SPH Contributes to Groundbreaking Global Study
Treating developing world children with pneumonia at home| From BU Today | By Lisa Chedekel
Pakistan “lady health workers” treat a child with respiratory problems. Photo courtesy of Save the Children
Pneumonia—dubbed “the forgotten killer of children” by UNICEF—is the leading cause of death worldwide for children under five years old.
A breakthrough study by researchers from Boston University, Save the Children, and the World Health Organization (WHO), published online in November in the British medical journal The Lancet, has found that allowing community health workers to treat severe pneumonia in young children in a home setting is more effective and just as safe as the current recommendation of referral to a health facility.
In the study, based in the Haripur district of Pakistan, the research team found that home-based treatment of severe pneumonia by a corps of “lady health workers” armed with training and five days’ worth of oral amoxicillin reduces treatment delays and failures compared to the standard practice of administering one dose of antibiotics and referring a child to a hospital or clinic for intravenous drugs.
Because of a scarcity of health care facilities, developing countries such as Pakistan have turned increasingly to community health workers, known as CHWs, to fill the gap.
“This really is the capstone in a 10-year portfolio of research in which we were trying to provide a scientific rationale for community case management of pneumonia,” says study coauthor Donald Thea, a professor of international health at the School of Public Health and a researcher with Boston University’s Center for Global Health & Development (CGHD).
Thea says the study findings are “proof of principle that trained community health workers can identify and manage this very complex disease.”
The research team initially had set out to show that home-based treatment was equivalent to the current standard of care, but what they found was that it produced better outcomes.
“Our study aimed to show that children can recover just as well from severe pneumonia when treated at home as when referred to a health facility,” says study principal investigator Salim Sadruddin, of Save the Children. “In fact, we found that frontline health workers treating children at home can be even more effective.”
Thea says he hopes the study will help to sway the WHO to revise its recommended hospital-referral guidance for severe pneumonia to allow for community management of the disease in areas where there are “trained and well-organized community health workers,” as there are in Pakistan.
A prior study by Thea and colleagues, also in Pakistan, showed that administering oral amoxicillin to children with severe pneumonia worked as well as the injected drugs given in hospitals. But that study was hospital-based, and it had physicians, rather than the community health workers, overseeing care.
“Changing the standard of care will be hugely beneficial, especially for the many children who are referred to hospitals but never reach them,” Thea says.
Elizabeth Mason, director of WHO’s Department of Maternal, Newborn, Child, and Adolescent Health, calls the results of the Pakistan trial “very promising.”
“We will be looking closely at future studies,” she says. “If we see similar results in other places, we can update the global guidance to make treatment much more accessible for families, help governments make the most of limited resources, and save more children’s lives.”
A Lancet editorial accompanying the publication of the study notes that referrals to health facilities “do not always go according to plan. They entail transport costs, upkeep away from home, and possible loss of daily income to the family.”
The editorial goes on to say that the researchers “have given a fine example of how effective CHWs can be. It has been suggested that a reduction in childhood mortality of 25 to 30 percent could be achieved by well-trained and motivated CHWs.”
The study, published on the eve of World Pneumonia Day, November 12, compared outcomes between 1,857 young children treated at home with oral amoxicillin for five days, and 1,354 children in a control group who were given one dose of cotrimoxazole and referred to the nearest health center. Researchers looked at treatment failure at 6 days, as well as at relapse within 14 days.
With failure defined as the continued presence of fever or lower chest indrawing on day six, the results were clearly in favor of home-based therapy: a 9 percent failure rate, versus 18 percent.
The overall mortality for severe pneumonia cases was very low: two children in the control group and one in the intervention group died.
The authors credit the lady health workers, community members with basic training who are employed by the government, with accurately diagnosing severe pneumonia in 94 percent of the cases, as validated by an independent assessor. The Pakistani workers were given intensive training in how to recognize signs of severe pneumonia and to track treatment progress.
Pakistan has more than 90,000 women health workers who try to increase health awareness and improve child and maternal health, particularly in the poor rural areas where three-quarters of the country’s population live. Similar programs for community health workers are in place in other countries, among them Nepal and Malawi.
“For community case management of pneumonia to be successful and sustainable, community health workers will need to be adequately compensated and supervised,” the study recommends.
Thea says one of the most heartening aspects of the study was seeing Pakistani parents embrace the health workers as competent caregivers. At the start of the study, the lady health workers were called upon by families to provide care for fewer than one percent of suspected cases of pneumonia; by the end of the study, that care-seeking had climbed to 52 percent.
“Moms started flocking to the lady health workers with their children,” Thea says. “There was a complete virtuous cycle in the community. It was incredibly empowering for the health workers—to be able to actually cure children improved their status.”
The WHO Department of Child and Adolescent Health and Development funded the study through a grant from the U.S. Agency for International Development. In addition to Sadruddin and Thea, authors include William B. MacLeod and Matthew P. Fox, CGHD and SPH assistant professors; Shamim A. Qazi of the WHO; and a team from Save the Children.
The complete study can be viewed here.