Objective 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. Methods 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. Findings 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). Conclusions 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.
Liu L, Johnson HL, Cousens S, Perin J, Scott S, et al. (2012) Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 2151–2161. doi: 10.1016/s0140-6736(12)60560-1
Reed C, Madhi SA, Klugman KP, Kuwanda L, Ortiz JR, et al. (2012) Development of the respiratory index of severity in children (RISC) score among young children with respiratory infections in South Africa. PLoS ONE 7: e27793 doi:10.1371/journal.pone.0027793.
Shann F, Hart K, Thomas D (1984) Acute lower respiratory tract infections in children: possible criteria for selection of patients for antibiotic therapy and hospital admission. Bull World Health Organ 62: 749–753.
Theodoratou E, Al-Jilaihawi S, Woodward F, Ferguson J, Jhass A, et al. (2010) The effect of case management on childhood pneumonia mortality in developing countries. Int? J? Epidem 39: i155–i171. doi: 10.1093/ije/dyq032
Enarson PM, Gie R, Enarson DA, Mwansambo C (2009) Development and implementation of a national programme for the management of severe and very severe pneumonia in children in Malawi. PLoS Med 6: e1000137 doi:10.1371/journal.pmed.1000137.
Rogerson SR, Gladstone M, Callaghan M, Erhart L, Rogerson SJ, et al. (2004) HIV infection among paediatric in-patients in Blantyre, Malawi. Trans? R? Soc Trop Med Hyg 98: 544–555. doi: 10.1016/j.trstmh.2003.12.011
Enarson PM, Gie RP, Enarson DA, Mwansambo C, Graham SM (2010) The impact of HIV on standard case management for the inpatient treatment of childhood pneumonia in high HIV prevalence countries. Expert Rev Resp Med 4: 211–220. doi: 10.1586/ers.10.14
Enarson PM, Enarson DA, Gie RP (2005) Management of the child with cough or difficult breathing, A Guide for Low Income Countries. 2nd ed. The International Union Against Tuberculosis and Lung Disease, Paris.
WHO/UNICEF(2000) Management of the child with a serious infection or severe malnutrition: Guidelines for care at the first-referral level in developing countries. World Health Organisation, Geneva, WHO/FCH/CAH/001.
Enarson P, La Vincente S, Gie RP, Maganga ER, Chokani C (2008) Implementation of an oxygen concentrator system in district hospital paediatric wards throughout Malawi: Lessons from the field. Bull World Health Organ 86: 344–348. doi: 10.2471/blt.07.048017
McNally LM, Jeena PM, Gajee K, Thula SA, Sturm AW, et al. (2007) Effect of age, polymicrobial disease, and maternal HIV status on treatment response and cause of severe pneumonia in South African children: a prospective descriptive study. Lancet 369: 1440–1451. doi: 10.1016/s0140-6736(07)60670-9
Graham SM, Mankhambo L, Phiri A, Kaunda S, Chikaonda T, et al. (2011) Impact of human immunodeficiency virus infection on the etiology and outcome of severe pneumonia in Malawian children. Pediatr Infect Dis? J 30: 33–38. doi: 10.1097/inf.0b013e3181fcabe4
Graham SM, Mtitimila EI, Kamanga HS, Walsh AL, Hart CA, Molyneux ME (2000) The clinical presentation and outcome of Pneumocystis carinii pneumonia in Malawian children. Lancet 355: 369–373. doi: 10.1016/s0140-6736(98)11074-7
Duke T, Wandi F, Jonathan M, Matai S, Kaupa M, et al. (2008) Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea. Lancet 372: 1328–1333. doi: 10.1016/s0140-6736(08)61164-2
O'Brien KL, Wolfson LJ, Watt JP, Henkle E, Deloria-Knoll M, et al. (2009) Burden of disease caused by Streptococcus pneumonia in children younger than 5 years: global estimates. Lancet 374: 893–902. doi: 10.1016/s0140-6736(09)61204-6
Everett DB, Cornick J, Denis B, Chewapreecha C, Croucher N, et al. (2012) Genetic characterisation of Malawian pneumococci prior to the roll-out of the PCV13 vaccine using a high-throughput whole genome sequencing approach. PLoS One. 7: e44250. doi: 10.1371/journal.pone.0044250
Nantongo JM, Wobudeya E, Mupere E, Joloba M, Ssengooba W, et al. (2013) High incidence of pulmonary tuberculosis in children admitted with severe pneumonia in Uganda. BMC Pediatr 13: 16. doi: 10.1186/1471-2431-13-16
Bronzan RN, Taylor TE, Mwenechanya J, Tembo M, Kayira K, et al. (2007) Bacteremia in Malawian children with severe malaria: prevalence, etiology, HIV co-infection and outcome. J? Infect Dis 195: 895–904. doi: 10.1086/511437
Graham SM, English M (2009) Nontyphoidal salmonellae: a management challenge for children with community acquired invasive disease in tropical African countries. Lancet 372: 267–269. doi: 10.1016/s0140-6736(09)60073-8
Gordon M, Graham SM, Walsh AL, Wilson L, Phiri A, et al. (2008) Epidemics of invasive Salmonella enteritidis serovar Enteritidis and S.Typhimurium infections among adults and children, associated with multidrug resistance in Malawi. Clin Infect Dis 46: 963–969. doi: 10.1086/529146
Chisti MJ, Terbruegge M, La Vincente S, Graham SM, Duke T (2009) Pneumonia in severely malnourished children in developing countries – mortality risk, aetiology and validity of WHO clinical signs: a systematic review. Trop Med Int Health 14: 1173–1189. doi: 10.1111/j.1365-3156.2009.02364.x