Academic journal article Bulletin of the World Health Organization

Community Case Management of Pneumonia: At a Tipping Point?/ Prise En Charge Communautaire Des Cas De Pneumonie : Une Strategie Sur le Point De L'emporter?/ Tratamiento Comunitario De Los Casos De Neumonia: [??]Punto De Inflexion?

Academic journal article Bulletin of the World Health Organization

Community Case Management of Pneumonia: At a Tipping Point?/ Prise En Charge Communautaire Des Cas De Pneumonie : Une Strategie Sur le Point De L'emporter?/ Tratamiento Comunitario De Los Casos De Neumonia: [??]Punto De Inflexion?

Article excerpt

Introduction

Pneumonia is the leading cause of mortality among children under five years of age, (1) despite effective vaccines and nutritional and environmental interventions. (2,3) Most children with signs of pneumonia in developing countries need antibiotics, as they are more likely to have a bacterial etiology. (4) Expanding the coverage of antibiotic treatment for pneumonia is vital to meet the Millennium Development Goal 4 (MDG 4) of reducing under-five mortality by two-thirds by 2015, compared to 1990 levels. (5,6) However, many children with pneumonia do not receive timely, appropriate treatment at health facilities, (7) especially children from poorer familles. (8) Community case management (CCM) of pneumonia, (9) complementing facility-based management, is a strategy to deliver antibiotics outside health facilities where access to treatment is poor.

CCM of pneumonia requires training community health workers (CHWs) to use algorithms developed in the 1980s (10) to assess danger signs in children with a cough, count respiratory rates, and look for chest in-drawing to classify respiratory illness. CHWs recommend and dispense oral antibiotics for cases classified as simple pneumonia, usually in children 2-59 months of age, and refer to health facilities young infants or children with danger signs or chest in-drawing.

CHWs can effectively manage respiratory illness and prescribe antibiotics appropriately, (11-14) with few exceptions. (15,16) A meta-analysis of nine studies round that CCM of pneumonia reduced overall mortality in children 0-4 years by 24% (95% confidence interval, CI: 14-33) and pneumonia-specific mortality in children 0-4 years by 36% (95% CI: 20-49). (17) In 2002, WHO convened experts to review the evidence and field experience of CCM of pneumonia. Their consensus statement called for the national health authorities, WHO, the United Nations Children's Fund (UNICEF) and nongovernmental organizations (NGOs) to support implementation of CCM of pneumonia. (18) A 2005 joint policy recommendation from WHO and UNICEF also recommended that "community-level treatment [of pneumonia] be carried out by well-trained and supervised CHWs". (19)

The global health community has renewed appeals for more action to prevent and treat child pneumonia to reach the MDG 4. (3,5,20) Pneumonia case management with antibiotics remains a central control strategy, both through facilities and in the community. (3) Here, we review the policies, implementation and plans for CCM of pneumonia in countries with the highest levels of child mortality.

Methods

The study examined CCM of pneumonia among the 57 Asian and African countries included in the 60 countries that were the focus of the first Countdown to 2015 (21) and accounted for 94% of global mortality among children less than five years of age in 2004; Latin American countries (Brazil, Haiti and Mexico) were excluded from the analysis. We defined CCM of pneumonia as oral antibiotics for simple pneumonia in a child 2-59 months of age, administered by a health worker in the community, as defined by the respondent.

Data sources

We drafted, pilot-tested and refined a self-administered questionnaire regarding countries' CCM of pneumonia policies, implementation and plans. Questionnaires were distributed electronically in June 2007 from UNICEF and WHO headquarters and regional offices to WHO and UNICEF incountry Integrated Management of Childhood Illness (IMCI) experts, requesting that they and Ministry of Health counterparts jointly complete the questionnaire. We tracked responses to maximize return and clarified inconsistencies or omissions through followon e-mail requests, phone calls and/or face-to-face encounters. Representatives from non-responding countries received four requests.

Respondents were asked about their countries' community IMCI (C-IMCI) policies and components, policies and implementation regarding CHWs dispensing oral antibiotics for pneumonia, other treatments for childhood illnesses provided in the community, and future plans for CCM of pneumonia. …

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