3 June, 2015. First enrollment was done on 26 August, 2015.
Collapse
Affiliation(s)
- Dhiren Modi
- Community Health Department, SEWA Rural, Jhagadia, Bharuch, Gujarat, India
| | - Nishith Dholakia
- Commissionerate of Health, Government of Gujarat, Gandhinagar, Gujarat, India
| | - Ravi Gopalan
- Argusoft India Ltd., Gandhinagar, Gujarat, India
| | | | - Kapilkumar Dave
- Community Health Department, SEWA Rural, Jhagadia, Bharuch, Gujarat, India
| | - Shobha Shah
- Community Health Department, SEWA Rural, Jhagadia, Bharuch, Gujarat, India
| | - Gayatri Desai
- Community Health Department, SEWA Rural, Jhagadia, Bharuch, Gujarat, India
| | - Shamim A. Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Anju Sinha
- Division of Reproductive Biology, Maternal & Child Health, Indian Council of Medical Research, New Delhi, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Anand
- Population Research Centre, Institute of Social and Economic Change, Bengaluru, India
| | - Shrey Desai
- Community Health Department, SEWA Rural, Jhagadia, Bharuch, Gujarat, India
| | - Pankaj Shah
- Community Health Department, SEWA Rural, Jhagadia, Bharuch, Gujarat, India
| |
Collapse
|
16
|
Sadruddin S, Khan IUH, Fox MP, Bari A, Khan A, Thea DM, Khan A, Khan I, Ahmad I, Qazi SA. Comparison of 3 Days Amoxicillin Versus 5 Days Co-Trimoxazole for Treatment of Fast-breathing Pneumonia by Community Health Workers in Children Aged 2-59 Months in Pakistan: A Cluster-randomized Trial. Clin Infect Dis 2019; 69:397-404. [PMID: 30596964 PMCID: PMC6637273 DOI: 10.1093/cid/ciy918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 11/22/2018] [Indexed: 11/21/2022] Open
Abstract
Background Globally, most deaths due to childhood pneumonia occur at the community level. Some countries are still using oral co-trimoxazole, despite a World Health Organization recommendation of oral amoxicillin for the treatment of fast-breathing pneumonia in children at the community level. Methods We conducted an unblinded, cluster-randomized, controlled-equivalency trial in Haripur District, Pakistan. Children 2–59 months of age with fast-breathing pneumonia were treated with oral amoxicillin suspension (50 mg/kg/day) for 3 days in 14 intervention clusters and oral co-trimoxazole suspension (8 mg trimethoprim/kg and 40 mg sulfamethoxazole/kg/day) for 5 days in 14 control clusters by lady health workers (LHW). The primary outcome was treatment failure by day 4 for intervention clusters and by day 6 for control clusters. The analysis was per protocol. Results Out of the 15 749 cases enrolled in the study, 9153 cases in intervention and 6509 cases in control clusters were included in the analysis. Treatment failure rates were 3.6% (326) in intervention clusters and 9.1% (592) in control clusters. After adjusting for clustering, the risk of treatment failure was lower in intervention clusters (risk difference [RD] -5.5%, 95% confidence interval [CI] -7.4–-3.7%) than in control clusters. Children with incomplete adherence had a small increase in treatment failure versus those with complete adherence (RD 2.9%, 95% CI 1.6–4.1%). No deaths or serious adverse events occurred. Conclusions A 3-day course of oral amoxicillin, administered by LHWs, is an effective and safe treatment for fast-breathing pneumonia in children 2–59 months of age. A shorter course of amoxicillin improves adherence to therapy, is low in cost, and puts less pressure on antimicrobial resistance. Clinical Trials Registration ISRCTN10618300.
Collapse
Affiliation(s)
| | | | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Massachusetts.,Department of Epidemiology, Boston University School of Public Health, Massachusetts
| | | | - Attaullah Khan
- Directorate General, Health Services, Khyber Pakhtunkhwa
| | - Donald M Thea
- Department of Global Health, Boston University School of Public Health, Massachusetts
| | | | - Inamullah Khan
- United Nations International Children's Emergency Fund Peshawar
| | - Ijaz Ahmad
- Health Sector Reform Unit, Department of Health, Khyber Pakhtunkhwa, Pakistan
| | | |
Collapse
|
17
|
Kirolos A, Ayede AI, Williams LJ, Fowobaje KR, Nair H, Bakare AA, Oyewole OB, Qazi SA, Campbell H, Falade AG. Care seeking behaviour and aspects of quality of care by caregivers for children under five with and without pneumonia in Ibadan, Nigeria. J Glob Health 2018; 8:020805. [PMID: 30254743 PMCID: PMC6150609 DOI: 10.7189/jogh.08.020805] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study aimed to investigate the differences in reported care seeking behaviour and treatment between children with pneumonia and children without pneumonia with cough and/or difficult breathing. METHODS Three hundred and two children aged 0-59 months with fast breathing pneumonia were matched with 302 children seeking care for cough and/or difficult breathing at four outpatient clinics in Ibadan, Nigeria. After follow up at home, Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questionnaires were administered in the community by trained field workers to gather information around care seeking delay, patterns of care seeking, appropriateness of care seeking and treatment provided once care was sought. Multivariable analysis was carried out to determine significant factors associated with care seeking delay. RESULTS Children with pneumonia had a significantly longer delay (median = 3d) before seeking care than those without pneumonia (median = 2d; P = 0.001). The length of the delay was 21% (95% confidence interval (CI) = 1%-42%) greater in those aged 0-1 month and 11% (95% CI = 5%-42%) greater in those aged 2-11 months compared to those aged 12-59 months. The length of delay was 17% (95% CI = 5%-30%) greater in rural locations than urban ones, and 33% (95% CI = 7%-51%) shorter in fathers with only primary education compared to higher education, adjusted for covariates. The range of places where care was sought showed the same distribution in those with and without pneumonia. Twenty two per cent of those with pneumonia sought care first from inappropriate providers. The number of children for whom caregivers reported having received antibiotic treatment was 92% for those with pneumonia and 84% for those without pneumonia. CONCLUSIONS Given that children with pneumonia and cough/cold had similar patterns of reported care seeking information gathered on care seeking (type of provider visited) from DHS and MICS surveys on those with 'symptoms of acute respiratory infection' in this setting provide a reasonably valid indication of care seeking behaviours in children with pneumonia. There are high levels of antibiotic overuse for children with cough/cold in this setting which risks worsening antibiotic resistance.
Collapse
Affiliation(s)
- Amir Kirolos
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
- Joint first authorship
| | - Adejumoke I Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
- University College Hospital, Ibadan, Nigeria
- Joint first authorship
| | - Linda J Williams
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
- Joint first authorship
| | | | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | | | | | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
- Joint senior authorship
| | - Adegoke G Falade
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria
- University College Hospital, Ibadan, Nigeria
- Joint senior authorship
| |
Collapse
|
18
|
Ayede AI, Kirolos A, Fowobaje KR, Williams LJ, Bakare AA, Oyewole OB, Olorunfemi OB, Kuna O, Iwuala NT, Oguntoye A, Kusoro SO, Okunlola ME, Qazi SA, Nair H, Falade AG, Campbell H. A prospective validation study in South-West Nigeria on caregiver report of childhood pneumonia and antibiotic treatment using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questions. J Glob Health 2018; 8:020806. [PMID: 30254744 DOI: 10.7189/jogh.08.020806] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Childhood pneumonia is the single largest infectious cause of death in children under five worldwide. Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) provide health information on care sought for sick children in resource poor settings. Despite not being primarily designed to identify childhood pneumonia, there are concerns that reported episodes of "symptoms of acute respiratory infection" in DHS and MICS are often interpreted by other groups as a "proxy" for childhood pneumonia. Using DHS5 and MICS5 survey tools, this study aimed to assess how accurately caregivers report of "symptoms of acute respiratory infection" reflect pneumonia episodes and antibiotic use in children under five. Methods Children aged 0 to 59 months presenting with cough and/or difficult breathing were recruited from four study hospitals in Ibadan, Nigeria from August 2015 to March 2017. Children were assessed using World Health Organization (WHO) standard criteria by study physicians to identify whether they had pneumonia. Three hundred and two matched children in each category of 'pneumonia' and "no pneumonia" were followed up at home, either two or eight weeks later, using questions from DHS5 and MICS5 surveys to assess the accuracy of caregiver recall of pneumonia. Results The specificity of DHS5 and MICS5 questions for identifying childhood pneumonia were 87.4 (95% confidence interval (CI) = 83.1-91.0) and 86.1 (95% CI = 81.7-89.8) respectively and the sensitivity of questions were 37.1 (95% CI = 31.6-42.8) and 37.1 (95% CI = 31.6-42.8). Correct recall of antibiotic treatment was poor (kappa statistic = 0.064) but improved with the use of medicine pill boards (kappa statistic = 0.235). Conclusions DHS5 and MICS5 survey questions are not designed to identify childhood pneumonia and this study confirms that they do not accurately discern episodes of childhood pneumonia from cough/cold in children under five. The proportion of pneumonia episodes appropriately treated with antibiotics cannot be accurately assessed using current DHS and MICS surveys. If these results are used to guide programmatic decisions, it is likely to encourage overuse and inappropriate prescribing of antibiotics for episodes of cough/cold. International agencies who continue to use these household data to monitor the proportion of children with pneumonia who receive antibiotic treatment should be discouraged from doing this as these data are likely to mislead national and global programmes. Medicine pill boards are used in a number of DHS surveys and should be promoted for wider use in national population surveys to improve the accuracy of antibiotic recall.
Collapse
Affiliation(s)
- Adejumoke I Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,University College Hospital, Ibadan, Nigeria.,Joint first authorships
| | - Amir Kirolos
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK.,Joint first authorships
| | | | - Linda J Williams
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | | | | | | | | | | | | | | | | | - Shamim A Qazi
- Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | - Adegoke G Falade
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,University College Hospital, Ibadan, Nigeria.,Joint last authorships
| | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK.,Joint last authorships
| |
Collapse
|
19
|
Ayede AI, Kirolos A, Fowobaje KR, Williams LJ, Bakare AA, Oyewole OB, Olorunfemi OB, Kuna O, Iwuala NT, Oguntoye A, Kusoro SO, Okunlola ME, Qazi SA, Nair H, Falade AG, Campbell H. A prospective validation study in South-West Nigeria on caregiver report of childhood pneumonia and antibiotic treatment using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questions. J Glob Health 2018. [PMID: 30254744 PMCID: PMC6150611 DOI: 10.7189/jogh.08-020806] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Childhood pneumonia is the single largest infectious cause of death in children under five worldwide. Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) provide health information on care sought for sick children in resource poor settings. Despite not being primarily designed to identify childhood pneumonia, there are concerns that reported episodes of “symptoms of acute respiratory infection” in DHS and MICS are often interpreted by other groups as a “proxy” for childhood pneumonia. Using DHS5 and MICS5 survey tools, this study aimed to assess how accurately caregivers report of “symptoms of acute respiratory infection” reflect pneumonia episodes and antibiotic use in children under five. Methods Children aged 0 to 59 months presenting with cough and/or difficult breathing were recruited from four study hospitals in Ibadan, Nigeria from August 2015 to March 2017. Children were assessed using World Health Organization (WHO) standard criteria by study physicians to identify whether they had pneumonia. Three hundred and two matched children in each category of ‘pneumonia’ and “no pneumonia” were followed up at home, either two or eight weeks later, using questions from DHS5 and MICS5 surveys to assess the accuracy of caregiver recall of pneumonia. Results The specificity of DHS5 and MICS5 questions for identifying childhood pneumonia were 87.4 (95% confidence interval (CI) = 83.1-91.0) and 86.1 (95% CI = 81.7–89.8) respectively and the sensitivity of questions were 37.1 (95% CI = 31.6-42.8) and 37.1 (95% CI = 31.6-42.8). Correct recall of antibiotic treatment was poor (kappa statistic = 0.064) but improved with the use of medicine pill boards (kappa statistic = 0.235). Conclusions DHS5 and MICS5 survey questions are not designed to identify childhood pneumonia and this study confirms that they do not accurately discern episodes of childhood pneumonia from cough/cold in children under five. The proportion of pneumonia episodes appropriately treated with antibiotics cannot be accurately assessed using current DHS and MICS surveys. If these results are used to guide programmatic decisions, it is likely to encourage overuse and inappropriate prescribing of antibiotics for episodes of cough/cold. International agencies who continue to use these household data to monitor the proportion of children with pneumonia who receive antibiotic treatment should be discouraged from doing this as these data are likely to mislead national and global programmes. Medicine pill boards are used in a number of DHS surveys and should be promoted for wider use in national population surveys to improve the accuracy of antibiotic recall.
Collapse
Affiliation(s)
- Adejumoke I Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,University College Hospital, Ibadan, Nigeria.,Joint first authorships
| | - Amir Kirolos
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK.,Joint first authorships
| | | | - Linda J Williams
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | | | | | | | | | | | | | | | | | - Shamim A Qazi
- Department of Maternal Newborn Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Harish Nair
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | - Adegoke G Falade
- Department of Paediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,University College Hospital, Ibadan, Nigeria.,Joint last authorships
| | - Harry Campbell
- Centre for Global Health Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK.,Joint last authorships
| |
Collapse
|
20
|
Das MK, Arora NK, Dalpath S, Kumar S, Qazi SA, Bahl R. Improving quality of care for perinatal and newborn care at district and subdistrict hospitals in Haryana, India: Implementation research protocol. J Adv Nurs 2018; 74:2904-2911. [PMID: 29989201 DOI: 10.1111/jan.13791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2018] [Indexed: 11/27/2022]
Abstract
AIM This implementation research aims to improve quality of care for mothers and newborns in three districts of Haryana, India at different public health facilities. BACKGROUND The decline in key maternal and newborn health indicators in India is relatively slower than expected and missed the millennium development goals. The multifold rise in institutional delivery in last decade has limited impact on neonatal and maternal mortality. Despite investments in infrastructure, equipment, supplies, monitoring tools, and also manpower, suboptimal gains in indicators point towards potential challenge in quality of care. DESIGN This study adopts pre-post, quasi-experimental study design with repeated observations using mixed research methods to document the impact of the plan-do-study-act implementation cycles. METHODS The quality improvement interventions shall be implemented at three district hospitals and six-first referral unit hospitals in three districts of Haryana targeting the antenatal, delivery, newborn care services with nurses as the key partners. Formative research, situational analysis, and root-cause analysis shall inform the contextualization, prioritization of interventions. Incremental plan-do-study-act cycles over 15 months shall be implemented. The changes in adherence to protocols, appropriate documentation, reduction in delays, and client satisfaction shall be documented for 16 indicators across delivery, antenatal, and sick newborn care domains. DISCUSSION The successful implementation of the quality improvement processes has the potential of improving the pregnancy outcomes in terms of stillbirths, maternal, and newborn mortality and sick newborn outcomes. The feasibility and learning of coimplementation in the public health system shall inform integration into standards and scaling up.
Collapse
Affiliation(s)
| | | | - Suresh Dalpath
- Department of Health and Family Welfare, Government of Haryana, Haryana, India
| | - Saket Kumar
- Department of Health and Family Welfare, Government of Haryana, Haryana, India
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Rajib Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| |
Collapse
|
21
|
Saha SK, Schrag SJ, El Arifeen S, Mullany LC, Shahidul Islam M, Shang N, Qazi SA, Zaidi AKM, Bhutta ZA, Bose A, Panigrahi P, Soofi SB, Connor NE, Mitra DK, Isaac R, Winchell JM, Arvay ML, Islam M, Shafiq Y, Nisar I, Baloch B, Kabir F, Ali M, Diaz MH, Satpathy R, Nanda P, Padhi BK, Parida S, Hotwani A, Hasanuzzaman M, Ahmed S, Belal Hossain M, Ariff S, Ahmed I, Ibne Moin SM, Mahmud A, Waller JL, Rafiqullah I, Quaiyum MA, Begum N, Balaji V, Halen J, Nawshad Uddin Ahmed ASM, Weber MW, Hamer DH, Hibberd PL, Sadeq-Ur Rahman Q, Mogan VR, Hossain T, McGee L, Anandan S, Liu A, Panigrahi K, Abraham AM, Baqui AH. Causes and incidence of community-acquired serious infections among young children in south Asia (ANISA): an observational cohort study. Lancet 2018; 392:145-159. [PMID: 30025808 PMCID: PMC6053599 DOI: 10.1016/s0140-6736(18)31127-9] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 05/08/2018] [Accepted: 05/15/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND More than 500 000 neonatal deaths per year result from possible serious bacterial infections (pSBIs), but the causes are largely unknown. We investigated the incidence of community-acquired infections caused by specific organisms among neonates in south Asia. METHODS From 2011 to 2014, we identified babies through population-based pregnancy surveillance at five sites in Bangladesh, India, and Pakistan. Babies were visited at home by community health workers up to ten times from age 0 to 59 days. Illness meeting the WHO definition of pSBI and randomly selected healthy babies were referred to study physicians. The primary objective was to estimate proportions of specific infectious causes by blood culture and Custom TaqMan Array Cards molecular assay (Thermo Fisher, Bartlesville, OK, USA) of blood and respiratory samples. FINDINGS 6022 pSBI episodes were identified among 63 114 babies (95·4 per 1000 livebirths). Causes were attributed in 28% of episodes (16% bacterial and 12% viral). Mean incidence of bacterial infections was 13·2 (95% credible interval [CrI] 11·2-15·6) per 1000 livebirths and of viral infections was 10·1 (9·4-11·6) per 1000 livebirths. The leading pathogen was respiratory syncytial virus (5·4, 95% CrI 4·8-6·3 episodes per 1000 livebirths), followed by Ureaplasma spp (2·4, 1·6-3·2 episodes per 1000 livebirths). Among babies who died, causes were attributed to 46% of pSBI episodes, among which 92% were bacterial. 85 (83%) of 102 blood culture isolates were susceptible to penicillin, ampicillin, gentamicin, or a combination of these drugs. INTERPRETATION Non-attribution of a cause in a high proportion of patients suggests that a substantial proportion of pSBI episodes might not have been due to infection. The predominance of bacterial causes among babies who died, however, indicates that appropriate prevention measures and management could substantially affect neonatal mortality. Susceptibility of bacterial isolates to first-line antibiotics emphasises the need for prudent and limited use of newer-generation antibiotics. Furthermore, the predominance of atypical bacteria we found and high incidence of respiratory syncytial virus indicated that changes in management strategies for treatment and prevention are needed. Given the burden of disease, prevention of respiratory syncytial virus would have a notable effect on the overall health system and achievement of Sustainable Development Goal. FUNDING Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Samir K Saha
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh.
| | - Stephanie J Schrag
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | - Shams El Arifeen
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Luke C Mullany
- Johns Hopkins Bloomberg, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mohammad Shahidul Islam
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | - Nong Shang
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | - Shamim A Qazi
- Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland
| | - Anita K M Zaidi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Pinaki Panigrahi
- Center for Global Health and Development, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sajid B Soofi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Nicholas E Connor
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | - Dipak K Mitra
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | - Rita Isaac
- Christian Medical College, Bagayam, Vellore, India
| | - Jonas M Winchell
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | - Melissa L Arvay
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | - Maksuda Islam
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | - Yasir Shafiq
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Imran Nisar
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Benazir Baloch
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Murtaza Ali
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Maureen H Diaz
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | | | - Pritish Nanda
- Asian Institute of Public Health, Bhubaneswar, India
| | | | | | - Aneeta Hotwani
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - M Hasanuzzaman
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | - Sheraz Ahmed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Mohammad Belal Hossain
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | - Shabina Ariff
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | - Imran Ahmed
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Syed Mamun Ibne Moin
- Johns Hopkins Bloomberg, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Arif Mahmud
- Johns Hopkins Bloomberg, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jessica L Waller
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | - Iftekhar Rafiqullah
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | | | - Nazma Begum
- Johns Hopkins Bloomberg, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Jasmin Halen
- Christian Medical College, Bagayam, Vellore, India
| | - A S M Nawshad Uddin Ahmed
- Department of Microbiology, Child Health Research Foundation, Dhaka Shishu Hospital, Sher-E-Bangla Nagar, Dhaka, Bangladesh
| | - Martin W Weber
- Child and Adolescent Health and Development Division, World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - Davidson H Hamer
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Patricia L Hibberd
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | | | | | - Tanvir Hossain
- Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | - Lesley McGee
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | | | - Anran Liu
- Centers for Disease Control and Prevention, Respiratory Diseases Branch, Atlanta, GA, USA
| | - Kalpana Panigrahi
- Center for Global Health and Development, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Abdullah H Baqui
- Johns Hopkins Bloomberg, School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
22
|
Zhang S, Incardona B, Qazi SA, Stenberg K, Campbell H, Nair H. Cost-effectiveness analysis of revised WHO guidelines for management of childhood pneumonia in 74 Countdown countries. J Glob Health 2018; 7:010409. [PMID: 28400955 PMCID: PMC5344007 DOI: 10.7189/jogh.07.010409] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background Treatment of childhood pneumonia is a key priority in low–income countries, with substantial resource implications. WHO revised their guidelines for the management of childhood pneumonia in 2013. We estimated and compared the resource requirements, total direct medical cost and cost-effectiveness of childhood pneumonia management in 74 countries with high burden of child mortality (Countdown countries) using the 2005 and 2013 revised WHO guidelines. Methods We constructed a cost model using a bottom up approach to estimate the cost of childhood pneumonia management using the 2005 and 2013 WHO guidelines from a public provider perspective in 74 Countdown countries. The cost of pneumonia treatment was estimated, by country, for year 2013, including costs of medicines and service delivery at three different management levels. We also assessed country–specific lives saved and disability adjusted life years (DALYs) averted due to pneumonia treated in children aged below five years. The cost-effectiveness of pneumonia treatment was estimated in terms of cost per DALY averted by fully implementing WHO treatment guidelines relative to no treatment intervention for pneumonia. Results Achieving full treatment coverage with the 2005 WHO guidelines was estimated to cost US$ 2.9 (1.9–4.2) billion compared to an estimated US$ 1.8 (0.8–3.0) billion for the revised 2013 WHO guidelines in these countries. Pneumonia management in young children following WHO treatment guidelines could save up to 39.8 million DALYs compared to a zero coverage scenario in the year 2013 in the 74 Countdown countries. The median cost-effectiveness ratio per DALY averted in 74 countries was substantially lower for the 2013 guidelines: US$ 26.6 (interquartile range IQR: 17.7–45.9) vs US$ 38.3 (IQR: US$ 26.2–86.9) per DALY averted for the 2005 guideline respectively. Conclusions Child pneumonia management as detailed in standard WHO guidelines is a very cost–effective intervention. Implementation of the 2013 WHO guidelines is expected to result in a 39.5% reduction in treatment costs compared to the 2005 guidelines which could save up to US$ 1.16 (0.68–1.23) billion in the 74 Countdown countries, with potential savings greatest in low HIV burden countries which can implement effective community case management of pneumonia.
Collapse
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, China
| | | | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Karin Stenberg
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - 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
| | | |
Collapse
|
23
|
Arora NK, Mohapatra A, Gopalan HS, Wazny K, Thavaraj V, Rasaily R, Das MK, Maheshwari M, Bahl R, Qazi SA, Black RE, Rudan I. Setting research priorities for maternal, newborn, child health and nutrition in India by engaging experts from 256 indigenous institutions contributing over 4000 research ideas: a CHNRI exercise by ICMR and INCLEN. J Glob Health 2018; 7:011003. [PMID: 28686749 PMCID: PMC5481897 DOI: 10.7189/jogh.07.011003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Health research in low– and middle– income countries (LMICs) is often driven by donor priorities rather than by the needs of the countries where the research takes place. This lack of alignment of donor’s priorities with local research need may be one of the reasons why countries fail to achieve set goals for population health and nutrition. India has a high burden of morbidity and mortality in women, children and infants. In order to look forward toward the Sustainable Development Goals, the Indian Council of Medical Research (ICMR) and the INCLEN Trust International (INCLEN) employed the Child Health and Nutrition Research Initiative’s (CHNRI) research priority setting method for maternal, neonatal, child health and nutrition with the timeline of 2016–2025. The exercise was the largest to–date use of the CHNRI methodology, both in terms of participants and ideas generated and also expanded on the methodology. Methods CHNRI is a crowdsourcing–based exercise that involves using the collective intelligence of a group of stakeholders, usually researchers, to generate and score research options against a set of criteria. This paper reports on a large umbrella CHNRI that was divided into four theme–specific CHNRIs (maternal, newborn, child health and nutrition). A National Steering Group oversaw the exercise and four theme–specific Research Sub–Committees technically supported finalizing the scoring criteria and refinement of research ideas for the respective thematic areas. The exercise engaged participants from 256 institutions across India – 4003 research ideas were generated from 498 experts which were consolidated into 373 research options (maternal health: 122; newborn health: 56; child health: 101; nutrition: 94); 893 experts scored these against five criteria (answerability, relevance, equity, innovation and out–of–box thinking, investment on research). Relative weights to the criteria were assigned by 79 members from the Larger Reference Group. Given India’s diversity, priorities were identified at national and three regional levels: (i) the Empowered Action Group (EAG) and North–Eastern States; (ii) States and Union territories in Northern India (including West Bengal); and (iii) States and Union territories in Southern and Western parts of India. Conclusions The exercise leveraged the inherent flexibility of the CHNRI method in multiple ways. It expanded on the CHNRI methodology enabling analyses for identification of research priorities at national and regional levels. However, prioritization of research options are only valuable if they are put to use, and we hope that donors will take advantage of this prioritized list of research options.
Collapse
Affiliation(s)
| | | | | | - Kerri Wazny
- Centre for Global Health Research, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Scotland, UK
| | | | - Reeta Rasaily
- The Indian Council of Medical Research, New Delhi, India
| | - Manoj K Das
- The INCLEN Trust International, New Delhi, India
| | | | - Rajiv Bahl
- World Health Organization, Geneva, Switzerland
| | | | - Robert E Black
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Igor Rudan
- Centre for Global Health Research, Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Scotland, UK
| |
Collapse
|
24
|
Affiliation(s)
- Karin Kallander
- Malaria Consortium, London EC2A 4LT, UK; Karolinska Institutet, Stockholm, Sweden.
| | | | | |
Collapse
|
25
|
Moxon SG, Ruysen H, Kerber KJ, Amouzou A, Fournier S, Grove J, Moran AC, Vaz LME, Blencowe H, Conroy N, Gülmezoglu A, Vogel JP, Rawlins B, Sayed R, Hill K, Vivio D, Qazi SA, Sitrin D, Seale AC, Wall S, Jacobs T, Ruiz Peláez J, Guenther T, Coffey PS, Dawson P, Marchant T, Waiswa P, Deorari A, Enweronu-Laryea C, Arifeen S, Lee ACC, Mathai M, Lawn JE. Count every newborn; a measurement improvement roadmap for coverage data. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S8. [PMID: 26391444 PMCID: PMC4577758 DOI: 10.1186/1471-2393-15-s2-s8] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background The Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity. Methods In a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout. Results ENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care. Conclusions The ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.
Collapse
|
26
|
Simen-Kapeu A, Seale AC, Wall S, Nyange C, Qazi SA, Moxon SG, Young M, Liu G, Darmstadt GL, Dickson KE, Lawn JE. Treatment of neonatal infections: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S6. [PMID: 26391217 PMCID: PMC4578441 DOI: 10.1186/1471-2393-15-s2-s6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background Around one-third of the world's 2.8 million neonatal deaths are caused by infections. Most of these deaths are preventable, but occur due to delays in care-seeking, and access to effective antibiotic treatment with supportive care. Understanding variation in health system bottlenecks to scale-up of case management of neonatal infections and identifying solutions is essential to reduce mortality, and also morbidity. Methods A standardised bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the development of the Every Newborn Action Plan. Country workshops involved technical experts to complete a survey tool, to grade health system "bottlenecks" hindering scale up of maternal-newborn intervention packages. Quantitative and qualitative methods were used to analyse the data, combined with literature review, to present priority bottlenecks and synthesise actions to improve case management of newborn infections. Results For neonatal infections, the health system building blocks most frequently graded as major or significant bottlenecks, irrespective of mortality context and geographical region, were health workforce (11 out of 12 countries), and community ownership and partnership (11 out of 12 countries). Lack of data to inform decision making, and limited funding to increase access to quality neonatal care were also major challenges. Conclusions Rapid recognition of possible serious bacterial infection and access to care is essential. Inpatient hospital care remains the first line of treatment for neonatal infections. In situations where referral is not possible, the use of simplified antibiotic regimens for outpatient management for non-critically ill young infants has recently been reported in large clinical trials; WHO is developing a guideline to treat this group of young infants. Improving quality of care through more investment in the health workforce at all levels of care is critical, in addition to ensuring development and dissemination of national guidelines. Improved information systems are needed to track coverage and adequately manage drug supply logistics for improved health outcomes. It is important to increase community ownership and partnership, for example through involvement of community groups.
Collapse
|
27
|
Affiliation(s)
- Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Donald M Thea
- Global Health, Boston University School of Public Health, Massachusetts
| |
Collapse
|
28
|
Sadruddin S, Khan IUH, Bari A, Khan A, Ahmad I, Qazi SA. Effect of community mobilization on appropriate care seeking for pneumonia in Haripur, Pakistan. J Glob Health 2015; 5:010405. [PMID: 25798232 PMCID: PMC4357212 DOI: 10.7189/jogh.05.010405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Appropriate and timely care seeking reduces mortality for childhood illnesses including pneumonia. Despite over 90 000 Lady Health Workers (LHWs) deployed in Pakistan, whose tasks included management of pneumonia, only 16% of care takers sought care from them for respiratory infections. As part of a community case management trial for childhood pneumonia, community mobilization interventions were implemented to improve care seeking from LHWs in Haripur district, Pakistan. The objective of the study was to increase the number of children receiving treatment for pneumonia and severe pneumonia by Lady Health Workers (LHWs) through community mobilization approaches for prompt recognition and care seeking in 2 to 59 month-old children. METHODS To assess pneumonia care seeking practices, pre and post-intervention household surveys were conducted in 28 target Union Councils. Formative research to improve existing LHW training materials, job aids and other materials was carried out. Advocacy events were organized, LHWs and male health promoters were trained in community mobilization, non-functional women and male health committees were revitalized and LHWs and male health promoters conducted community awareness sessions. RESULTS The community mobilization interventions were implemented from April 2008 - December 2009. Project and LHW program staff organized 113 sensitization meetings for opinion leaders, which were attended by 2262 males and 3288 females. The 511 trained LHWs organized 6132 community awareness sessions attended by 50 056 women and 511 male promoters conducted 523 sessions attended by 7845 males. In one year period, the number of LHWs treating pneumonia increased from 11 in April 2008 to 505 in March 2009. The care seeking from LHWs for suspected pneumonia increased from 0.7% in pre-intervention survey to 49.2% in post-intervention survey. CONCLUSION The increase in care seeking from LHWs benefited the community through bringing inexpensive appropriate care closer to home and reducing burden on overstretched health facilities. The community mobilization interventions led to improvements in appropriate care seeking that would not have been achievable just by strengthening pneumonia case management skills of LHWs. In addition to strengthening skills, community mobilization and behavior change activities should also be included in community case management programmes.
Collapse
Affiliation(s)
| | | | - Abdul Bari
- Independent consultant, formerly with Save the Children, Pakistan
| | - Attaullah Khan
- Directorate General Health Services, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Ijaz Ahmad
- Health Sector Reform Unit, Department of Health, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Shamim A Qazi
- World Health Organization, Department of Maternal, Newborn, Child and Adolescent Health, Geneva, Switzerland
| |
Collapse
|
29
|
Seale AC, Blencowe H, Manu AA, Nair H, Bahl R, Qazi SA, Zaidi AK, Berkley JA, Cousens SN, Lawn JE. Estimates of possible severe bacterial infection in neonates in sub-Saharan Africa, south Asia, and Latin America for 2012: a systematic review and meta-analysis. Lancet Infect Dis 2014; 14:731-741. [PMID: 24974250 PMCID: PMC4123782 DOI: 10.1016/s1473-3099(14)70804-7] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Bacterial infections are a leading cause of the 2·9 million annual neonatal deaths. Treatment is usually based on clinical diagnosis of possible severe bacterial infection (pSBI). To guide programme planning, we have undertaken the first estimates of neonatal pSBI, by sex and by region, for sub-Saharan Africa, south Asia, and Latin America. METHODS We included data for pSBI incidence in neonates of 32 weeks' gestation or more (or birthweight ≥1500 g) with livebirth denominator data, undertaking a systematic review and forming an investigator group to obtain unpublished data. We calculated pooled risk estimates for neonatal pSBI and case fatality risk, by sex and by region. We then applied these risk estimates to estimates of livebirths in sub-Saharan Africa, south Asia, and Latin America to estimate cases and associated deaths in 2012. FINDINGS We included data from 22 studies, for 259 944 neonates and 20 196 pSBI cases, with most of the data (18 of the 22 studies) coming from the investigator group. The pooled estimate of pSBI incidence risk was 7·6% (95% CI 6·1-9·2%) and the case-fatality risk associated with pSBI was 9·8% (7·4-12·2). We estimated that in 2012 there were 6·9 million cases (uncertainty range 5·5 million-8·3 million) of pSBI in neonates needing treatment: 3·5 million (2·8 million-4·2 million) in south Asia, 2·6 million (2·1 million-3·1 million) in sub-Saharan Africa, and 0·8 million (0·7 million-1·0 million) in Latin America. The risk of pSBI was greater in boys (risk ratio 1·12, 95% CI 1·06-1·18) than girls. We estimated that there were 0·68 million (0·46 million-0·92 million) neonatal deaths associated with pSBI in 2012. INTERPRETATION The need-to-treat population for pSBI in these three regions is high, with ten cases of pSBI diagnosed for each associated neonatal death. Deaths and disability can be reduced through improved prevention, detection, and case management. FUNDING The Wellcome Trust and the Bill & Melinda Gates Foundation through grants to Child Health Epidemiology Reference Group (CHERG) and Save the Children's Saving Newborn Lives programme.
Collapse
Affiliation(s)
- Anna C Seale
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; KEMRI-Wellcome Trust Centre for Geographic Medicine and Research-Coast, Kilifi, Kenya.
| | - Hannah Blencowe
- Faculty of Epidemiology and Population Health UK, London School of Hygiene and Tropical Medicine, London, UK
| | - Alexander A Manu
- Faculty of Epidemiology and Population Health UK, London School of Hygiene and Tropical Medicine, London, UK
| | - Harish Nair
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Public Health Foundation of India, New Delhi, India
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Anita K Zaidi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - James A Berkley
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK; KEMRI-Wellcome Trust Centre for Geographic Medicine and Research-Coast, Kilifi, Kenya
| | - Simon N Cousens
- Faculty of Epidemiology and Population Health UK, London School of Hygiene and Tropical Medicine, London, UK
| | - Joy E Lawn
- Faculty of Epidemiology and Population Health UK, London School of Hygiene and Tropical Medicine, London, UK; Centre for Maternal, Adolescent, Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK; Saving Newborn Lives/Save the Children, Washington, DC, USA
| |
Collapse
|
30
|
Abstract
Community-acquired pneumonia (CAP) remains a force to reckon with, as it accounts for 1.1 million of all deaths in children less than 5 years of age globally, with disproportionately higher mortality occurring in the low and middle income-countries (LMICs) of Southeast Asia and Africa. Existing strategies to curb pneumonia-related morbidity and mortality have not effectively translated into meaningful control of pneumonia-related burden. In the present systematic review, we conducted a meta-analysis of trials conducted in LMICs to determine the most suitable antibiotic therapy for treating pneumonia (very severe, severe and non-severe). While previous reviews, including the most recent review by Lodha et al, have focused either on single modality of antibiotic therapy (such as choice of antibiotic) or children under the age of 16 years, the current review updates evidence on the choice of drug, duration, route and combination of antibiotics in children specifically between 2 and 59 months of age. We included randomised controlled trials (RCTs) and quasi-RCTs that assessed the route, dose, combination and duration of antibiotics in the management of WHO-defined very severe/severe/non-severe CAP. Study participants included children between 2 and 59 months of age with CAP. All available titles and abstracts were screened for inclusion by two review authors independently. All data was entered and analysed using Review Manager 5 software. The review identified 8122 studies on initial search, of which 22 studies which enrolled 20,593 children were included in meta-analyses. Evidence from these trials showed a combination of penicillin/ampicillin and gentamicin to be effective for managing very severe pneumonia in children between 2 and 59 months of age, and oral amoxicillin to be equally efficacious, as other parenteral antibiotics for managing severe pneumonia in children of this particular age group. Oral amoxicillin was also found to be effective in non-severe pneumonia as well. The review further found a short 3 day course of antibiotics to be equally beneficial as 5 day course for managing non-severe pneumonia in children between 2 and 59 months of age. This review updates evidence on the general spectrum of antibiotic recommendation for CAP in children between 2 and 59 months of age, which is an age group that warrants special focus owing to its high disease and mortality burden. Evidence derived from the review found oral amoxicillin to be equally effective as parenteral antibiotics for severe pneumonia in the 2-59 month age group, which holds important implications for LMICs where parenteral drug administration is an issue. Also, the review's finding that 3 day course of antibiotic is equally effective as 5 day course for non-severe pneumonia for 2-59 months of age is again beneficial for LMICs, as a shorter therapy will be associated with a lower cost. The review addresses some research gaps in antibiotic treatment for CAP as well, and this crucial information is presented with the aim of providing a targeted cure for the middle and low income setting.
Collapse
|
31
|
Ahmed ASMNU, Khan NZ, Hussain M, Amin MR, Hanif M, Mahbub M, El-Arifeen S, Baqui AH, Qazi SA, Saha SK. Follow-up of cases of Haemophilus influenzae type b meningitis to determine its long-term sequelae. J Pediatr 2013; 163:S44-9. [PMID: 23773594 DOI: 10.1016/j.jpeds.2013.03.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To measure physical and neurologic impact of Haemophilus influenzae type b (Hib) meningitis on surviving children through short- and long-term follow-up. STUDY DESIGN Cases of Hib meningitis, diagnosed at a tertiary level pediatric hospital, were subjected to short- and long-term follow-up and compared with age, sex, and area of residence matched healthy controls. Follow-up assessments included thorough physical and neurodevelopmental assessments using a standardized protocol by a multidisciplinary team. RESULTS Assessments of short-term follow-up cohort (n = 64) revealed hearing, vision, mental, and psychomotor deficits in 7.8%, 3%, 20%, and 25% of the cases, respectively. Deficits were 10%, 1.4%, 21%, and 25% in long-term follow-up cohort (n = 71), in that order. Mental and psychomotor deficits were found in 2% of the controls, none of whom had vision or hearing deficits. CONCLUSIONS In addition to risk of death, Hib meningitis in children causes severe disabilities in survivors. These data facilitated a comprehensive understanding of the burden of Hib meningitis, specifically in developing countries where disabled children remain incapacitated because of lack of resources and facilities. The evidence generated from this study is expected to provide a compelling argument in favor of introduction and continuation of Hib conjugate vaccine in the national immunization program for children.
Collapse
Affiliation(s)
- A S M Nawshad Uddin Ahmed
- Department of Pediatrics, Bangladesh Institute of Child Health, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Pneumonia is a widespread and common infectious lung disease that causes inflammation, which can lead to reduced oxygenation, shortness of breath, and death. An estimated nearly 1.2 million children younger than 5 years died in 2011 from pneumonia. Most of these deaths occured in developing countries where access to care is limited and interventions that have improved care in developed countries are scarce. Despite substantial increases in our understanding of the clinical syndrome of pneumonia and its aetiologies, its accurate diagnosis is challenging when clinical indicators are relied on, and improves only modestly with addition of laboratory, microbiological, or radiographical tests. Prevention programmes and treatment guidelines have led to impressive reductions in disease, but children remain at risk of misdiagnosis and inadequate treatment. Research to address challenges in the aetiological diagnosis of pneumonia and widespread implementation of treatment interventions beyond vaccines and antibiotics are necessary to mitigate the burden of pneumonia and improve child survival.
Collapse
Affiliation(s)
- Rasa Izadnegahdar
- Center for Global Health and Development, Boston University, Boston, MA, USA.
| | - Adam L Cohen
- Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa; Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Keith P Klugman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA; Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Shamim A Qazi
- Department of Maternal, Newborn, Child and Adolescent Health, WHO, Geneva, Switzerland
| |
Collapse
|
33
|
Nair H, Simões EA, Rudan I, Gessner BD, Azziz-Baumgartner E, Zhang JSF, Feikin DR, Mackenzie GA, Moiïsi JC, Roca A, Baggett HC, Zaman SM, Singleton RJ, Lucero MG, Chandran A, Gentile A, Cohen C, Krishnan A, Bhutta ZA, Arguedas A, Clara AW, Andrade AL, Ope M, Ruvinsky RO, Hortal M, McCracken JP, Madhi SA, Bruce N, Qazi SA, Morris SS, El Arifeen S, Weber MW, Scott JAG, Brooks WA, Breiman RF, Campbell H. Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis. Lancet 2013; 381:1380-1390. [PMID: 23369797 PMCID: PMC3986472 DOI: 10.1016/s0140-6736(12)61901-1] [Citation(s) in RCA: 515] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010. METHODS We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies. FINDINGS We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3-13·9 million) episodes of severe and 3·0 million (2·1-4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265,000 (95% CI 160,000-450,000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals. INTERPRETATION Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities. FUNDING WHO.
Collapse
Affiliation(s)
- Harish Nair
- Centre for Population Health Sciences, Global Health Academy, The University of Edinburgh, Edinburgh, UK; Public Health Foundation of India, New Delhi, India.
| | - Eric Af Simões
- University of Colorado Denver and Children's Hospital, Denver, CO, USA; The University of Padjadjaran, Bandung, Indonesia
| | - Igor Rudan
- Centre for Population Health Sciences, Global Health Academy, The University of Edinburgh, Edinburgh, UK
| | | | - Eduardo Azziz-Baumgartner
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Jian Shayne F Zhang
- School of Population Health, The University of Melbourne, VIC, Australia; Social Insurance Fund Management Centre, Jiangsu, China
| | - Daniel R Feikin
- Centers for Disease Control and Prevention, Nairobi, Kenya; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Grant A Mackenzie
- Child Survival Theme, The Gambia Unit, Medical Research Council, Banjul, The Gambia
| | - Jennifer C Moiïsi
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Anna Roca
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde da Manhiça, Ministerio de Saúde, Maputo, Mozambique
| | - Henry C Baggett
- International Emerging Infections Program, Global Disease Detection Regional Centre, Thailand MOPH-US CDC Collaboration, Nonthaburi, Thailand
| | - Syed Ma Zaman
- Child Survival Theme, The Gambia Unit, Medical Research Council, Banjul, The Gambia; Health Protection Services Colindale, Health Protection Agency, London, UK
| | - Rosalyn J Singleton
- Arctic Investigations Program, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Anchorage, AK, USA; Alaska Native Tribal Health Consortium, Anchorage, AK, USA
| | - Marilla G Lucero
- Research Institute for Tropical Medicine, Department of Health, Alabang, Muntinlupa, Philippines
| | - Aruna Chandran
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Angela Gentile
- Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Sandringham, South Africa; School of Public Health and Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Anand Krishnan
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Adriano Arguedas
- Instituto de Atención Pediatrica, Universidad de Ciencias Médicas de Centro América, San José, Costa Rica
| | | | | | - Maurice Ope
- East African Community Secretariat, Arusha, Tanzania
| | | | - María Hortal
- Program for Basic Sciences Development, National University/PNUD, Montevideo, Uruguay
| | - John P McCracken
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala
| | - Shabir A Madhi
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Sandringham, South Africa; Department of Science and Technology, and National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Shamim A Qazi
- Department of Maternal, Neonatal and Child and Adolescent Health, WHO, Geneva, Switzerland
| | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - J Anthony G Scott
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - W Abdullah Brooks
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Harry Campbell
- Centre for Population Health Sciences, Global Health Academy, The University of Edinburgh, Edinburgh, UK
| |
Collapse
|
34
|
Fox MP, Thea DM, Sadruddin S, Bari A, Bonawitz R, Hazir T, Bin Nisar Y, Qazi SA. Low rates of treatment failure in children aged 2-59 months treated for severe pneumonia: a multisite pooled analysis. Clin Infect Dis 2012; 56:978-87. [PMID: 23264361 DOI: 10.1093/cid/cis1201] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Despite advances in childhood pneumonia management, it remains a major killer of children worldwide. We sought to estimate global treatment failure rates in children aged 2-59 months with World Health Organization-defined severe pneumonia. METHODS We pooled data from 4 severe pneumonia studies conducted during 1999-2009 using similar methodologies. We defined treatment failure by day 6 as death, danger signs (inability to drink, convulsions, abnormally sleepy), fever (≥38°C) and lower chest indrawing (LCI; days 2-3), LCI (day 6), or antibiotic change. RESULTS Among 6398 cases of severe pneumonia from 10 countries, 564 (cluster adjusted: 8.5%; 95% confidence interval [CI], 5.9%-11.5%) failed treatment by day 6. The most common reasons for clinical failure were persistence of fever and LCI or LCI or fever alone (75% of failures). Seventeen (0.3%) children died. Danger signs were uncommon (<1%). Infants 6-11 months and 2-5 months were 2- and 3.5-fold more likely, respectively, to fail treatment (adjusted OR [AOR], 1.8 [95% CI, 1.4-2.3] and AOR, 3.5 [95% CI, 2.8-4.3]) as children aged 12-59 months. Failure was increased 7-fold (AOR, 7.2 [95% CI, 5.0-10.5]) when comparing infants 2-5 months with very fast breathing to children 12-59 months with normal breathing. CONCLUSIONS Our findings demonstrate that severe pneumonia case management with antibiotics at health facilities or in the community is associated with few serious morbidities or deaths across diverse geographic settings and support moves to shift management of severe pneumonia with oral antibiotics to outpatients in the community.
Collapse
Affiliation(s)
- Matthew P Fox
- Center for Global Health and Development, Boston University, Boston, MA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Soofi S, Ahmed S, Fox MP, MacLeod WB, Thea DM, Qazi SA, Bhutta ZA. Effectiveness of community case management of severe pneumonia with oral amoxicillin in children aged 2-59 months in Matiari district, rural Pakistan: a cluster-randomised controlled trial. Lancet 2012; 379:729-37. [PMID: 22285055 DOI: 10.1016/s0140-6736(11)61714-5] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pneumonia is a leading global cause of morbidity and mortality in children younger than 5 years. In Pakistan, the proportion of deaths due to pneumonia is higher in rural areas than it is in urban areas, with a substantial proportion of individuals dying at home because referral for care is problematic in such areas. We aimed to establish whether community case identification and management of severe pneumonia by oral antibiotics delivered through community health workers has the potential to reduce the number of infants dying at home. METHODS We did a cluster-randomised controlled trial in Matiari district of rural Sindh, Pakistan. Public-sector lady health workers (LHWs) undertook community case management of WHO-defined severe pneumonia. The children in intervention clusters with suspected pneumonia were screened by LHWs and those diagnosed with severe pneumonia were prescribed oral amoxicillin syrup (90 mg/kg per day in two doses) for 5 days at home. Children in control clusters were given one dose of oral co-trimoxazole and were referred to their nearest health facility for admission and intravenous antibiotics, as per government policy. In both groups, follow-up visits at home were done at days 2, 3, 6, and 14 by LHW. The primary outcome was treatment failure by day 6 after enrolment. We matched and randomly allocated 18 clusters (union councils, the smallest administrative unit of the district) to either intervention and control using a computer-generated randomisation scheme. Analyses were done per-protocol. This trial is registered with ClinicalTrials.gov, number NCT01192789. FINDINGS 2341 children in intervention clusters and 2069 children in control clusters participated in the study, enrolled between Feb 13, 2008, and March 15, 2010. We recorded 187 (8%) treatment failures by day 6 in the intervention group and 273 (13%) in the control group. After adjusting for clustering, the risk difference for treatment failure was -5·2% (95% CI -13·7% to 3·3%). We recorded three deaths, two by day 6 and one between days 7 and 14. We recorded no serious adverse events. INTERPRETATION Public sector LHWs in Pakistan were able to satisfactorily diagnose and treat severe pneumonia at home in rural Pakistan. This strategy might effectively reach children with pneumonia in settings where referral is difficult, and it could be a key component of community detection and management strategies for childhood pneumonia. FUNDING US Agency for International Development through grants to John Snow Incorporation and Boston University, USA.
Collapse
Affiliation(s)
- Sajid Soofi
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | | | | |
Collapse
|
36
|
Bari A, Sadruddin S, Khan A, Khan IUH, Ullah A, Lehri IA, Macleod WB, Fox MP, Thea DM, Qazi SA. Community case management of severe pneumonia with oral amoxicillin in children aged 2-59 months in Haripur district, Pakistan: a cluster randomised trial. Lancet 2011; 378:1796-803. [PMID: 22078721 PMCID: PMC3685294 DOI: 10.1016/s0140-6736(11)61140-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND First dose oral co-trimoxazole and referral are recommended for WHO-defined severe pneumonia. Difficulties with referral compliance are reported in many low-resource settings, resulting in low access to appropriate treatment. The objective in this study was to assess whether community case management by lady health workers (LHWs) with oral amoxicillin in children with severe pneumonia was equivalent to current standard of care. METHODS In Haripur district, Pakistan, 28 clusters were randomly assigned with stratification in a 1:1 ratio to intervention and control clusters by use of a computer-generated randomisation sequence. Children were included in the study if they were aged 2-59 months with WHO-defined severe pneumonia and living in the study area. In the intervention clusters, community-based LHWs provided mothers with oral amoxicillin (80-90 mg/kg per day or 375 mg twice a day for infants aged 2-11 months and 625 mg twice a day for those aged 12-59 months) with specific guidance on its use. In control clusters, LHWs gave the first dose of oral co-trimoxazole (age 2-11 months, sulfamethoxazole 200 mg plus trimethoprim 40 mg; age 12 months to 5 years, sulfamethoxazole 300 mg plus trimethoprim 60 mg) and referred the children to a health facility for standard of care. Participants, carers, and assessors were not masked to treatment assignment. The primary outcome was treatment failure by day 6. Analysis was per protocol with adjustment for clustering within groups by use of generalised estimating equations. This study is registered, number ISRCTN10618300. FINDINGS We assigned 1995 children to treatment in 14 intervention clusters and 1477 in 14 control clusters, and we analysed 1857 and 1354 children, respectively. Cluster-adjusted treatment failure rates by day 6 were significantly reduced in the intervention clusters (165 [9%] vs 241 [18%], risk difference -8·9%, 95% CI -12·4 to -5·4). Further adjustment for baseline covariates made little difference (-7·3%, -10·1 to -4·5). Two deaths were reported in the control clusters and one in the intervention cluster. Most of the risk reduction was in the occurrence of fever and lower chest indrawing on day 3 (-6·7%, -10·0 to -3·3). Adverse events were diarrhoea (n=4) and skin rash (n=1) in the intervention clusters and diarrhoea (n=3) in the control clusters. INTERPRETATION Community case management could result in a standardised treatment for children with severe pneumonia, reduce delay in treatment initiation, and reduce the costs for families and health-care systems. FUNDING United States Agency for International Development (USAID).
Collapse
Affiliation(s)
- Abdul Bari
- Save the Children US, Pakistan Country Office
| | | | | | | | - Aman Ullah
- Save the Children US, Pakistan Country Office
| | - Iqbal A. Lehri
- National Program for Family Planning and Primary Health Care, Pakistan
| | - William B. Macleod
- Department of International Health, Boston University School of Public Health, Boston, USA
- Center for Global Health and Development, Boston University, Boston, USA
| | - Matthew P. Fox
- Center for Global Health and Development, Boston University, Boston, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Donald M Thea
- Department of International Health, Boston University School of Public Health, Boston, USA
- Center for Global Health and Development, Boston University, Boston, USA
| | - Shamim A. Qazi
- World Health Organization, Department of Child and Adolescent Health and Development, Geneva, Switzerland
| |
Collapse
|
37
|
Punpanich W, Groome M, Muhe L, Qazi SA, Madhi SA. Antibiotic and systemic therapies for pneumonia in human immunodeficiency virus (HIV)-infected and HIV-exposed children. J Infect Dev Ctries 2011; 6:109-19. [DOI: 10.3855/jidc.2004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 07/04/2011] [Accepted: 07/04/2011] [Indexed: 10/31/2022] Open
Abstract
Introduction: Pneumonia is the leading cause of mortality in both human immunodeficiency virus (HIV)-infected and HIV-exposed children. Administration of appropriate empirical antimicrobial and/or adjunctive systemic therapies may improve clinical outcomes. Methodology: To identify effective antimicrobial and/or adjunctive systemic therapy for pneumonia in HIV-infected and HIV-exposed, uninfected children, we searched for published and unpublished studies from 11 databases including MedLine, Global Health Database, Biological Abstracts (BIOSIS), the Cochrane Central Register of Controlled Trials, the World Health Organization Library Information System, AIDSLine, and the System for Information on Grey Literature in Europe, along with additional four regional databases including African Index Medicus, Latin America and Caribbean, Eastern Mediterranean, and South-East Asian databases. Data from full articles of selected studies were independently extracted by two reviewers. Results: No a priori planned randomized controlled trials (RCT) were identified, only subgroup analyses of an RCT comparing oral amoxicillin versus parenteral penicillin for severe pneumonia in children. HIV-infected children had significantly higher treatment failure rates compared to their uninfected counterparts. An RCT study investigating adjunctive corticosteroid therapy for Pneumocystis jiroveci pneumonia (PCP) failed to identify a statistically significant reduction in mortality in the treatment group with a relative risk of 0.57 (95% CI 0.30-1.07). A before-after observational study showed substantial beneficial effect of corticosteroid treatment in reducing mortality among HIV-infected children with PCP. Conclusions: Insufficient evidence exists to identify effective antimicrobial treatment regimens for HIV-associated pneumonia in paediatric populations or confirm the beneficial effect of corticosteroid treatment for HIV-infected children with PCP.
Collapse
|
38
|
Bellos A, Mulholland K, O'Brien KL, Qazi SA, Gayer M, Checchi F. The burden of acute respiratory infections in crisis-affected populations: a systematic review. Confl Health 2010; 4:3. [PMID: 20181220 PMCID: PMC2829474 DOI: 10.1186/1752-1505-4-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 02/11/2010] [Indexed: 02/03/2023] Open
Abstract
Crises due to armed conflict, forced displacement and natural disasters result in excess morbidity and mortality due to infectious diseases. Historically, acute respiratory infections (ARIs) have received relatively little attention in the humanitarian sector. We performed a systematic review to generate evidence on the burden of ARI in crises, and inform prioritisation of relief interventions. We identified 36 studies published since 1980 reporting data on the burden (incidence, prevalence, proportional morbidity or mortality, case-fatality, attributable mortality rate) of ARI, as defined by the International Classification of Diseases, version 10 and as diagnosed by a clinician, in populations who at the time of the study were affected by natural disasters, armed conflict, forced displacement, and nutritional emergencies. We described studies and stratified data by age group, but did not do pooled analyses due to heterogeneity in case definitions. The published evidence, mainly from refugee camps and surveillance or patient record review studies, suggests very high excess morbidity and mortality (20-35% proportional mortality) and case-fatality (up to 30-35%) due to ARI. However, ARI disease burden comparisons with non-crisis settings are difficult because of non-comparability of data. Better epidemiological studies with clearer case definitions are needed to provide the evidence base for priority setting and programme impact assessments. Humanitarian agencies should include ARI prevention and control among infants, children and adults as priority activities in crises. Improved data collection, case management and vaccine strategies will help to reduce disease burden.
Collapse
Affiliation(s)
- Anna Bellos
- Disease Control in Humanitarian Emergencies, World Health Organization, Geneva, Switzerland
| | | | | | | | | | | |
Collapse
|
39
|
Gulani A, Sachdev HPS, Qazi SA. Efficacy of short course (<4 days) of antibiotics for treatment of acute otitis media in children: a systematic review of randomized controlled trials. Indian Pediatr 2009; 47:74-87. [PMID: 19736367 DOI: 10.1007/s13312-010-0010-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Accepted: 03/04/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the efficacy of a short course of antibiotics (<4 days) in comparison to a longer course (>4 days) for the treatment of acute otitis media in children. DATA SOURCES Electronic databases, hand search of reviews, bibliographies of books, abstracts and proceedings of international conferences. REVIEW METHODS Randomized controlled trials of the empiric treatment of acute otitis media comparing antibiotic regimens of <4 days versus > 4 days in children between four weeks to eighteen years of age were included. The trials were grouped by pharmacokinetic behavior of short-course antibiotics into short-acting antibiotics, parenteral ceftriaxone, and long-acting azithromycin. RESULTS We reviewed 35 trials, which provided 38 analytic components. Overall, there was no evidence of an increased risk of treatment failure until one month with a short-course of antibiotics (RR=1.06, 95% CI 0.95 to 1.17, P=0.298). Use of short-acting oral antibiotic in short-course was associated with a significantly increased risk of treatment failure (RR=2.27, 95% CI: 1.04 to 4.99). There was a slightly increased risk of treatment failure with parenteral ceftriaxone (RR=1.13, 95% CI 0.99 to 1.30). The risk of adverse effects was significantly lower with short-course regimens (RR=0.58, 95% CI: 0.48 to 0.70). CONCLUSION There is no evidence of an increased risk of treatment failure with short course of antibiotics for acute otitis media. Among the short course regimens, azithromycin use was associated with a lower risk of treatment failure while short acting oral antibiotics and parenteral ceftriaxone may be associated with a higher risk of treatment failure.
Collapse
Affiliation(s)
- Anjana Gulani
- Department of Pediatrics and Clinical Epidemology, Sitaram Bhartia Institute of Science and Research, Qutab Institutional Area, New Delhi 110 016, India
| | | | | |
Collapse
|
40
|
Lochindarat S, Qazi SA, Bunnag T, Nisar YB, Jatanachai P. Are we adequately managing children with wheeze using the standard case management guidelines? J Med Assoc Thai 2008; 91 Suppl 3:S60-S68. [PMID: 19253498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Prevalence of wheezing is increasing, bronchodilators are sub-optimally utilized and antibiotics are over-prescribed. In Thailand, current case management guidelines based on WHO guidelines, recommend two doses of rapid-acting bronchodilator for children with audible wheeze and fast breathing (FB) and/or lower chest indrawing (LCI). OBJECTIVE To document the response of children with wheeze with FB and/or LCI to up to three doses of bronchodilator therapy and followed children whose FB and LCI disappeared for 7 days. MATERIAL AND METHOD We documented response to up to three dose of inhaled salbutamol in consecutively assessed eligible children 1-59 months of age presenting with auscultatory/audible wheeze and FB [WHO defined non-severe pneumonia (NSP)] and/or LCI [WHO defined severe pneumonia (SP)] at the outpatient department of a referral hospital. Data were collected for up to 7 days in responders to bronchodilator therapy. RESULTS Of 534 children were screened from November 2001 to February 2003, 263 (49.3%) had wheeze and NSP and 271 (50.7%) had wheeze and SP Forty-eight children (9%) had audible wheeze. At screening, 224/263 (85.2%) children in the NSP group and 195/271 (72.0%) in the SP group responded to inhaled salbutamol. 86/419 (20.5%) responded to the third dose of bronchodilator Four hundred and nineteen responders were enrolled and followed up. On follow-up, 14/217 (6.5%) responders among the NSP group and 24/190 (12.6%) among the SP group showed deterioration. Age 1-11 months at screening was identified as an independent predictor of subsequent deterioration. Two seasonal peaks from December to March and from August to October were documented. CONCLUSION A third dose of bronchodilator therapy at screening will improve the specificity of case management guidelines and reduce antibiotic use. Physicians should use auscultation for management of wheeze.
Collapse
Affiliation(s)
- Sorasak Lochindarat
- Queen Sirikit National Institute of Child Health, Department of Medical Services, College of Medicine, Rangsit University, Bangkok, Thailand.
| | | | | | | | | |
Collapse
|
41
|
Hazir T, Fox LM, Nisar YB, Fox MP, Ashraf YP, MacLeod WB, Ramzan A, Maqbool S, Masood T, Hussain W, Murtaza A, Khawar N, Tariq P, Asghar R, Simon JL, Thea DM, Qazi SA. Ambulatory short-course high-dose oral amoxicillin for treatment of severe pneumonia in children: a randomised equivalency trial. Lancet 2008; 371:49-56. [PMID: 18177775 DOI: 10.1016/s0140-6736(08)60071-9] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND WHO case management guidelines for severe pneumonia involve referral to hospital for treatment with parenteral antibiotics. If equally as effective as parenteral treatment, home-based oral antibiotic treatment could reduce referral, admission, and treatment costs. Our aim was to determine whether home treatment with high-dose oral amoxicillin and inpatient treatment with parenteral ampicillin were equivalent for the treatment of severe pneumonia in children. METHODS This randomised, open-label equivalency trial was done at seven study sites in Pakistan. 2037 children aged 3-59 months with severe pneumonia were randomly allocated to either initial hospitalisation and parenteral ampicillin (100 mg/kg per day in four doses) for 48 h, followed by 3 days of oral amoxicillin (80-90 mg/kg per day; n=1012) or to home-based treatment for 5 days with oral amoxicillin (80-90 mg/kg per day in two doses; n=1025). Follow-up assessments were done at 1, 3, 6, and 14 days after enrollment. The primary outcome was treatment failure (clinical deterioration) by day 6. Analyses were done per protocol and by intention to treat. This trial is registered, ISRCTN95821329. FINDINGS In the per-protocol population, 36 individuals were excluded from the hospitalised group and 37 from the ambulatory group, mainly because of protocol violations or loss to follow-up. There were 87 (8.6%) treatment failures in the hospitalised group and 77 (7.5%) in the ambulatory group (risk difference 1.1%; 95% CI -1.3 to 3.5) by day 6. Five (0.2%) children died within 14 days of enrollment, one in the ambulatory group and four in the hospitalised group. In each case, treatment failure was declared before death and the antibiotic had been changed. None of the deaths were considered to be associated with treatment allocation; there were no serious adverse events reported in the trial. INTERPRETATION Home treatment with high-dose oral amoxicillin is equivalent to currently recommended hospitalisation and parenteral ampicillin for treatment of severe pneumonia without underlying complications, suggesting that WHO recommendations for treatment of severe pneumonia need to be revised.
Collapse
Affiliation(s)
- Tabish Hazir
- Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Hazir T, Qazi SA, Bin Nisar Y, Maqbool S, Asghar R, Iqbal I, Khalid S, Randhawa S, Aslam S, Riaz S, Abbasi S. Comparison of standard versus double dose of amoxicillin in the treatment of non-severe pneumonia in children aged 2-59 months: a multi-centre, double blind, randomised controlled trial in Pakistan. Arch Dis Child 2007; 92:291-7. [PMID: 16547082 PMCID: PMC2083693 DOI: 10.1136/adc.2005.092494] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION WHO pneumonia case management guidelines recommend oral amoxicillin as first line treatment for non-severe pneumonia. Increasing treatment failure rates have been reported over a period of time, which could possibly be due to increasing minimum inhibitory concentrations of Streptococcus pneumoniae and Haemophilus influenzae for amoxicillin. Microbiological data show that this resistance can be overcome by increasing amoxicillin dosage. Based on this data, we examined whether we can improve the clinical outcome in non-severe pneumonia by doubling the dose of amoxicillin. METHODS A double blind randomised controlled trial was conducted in the outpatient departments of four large hospitals in Pakistan. Children aged 2-59 months with non-severe pneumonia were randomised to receive either standard (45 mg/kg/day) or double dose (90 mg/kg/day) oral amoxicillin for 3 days and then followed up for 14 days. Final outcome was treatment failure by day 5. RESULTS From September 2003 to June 2004, 876 children completed the study. 437 were randomised to standard and 439 to double dose oral amoxicillin. 20 (4.5%) children in the standard and 25 (5.7%) in the double dose group had therapy failure by day 5. Including the relapses, by day 14 there were 26 (5.9%) cumulative therapy failures with standard and 35 (7.9%) with double dose amoxicillin. These differences were not statistically significant (p = 0.55 and p = 0.29, respectively). CONCLUSION Clinical outcome in children aged 2-59 months with non-severe pneumonia is the same with standard and double dose oral amoxicillin. Non-severe pneumonia can be treated effectively and safely with a 3 day course of a standard dose.
Collapse
Affiliation(s)
- Tabish Hazir
- Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Hazir T, Nisar YB, Qazi SA, Khan SF, Raza M, Zameer S, Masood SA. Chest radiography in children aged 2-59 months diagnosed with non-severe pneumonia as defined by World Health Organization: descriptive multicentre study in Pakistan. BMJ 2006; 333:629. [PMID: 16923771 PMCID: PMC1570841 DOI: 10.1136/bmj.38915.673322.80] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To evaluate the chest radiographs of children diagnosed with non-severe pneumonia on the basis of the current World Health Organization guidelines (fast breathing alone) for radiological evidence of pneumonia. DESIGN Descriptive analysis. SETTING Outpatient departments of six hospitals in four cities in Pakistan. PARTICIPANTS 2000 children with non-severe pneumonia were enrolled; 1932 children were selected for chest radiography. INTERVENTIONS Two consultant radiologists used standardised WHO definitions to evaluate chest radiographs; no clinical information was made available to them. If they disagreed, the radiographs were read by a third radiologist; the final classification was based on agreement between two of the three radiologists. MAIN OUTCOME MEASURES Presence or absence of pneumonia on radiographs. RESULTS Chest radiographs were reported normal in 1519 children (82%). Radiological evidence of pneumonia was reported in only 263 (14%) children, most of whom had interstitial pneumonitis. Lobar consolidation was present in only 26 children. The duration of illness did not correlate significantly with the presence of radiological changes (relative risk 1.17, 95% confidence interval 0.91 to 1.49). CONCLUSION Most children diagnosed with non-severe pneumonia on the basis of the current WHO definition had normal chest radiographs.
Collapse
Affiliation(s)
- Tabish Hazir
- ARI Research Cell, Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan.
| | | | | | | | | | | | | |
Collapse
|
44
|
Noorani QA, Qazi SA, Rasmussen ZA, Rehman GN, Khan SS, Muhammadullah I, Mohammad YK, Sher GA, Munir NH. Response to cotrimoxazole in the management of childhood pneumonia in first-level health care facilities. Int J Tuberc Lung Dis 2006; 10:932-8. [PMID: 16898380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Reports of high levels of antimicrobial resistance to cotrimoxazole in children with non-severe pneumonia (NSP) have prompted calls for a change to amoxicillin in the therapeutic guidelines at the first-level health care facility (FLHF). FLHFs lack data about the use of World Health Organization (WHO) acute respiratory infection (ARI) standard case management (SCM). OBJECTIVE To apply ARI SCM guidelines at the FLHF, assess clinical outcome of NSP with oral cotrimoxazole and determine the risk factors influencing treatment outcome. DESIGN Health care workers (HCWs) at 14 health centres managed children aged 2-59 months with NSP according to ARI SCM guidelines. The primary outcome was treatment failure, including change of antibiotic therapy and loss to follow-up. RESULTS Of 949 children enrolled, 110 (11.6%) failed therapy with oral cotrimoxazole. Clinical failure was significantly higher among children presenting with a fast respiratory rate of > or = 15 breaths/min above normal for age and wheezing on examination. CONCLUSIONS To treat children with NSP at the FLHF, oral cotrimoxazole is an acceptable treatment choice in view of the efficacy, cost and ease of use. In children with wheezing and signs of pneumonia, the decision to use antibiotic therapy should be made after a trial of bronchodilator therapy.
Collapse
Affiliation(s)
- Q A Noorani
- Department of Health, Aga Khan Foundation, Islamabad, Pakistan.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Hazir T, Qazi SA, Nisar YB, Maqbool S, Asghar R, Iqbal I, Khalid S, Randhawa S, Aslam S, Riaz S, Abbasi S. Can WHO therapy failure criteria for non-severe pneumonia be improved in children aged 2-59 months? Int J Tuberc Lung Dis 2006; 10:924-31. [PMID: 16898379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
Abstract
SETTING In the recent past, there have been reports of rising treatment failure rates for non-severe pneumonia. It is felt that World Health Organization (WHO) criteria for therapy failure are too sensitive and that many children are unnecessarily classified as failures. We studied alternative, less sensitive therapy failure criteria. METHODS In this nested study we followed the clinical course of non-severe pneumonia in children aged 2-59 months using alternative therapy failure criteria. All children received amoxicillin and were followed up on days 3, 5 and 14 after enrollment. On day 3, children were labelled as therapy failure only if their condition had deteriorated. These failure rates were compared with those using WHO definitions. RESULTS During the study period, 876 children with non-severe pneumonia were followed up until day 14. On day 3, using alternative therapy failure criteria, 31 (3.5%) children were labelled as therapy failure compared to 95 (10.8%) using current WHO criteria. The difference was statistically significant (P = 0.001). CONCLUSIONS The alternative therapy failure criteria work reasonably well, without causing any higher risk to children with non-severe pneumonia. Antibiotics should be changed only in those children who show signs of deterioration on day 3. This would prevent unnecessary changes in antibiotic treatment in many children.
Collapse
Affiliation(s)
- T Hazir
- Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Qazi SA, Khan MA, Rizvi T, Khatoon Z, Peterson KE. Longitudinal growth patterns of Pakistani infants in a clinic based growth promotion program. Indian Pediatr 2003; 40:1043-53. [PMID: 14660835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVE To describe the operation of growth monitoring and promotion (GMP) clinic and longitudinal growth patterns of children. DESIGN Prospective observation and intervention. SETTING Outpatient department of a teaching hospital. METHODS Less than 6 months old infants were registered at GMP clinic and followed for up to two years of age. Mothers were provided information, education and counselling about healthy growth of their infants. The outcome measure was change in weight after follow-up. RESULTS We enrolled a cohort of 553 children in the first 6 months of life, of which 318 were males. Mean follow up period was 15.7 (SD+/-6.4) months. At enrollment 207 were underweight [weight-for-age Z score (WAZ<-2], of which 153 were from low-income families. The children from poorer families also gained weight regularly, although it was less than the higher income families. Of 346 infants with normal weight at registration, 305 maintained their weight gain by last follow-up visit. Of 207 underweight infants at enrollment 128 improved their weight gain by the last follow-up visit. Overall 433 infants followed-up at our GMP clinic either maintained or improved their weight gain. CONCLUSIONS Children at risk of undernutrition should be identified at an early age and through effective interaction between health workers and the family, their growth can be improved. Children of poor families can also benefit from this activity, provided a comprehensive approach is made available.
Collapse
Affiliation(s)
- Shamim A Qazi
- Children Hospital, Pakistan Institute of Medical Sciences, G-8/3, Islamabad, Pakistan.
| | | | | | | | | |
Collapse
|
47
|
Hazir T, Qazi SA, Abbas KA, Khan MA. Therapeutic re-appraisal of multiple drug resistant Salmonella typhi (MDRST) in Pakistani children. J PAK MED ASSOC 2002; 52:123-7. [PMID: 12071068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND The emergence of multi drug-resistant Salmonella typhi (MDRST) in many developing countries including Pakistan, has led to a search for suitable alternatives to conventional therapy. Quinolones have been found to be an effective alternative for the treatment of MDRST, in adults as well as in children. METHODS The efficacy of various therapeutic regimens currently used for the treatment of Typhoid was analysed. Children 1 month to 12 years of age admitted to the Children's Hospital from 1990 to 1993 with fever and Salmonella typhi isolated from blood cultures were included in this retrospective analysis. RESULTS The cumulative prevalence of Multiple Drug Resistant Salmonella typhi (MDRST) was 67.2%. Only 32.8% of isolated Salmonella typhi were susceptible to chloramphenicol and amoxicillin. The cumulative cure rate with conventional therapy (chloramphenicol or amoxicillin) was 47.4% and 53.6% children needed a change of therapy. The average hospital stay for the non-responders to conventional therapy was 9.2 days as compared to 7.7 days for the responders. The average hospital stay of the patients treated with a third generation cephalosporin was 12.7 days. Patients treated with ofloxacin, a flouroquinolone drug, did not need a change of therapy. The average hospital stay of the patients treated with flouroquinolones was 6.2 days. CONCLUSION There was a high prevalence of multiple drug resistant typhoid fever in hospitalized children, leading to a high failure rate with conventional therapy. This resulted in frequent change of therapy, delayed defervesence and prolonged hospital stay. The flouroquinolones were found to be the most effective drug against MDRST.
Collapse
Affiliation(s)
- T Hazir
- Children Hospital, Pakistan Institute of Medical Sciences, Islamabad
| | | | | | | |
Collapse
|
48
|
Abstract
The Pakistan program for control of acute respiratory tract infections (ARIs) adopted the standard ARI-case-management strategy of the World Health Organization and recommended co-trimoxazole for the management of nonsevere pneumonia. Reports in that country of high in vitro antimicrobial resistance of Streptococcus pneumoniae and Haemophilus influenzae to co-trimoxazole prompted the program to reevaluate its treatment policy. Two community-based studies during 1991-1993 showed in vivo efficacy of co-trimoxazole in 92% and 91% of children with nonsevere pneumonia. A third double-blind trial showed co-trimoxazole and oral amoxicillin to be equally effective in vivo in cases of nonsevere pneumonia, despite high in vitro resistance. Country-wide surveillance from 1991 to 1994 revealed 78.3%-79.9% in vitro resistance to co-trimoxazole among S. pneumoniae isolates and 59.5%-61.0% among H. influenzae isolates. Co-trimoxazole is still recommended by the Pakistan ARI control program. The fact that amoxicillin is three times more expensive and must be administered more frequently is a big impediment to recommending it as a first-line drug for nonsevere pneumonia.
Collapse
Affiliation(s)
- S A Qazi
- Federal ARI Cell, National ARI Control Programme, The Children's Hospital, Pakistan Institute of Medical Sciences,
| |
Collapse
|
49
|
Straus WL, Qazi SA, Kundi Z, Nomani NK, Schwartz B. Antimicrobial resistance and clinical effectiveness of co-trimoxazole versus amoxycillin for pneumonia among children in Pakistan: randomised controlled trial. Pakistan Co-trimoxazole Study Group. Lancet 1998; 352:270-4. [PMID: 9690406 DOI: 10.1016/s0140-6736(97)10294-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Co-trimoxazole is widely used in treatment of paediatric pneumonia in developing countries, but drug resistance may decrease its effectiveness. We studied the effectiveness of co-trimoxazole compared with that of amoxycillin in pneumonia therapy, and assessed the clinical impact of co-trimoxazole resistance. METHODS We recruited 595 children, aged 2-59 months, with non-severe or severe pneumonia (WHO criteria) diagnosed in the outpatient wards of two urban Pakistan hospitals. Patients were randomly assigned on a 2:1 basis co-trimoxazole (n=398) or amoxycillin (n=197) in standard WHO doses and dosing schedules, and were monitored in study wards. The primary outcome was inpatient therapy failure (clinical criteria) or clinical evidence of pneumonia at outpatient follow-up examination. FINDINGS There were 92 (23%) therapy failures in the co-trimoxazole group and 30 (15%) in the amoxycillin group (p=0.03)-26 (13%) versus 12 (12%) among children with non-severe pneumonia (p=0.856) and 66 (33%) versus 18 (18%) among those with severe pneumonia (p=0.009). For patients with severe pneumonia, age under 1 year (p=0.056) and positive chest radiographs (p=0.005) also predicted therapy failure. There was no significant association between antimicrobial minimum inhibitory concentration and outcome among bacteraemic children treated with co-trimoxazole. INTERPRETATION Co-trimoxazole provided effective therapy in non-severe pneumonia. For severe, life-threatening pneumonia, however, co-trimoxazole is less likely than amoxycillin to be effective.
Collapse
Affiliation(s)
- W L Straus
- Centers for Disease Control and Prevention, Public Health Service, Department of Health and Human Services, Atlanta, USA.
| | | | | | | | | |
Collapse
|
50
|
Qazi SA, Khan S, Khan MA. Epidemiology of childhood tuberculosis in a hospital setting. J PAK MED ASSOC 1998; 48:164-7. [PMID: 9813987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
A study of two hundred cases of tuberculosis over a span of two years was carried out at the pediatric department of a hospital in Islamabad. The diagnosis was based upon history, clinical examination, chest and other relevant radiography, Mantoux test, erythrocyte sedimentation rate (ESR) and where necessary cerebrospinal, pleural and ascitic fluid examinations and lymph gland histopathology were done. An equal number of male and female children upto 12 years of age were enrolled. The children usually presented with fever, cough, weight loss or failure to thrive and pallor. The most commonly affected age group was between 2-5 years and pulmonary tuberculosis was the most frequent diagnosis followed by tuberculous adenitis.
Collapse
Affiliation(s)
- S A Qazi
- Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad
| | | | | |
Collapse
|