Reducing Deaths from Severe Pneumonia in Children in Malawi by Improving Delivery of Pneumonia Case Management
Identifieur interne : 002A21 ( Pmc/Curation ); précédent : 002A20; suivant : 002A22Reducing Deaths from Severe Pneumonia in Children in Malawi by Improving Delivery of Pneumonia Case Management
Auteurs : Penelope M. Enarson [France, Afrique du Sud] ; Robert P. Gie [Afrique du Sud] ; Charles C. Mwansambo [Malawi] ; Ellubey R. Maganga [Malawi] ; Carl J. Lombard [Afrique du Sud] ; Donald A. Enarson [France, Afrique du Sud] ; Stephen M. Graham [France, Australie]Source :
- PLoS ONE [ 1932-6203 ] ; 2014.
Abstract
To 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.
A 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.
Following 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).
The 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.
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DOI: 10.1371/journal.pone.0102955
PubMed: 25050894
PubMed Central: 4106861
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Enarson</name><affiliation wicri:level="1"><nlm:aff id="aff1"><addr-line>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France</addr-line></nlm:aff><country xml:lang="fr">France</country><wicri:regionArea>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff2"><addr-line>Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg</wicri:regionArea></affiliation></author><author><name sortKey="Gie, Robert P" sort="Gie, Robert P" uniqKey="Gie R" first="Robert P." last="Gie">Robert P. Gie</name><affiliation wicri:level="1"><nlm:aff id="aff3"><addr-line>Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg</wicri:regionArea></affiliation></author><author><name sortKey="Mwansambo, Charles C" sort="Mwansambo, Charles C" uniqKey="Mwansambo C" first="Charles C." last="Mwansambo">Charles C. Mwansambo</name><affiliation wicri:level="1"><nlm:aff id="aff4"><addr-line>Ministry of Health, Lilongwe, Malawi</addr-line></nlm:aff><country xml:lang="fr">Malawi</country><wicri:regionArea>Ministry of Health, Lilongwe</wicri:regionArea></affiliation></author><author><name sortKey="Maganga, Ellubey R" sort="Maganga, Ellubey R" uniqKey="Maganga E" first="Ellubey R." last="Maganga">Ellubey R. 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Enarson</name><affiliation wicri:level="1"><nlm:aff id="aff1"><addr-line>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France</addr-line></nlm:aff><country xml:lang="fr">France</country><wicri:regionArea>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff2"><addr-line>Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg</wicri:regionArea></affiliation></author><author><name sortKey="Gie, Robert P" sort="Gie, Robert P" uniqKey="Gie R" first="Robert P." last="Gie">Robert P. Gie</name><affiliation wicri:level="1"><nlm:aff id="aff3"><addr-line>Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg</wicri:regionArea></affiliation></author><author><name sortKey="Mwansambo, Charles C" sort="Mwansambo, Charles C" uniqKey="Mwansambo C" first="Charles C." last="Mwansambo">Charles C. Mwansambo</name><affiliation wicri:level="1"><nlm:aff id="aff4"><addr-line>Ministry of Health, Lilongwe, Malawi</addr-line></nlm:aff><country xml:lang="fr">Malawi</country><wicri:regionArea>Ministry of Health, Lilongwe</wicri:regionArea></affiliation></author><author><name sortKey="Maganga, Ellubey R" sort="Maganga, Ellubey R" uniqKey="Maganga E" first="Ellubey R." last="Maganga">Ellubey R. Maganga</name><affiliation wicri:level="1"><nlm:aff id="aff5"><addr-line>UNICEF Malawi, Lilongwe, Malawi</addr-line></nlm:aff><country xml:lang="fr">Malawi</country><wicri:regionArea>UNICEF Malawi, Lilongwe</wicri:regionArea></affiliation></author><author><name sortKey="Lombard, Carl J" sort="Lombard, Carl J" uniqKey="Lombard C" first="Carl J." last="Lombard">Carl J. Lombard</name><affiliation wicri:level="1"><nlm:aff id="aff6"><addr-line>Biostatistics Unit, South Africa Medical Research Council (MRC), Cape Town, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Biostatistics Unit, South Africa Medical Research Council (MRC), Cape Town</wicri:regionArea></affiliation></author><author><name sortKey="Enarson, Donald A" sort="Enarson, Donald A" uniqKey="Enarson D" first="Donald A." last="Enarson">Donald A. Enarson</name><affiliation wicri:level="1"><nlm:aff id="aff1"><addr-line>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France</addr-line></nlm:aff><country xml:lang="fr">France</country><wicri:regionArea>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff2"><addr-line>Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa</addr-line></nlm:aff><country xml:lang="fr">Afrique du Sud</country><wicri:regionArea>Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg</wicri:regionArea></affiliation></author><author><name sortKey="Graham, Stephen M" sort="Graham, Stephen M" uniqKey="Graham S" first="Stephen M." last="Graham">Stephen M. Graham</name><affiliation wicri:level="1"><nlm:aff id="aff1"><addr-line>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France</addr-line></nlm:aff><country xml:lang="fr">France</country><wicri:regionArea>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="aff7"><addr-line>Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia</addr-line></nlm:aff><country xml:lang="fr">Australie</country><wicri:regionArea>Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne</wicri:regionArea></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>To 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.</p></sec><sec><title>Methods</title><p>A 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 1<sup>st</sup> 2000 until 31<sup>st</sup> 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.</p></sec><sec><title>Findings</title><p>Following 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).</p></sec><sec><title>Conclusions</title><p>The nationwide implementation of the CLHP significantly reduced CFR in Malawian infants and children (2–59 months) treated for severe pneumonia. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id><journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosone</journal-id><journal-title-group><journal-title>PLoS ONE</journal-title></journal-title-group><issn pub-type="epub">1932-6203</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25050894</article-id><article-id pub-id-type="pmc">4106861</article-id><article-id pub-id-type="publisher-id">PONE-D-13-50231</article-id><article-id pub-id-type="doi">10.1371/journal.pone.0102955</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v2"><subject>Medicine and Health Sciences</subject><subj-group><subject>Health Care</subject><subj-group><subject>Health Care Policy</subject><subject>Health Care Quality</subject></subj-group></subj-group><subj-group><subject>Infectious Diseases</subject><subj-group><subject>Bacterial Diseases</subject><subj-group><subject>Bacterial Pneumonia</subject></subj-group></subj-group></subj-group><subj-group><subject>Pediatrics</subject><subj-group><subject>Child Health</subject></subj-group></subj-group><subj-group><subject>Public and Occupational Health</subject></subj-group><subj-group><subject>Pulmonology</subject><subj-group><subject>Respiratory Infections</subject><subj-group><subject>Lower Respiratory Tract Infections</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v2"><subject>Research and Analysis Methods</subject><subj-group><subject>Research Design</subject><subj-group><subject>Clinical Research Design</subject><subject>Prospective Studies</subject></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Reducing Deaths from Severe Pneumonia in Children in Malawi by Improving Delivery of Pneumonia Case Management</article-title><alt-title alt-title-type="running-head">Malawi Child Lung Health Project Outcomes</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Enarson</surname><given-names>Penelope M.</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="corresp" rid="cor1"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Gie</surname><given-names>Robert P.</given-names></name><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Mwansambo</surname><given-names>Charles C.</given-names></name><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Maganga</surname><given-names>Ellubey R.</given-names></name><xref ref-type="aff" rid="aff5"><sup>5</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lombard</surname><given-names>Carl J.</given-names></name><xref ref-type="aff" rid="aff6"><sup>6</sup></xref></contrib><contrib contrib-type="author"><name><surname>Enarson</surname><given-names>Donald A.</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Graham</surname><given-names>Stephen M.</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff7"><sup>7</sup></xref></contrib></contrib-group><aff id="aff1"><label>1</label><addr-line>Child Lung Health Division, International Union Against Tuberculosis and Lung Disease, Paris, France</addr-line></aff><aff id="aff2"><label>2</label><addr-line>Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa</addr-line></aff><aff id="aff3"><label>3</label><addr-line>Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, University of Stellenbosch, Tygerberg, South Africa</addr-line></aff><aff id="aff4"><label>4</label><addr-line>Ministry of Health, Lilongwe, Malawi</addr-line></aff><aff id="aff5"><label>5</label><addr-line>UNICEF Malawi, Lilongwe, Malawi</addr-line></aff><aff id="aff6"><label>6</label><addr-line>Biostatistics Unit, South Africa Medical Research Council (MRC), Cape Town, South Africa</addr-line></aff><aff id="aff7"><label>7</label><addr-line>Centre for International Child Health, University of Melbourne Department of Paediatrics and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Ferrand</surname><given-names>Rashida A.</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>London School of Hygiene and Tropical Medicine, United Kingdom</addr-line></aff><author-notes><corresp id="cor1">* E-mail: <email>penarson@theunion.org</email></corresp><fn fn-type="conflict"><p><bold>Competing Interests: </bold>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con"><p>Conceived and designed the experiments: PME RPG DAE. Performed the experiments: PME RPG CCM ERM SMG DAE. Analyzed the data: PME CJL RPG DAE. Contributed reagents/materials/analysis tools: PME RPG ERM CJL DAE. Wrote the paper: PME RPG CCM ERM SMG DAE CJL.</p></fn></author-notes><pub-date pub-type="collection"><year>2014</year></pub-date><pub-date pub-type="epub"><day>22</day><month>7</month><year>2014</year></pub-date><volume>9</volume><issue>7</issue><elocation-id>e102955</elocation-id><history><date date-type="received"><day>2</day><month>12</month><year>2013</year></date><date date-type="accepted"><day>26</day><month>6</month><year>2014</year></date></history><permissions><copyright-year>2014</copyright-year><copyright-holder>Enarson et al</copyright-holder><license><license-p>This is an open-access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><abstract><sec><title>Objective</title><p>To 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.</p></sec><sec><title>Methods</title><p>A 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 1<sup>st</sup> 2000 until 31<sup>st</sup> 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.</p></sec><sec><title>Findings</title><p>Following 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).</p></sec><sec><title>Conclusions</title><p>The 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.</p></sec></abstract><funding-group><funding-statement>The CLHP was primarly funded by the MoH of Malawi, who contributed 69% of the running costs comprising facilities and human resources that are part of the existing health system. The Bill and Melinda Gates Foundation funded the remaining 31% of the costs, 21% of which was investment and 79% operating costs. The Bill & Melinda Gates Foundation grant ID#: 413 <ext-link ext-link-type="uri" xlink:href="http://www.gatesfoundation.org/Pages/home.aspx">http://www.gatesfoundation.org/Pages/home.aspx</ext-link>). The external funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement></funding-group><counts><page-count count="13"></page-count></counts></article-meta></front></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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