Feasibility of Training Clinical Officers in Point-of-Care Ultrasound for Pediatric Respiratory Diseases in Aweil, South Sudan

Adi Nadimpalli,Lisa Umphrey,Evgenia Zelikova,Carrie Teicher,Sachita Shah,Northan Hurtado,James W Tsung,Ramon Sanchez,Alan Gonzalez

doi:10.4269/ajtmh.18-0745

Abstract

.Lower respiratory tract infections (LRTIs) are the leading cause of deaths in children < 5 years old worldwide, particularly affecting low-resource settings such as Aweil, South Sudan. In these settings, diagnosis can be difficult because of either lack of access to radiography or clinical algorithms that overtreat children with antibiotics who only have viral LRTIs. Point-of-care ultrasound (POCUS) has been applied to LRTIs, but not by nonphysician clinicians, and with limited data from low-resource settings. Our goal was to examine the feasibility of training the mid-level provider cadre clinical officers (COs) in a Médecins Sans Frontières project in South Sudan to perform a POCUS algorithm to differentiate among causes of LRTI. Six COs underwent POCUS training, and each subsequently performed 60 lung POCUS studies on hospitalized pediatric patients < 5 years old with criteria for pneumonia. Two blinded experts, with a tiebreaker expert adjudicating discordant results, served as a reference standard to calculate test performance characteristics, assessed image quality and CO interpretation. The COs performed 360 studies. Reviewers rated 99.1% of the images acceptable and 86.0% CO interpretations appropriate. The inter-rater agreement (κ) between COs and experts for lung consolidation with air bronchograms was 0.73 (0.63–0.82) and for viral LRTI/bronchiolitis was 0.81 (0.74–0.87). It is feasible to train COs in South Sudan to use a POCUS algorithm to diagnose pneumonia and other pulmonary diseases in children < 5 years old.

Highlights

Pneumonia is the single largest infectious cause of death in children worldwide, killing 2,500 children younger than 5 years a day and accounting for 15% of all under-five deaths globally.[1]
Our goal was to examine the feasibility of training the mid-level provider cadre clinical officers (COs) in a Medecins Sans Frontieres project in South Sudan to perform a Point-of-care ultrasound (POCUS) algorithm to differentiate among causes of Lower respiratory tract infections (LRTIs)
This study evaluates a training program undertaken in Aweil, South Sudan, where significant patient care is provided by clinical officers (COs), mid-level clinicians with 3 years of medical education, using a variant of the task-shifting model.[12,13]

Summary

Introduction

Pneumonia is the single largest infectious cause of death in children worldwide, killing 2,500 children younger than 5 years a day and accounting for 15% of all under-five deaths globally.[1]. Accurate diagnosis and proper management of pneumonia can be challenging, especially in low-resource settings where skilled clinicians are limited, and standard imaging may be unavailable.[3] many children diagnosed clinically with pneumonia have viral infections only, leading to suboptimal antibiotic stewardship and concern for increasing antibiotic resistance.[4] There has been significant interest in using portable ultrasound technology in low- and middle-income countries (LMICs), as it requires significantly less infrastructure and training than the current gold standard diagnostic imaging using chest X-rays.[5] Point-of-care ultrasound (POCUS) is a widely used clinical imaging method for rapid diagnosis, can expedite treatment at the bedside, and is relatively easy to learn.[6,7,8] It can be brought to wherever the patient is located and does not emit radiation. The work by Reali et al.[10] in 2014 showed that lung ultrasounds can be at least as effective as chest X-ray in diagnosing pneumonias in pediatric patients. A 2015 study by Chavez et al.[11] in two resource-limited settings shows that lung POCUS can be taught efficiently to general

Objectives

Results

Discussion

Conclusion