New research published in The Lancet finds that much higher proportions of children with severe pneumonia are treated correctly if they are allowed to be treated at local, first-level facilities instead of hospitals.
Since the mid-1990s and the issuance of The Intergrated Management of Childhood Illness (IMCI) guidelines, it has been suggested that children with severe pneumonia are treated at hospitals. In poorer and more rural areas, however, children are often referred to hospital care but do not attend; many fail to receive adequate care. An alternative to hospitals is treatment in local, first-level facilities, and it is the safety and effectiveness of these facilities that Drs. Enayet Karim Chowdhury and Shams El Arifeen (International Center for Diarrheal Disease Research, Bangladesh [ICDDR,B]) and colleagues study in their recent research. These modified guidelines also recommend that children with the most severe cases of pneumonia are referred to the hospital.
The study sample consisted of two cohorts of children from 10 first-level health facilities in rural Matlab, Bangladesh – all facilities that had been using the previous IMCI guidelines. One cohort included 261 children who attended the facilities between May 2003 and April 2004, before the researchers implemented the modified guidelines. In this group, 94% were referred to hospital, 36% received appropriate care, and 1.1% (3 children) died. In the second cohort, 1,271 children were treated at the facilities after the modified guidelines were implemented. In this group, 8% were referred to hospital, 90% received appropriate care, and 0.6% (7 children) died.
“Local adaptation of the IMCI guidelines, with appropriate training and supervision, could allow safe and effective management of severe pneumonia, especially if compliance with referral is difficult because of geographic, financial, or cultural barriers,” conclude the authors.
An accompanying comment written by Dr Igor Rudan (Croatian Centre for Global Health, University of Split Medical School, Croatia) and Dr Harry Campbell (University of Edinburgh Medical School, UK) notes that: “We welcome a substantial increase in investment in controlled trials in developing countries to address crucial gaps in information – such as correct case management of severe pneumonia in children with HIV infection – and in health-policy and systems research to identify effective ways to improve and scale up implementation of interventions against pneumonia.”
Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study
Enayet K Chowdhury, Shams El Arifeen, Muntasirur Rahman, DM Emdadul Hoque, M Altaf Hossain, Khadija Begum, Ashraf Siddik, Nazma Begum, Qazi Sadeq-ur Rahman, Tasnima Akter, Twaha M Haque, ZA Motin Al-Helal, Abdullah H Baqui, Jennifer Bryce, Robert E Black
The Lancet (2008).
DOI:10.1016/S0140-6736(08)61166-6
Written by: Peter M Crosta