February, 2017 - SUPPORT Summary of a systematic review | print this article |

Does community case management of pneumonia reduce mortality from childhood pneumonia?

Pneumonia is the leading cause of death in children worldwide and the great majority of these deaths occur in resource-limited settings. Effective case management is an important strategy to reduce pneumonia related morbidity and mortality in children. Pneumonia case management includes appropriate choice of antibiotic and additional supportive treatments, prompt and appropriate referral for inpatient care, and management of treatment failure.

 

 

Key messages

  • Community case management of pneumonia may reduce all cause mortality and mortality due to acute lower respiratory infection.
  • All studies were conducted in low and middle income countries.

 

 

 

 

Background

Over 2 million children die from pneumonia each year, accounting for almost one in five under 5 deaths worldwide. The World Health Organization developed a case management strategy in the 1980s aiming to reduce pneumonia related deaths. As part of the primary care approach, children with pneumonia require access to good quality basic first level care that could be provided by lay health workers (community case management). Community case management includes appropriate choice of antibiotic, prompt and appropriate referral for inpatient care, and management of treatment failure.

 

About 10% of children presenting with pneumonia (severe or very severe) may require referral to a first referral or district hospital for a higher level of care. Hospital case management includes oxygen, intraveous fluids or antibiotics, zinc and vitamin A supplements.

 



About the systematic review underlying this summary

Review objectives: To assess the effectiveness of pneumonia case management on mortality and morbidity from childhood pneumonia.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, cluster randomised trials, quasi-experimental studies, and observational studies investigating the effect of community and hospital case management (including antibiotics, oxygen, zinc and vitamin A supplements) Fourteen studies were included for community case management: quasi-experimental (1), before-after study (2), concurrent cohort studies (8), other observational studies (3). Ten studies were included for hospital case management with antibiotics: before-after studies (2), case series (mostly arms of randomised trials) (8). One before-after study of oxygen treatment and 11 randomised trials of supplements.
Participants Under five-year-old children with pneumonia Children from rural and urban areas
Settings Community and hospital India (8), Pakistan (4), Papua New Guinea (3), Bangladesh (2), Nepal (2), Tanzania (2). One each from: Malaysia, Philippines, South Africa, Mozambique, Yemen, Brazil, Ecuador, Guatemala, Peru, Uruguay and Vietnam. Three multi-country: Colombia; Ghana; India; Mexico; Pakistan; South Africa; Vietnam; Zambia India; Bangladesh; Ecuador; Mexico; Yemen, Fiji and China
Outcomes Mortality, morbidity and healthcare utilization All-cause mortality of children with pneumonia; treatment failure rates; length of hospitalization, time to resolution of severe illness, lethargy, inability to eat, low oxygen saturation, chest indrawing and tachypnoea
Date of most recent search: August 2008
Limitations: This is a well-conducted systematic review with only minor limitations, but the search was done in 2008.

Theodoratou E, Al-Jilaihawi S, Woodward F, et al. The effect of case management on childhood pneumonia mortality in developing countries. Int J Epidemiol 2010; 39 Suppl 1:i155-71.

Theodoratou E, Al-Jilaihawi S, Woodward F, et al. The effect of case management on childhood pneumonia mortality in developing countries. Int J Epidemiol 2010; 39 Suppl 1:i155-71.

Summary of findings

Thirty six studies were included in the review. Fourteen studies evaluated community case management of pneumonia. Ten of these reported all cause mortality and 10 reported acute lower respiratory infection mortality. 

The other studies included in the review evaluated components of hospital care for children with pneumonia and we do not report on those here.

 

Community case management of pneumonia

 

  • Community case management of pneumonia may reduce all cause mortality and acute lower respiratory infection mortality. The certainty of this evidence is low.

 

Community case management of childhood pneumonia with antibiotics 

People:  Children under five years old with pneumonia
Settings
:  Community
Intervention
: Community case management
Comparison
: Usual care (No community case management)
Outcomes
Impact (95% CI) 
Certainty of the evidence
(GRADE)
All cause mortality

For 0 to 5 years old: Relative reduction of 35% (18 to 48%)

- 0 to 1-month-old: 42% (23 to 54%)

- 0 to 1-year-old: 42% (33 to 55%)

- 1 to 4 years old: 49% (from an increase of 7% to a reduction of 76%)

 


Low

Acute lower respiratory infection mortality

For 0 to 5 years old: Relative reduction of 21% (12 to 30%)

- 0 to 1-month-old: 27% (18 to 35%)

- 0 to 1-year-old: 21% (14 to 28%)

- 1to 4 years old: 51% (30 to 66%)

 

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All studies included in the systematic review were conducted in low- and middle income countries.

 

Most of the studies were from areas in which HIV was not a major public health problem.

 


Considering the settings of the included stud-ies, these findings are likely to be applicable to low-income countries. However, because the re-view did not report baseline conditions there is uncertainty about the applicability of the findings across different settings.

 

  • The effect of case management in areas where HIV is a major problem may substantially differ from the estimates in regions where HIV is not such a problem.
  • New vaccines might potentially reduce the ab-solute benefits of pneumonia case management.
  • Weak infrastructure, shortage of essential sup-plies and insufficient health staff in low-income countries require consideration of the availability, acceptability and costs of pneumonia case man-agement interventions.

 


EQUITY
Pneumonia case management may reduce mortality even in rural areas with very limited access to health services and severely limited resources.

Resources needed for pneumonia case management may be less available in disadvantaged settings.

 

  • Pneumonia case management may increase inequity if they are not applied to these populations.

 

ECONOMIC CONSIDERATIONS
The systematic review did not address economic considerations.
Local costing should be considered prior to scaling up pneumonia case management.
MONITORING & EVALUATION
There is low or very low certainty evidence of the effects of pneumonia case management on mortality. 

More rigorous and larger studies are required to determine the effectiveness and the cost effectiveness of pneumonia case management.

 

  • Studies should describe the components of pneumonia case management, such as antibiotic availability, percentage of detected cases, case treatment rates, and treatment compliance.
  • Studies should assess differential effects by risk subgroups.

 


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Graham SM, English M, Hazir T, et al. Challenges to improving case management of child hood pneumonia at health facilities in resource limited settings. Bull World Health Organ 2008; 86(5):349-55.

 

Zaidi AK, Ganatra HA, Syed S, et al. Effect of case management on neonatal mortality due to sepsis and pneumonia. BMC Public Health 2011; 11 Suppl 3:S13.

 

Enarson PM, Gie RP, Mwansambo CC, et al. Reducing deaths from severe pneumonia in children in Malawi by improving delivery of pneumonia case management. PLoS One 2014; 9(7):e102955.

 

Hickam DH, Weiss JW, Guise JM, et al. Outpatient case management for adults with medical illness and complex care needs. Rockville (MD): Agency for Healthcare Research and Quality, 2013.

 

Sazawal S, Black RE, Pneumonia Case Management Trials Group. Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta analysis of community based trials. Lancet Infect Dis 2003; 3(9):547-56.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by Mike English. We did not receive any comments from the

review authors.

 

This review should be cited as

Theodoratou E, Al Jilaihawi S, Woodward F, et al. The effect of case management on childhood pneumonia mortality in developing countries. Int J Epidemiol 2010; 39 Suppl 1:i155-71.

 

The summary should be cited as

Ciapponi A. Does community case management of pneumonia reduce mortality from childhood pneumonia? A SUPPORT Summary of a systematic review. February 2017. www.supportsummaries.org

 

Keywords

evidence informed health policy, evidence based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, childhood pneumonia, case management, community

 

 

 

 



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