SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
February, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
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.
People deciding whether to introduce pneumonia case management into practice
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.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
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.
| 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.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
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 childhood pneumonia with antibiotics |
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| People: Children under five years old with pneumonia Settings: Community Intervention: Community case management Comparison: Usual care (No community case management) |
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| Outcomes |
Impact (95% CI)
|
Certainty of the evidence (GRADE) |
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| 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%)
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Low |
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| 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 |
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| GRADE: GRADE Working Group grades of evidence (see above and last page) | |||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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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.
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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.
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| 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.
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| 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.
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*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 |
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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.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by Mike English. We did not receive any comments from the
review authors.
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.
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
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
