Reducing deaths from severe pneumonia in children in Malawi by improving delivery of pneumonia case management.

Penelope M Enarson,Robert P Gie,Carl J Lombard,Stephen M Graham,Ellubey R Maganga,Donald A Enarson,Charles C Mwansambo,Rashida A Ferrand

doi:10.1371/journal.pone.0102955

Abstract

ObjectiveTo evaluate the pneumonia specific case fatality rate over time following the implementation of a Child Lung Health Programme (CLHP) within the existing government health services in Malawi to improve delivery of pneumonia case management.MethodsA prospective, nationwide public health intervention was studied to evaluate the impact on pneumonia specific case fatality rate (CFR) in infants and young children (0 to 59 months of age) following the implementation of the CLHP. The implementation was step-wise from October 1st 2000 until 31st December 2005 within paediatric inpatient wards in 24 of 25 district hospitals in Malawi. Data analysis compared recorded outcomes in the first three months of the intervention (the control period) to the period after that, looking at trend over time and variation by calendar month, age group, severity of disease and region of the country. The analysis was repeated standardizing the follow-up period by using only the first 15 months after implementation at each district hospital.FindingsFollowing implementation, 47,228 children were admitted to hospital for severe/very severe pneumonia with an overall CFR of 9•8%. In both analyses, the highest CFR was in the children 2 to 11 months, and those with very severe pneumonia. The majority (64%) of cases, 2–59 months, had severe pneumonia. In this group there was a significant effect of the intervention Odds Ratio (OR) 0•70 (95%CI: 0•50–0•98); p = 0•036), while in the same age group children treated for very severe pneumonia there was no interventional benefit (OR 0•97 (95%CI: 0•72–1•30); p = 0•8). No benefit was observed for neonates (OR 0•83 (95%CI: 0•56–1•22); p = 0•335).ConclusionsThe nationwide implementation of the CLHP significantly reduced CFR in Malawian infants and children (2–59 months) treated for severe pneumonia. Reasons for the lack of benefit for neonates, infants and children with very severe pneumonia requires further research.

Highlights

Pneumonia is the most frequent cause of death in children less than five years of age [1]
In 1984, the World Health Organization (WHO) introduced standardized case-management (SCM) of pneumonia [3] that became an important part of integrated child health programmes and WHO recommended approaches in clinical care [4]
The trend in case fatality rates in infants and young children (1 week to 59 months of age) hospitalized and treated for severe and very severe pneumonia was evaluated over the course of the implementation of a nationwide programme to deliver standardized case management for childhood pneumonia

Summary

Introduction

Pneumonia is the most frequent cause of death in children less than five years of age [1]. In sub-Saharan Africa, child pneumonia deaths account for an estimated 18% of under-five mortality of which three per cent occur in the neonatal period [1]. In the years just prior to the intervention, Malawi reported a high under-5 mortality of 189 per 1,000 live births for the period 1996–2000.8 Known risk factors for frequency and severity of child pneumonia such as low birth weight (20% of live births), malnutrition (48% of children with moderate or severe stunting) and HIV infection (91,000 children living with HIV in 2006) were all highly prevalent in Malawi at the time of the intervention [16]. The estimated percentage of HIV+ pregnant women who received a full package of care to prevent mother-to-child transmission (MTCT) of HIV in 2004 was only 2.3%

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Discussion

Conclusion