Allowing children with severe pneumonia to be treated at local, first-level facilities instead of hospitals means much higher proportions of children are treated correctly. These are the conclusions of authors of an Article published early Online in an upcoming edition of The Lancet.
The Intergrated Management of Childhood Illness (IMCI) guidelines, developed in the mid-1990s, recommend that children with severe pneumonia attend hospital. However, in many poorer settings, children who are referred do not attend hospital and do not receive adequate care. Dr Enayet Karim Chowdhury and Dr Shams El Arifeen, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), and colleagues studied the safety and effectiveness of modified guidelines that allowed children to be treated locally in first-level facilities, with referral to hospital only for the most severe cases.
The study used 10 first-level health facilities in Matlab, rural Bangladesh, that had been using the previous IMCI guidelines, and assessed children from two cohorts. The first was 261 children who attended the facilities between May 2003 and April 2004, before implementation of the modified guidelines. Of these, 94% were referred to hospital, and only 36% ended up receiving the appropriate care, while 1.1% (three children) died. The second cohort contained 1271 children treated at the facilities post-implementation of the modified guidelines. Of these, only 8% were referred to hospital, and 90% received appropriate care, while the mortality was 0.6% (seven deaths). The authors conclude: "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."
In an accompanying Comment, Dr Igor Rudan, Croatian Centre for Global Health, University of Split Medical School, Croatia, and Dr Harry Campbell, University of Edinburgh Medical School, UK, say: "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."
Dr Enayet Chowdhury and Dr Shams El Arifeen, International Centre for Diarrhoeal Disease Research, Bangladesh T) +880 2 881 0115 E) shams@icddrb.org
Dr Igor Rudan, Croatian Centre for Global Health, University of Split Medical School, Croatia T) +385-91-3011-575 E) irudan@hotmail.com
http://press.thelancet.com/bangladeshfinal.pdf
Journal
The Lancet