Community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Haripur district, Pakistan: a cluster randomised trial

Abstract

Background First dose oral cotrimoxazole and referral is the recommended treatment for WHO-defined severe pneumonia. Difficulties with referral compliance are reported from many low resource settings resulting in low access to appropriate treatment. Methods In a cluster-randomized equivalence trial in Haripur District, Pakistan 28 clusters were randomized equally to intervention and control clusters. In 14 intervention clusters children 2-59 months of age with severe pneumonia were treated with oral amoxicillin by community-based Lady Health Workers (LHW). In 14 control clusters LHWs gave first dose of oral cotrimoxazole and referred to a health facility for appropriate treatment, which was standard of care. The objective was to determine whether community case-management (CCM) of severe pneumonia by LHW using oral amoxicillin was equivalent to current standard of care. Primary outcome was treatment failure on day 6 of treatment. Participants, care givers, and assessors were not blinded to study therapy. Per-protocol analysis was conducted adjusting for clustering within arms using generalized estimating equations. Findings 1995 children were randomized to intervention and 1477 to control clusters. We analysed 1857 children randomized to intervention and 1354 randomized to control clusters. They were similar in sex, age, and clinical characteristics. Treatment failure was 8·9% (165/1857) in intervention and 17·8% (241/1354) in control clusters. Cluster adjusted failure rates, the primary outcome, were significantly reduced in intervention clusters (risk difference (RD) -8·9%; 95% CI:-12.4% to -5.4%) by day 6. Further adjusting for baseline covariates made little difference (RD: -7·3%, CI: -10·1% to -4·5%). Three deaths occurred, only one in the intervention arm. Two deaths were before day 6, while one occurred between day 6 and 14. Most reduction in risk was in fever and lower chest indrawing on day 3 (RD -6·38%; 95% CI: -8·3% to -4·5%). Age, gender and very fast breathing were predictive of treatment failure. Interpretation CCM of severe pneumonia by LHWs resulted in reduced treatment failure versus current standard of care. CCM could result in standardized therapy for severe pneumonia, reduce delay in treatment initiation and costs for families and health systems. Funding United States Agency for International Development.

Pneumonia in low and middle income countries: progress and challenges

“…Community based case management of childhood pneumonia may reduce pneumonia mortality by 70% 15. Accumulating evidence suggests that community based use of oral antibiotics for severe pneumonia may be a feasible and effective strategy for reducing mortality 12 16 17. Furthermore, short course antibiotic therapy (3 rather than 5 days) has been reported to be effective for pneumonia in immunocompetent children 18…”

Where there is no doctor: can volunteer community health workers in rural Uganda provide integrated community case management?

“…15 In Asia, Pakistan and Nepal have well-established and studied iCCM programs. 16,17 African iCCM studies are few, 14,18 and less still have assessed health outputs and outcomes. 5,14,[19][20][21][22][23] National programs in sub-Saharan Africa are new and while early studies are demonstrating implementation feasibility and early positive outcomes 7,8 , more studies are needed to understand implementation in a variety of contexts including use of volunteer CHWs with limited formal education and short iCCM training.…”

Point-of-Care Ultrasound in Resource-Limited Settings: Common Applications

“…Because the CHW is not expected to treat chest indrawing pneumonia, these guidelines will retain two age bands and will not be revised at the present time. Some data from Asia (56,57) shows that CHWs can manage chest indrawing pneumonia with oral amoxicillin. However, current CHW guidelines will not be changed until more evidence becomes available from additional regions and countries.…”

“…Bari et al (56) aimed to compare community management of children with chest indrawing pneumonia by lady health workers (LHWs), using oral amoxicillin, to the standard of care: a first dose of cotrimoxazole followed by referral. Twenty-eight clusters in the Haripur district of Pakistan were randomly assigned equally in a 1:1 ratio to either intervention or control.…”