Community health workers caring for children with pneumonia

Lung Week is 12-17 November

Despite being preventable and curable, pneumonia is the leading killer of children under 5 years old. In 2011 alone, 1.3 million children died from this preventable and treatable illness, accounting for 18% of child mortality. In 2008, there were an estimated 203,000 deaths due to Haemophilus influenzae type b (Hib) and 541,000 deaths due to Streptococcus pneumoniae (pneumococcus) in children under five. Effective vaccine for pneumonia caused by pneumococcus exists - yet children who are likely to be at a high risk of pneumonia are least likely to get the protection.

Despite huge adverse impact of pneumonia on child's health and survival, median national coverage levels of pneumonia related services is appalling. Care-seeking for pneumonia is as low as 48%, and antibiotics for pneumonia are only reaching 27% of those children who need it most. One way to early diagnose, treat and care for childhood pneumonia is to bring healthcare closer to homes, especially in developing countries. Studies done in at least two countries show evidence that community healthcare workers can make a very positive contribution in helping save lives of children from pneumonia.

"Traditionally childhood pneumonia is managed in hospitals, some studies have shown now it can be done at the community level. Pakistan and Bangladesh both have shown the key role of community healthcare workers (HCW) in identifying children with pneumonia and providing antibiotics before they take a long journey to hospital and before the disease becomes severe. Pneumonia can be very progressive within 24 hours. The attention should be more at the community level too. This is one way to help improve health responses to childhood pneumonia in developing countries" said Dr Stephen Graham, Chair of the Childhood TB Subgroup of DOTS Expansion Working Group of Stop TB Partnership; and faculty at the Centre for International Child Health, University of Melbourne, Australia. Dr Graham is a senior consultant with the International Union Against Tuberculosis and Lung Disease (The Union) and he gave an exclusive interview to Citizen News Service - CNS.

In a study published in BMJ earlier this year, children following apparently effective treatment of severe pneumonia experienced considerable morbidities due to cough, fever, rapid breathing, chest indrawing, feeding difficulty, and diarrhea following discharge and 'day-care' children experienced significantly more from all of the above morbidities except fever during their follow-up period compared to hospital-care children. The findings indicate the importance of follow-up of children with severe pneumonia irrespective of their primary site of management (day-care clinic or hospital) for early detection and efficient management of medical problems reducing the risk of death. According to this study, establishment of an effective community follow-up of non-compliant children, whenever possible, would be ideal to address the problem of ‘non-compliance with follow-up’.

In another study done in Hala, Pakistan, due to community-based interventions, there was a 15% reduction in neonatal mortality, and 21% reduction in stillbirths. In another randomised controlled trial (RCT) study done in Pakistan to evaluate community management of severe pneumonia, strong evidence emerged that community healthcare workers can effectively treat severe pneumonia (chest indrawing) with oral amoxycillin.

VACCINE
Vaccines can help us prevent some serious forms of pneumonia - for example, there is an effetive vaccine to prevent children from pneumonia caused by pneumococcus, which accounts for a significant burden of pneumonia-related deaths. "Pneumococcal vaccine is very effective and I think it can make a big difference including among those children who have difficulties in getting access to health services" said Dr Graham.

HIV AND CHILDHOOD PNEUMONIA
The HIV epidemic has sharply increased the incidence, severity, and mortality of childhood pneumonia in the developing world, particularly in sub-Saharan Africa. HIV is a major risk factor for pneumonia related deaths among children. This gives us another reason to push for universal access to prevention of mother to child transmission (PMTCT) related services and care. "That definitely reduces number of children dying of pneumonia" said Dr Graham.

INDOOR AIR POLLUTION
According to the World Health Organization (WHO), nearly half of deaths among children under five years old from pneumonia are due to particulate matter inhaled from indoor air pollution from household solid fuels. Tobacco smoke is another risk factor that puts children at risk of developing acute respiratory infections (ARIs) such as pneumonia. Enforcing comprehensive tobacco control measures and raising awareness about the health hazards of indoor air pollution on family's health are need of the hour.

OXYGEN
"Availability of oxygen in the hospital is important to reduce death in children with pneumonia" stressed Dr Graham. Absence of oxygen or inadequate oxygen supplies has serious adverse consequences for childhood pneumonia treatment and care. In a study done in Papua New Guinea (PNG) on the effect of an improved oxygen system on death rate in children with pneumonia, the evidence was clear on how availability of oxygen can reduce mortality, and improve quality of care for children with pneumonia in developing countries. The cost-effectiveness of this system compared favourably with that of other public-health interventions.

Dr Graham strongly recommended that we should stop prescribing antibiotics to children who don’t need them. Irrational use of antibiotics may develop drug resistance in severe cases. Antibiotic policy and adequate availability of oxygen are two measures Dr Graham recommended for healthcare facilities.

Let's hope during this year's Lung Week (12-17 November) and World Pneumonia Day (12 November) the message gets out loud and clear: no child should die of curable disease like pneumonia and all those children who need pneumonia-related care have access to these services.

Bobby Ramakant writes for Citizen News Service – CNS. www.citizen-news.org

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