Community Case Management of Childhood Pneumonia

RESEARCH REPORT Community Case Management of Childhood Pneumonia Key Points Pneumonia is the leading cause of mortality among children under the age of 5 years, resulting in more than 2 million deaths each year. Although this disease is preventable and treatable, poor recognition of symptoms and lack of access to care contribute to greater than necessary burden of disease. This report examines the effectiveness of community case management (CCM), one of many interventions to reduce pneumonia mortality.

CCM of pneumonia employs community-based health workers (CHW) to diagnose accurately and treat the disease within their communities. At the core of this strategy is an algorithm that CHWs can use to identify and treat pneumonia that focuses on determining the appropriate course of action for chest in-drawing and rapid breathing.

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CCM is an effective strategy for reducing childhood pneumonia mortality, particularly given its ability to reach children in rural and isolated geographic areas, who often have the highest mortality rates. Evidence suggests that CCM may also help to: ο Reduce the burden of severe pneumonia ο Reduce geographic and financial barriers to care ο Alleviate human resource constraints.

However, the effectiveness of CCM is often limited by weak health systems and poor training and supervision for CHWs. Some other challenges include: ο Limited capacity for training and supervision ο Overlap between malaria and pneumonia symptoms ο Lack of guidelines on treatment for HIV-positive children.

For CCM programs to achieve success, they must overcome these challenges, and need government policies that enhance their ability to succeed. More research is needed to determine how programs can overcome these obstacles and grow to scale successfully.

Background Pneumonia is the leading cause of mortality among children under the age of five years, resulting in more than 2 million deaths each year.1 Among children between age one month and five years, pneumonia accounts for 19 percent of deaths; among neonates (birth to one month), 26 percent of deaths are due

to severe infection and about one-third of this is pneumonia.1, 2 Pneumonia affects the world’s poorest children disproportionately, with approximately 95 percent of the more than 150 million new cases of pneumonia every year occurring in the developing world.1 South Asia and subSaharan Africa alone account for about 50

percent of the total pneumonia cases and just 15 givers recognize the key symptoms of pneumonia or countries account for nearly 75 percent of all pneu- seek health care for their sick children – only 1 in 5 monia deaths.1 caregivers know the danger signs of pneumonia, and just over half of infected children receive appropriate Pneumonia is an acute lower respiratory infection care.1 Children from rural areas and children born to caused by pathogens (bacteria, viruses, fungi or mothers with less education are less likely to receive parasites) that attack the lungs. In developing coun- appropriate care. In addition, children from poorer tries, the bacterial pathogens Streptococcus pneumoniae families may be less likely to receive antibiotics.5 and Haemophilus influenzae type b (Hib) are the leading Other challenges include ineffective communication causes of pneumonia.3 These pathogens migrate with primary care providers regarding approprifrom the mouth or nose, where they normally reside, ate contact information for a child’s caregiver and to the lungs, where they infect the alveoli (air sacs regarding the treatments and guidelines provided in the lung that exchange oxygen and carbon diox- by CHWs once the child returns home.6 ide). Alternatively, these pathogens are transmitted from person to person by infectious secretions, such The risk of pneumonia can is increased by some as droplets from the nose or throat.1, 4 Symptoms of environmental conditions or behavioral practices. pneumonia include cough, difficult or rapid breath- Children living in overcrowded houses or those ing, fever, muscle aches, head aches, chills, wheez- exposed to indoor air pollution, including seconding and loss of appetite.1 hand smoke, may be more likely to develop pneumonia. Children with compromised immune sysEarly recognition of pneumonia and appropriate tems or other illnesses may also be at greater risk of care-seeking behavior are essential to reduce the infection. Other risk factors include rainfall burden of the disease. Unfortunately, too few carePercentage of Caregivers that Recognize the Key Danger Signs of Pneumonia1

Fast Breathing

17%

Difficult Breathing

21%

0%

5%

10%

15%

20%

25%

Percentage of Caregivers that Take Children with Pneumonia to Appropriate Provider1 54%

Developing countries

41%

Sub-Saharan Africa

50%

CEE/CIS Latin America and the Caribbean

52%

59%

South Asia East Asia and the Pacific (excluding China)

62%

Middle East and North Africa

66% 0%

2

10%

20%

30%

40%

50%

60%

70%

Risk Factors for Childhood Pneumonia1, 7-9 • • • • • • • • •

Indoor air pollution Exposure to parental smoking Living in crowded homes Non-exclusive breastfeeding Malnutrition Zinc deficiency Low birth weight Infection with HIV and other diseases Mother’s experience as a caregiver

Interventions to Prevent Childhood Pneumonia1, 7-9 • • • • • • • •

Childhood immunizations Exclusive breastfeeding Adequate zinc Adequate nutrition Adequate hand washing Reduction of indoor pollution Hand washing Prevention of HIV/AIDS

(humidity), high altitude (cold air), outdoor air disease may influence the appropriateness of differpollution, vitamin A deficiency, mother’s education, ent treatments. day care attendance and birth order.7 There are numerous interventions to prevent childhood pneumonia, including childhood immunizations, exclusive breastfeeding, adequate nutrition and zinc, proper hygiene, reduction of air pollution and HIV prevention.1, 3, 10 Childhood immunizations (especially Haemophilus influenzae type b (Hib), measles, and pneumococcal vaccines) play a key role in prevention by both preventing infections that are the direct cause of pneumonia and also preventing childhood infections that may increase the risk of pneumonia. Exclusive breastfeeding delivers a number of antibodies, antioxidants, and hormones required for a strong immune system. Adequate zinc intake helps to prevent pneumonia, reduce the duration and severity of the disease and reduces treatment failure rates. Other important prevention interventions include adequate nutrition, reduction of indoor air pollution and prevention of HIV/ AIDS. Antibiotic treatment for childhood pneumonia significantly reduces mortality.1 Cotrimoxazole and amoxicillin are two antibiotics that are commonly used to treat children with pneumonia in developing countries.1 It is essential that children receive treatment as soon as possible; without treatment, the infection may develop into severe pneumonia.

WHO guidelines indicate that hospital-based treatment for severe pneumonia is warranted. Health care workers should select treatment based on their local context, as drug resistance and other endemic

Global Action Plan for Prevention and Control of Pneumonia (GAPP)10 In November 2009, UNICEF and the WHO released the Global Action Plan for Prevention and Control of Pneumonia (GAPP), which was developed to increase awareness about childhood pneumonia and provide a plan for reducing the burden of this disease. 10 GAPP calls for a comprehensive approach to reducing the burden of pneumonia by implementing an integrated package including multiple protection, prevention and treatment interventions. It also endorsed CCM for pneumonia as one of the key components to reducing childhood pneumonia.

Implementing GAPP interventions in the 68 countries with high child mortality will cost US$39 billion for 2010-2015. This can avert up to 1.2 million post-neonatal pneumonia deaths and another 0.4 million deaths due to neonatal pneumonia/sepsis by 2015.

Community Case Management of Pneumonia CCM of pneumonia is a strategy to reduce pneumonia morbidity and mortality by engaging and training CHWs to diagnose and treat childhood pneumonia within their own communities through 3

the use of standardized criteria.11 The use of these criteria was first proposed at a 1980 WHO consultation, based on the findings of Frank Shann and others in Papua New Guinea.11, 12 Additional work showed that:13 ο Chest in-drawing is a reliable sign of severe pneumonia and an indicator to admit children to the hospital for intensive antibiotic treatment. ο Cough and respiratory rates greater than 40 or 50 per minute are a reliable sign of nonsevere pneumonia and an indicator to start children on a course of antibiotics.

Later studies supported the use of these criteria and led to an algorithm (i.e., guidelines) that assist health care workers in identifying and treating pneumonia in the absence of direct supervision.11 The CCM strategy was incorporated into WHO’s acute respiratory case (ARI) management guidelines in the 1980s. In the mid-1990s, the program was adopted into WHO’s Integrated Management

of Childhood Illness (IMCI) program, which was designed to address several common early childhood illnesses, including diarrhea, malaria, pneumonia, malnutrition and measles.

Community health workers who provide CCM of pneumonia are trained to: Assess sick children for pneumonia; Select appropriate treatments; Administer antibiotics properly; Counsel parents about the importance of following treatment regimens; • Provide supportive home care; and • Follow up with and refer families to a health facility should complications arise.5 • • • •

Measuring the Effectiveness of Community Case Management of Pneumonia A large body of evidence indicates that CCM and the WHO guidelines provide an effective strategy to reduce death and illness associated with childhood pneumonia.5, 20-26 When used correctly, the

Identification and Treatment of Childhood Pneumonia according to the World Health Organization’s Integrated Management of Childhood Illness Guidelines1 Sign Î -Fast breathing -Lower chest wall in-drawing -Stridor in calm child* -Fast breathing

-No fast breathing

Classification Î Severe pneumonia

Treatment -Refer to hospital for injectable antibiotics and oxygen if needed -Give first dose of appropriate antibiotic

Non-severe pneumonia

-Prescribe appropriate antibiotic -Advise mother on other supportive measures and when to return for a follow up visit -Advise mother on other supportive measures and when to return if symptoms persist or get worse.

Other respiratory illness

What is Fast Breathing?

If the child is…

2 months to 12 months 12 months to 5 years old

The child has fast breathing if you count…

50 breaths or more per minute 40 breaths or more per minute

*Stridor is a high-pitched sound, caused by blockage in the throat or larynx, that may be heard during intake of breath.14 4

Who are Community Health Workers?15 “Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers.� 16 World Health Organization, 2007 CHWs perform many different tasks, ranging from community health education to direct provision of care, and address a broad array of health issues, including maternal, newborn and child health, reproductive health, and infectious and chronic diseases.16 They offer a unique perspective in that they have greater access to individuals living in hard to reach places and may have a better understanding of local customs and beliefs, compared to other health care providers. They may be employed by the government, non-governmental organizations (NGO), or others in the private sector. Many CHWs are unpaid volunteers; others are paid or receive in-kind incentives.6 In some cases, they charge their clients for the price of their antibiotics; in other cases, they charge a fee for their services. CHWs may also be paid directly by their clients, from community-based insurance schemes or by the government.17 CHWs need training, supervision, access to equipment and medicines to provide quality care, and to work as part of a larger health care team. 6, 18 The training received varies by content, duration, location and quality. Equipment and supplies may be provided by the government, purchased by community funds, or distributed by NGOs or other actors in the private sector. In the case of CCM of childhood pneumonia, supplies may include antibiotics and timers. To perform effectively, CHWs need appropriate supervision and government support, which may require changing policies or setting aside an adequate portion of the national budget for community health workers.19

guidelines can accurately identify about 80 percent of children who require antibiotic treatment and more than 80 percent of children who have severe pneumonia.27 This translates into the correct diagnosis of 120 million cases per year, but leaves 30 million cases undiagnosed and untreated. Frequent misdiagnosis of pneumonia and other respiratory infections results in unnecessary antibiotic treatment for approximately 20 to 30 percent of cases.27

in neonates (42 percent), followed by infants (36 percent) and children (36 percent).

Although current WHO guidelines indicate that children with severe pneumonia should be treated in a hospital with injectable antibiotics, some research indicates that even children with severe pneumonia can be effectively treated at home by CHWs.28 In Africa, Asia, Europe and Latin America, studies have shown that oral antibiotics may be as effective as injectables, which may change manA meta-analysis of nine community-based studies agement protocols in developing countries, save in seven countries (Tanzania, Pakistan, Philippines, lives and relieve overburdened health systems.29 India, Nepal, Bangladesh, and Indonesia) found Antibiotics administered by CHWs in the home that CCM reduced total childhood mortality by could reduce the cost and inconvenience of hos24 percent, and reduced childhood pneumonia pitalization for the family, while also reducing the mortality by 36 percent.24 The reduction of total strain on crowded hospital or clinic facilities.28 mortality was greatest in children aged 1 – 4 years (24 percent), followed by infants between 1 and Advantages of a Community-based Approach 12 months of age (20 percent) and neonates under 1 month old (20 percent). Conversely, the reduc- Reduces Geographic and Financial Barriers to tion in total pneumonia mortality was greatest Care. CCM of childhood pneumonia may over5

come barriers to care, including travel and time costs. Compared to most primary health care providers, CHWs have access to a broader group of individuals and are particularly effective in delivering care to rural, hard-to-reach populations, where children are less likely to receive appropriate care and less likely to be treated with antibiotics.1, 9, 30 Community health workers can also provide services for mothers and caregivers who may not

be able to afford time away from their homes and workplaces to stay with children in a health care facility.31 For example, in an assessment of a CCM program in Nicaragua, mothers reported that they were able to consult a CHW as soon as their child fell ill, rather than waiting several days before accessing care, and that they no longer had to worry about travelling to a care facility.32

Case Studies: Successes Nepal In 1991, Nepal’s Ministry of Health estimated that 30 to 40 percent of all child deaths in the country were a result of pneumonia infection. After reviewing positive findings of CCM for childhood pneumonia studies in Jumla, the government decided to introduce this strategy into the public health system. A technical working group was established to oversee the implementation of this new strategy, and in 1995, 1,497 female community health volunteers (FCHVs) and 525 health facility staff were trained to provide CCM for childhood pneumonia across 4 districts. Because of government concerns about the competency of illiterate FCHVs, the four pilot districts were divided into two “treatment” and two “referral” districts. In 1997, an evaluation of the program found that all FCHVs could correctly classify and treat pneumonia. As a result of this promising evidence, the government converted the “referral” districts to “treatment” districts, and gradually scaled-up the program. Ten years later, CCM coverage in 40 of Nepal’s 75 districts saves 6,000 lives per year; if community care is expanded nationwide, an estimated 10,200 lives will be saved annually.21, 26 Ethiopia In 2005, Save the Children trained 45 volunteers in community case management in Liben District of Ethiopia. Collectively, 32 of these volunteers treated 4,787 cases of malaria, pneumonia, conjunctivitis, diarrhea and measles from July 2005 to August 2006. CCM workers treated 2.5 times as many patients with acute respiratory infection, pneumonia, and diarrhea than health facility staff in the same district. In addition to increasing the number of cases treated, the trained community volunteers provided good quality care – more than half scored at least 90 percent when assessed on their ability to apply the guidelines. The CCM strategy also increased caregiver’s knowledge about the danger signs of pneumonia and care-seeking behavior.23 India In Gadchiroli, India, community-based interventions, including CCM, effectively reduced child pneumonia mortality and had a positive impact on neonatal mortality.25 Fifty-eight villages were included in the intervention group and 44 villages in the control group, covering 6,176 and 3,947 children under the age of five, respectively; paramedics, village health workers and traditional birth attendants received training. The intervention included education about childhood pneumonia, case management of pneumonia and treatment of pneumonia with co-trimoxazole. Within one year, childhood pneumonia deaths were significantly lower in the intervention versus the control villages (8.1 versus 17.5 deaths per 1000 children, respectively); for infants, mortality was 89 versus 121 per 1000, respectively. Neonates in the intervention villages were also significantly less likely to die from birth injury, prematurity, small baby and bleeding disorders than neonates in the control districts, due to the improved skills of traditional birth attendants.

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Cost-Effective and Reduces Severe Pneumonia.

CCM is cost-effective in several ways, particularly when compared to other interventions to reduce child mortality due to pneumonia.33 By identifying and treating cases of non-severe pneumonia early in the course of the disease, CCM helps to prevent the progression from non-severe to severe pneumonia.34 This helps to alleviate the burden of severe pneumonia cases on primary care facilities and clinics.34 Severe pneumonia is also far more costly to treat than non-severe pneumonia, so by preventing the disease progression, CCM saves money.34 In addition, employing CHWs may be more cost effective than building and staffing facilities in remote and hard to reach areas, which often have some of the highest rates of childhood mortality due to pneumonia.17 Alleviates Human Resources Constraints. In many developing countries, health systems are struggling to scale up essential interventions in the face of resource constraints. Two of the primary challenges these countries face are the severe shortage in the health care workforce and the high cost of educating and training new professionals.15 Community health workers present an alternative and complementary solution to this human resource shortage. Although the scope of work for CHWs is more limited than that of physicians and nurses, the cost of training community health workers is considerably lower.

Acceptability in the Community. CHWs may be more acceptable care providers to mothers or other caregivers, compared to other health professionals. Many CHWs work in the live in the area in which they provide services, so mothers may already know them as neighbors and may feel more comfortable welcoming them into their homes. In Nicaragua, one mother said of CHWs, “we have grown up together, we are at home with them.”32 In an intervention in India, traditional birth attendants were involved in case management because they were the only health care workers with “natural access to newborn infants.”25 Challenges of CCM for Pneumonia Although CCM offers opportunities to address childhood pneumonia, it is not a panacea. It also faces several barriers. Challenges for providing accurate and adequate management of pneumonia include poor training and supervision, weak health systems, overlap of malaria and pneumonia symptoms, cultural and linguistic differences, inadequate government support for this strategy and barriers to scaling up these programs.

Training and Supervision. Training and supervision are critical to ensure that health care workers have the knowledge and tools they need correctly to fulfill their role as health care providers.39 Therefore, lack of training and adequate supervision can limit the effectiveness of this intervention.

Treatment Costs Per Epidode for Acute Lower Respiratory Infection (2001 US$)34 Disease Severity Î Location Î Low- and middleincome countries East Asia and the Pacific Latin America and the Caribbean Middle East and North Africa South Asia Sub-Saharan Africa

Non-severe CCM* 8

Non-severe Clinic/Hospital* 2

Severe Hospital 82

Very Severe Hospital 172

6

2

75

160

13

4

134

256

22

3

112

223

5 7

2 2

66 64

148 145

*The cost of community-based treatment for non-severe pneumonia is higher than the cost of clinic/hospital-based treatment because CCM includes four visits (one initial one-hour visit and three follow-up visits), whereas facility-based treatment includes just one visit.

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Accurate Administration of Antibiotic Drugs Much evidence shows that community health workers can administer antibiotics successfully if they are adequately trained, but antibiotic misuse is still a common concern related to CCM of pneumonia.3, 21, 26, 30, 35 In fact, antibiotic misuse is one of the primary factors contributing to poor government support for CCM programs.17, 36 Policy barriers that prevent CHWs from prescribing and administering antibiotics make community-based programs difficult to implement.9 Antibiotic misuse – e.g., prescribing antibiotics for children who do not need them, administering the incorrect dosage, and failure to follow dosage regimens – is a serious public health threat, as it can lead to the development of drug resistance throughout the community.20 •

In Bangladesh, children in one study received antibiotics, but about one-quarter received less than the recommended dosage.

•

In Niger, a study found that caregivers who knew the dose and frequency of the antibiotic regimen did not know the duration of treatment.”37

Unskilled providers and personal use of antibiotics also contribute to the development of drug resistance.17 CCM of pneumonia may mitigate this problem, as skilled CHWs with appropriate training would replace unskilled providers and reduce the need for self-treatment.

There are several strategies that reduce the misuse of antibiotics. Providing pre-packaged antibiotic treatments or blister packets that contain the appropriate treatment dosage can reduce mistakes in the administration of antibiotics.6, 38 Branding antibiotics so that they are specifically associated with pneumonia may help to ensure that antibiotics are not being used to treat other conditions.25

CHWs to assist caregivers in securing needed care for children with severe pneumonia. Community health workers may not refer children if they know that accessing an appropriate facility is impossible.41 For example, in one evaluation of CCM for The capacity of CHWs to develop an understand- acute respiratory infections in Nepal, 22 percent ing of the training materials, learn essential skills of the mothers or caregivers with a child who had and work with supervisors to ensure quality of severe pneumonia were referred to the nearest care is also a critical factor in program effective- health facility by a CHW found that the facilness.35, 40 Many different types of training programs ity was either closed during regular hours or was exist, varying in terms of duration, content and without medicine.41 method of teaching. Periodic refresher classes offer a means of improving a community health worker’s Weak health systems may also compromise community health workers’ standing in their commuability to manage of childhood pneumonia.30 nity.21 Strong supply chains are necessary to ensure Health Systems and Integrated Services. Weak that when a child is diagnosed with pneumonia, health systems limit the effectiveness of commu- antibiotic treatment is readily available. If CHWs nity-based case management of childhood pneu- diagnose children with pneumonia, but cannot monia. Without strong referral systems and then provide treatment due to lack of antibiotics, their access to appropriate facilities, it is difficult for credibility is damaged within their community.

However, with the appropriate training, supervision and support, CHWs can provide a broader range of services beyond pneumonia diagnosis and treatment to children in their homes.

8

Health systems need to provide CHWs with all of the tools and resources they need to adequately manage childhood pneumonia within their communities.5 Such needs include access to drugs, supplies (e.g., timers to measure breaths per minute and cards to record their patients’ treatment), training, supervision and links to referral.27, 42 Some medical personnel perceive CHWs as unskilled or qualified, and do not provide a supportive environment.15

likely to die than HIV-uninfected children.39 Cultural and Linguistic Challenges. Differences in culture and language may also inhibit the effectiveness of CCM of pneumonia. Trainers, supervisors, and community health workers may have difficulty translating technical medical terms, especially if there are no words to describe a specific set of medical symptoms in their communities.

In one Kenyan study, a community was familiar with the medical terms “pneumonia” and “bronchopneumonia,” but had no specific term to describe “rapid breathing,” one of the criteria in the pneumonia management algorithm.

However, this community did have a term synonymous with chest in-drawing (“rimunia”), one of the key symptoms of severe pneumonia.

As a result, caregivers in the community failed to recognize the significance of rapid breathing in their children, but regularly recognized chest in-drawing.44 This resulted in delayed access to care and treatment for children with rapid breathing and relatively timely diagnosis and treatment of the children with chest indrawing (“rimunia”).

CCM for pneumonia should be scaled up in conjunction with other child health interventions.3, 36 Children rarely exhibit just one, isolated childhood illness; it is likely that a child may experience other co-infections simultaneously.40 An integrated approach to childhood illness can capitalize on natural linkages and overlap with other interventions to provide more efficient and cost-effective care. 23, 41 It is also important for community-based care to be integrated with the provision of care at primary and secondary health facilities.42 Without scaling up health systems as a whole, CHWs will not have access to the resources they need to provide treatment and referral to children in their community.42 Cooperation at all levels of the health system is critical to providing a seamless course of In another study in Kenya, linguistic differencmedical care. es contributed to a lack of confidence in pneumonia case management guidelines.40 Mothers Pneumonia and Other Diseases. Properly diagincluded in this study use the term “oriere,” nosing childhood pneumonia may be difficult, the Luo word for “convulsions” to describe as its symptoms are often mistaken for those of 6, 20, 39 when a child is startled or shivering.40 As a childhood malaria.

Community-based case result, community health workers may have algorithms for pneumonia and malaria are reladismissed caretakers’ reports of convulsions.40 tively accurate in predicting pneumonia in malariaThis problem could be solved by clarifying the endemic areas.43 Although there is evidence to sugpneumonia management guidelines. gest that CHWs can correctly manage ARI, studies of CHW effectiveness in sub-Saharan Africa are limited. In particular, more evidence on CHW Lack of Government Support. Gaining governcapacity to distinguish between pneumonia and ment support for CCM of childhood pneumonia malaria is needed, as many countries in the region programs is often a difficult, but critical, step in implementing and scaling up these programs. are malaria endemic.

Although CCM is a cost-effective approach, the Current case management guidelines for commu- costs may may be substantial, particularly in the 22, 36, 45 Governments may nity-based care of childhood pneumonia do not initial implementation. turn to partnerships with donors as one strategy adequately address the needs of children who have both pneumonia and HIV/AIDS. Even with health to defray program expenses. Providing evidence of care worker adherence to IMCI diagnostic and the success of CCM through pilot programs may 45 treatment guidelines, children infected with both be one way to overcome government hesitations. pneumonia and HIV are three to eight times more 9

Challenges of Scale-up. Scaling up CCM will create many new challenges for health care workers, supervisors, and managers. HCWs may be expected to take on additional tasks without the appropriate training. Shifting from small-scale programs to national programs poses serious challenges to supervision and management of a growing number of community health workers.15

guidelines can influence a government’s decision to endorse this intervention. In a survey of 57 countries in Africa and Asia with high child mortality rates, half of the countries reported some implementation of CCM of pneumonia, and approximately one-third (20/54) reported supportive government policies. A sustainable plan for CCM of pneumonia requires incorporating this strategy into a national health plan, ensuring adequate budgetary support International and government support for CCM of for the programs, and consulting the appropriate pneumonia is crucial for scaling up this strategy. actors, including regional ministers and elected Including community case management in inter- officials.36 national policy recommendations and treatment Highlighting the Challenges In general, CHWs appear to be adept in correctly identifying and treating children with pneumonia, but a small number of studies suggest otherwise.30, 40 In a four-year evaluation of the performance of CHWs in the Siaya District, Kenya, several deficiencies were found in the treatment of children with pneumonia.40 Evaluations were performed in 1998, 1999 and 2001. These evaluations found that only 57.8 percent, 35.5 percent, and 38.9 percent of children, respectively, were treated “adequately” (with an antibiotic, antimalarial, oral rehydration solution, or referral) for non-severe pneumonia, and 27.7 percent, 77.3 percent, and 74.3 percent, respectively, for severe pneumonia. Several factors contributed to the deficiencies in the management of sick children, including complexity of management guidelines, poor supervision, criticisms for severe diagnosis, lack of confidence in management guidelines and inadequate practice using guidelines.

In a competency-based training and evaluation study of CCM for acute respiratory infections in Bolivia, CHWs already trained using the modified WHO ARI case management guidelines were evaluated both before and after a day-long ARI refresher course. Though CHWs “were able to absorb most of the information needed to implement competently the WHO ARI case management protocol,” they continued to have difficulty classifying children with severe pneumonia even after the refresher course. About one-third of the cases of severe pneumonia presented during the evaluation after the refresher course were misclassified, “principally through failure to recognize chest in-drawing.”30

Research Needs

10

knowledge and skills are retained over time; the optimal frequency for refresher courses; the Research is needed in several key areas: appropriate content and frequency of supervisory visits; and the ability of training to improve To highlight the qualities associated with CHWs’ ability to identify, diagnose and treat CHW effectiveness in implementing case mancorrectly children with pneumonia.9, 30 agement. For example, more evidence is needed To collect data on the cost-effectiveness of on the impact illiteracy or semi-literacy has on CCM strategies, including costs associated health care workers and community case manwith training health care workers.9, 39 agement, as results are somewhat mixed.21, 25 To expand CCM to include multiple diseas To determine the most effective types of traines.17 ing. For example, it is unclear how well To scale up community-based research effec-

tively, including the assessment of how health workers, supervisors and managers navigate large-scale programs.3 To assess the scope and scale of antibiotic misuse, as well as associated antibiotic resistance.

In addition, research is needed on how to monitor effectively the administration and distribution of drugs.23 To develop the most effective guidelines and identify the best courses of action for community-based care and treatment of young children.46 To improve the specificity of identification criteria. 10, 34 The development of new rapid tests to diagnose malaria may also help to reduce misdiagnosis. 20 To determine whether CCM can be used to treat successfully children with severe pneumonia.29 To develop new tools that will enable CHWs to collect more detailed epidemiological data on childhood pneumonia.10

of already overcrowded hospital wards, making room for other children in greater need of medical attention.

However, CCM is not without its challenges.

Perhaps the greatest challenge is the need for stronger health systems or integrated programs of care. These needs include improved supervision and management of CHWs, adequate and reliable supply chains and effective drug management.

Without these critical components, CHWs may not only be unable to provide treatment, but may also lose credibility in their community. In addition, malaria infections may overlap with pneumonia, making it difficult for health care workers to diagnose and treat the disease; other infections, such as HIV, may require treatment outside the scope of health care worker’s training. Additional research is needed to determine the most efficient and effective training programs for community health workers and the best way to integrate pneumonia case management programs into broader programs to treat additional childhood disease.

Conclusion Community case management is clearly an effective intervention to reduce childhood mortality.

One of the greatest advantages of this approach is its ability to treat children in even the most remote regions. In addition, early identification and treatment for non-severe pneumonia may prevent the onset of severe pneumonia – reducing both the burden of disease for the child and the costs of more extensive treatment borne by families and health care facilities. By reaching sick children early, community health care workers help to keep them out References 1. Wardlaw T, Johansson EW, Hodge M. Pneumonia: the forgotten killer of children. New York: UNICEF, the World Bank; 2006.

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4. National Institute of Allergy and Infectious Disease. Health & Research A to Z: Pneumonia 2006 [cited May 1, 2010]; Available from: http://www.niaid.nih.gov/topics/pneumonia/Pages/Default. aspx 5. WHO. The United Nations Children's Fund (UNICEF).

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Evidence base for the community management of pneumonia.

Ultimately, too many children are dying from pneumonia, a preventable and treatable disease. CCM is one strategy that can reduce childhood pneumonia mortality and may have broader benefits to families and communities. It is an integral part of the WHO’s Global Action Plan for Prevention and Control of Pneumonia; without it, the Plan’s goals will be difficult, if not impossible, to reach.

Without mobilizing all actors to prevent childhood illness, including community health workers, Millennium Development Goal 4 will be exceedingly difficult to reach.

Stockholm: World Health Organization; 2002 June 11-12, 2002.

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