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August 19, 2008

Study Recommends Modifying Pneumonia Treatment Guidelines in Developing Countries

A study published online on August 19 in The Lancet builds on the evidence that local health facilities are able to correctly treat and manage severe childhood pneumonia. Moreover, the study suggests that more children will be correctly treated if only the most urgent cases are referred to hospitals. The study was conducted in Bangladesh by researchers from the Johns Hopkins Bloomberg School of Public Health and the International Centre for Diarrhoeal Disease Research, Bangladesh. Funding was provided through the Bill & Melinda Gates Foundation, World Health Organization’s Department of Child and Adolescent Health and Development, and the U.S. Agency for International Development.

Many developing nations have implemented the Integrated Management of Childhood Illness (IMCI) guidelines, developed by WHO and UNICEF in the mid-1990s. The IMCI recommends that providers refer children with severe pneumonia to hospitals. However, many caregivers are not able to comply with these referrals, and child deaths due to pneumonia continue to number over 2 million a year—more than any other disease. 

In 2004, after the researchers showed that compliance rates with referral were very low, some facilities in Bangladesh modified their guidelines to recommend treatment at the local facility, with referral only when a life-threatening danger sign was present. “One of the main concerns with treating severe pneumonia at first-line health facilities was safety. Our study shows that it is both safe and very effective,” noted Robert Black, PhD, MPH, senior author and chair of the Bloomberg School’s Department of International Health. 

The study followed two groups from rural health facilities in Matlab, Bangladesh. The first group attended the facilities before the treatment guidelines were modified. Of these, 94 percent were referred to hospital, and only 36 percent ended up receiving appropriate care. The second cohort of children was treated at the local health facilities, unless the illness was very severe; only 8 percent were referred to hospital, and overall 90 percent of ill children received appropriate care.

Jennifer Bryce, EdD, senior scientist in the Department of International Health, concluded that, “This study shows that more children would be correctly treated if national guidelines were modified to manage most cases of severe pneumonia at local health facilities in settings where referral compliance is limited.  Modifying the guidelines was accepted by health workers and produced excellent results.”

The article “Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study,” was written by 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, and Robert E. Black.--Brandon Howard

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