KARACHI, Jan 30: Lady Health Workers (LHWs) can effectively help identify and treat most cases of severe pneumonia in children without an increased risk of treatment failure, adverse events or death by administering simple oral antibiotics, says a study carried out in Matiari district of Sindh.

The research published in The Lancet journal on Monday, was conducted by the Aga Khan University’s division of women and child health in collaboration with the Lady Health Workers Programme of the Sindh government, the Boston University’s Centre for Global Health and Development and the World Health Organisation’s Department of Child and Adolescent Health.

The study titled “Effectiveness of community case management of severe pneumonia with oral amoxicillin in children aged 2-59 months in Matiari district, rural Pakistan: a cluster randomised controlled trial”, says that pneumonia is a leading global cause of morbidity and mortality in children younger than five years. Of the estimated 8.8 million deaths worldwide in children in 2008, it accounted for 1.6 million deaths.

Pakistan, it says, is one of the five countries (others being India, Nigeria, Democratic Republic of Congo and China) where 49 per cent (4.294 million) of all child deaths occur.

“More than half of all global pneumonia-associated deaths of children younger than five years occur in the same five countries. Of the 464,886 deaths of children younger than five years reported in Pakistan, an estimated 84,210 are caused by pneumonia, mostly in rural areas, with a substantial proportion of individuals dying at home because referral for care is problematic in these areas,” the reports says.

Devolved care

According to the study’s findings, community-case management of pneumonia could potentially reduce pneumonia mortality by up to 70 per cent. Timely initiation of appropriate care for pneumonia or malaria, the report says, was higher in children with fever seen by a community health worker, trained and supplied with rapid diagnostic tests and effective oral drugs compared with referral to a facility.

This strategy of devolved care of severe pneumonia cases closer to poor households could potentially allow a larger proportion of patients with severe pneumonia to receive appropriate treatment at the community level, it says.

The trial was carried out in Matiari, 250 kilometres north of Karachi, with 1,600 villages and an estimated population of 600,000 and high rates of this disease and limited resources. It looked at the management of severe pneumonia in under-five children at home by the Lady Health Workers Programme versus referral to the nearest health facility — a basic health unit, a rural health centre or a hospital.

More than 4,000 children participated in the study while training sessions were organised for LHWs, data collectors, and physicians working in the study area.

Low failure rate

It was found that of the total 2,341 children treated at home for pneumonia, treatment failure was reported in only 8 per cent cases whereas treatment failure was 13 per cent in cases referred to a health facility.

“Because of the low compliance with referral to the poorly functioning and overburdened public-sector health facilities and the many pneumonia deaths in childhood in Pakistan that occur at home or in transit, we believe that the inclusion of community management of severe pneumonia into the LHW Programme would address these health system and financial bottlenecks,” the study suggests.

It says that the community-based management of severe pneumonia cases with oral amoxicillin can reduce the following: risk of complications such as needle-borne infections and unnecessary injections; the need for referral or unnecessary admission to hospital; indirect costs like transport, food, etc; emergence of antimicrobial resistance caused by widespread use of inappropriate second-line antibiotics.

The results confirm that oral amoxicillin is an effective antibiotic for treatment of severe pneumonia at domiciliary level in settings with a low prevalence of HIV— revision of the guidelines for management of severe pneumonia is needed.

The findings also validate a parallel trial (with a similar study design), carried out in the north of Pakistan, in Haripur district, by Save the Children with the support of USAID and WHO.