Severe pneumonia in a remote hilly area : Integrated management of childhood illness
http://www.100md.com
《美国医学杂志》
Civil Hospital, Rohru, District Shimla, Himachal Pradesh, India
Abstract
Objective: This study aims to profile children with severe pneumonia in the perspective of Integrated Management of Childhood Illness (IMCI) strategy in a resource-constrained environment. Methods: 115 consecutive children, aged 2 months to 10 yr, hospitalized with severe pneumonia were prospectively evaluated between May 1997 and June 1998 at a civil hospital in the northern hilly state of India. Results: All children had tachypnea and lower chest wall indrawing. Grunting was observed in 39.7%, inability to drink in 16.5%, and cyanosis in 1.7% cases. Radiological investigation was carried out only in 90 children that included abnormal chest radiographs (CXRs) in 76.6% cases. Feeding malpractices, vaccination inconsistencies, exposure hazards to smoking, micronutrient as well as macronutrient deficiencies, treatment from unqualified practitioners, inconsequential involvement of health care workers, predominant burden on mothers in the care of sick children, failure to recognize signs and symptoms of pneumonia by parents at home, lack of oxygen facilities, problems of accessibility and less faith on primary health care services were widely prevalent bottlenecks for effective implementation of 3 components of IMCI. Conclusion: Our study offers practical insights that can be useful in customizing IMCI to needs of children with pneumonia in a resource-constrained environment.
Keywords: Severe pneumonia; Integrated Management of Childhood Illness (IMCI); Chest radiograph
Childhood pneumonia clearly represents one of the most common infectious illnesses in developing countries and is of great importance as a cause of preventable mortality in children. To attack this global problem, the World Health Organization (WHO) shaped strategy for effective case management that had a remarkable impact on decreasing mortality due to childhood pneumonia in developing countries. [1],[2],[3] Tempering this success is the presence of treatment inconsistencies due to fragmented health service delivery in resource-limited settings. [4],[5],[6] Moreover in a continuum of health care, adverse impact of pneumonia is exponentially increased when it attacks a child lacking basic health care in a resource-constrained environment.[4],[7] In order to overcome constraints in the management of pneumonia particularly in rural areas, recent emphasis on Integrated Management of Childhood Illness (IMCI), therefore, is a step in right direction.[8],[9] As Indian adaptation of IMCI strategy undergoes large scale field trials in India, it behooves community clinicians and researchers, from a more comprehensive perspective, to consider not only the clinical profile and risk factors, but constraints within households and communities so as to overcome complicity with factors and practices that can reduce the operational effectiveness of pneumonia control program. In accordance with these perspectives, the present study focused on socio-demographic and community characteristics, basic health care practices as well as clinical features, course and management of children hospitalized with severe pneumonia.
Materials and Methods
Study Participants and Setting
All consecutive children, aged 2 months to 10 yr, hospitalized with severe pneumonia were prospectively evaluated in detail throughout their stay in hospital. The following were the reasons for exclusion: children having duration of illness >2 weeks or respiratory distress with predominant wheezing. Patients were recruited prospectively between May 1997 and June 1998 at a civil hospital (tehsil Rohru, district Shimla) serving a catchment area of approximately 100 villages in the northern hilly state (Himachal Pradesh) of India and caring for 200 to 300 patients per day (with pediatric patients constituting at least 1/3rd of daily outpatient department attendance). Rohru is approximately 4000 ft above sea level. Informed assent was taken from the parents or other caregivers before enrolment, and the study was granted local approval by Senior Medical Officer Incharge of hospital.
Diagnosis and Treatment
The diagnosis of pneumonia was based on either WHO criteria for children aged 5 yr or less or auscultatory/radiological signs of pneumonia in older children. According to World Health Organization (WHO) guidelines, a child with complaints of cough and/or fever was labeled as a case of severe pneumonia if both tachypnea and lower chest wall indrawing were present.[1]
Clinical evidence of rickets was recorded if at least two of the following criteria were found: widening of wrists, rachitic rosary, box-shaped head with frontal bossing, pectus deformity of chest and abnormally wide or open anterior fontanel. Nutritional status was expressed as z scores for weight for age and height for age using reference median values of healthy Indian children.[10]
Though all children hospitalized with pneumonia were originally planned to undergo radiographic examination within 24 hours of admission, only 78% (90/115) children had their chest radiographs (CXRs) done due to logistic problems. A single radiologist, who was blind to the clinical diagnosis, evaluated the radiographs according to the WHO classification.[11]
Data Collection
Information was collected in the form of a questionnaire that included child's age, sex, other socio-demographic parameters, prior treatment and its details, risk factors for acute lower respiratory tract infection (LRTI), immunization and feeding practices, anthropometric data and other systemic details. The two clinical researchers themselves meticulously recorded the history and physical findings, clinical course and resolution of symptoms and signs throughout the child's stay in hospital.
Statistical Analysis
Univariate analysis was carried out for analyzing the results of the present study. The study sample's socio-economic status (SES) was assessed by a composite measure constructed using a principal component analysis of 8 variables representing both parents' educational level, occupational status, and other social factors (domestic animals, number of living rooms, family size and vaccination status).
Results
Clinical Characteristics of Patients
The present study population consisted of 115 children- 67 boys and 48 girls. Majority of children affected were infants and toddlers (77.4%); infants up to 12 months alone were 46.1%. Only 9.6% of cases were above the age of 5 yr. Mean time to report in the present study was 5.8± 2.8 days with approximately th (i.e. 79.1%) reaching hospital within 7 days of onset of illness. Onset of respiratory illness (i.e. time between initial symptom and onset of tachypnea) was acute (< 48 hr) in only 20% patients and subacute (> 48 hr) in remaining 80% of cases. Cough was associated or preceded by upper respiratory symptoms in 70.4 % of cases. Symptoms of headache, sore throat and chest pain were reported by 6.1%, 1.7%, and 7% children respectively. The various presenting symptoms in the study cohort are itemized in table1.
Past Complaints
Previous health status of children enroled in the study was enquired. According to parental reports, 47% of children were ill for the first time, 29.6% had occasional sickness in the past whereas 23.5% used to fall frequently sick. Past history of contact with tuberculosis was observed in 11.3% of children. History of hospitalization in the last one year was obtained in 19.1% of patients for the following reasons: (1) pain in abdomen (6.1%), (2) pneumonia (7%), (3) seizure (0.9%), (4) trauma (0.9%), (5) fever (2.6%), and (6) indication not clear (0.9%). History of passage of worms in stool was given in 8.7%, pica in 18.3%, recent ear discharge in 11.3 %, which was active at the time of evaluation in 6.1% of patients.
Socio-demographic and Community Characteristics
Based on the principal component analysis, patients were categorized into three levels of SES: low, middle, and high. Thirty (26.1%) families belonged to low SES; 76 (66.1%) were from lower middle SES; and remaining 9 (7.8%) belonged to high SES group. Birth order of patients ranged from 1 to 6, with 75% of enroled patients ￡2 in birth order. Family set up was nuclear in 33.9% and joint in 66.1% cases. Source of drinking water was as follows: (1) community or household tap water (66.7%), (2) spring water (19.3%), (3) both (8.8%) and (4) other sources like hand pumps, well etc. in 5.3%. Domestic animals were owned by 29.6% of the families. Number of living rooms varied from 1 to 20 with a mode of 1. Kitchen was inside the living room in 40% of patients' houses. The mean distance covered by patients to reach the study site was 14.3± 8.9 km on bus (range; 0-65 km) and 0.79 ±1.5 km on foot (range; 0-10 km).
Accompanier
Enquiry about the attendants accompanying the affected child revealed that 52.2% of affected children were brought by single parent (mainly mother-46.2%), 40% by both parents, 4.3% by grandparents, and 3.5% by other relatives alone.
Smoking Patterns
Both parental and domestic smoking was present in 65.2%, domestic smoking alone in 25.2%, parental smoking alone in 5.2%, and none in 4.3% of cases. Nearly 90% of people used solid fuel for cooking ( e.g. wood, dung, coal) at their homes.
Vaccination Status
The vaccination status of the enroled children was as follows: completely vaccinated-with BCG scar 40% and without BCG scar 25.2%; incompletely vaccinated- 22.6%; and unvaccinated-12.2%. The various reasons given for not getting completely vaccinated included: (1) lack of time (13.9%), (2) not aware (12.2%), (3) not interested (5.2%), (4) staff absent (1.7%), (5) nonavailability of facility (0.9%), and (6) card misplaced (0.9%).
Feeding History
For better comprehension, feeding practices are described for infants under 12 months of age in the present study cohort (n=53). Only 2 (3.8%) infants were never breast-fed. Out of the remaining 51 infants, 20 (37.7%) were mainly breast-fed (with or without water), while top feeds were predominantly used in the rest. Latter group included use of bottle in 54.5% of children. Diluted top feeds were given in 90% of children. Weaning was initiated in the 6th month only in 32/42 (76.1%) of 6-12 month old affected infants.
Treatment Seeking Pattern
Prior treatment was received by 60.9 % of the study participants. It included oral drugs in 14.8%, injectables in 12.2 %, both oral and injectables in 2.6 %; and nature of drugs could not be ascertained in the remaining 31.3% of cases. Place of prior treatment included: registered medical practitioner (RMP) 18.3%, unqualified practitioners 16.5%, dispensary 13 %, primary health center (PHC) 4.3%, and civil hospital 2.6%; whereas 5.2% of patients were treated at home by parents. The mean duration of prior treatment was of 1.6 ± 1.8 days. Anthropometry, general physical findings and respiratory parameters are shown below in Figure1. Mean respiratory and heart rate in enroled patients were 64±14/min and 140±15/min respectively.
Radiological Characteristics
Out of 115 patients, radiological investigation was carried out only in 90 children due to logistic problems. Latter included normal chest radiographs in 18.8% (17/90); in 4.4% (4/90) CXRs were sub optimal; and in remaining 76.6% (69/90) CXRs were abnormal. Various radiological abnormalities, according to the WHO classification, were as follows: (1) end-point consolidation-56.5% (39/69); (2) other infiltrates (non end-point consolidation)-37.6% (26/69); (3) Pleural effusion-1.4%(1/69); and (4) non-significant infiltrates-4.3% (3/69)
Treatment
During their management, 23.5% (27) children received intravenous fluids because of severe respiratory distress (mainly inability to drink, drowsiness, or marked grunting) and/or dehydration. Parenteral antimicrobials (penicillin/ampicillin + chloramphenicol) were administered (at least for 48 hours or more) to 58.3% (67) patients. Severe shortage of oxygen limited its use to only those 2 infants who had obvious cyanosis. Children were also monitored for defervescence of their respiratory illness. The results revealing mean time taken for fever, cough, anorexia and tachypnea to decrease and become normal are shown in table2.
Discussion
The wide breadth of community-based epidemiological data strongly implicates important "extra pulmonary" factors primarily related to nutritional status, sociocultural variables and general healthcare practices involved in either delayed or inappropriate treatment of pneumonia. [12],[13] The uncertainty over pneumonia diagnosis and its management is further clouded by a substantial gap between recommended guidelines for diagnosis and treatment and actual clinical practice.[14], [15] Wide variations in WHO guidelines' use exist in resource- limited settings.[16],[17] Findings of the present study provide useful insights of all 3 components of IMCI that cannot be ignored when addressing the pertinent issue of lowering burden of illness due to pneumonia in children of developing countries.[18]
First component of training of field health workers assumes great importance in the backdrop of the present finding, that involvement of health care workers is of inconsequential benefit in remote areas, as prior treatment in the present study participants was never based on WHO guidelines and was ineffective. Feeding malpractices, vaccination inconsistencies, exposure hazards to smoking, micronutrient as well as macronutrient deficiencies are widely prevalent, therefore making them prone to acute infective illnesses including pneumonia. Suboptimal vaccination coverage in the present study demonstrates the inadequacy of healthcare workers in meeting the basic health needs of children that is deemed necessary to lower their susceptibility to respiratory tract infections. The results of this study have also broken the myth that breast-feeding is universal in rural areas. At least half of the studied children with acute LRTI were not given breast feeds, and use of top feeds with bottle was unexpectedly high in the present study. Therefore IMCI guidelines' emphasis to provide nutritional counseling needs to be considered with earnest. Also, it is imperative to improve the skills of health workers in managing micronutrient deficiencies, particularly iron (anemia 82.6%), vitamin D/calcium (rickets 36.5%), and vitamin A (2.7% in the present study participants) that can further aggravate the vulnerability of rural children to various respiratory pathogens, modify response to antimicrobial agents, and influence outcome from illness. [19] Study of pattern of resolution of symptoms and signs of pneumonia as in the present study will further provide useful insights for training health workers to decide improvement in attacks of severe pneumonia.
A second component of IMCI aims to improve health system support for child health service delivery. Implicit here is the concern that mean time taken to report to hospital in the present study was 5.8 days, suggesting that parents do not recognize the signs and symptoms of disease earlier that puts additional constraint on the effectiveness of ongoing management strategy. So there is an urgent need for health education to enable parents to recognize respiratory disease and seek an appropriate care. Moreover, local private and unqualified practitioners also need to be active participants in the program. Studies of health facility utilization patterns have shown that self-employed general practitioners working in the community see and treat the largest proportion of ARI patients. [4],[5],[6] This ground reality indicates the necessity of involving the public-private partnership in any national child survival program, including IMCI. Administration of oxygen to only 2 children with obvious cyanosis highlights the resource-constrained environment, where even minimal essential guidelines for administrating oxygen therapy in developing countries cannot be met.[20] Problems of accessibility and fragmented health service delivery, with some parents of affected children traveling a distance of 25 km or more by bus (10% approximately) or 5 km or more on foot (3%) to reach the present study hospital, are other major barriers to the successful implementation of IMCI strategy. About 39% of children with severe pneumonia reported to the civil hospital directly without receiving prior treatment. This widely prevalent practice of self-referral to higher levels of health care system points to either lack of faith on health care personnel in dispensary or subcenter, or their inaccessibility at the time of need. These issues warrant a serious advocacy for improving the health system support as envisaged in 2nd component of IMCI guidelines.
The third component focuses on a set of family practices that encourage the development and implementation of community-and household-based interventions that are important for child health. In this regard, the issue of accompanier also needs an insight particularly for various program managers involved in planning for care of sick children. Brunt of care of ALRTI in children was mainly borne out by already overburdened mothers (46% of children were accompanied to the hospital by mothers alone as compared to fathers who accompanied only 6% of children alone). A study by Lye et al had shown lack of concurrence between mother's perception of severity of respiratory illness and that of clinicians.[13] It is, therefore, deemed imperative that educational and training strategies be targeted specifically to the mothers in rural areas so that their ability to decipher the sickness of their children is enhanced further.
Conclusion
To conclude, despite disturbing epidemiological trend of mortality in childhood pneumonia in developing countries, recent evidence on Integrated Management of Childhood Illness (IMCI) strategy points to its effectiveness in managing childhood pneumonia. Therefore, efforts to expand the evidence base for such a policy must continue in parallel with its implementation, with necessary adaptation on the basis of local epidemiology, health system characteristics, and social and cultural influences. In this context, this study lays emphasis on improving family and community practices, and health care systems as well as case management skills of health workers. Finally, by highlighting the clinical and nonclinical correlates of severe childhood pneumonia that influence and affect the development or management of respiratory illness, the present study offers practical insights that can be useful for the process and outcome of IMCI implementation in resource-limited settings.
References
1. Programme for the control of acute respiratory infections. Acute respiratory infections in children: case management in small hospitals in developing countries. Geneva; World Health Organization; 1991.
2. Sazawal S, Black RE. Pneumonia Case Management Trials Group. Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. Lancet Inf Dis 2003; 3 : 547-556.
3. Bang AT, Bang RA, Tale O et al . Reduction in pneumonia mortality and total childhood mortality by means of community-based intervention trial in Gadchiroli, India. Lancet 1990; 336 : 201-206.
4. Cherian T. The lingering problem of acute respiratory infections. Natl Med J India 2003; 16(suppl 2): 11-14.
5. Kumar S. Much health care in rural India comes from unqualified practitioners (news). BMJ 2004; 328 : 975 .
6. Nagaraj A, Nagaraj VK, Lobo J. Perception of severity of acute respiratory tract infections and diarrhea in children under the age of five in rural India: utilization pattern of health services. Trop Doct 2004; 34: 222-223.
7. Khan TA, Madni SA, Zaidi AKM. Acute respiratory infections in Pakistan: have we made any progress J Coll Physicians Surg Pak 2004; 14: 440-448.
8. Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated the Sick Child. Bull World Health Organ 1997; 75 (Suppl 1): 7-24.
9. Tulloch J. Integrated approach to child health in developing countries. Lancet 1999; 354 (suppl 2): S II 16-20.
10. Bhatia V. Normal growth. In Desai MP, Bhatia V, Menon PSN, eds. Pediatric Endocrine disorders . Orient Longman Limited, 2001; 43-52.
11. World Health Organization Pneumonia Vaccine Trial Investigators' Group. Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. Geneva: World Health Organization, 2001.
12. I0 nternational Institute for population sciences (IIPS) and ORC Macro. 2002. National Family Health Survey (NFHS-2), India, 1998-99: Himachal Pradesh. Chapter 9, 193-204, Mumbai; IIPS.
13. Lye MS, Deavi U, Lai KPF, Kaur H, Nair RC, Choo KE. Acute respiratory infection in Malaysian Children. J Trop Paediatr 1994; 40 : 334-340.
14. Lakhanpaul M, Atkinson M, Stephenson T. Community acquired pneumonia in children: a clinical update. Arch Dis Child-Education and Practice Edition 2004; 89: ep 29-34.
15. Cherian T. Acute respiratory infections in developing countries: current status and future directions. Ind Pediatr 1997; 34: 877-884.
16. Adegbola RA, Obaro SK. Diagnosis of childhood pneumonia in tropics. Ann Trop Med Parasitol 2000; 94: 197-207.
17. Hadi A. Management of acute respiratory infections by community health volunteers: experience of Bangladesh Rural Advancement Committee (BRAC). Bull World Health Organ 2003; 81: 183-189.
18. Bryce J, Victora CG, Habicht JP, Vaughan P, Black RE. The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions. Am J Pub Health 2004; 94 : 406-415.
19. Banajeh SM, al-Sunbali NN, al-Sanahani SH. Clinical characteristics and outcome of children aged 5 years hospitalized with severe pneumonia in Yemen. Ann Trop Paediatr 1997; 17 : 321-326.
20. Qazi S. Oxygen therapy for acute respiratory infections in young children. Ind Pediatr 2002; 39 : 909-913.(Bharti Bhavneet, Bharti S)
Abstract
Objective: This study aims to profile children with severe pneumonia in the perspective of Integrated Management of Childhood Illness (IMCI) strategy in a resource-constrained environment. Methods: 115 consecutive children, aged 2 months to 10 yr, hospitalized with severe pneumonia were prospectively evaluated between May 1997 and June 1998 at a civil hospital in the northern hilly state of India. Results: All children had tachypnea and lower chest wall indrawing. Grunting was observed in 39.7%, inability to drink in 16.5%, and cyanosis in 1.7% cases. Radiological investigation was carried out only in 90 children that included abnormal chest radiographs (CXRs) in 76.6% cases. Feeding malpractices, vaccination inconsistencies, exposure hazards to smoking, micronutrient as well as macronutrient deficiencies, treatment from unqualified practitioners, inconsequential involvement of health care workers, predominant burden on mothers in the care of sick children, failure to recognize signs and symptoms of pneumonia by parents at home, lack of oxygen facilities, problems of accessibility and less faith on primary health care services were widely prevalent bottlenecks for effective implementation of 3 components of IMCI. Conclusion: Our study offers practical insights that can be useful in customizing IMCI to needs of children with pneumonia in a resource-constrained environment.
Keywords: Severe pneumonia; Integrated Management of Childhood Illness (IMCI); Chest radiograph
Childhood pneumonia clearly represents one of the most common infectious illnesses in developing countries and is of great importance as a cause of preventable mortality in children. To attack this global problem, the World Health Organization (WHO) shaped strategy for effective case management that had a remarkable impact on decreasing mortality due to childhood pneumonia in developing countries. [1],[2],[3] Tempering this success is the presence of treatment inconsistencies due to fragmented health service delivery in resource-limited settings. [4],[5],[6] Moreover in a continuum of health care, adverse impact of pneumonia is exponentially increased when it attacks a child lacking basic health care in a resource-constrained environment.[4],[7] In order to overcome constraints in the management of pneumonia particularly in rural areas, recent emphasis on Integrated Management of Childhood Illness (IMCI), therefore, is a step in right direction.[8],[9] As Indian adaptation of IMCI strategy undergoes large scale field trials in India, it behooves community clinicians and researchers, from a more comprehensive perspective, to consider not only the clinical profile and risk factors, but constraints within households and communities so as to overcome complicity with factors and practices that can reduce the operational effectiveness of pneumonia control program. In accordance with these perspectives, the present study focused on socio-demographic and community characteristics, basic health care practices as well as clinical features, course and management of children hospitalized with severe pneumonia.
Materials and Methods
Study Participants and Setting
All consecutive children, aged 2 months to 10 yr, hospitalized with severe pneumonia were prospectively evaluated in detail throughout their stay in hospital. The following were the reasons for exclusion: children having duration of illness >2 weeks or respiratory distress with predominant wheezing. Patients were recruited prospectively between May 1997 and June 1998 at a civil hospital (tehsil Rohru, district Shimla) serving a catchment area of approximately 100 villages in the northern hilly state (Himachal Pradesh) of India and caring for 200 to 300 patients per day (with pediatric patients constituting at least 1/3rd of daily outpatient department attendance). Rohru is approximately 4000 ft above sea level. Informed assent was taken from the parents or other caregivers before enrolment, and the study was granted local approval by Senior Medical Officer Incharge of hospital.
Diagnosis and Treatment
The diagnosis of pneumonia was based on either WHO criteria for children aged 5 yr or less or auscultatory/radiological signs of pneumonia in older children. According to World Health Organization (WHO) guidelines, a child with complaints of cough and/or fever was labeled as a case of severe pneumonia if both tachypnea and lower chest wall indrawing were present.[1]
Clinical evidence of rickets was recorded if at least two of the following criteria were found: widening of wrists, rachitic rosary, box-shaped head with frontal bossing, pectus deformity of chest and abnormally wide or open anterior fontanel. Nutritional status was expressed as z scores for weight for age and height for age using reference median values of healthy Indian children.[10]
Though all children hospitalized with pneumonia were originally planned to undergo radiographic examination within 24 hours of admission, only 78% (90/115) children had their chest radiographs (CXRs) done due to logistic problems. A single radiologist, who was blind to the clinical diagnosis, evaluated the radiographs according to the WHO classification.[11]
Data Collection
Information was collected in the form of a questionnaire that included child's age, sex, other socio-demographic parameters, prior treatment and its details, risk factors for acute lower respiratory tract infection (LRTI), immunization and feeding practices, anthropometric data and other systemic details. The two clinical researchers themselves meticulously recorded the history and physical findings, clinical course and resolution of symptoms and signs throughout the child's stay in hospital.
Statistical Analysis
Univariate analysis was carried out for analyzing the results of the present study. The study sample's socio-economic status (SES) was assessed by a composite measure constructed using a principal component analysis of 8 variables representing both parents' educational level, occupational status, and other social factors (domestic animals, number of living rooms, family size and vaccination status).
Results
Clinical Characteristics of Patients
The present study population consisted of 115 children- 67 boys and 48 girls. Majority of children affected were infants and toddlers (77.4%); infants up to 12 months alone were 46.1%. Only 9.6% of cases were above the age of 5 yr. Mean time to report in the present study was 5.8± 2.8 days with approximately th (i.e. 79.1%) reaching hospital within 7 days of onset of illness. Onset of respiratory illness (i.e. time between initial symptom and onset of tachypnea) was acute (< 48 hr) in only 20% patients and subacute (> 48 hr) in remaining 80% of cases. Cough was associated or preceded by upper respiratory symptoms in 70.4 % of cases. Symptoms of headache, sore throat and chest pain were reported by 6.1%, 1.7%, and 7% children respectively. The various presenting symptoms in the study cohort are itemized in table1.
Past Complaints
Previous health status of children enroled in the study was enquired. According to parental reports, 47% of children were ill for the first time, 29.6% had occasional sickness in the past whereas 23.5% used to fall frequently sick. Past history of contact with tuberculosis was observed in 11.3% of children. History of hospitalization in the last one year was obtained in 19.1% of patients for the following reasons: (1) pain in abdomen (6.1%), (2) pneumonia (7%), (3) seizure (0.9%), (4) trauma (0.9%), (5) fever (2.6%), and (6) indication not clear (0.9%). History of passage of worms in stool was given in 8.7%, pica in 18.3%, recent ear discharge in 11.3 %, which was active at the time of evaluation in 6.1% of patients.
Socio-demographic and Community Characteristics
Based on the principal component analysis, patients were categorized into three levels of SES: low, middle, and high. Thirty (26.1%) families belonged to low SES; 76 (66.1%) were from lower middle SES; and remaining 9 (7.8%) belonged to high SES group. Birth order of patients ranged from 1 to 6, with 75% of enroled patients ￡2 in birth order. Family set up was nuclear in 33.9% and joint in 66.1% cases. Source of drinking water was as follows: (1) community or household tap water (66.7%), (2) spring water (19.3%), (3) both (8.8%) and (4) other sources like hand pumps, well etc. in 5.3%. Domestic animals were owned by 29.6% of the families. Number of living rooms varied from 1 to 20 with a mode of 1. Kitchen was inside the living room in 40% of patients' houses. The mean distance covered by patients to reach the study site was 14.3± 8.9 km on bus (range; 0-65 km) and 0.79 ±1.5 km on foot (range; 0-10 km).
Accompanier
Enquiry about the attendants accompanying the affected child revealed that 52.2% of affected children were brought by single parent (mainly mother-46.2%), 40% by both parents, 4.3% by grandparents, and 3.5% by other relatives alone.
Smoking Patterns
Both parental and domestic smoking was present in 65.2%, domestic smoking alone in 25.2%, parental smoking alone in 5.2%, and none in 4.3% of cases. Nearly 90% of people used solid fuel for cooking ( e.g. wood, dung, coal) at their homes.
Vaccination Status
The vaccination status of the enroled children was as follows: completely vaccinated-with BCG scar 40% and without BCG scar 25.2%; incompletely vaccinated- 22.6%; and unvaccinated-12.2%. The various reasons given for not getting completely vaccinated included: (1) lack of time (13.9%), (2) not aware (12.2%), (3) not interested (5.2%), (4) staff absent (1.7%), (5) nonavailability of facility (0.9%), and (6) card misplaced (0.9%).
Feeding History
For better comprehension, feeding practices are described for infants under 12 months of age in the present study cohort (n=53). Only 2 (3.8%) infants were never breast-fed. Out of the remaining 51 infants, 20 (37.7%) were mainly breast-fed (with or without water), while top feeds were predominantly used in the rest. Latter group included use of bottle in 54.5% of children. Diluted top feeds were given in 90% of children. Weaning was initiated in the 6th month only in 32/42 (76.1%) of 6-12 month old affected infants.
Treatment Seeking Pattern
Prior treatment was received by 60.9 % of the study participants. It included oral drugs in 14.8%, injectables in 12.2 %, both oral and injectables in 2.6 %; and nature of drugs could not be ascertained in the remaining 31.3% of cases. Place of prior treatment included: registered medical practitioner (RMP) 18.3%, unqualified practitioners 16.5%, dispensary 13 %, primary health center (PHC) 4.3%, and civil hospital 2.6%; whereas 5.2% of patients were treated at home by parents. The mean duration of prior treatment was of 1.6 ± 1.8 days. Anthropometry, general physical findings and respiratory parameters are shown below in Figure1. Mean respiratory and heart rate in enroled patients were 64±14/min and 140±15/min respectively.
Radiological Characteristics
Out of 115 patients, radiological investigation was carried out only in 90 children due to logistic problems. Latter included normal chest radiographs in 18.8% (17/90); in 4.4% (4/90) CXRs were sub optimal; and in remaining 76.6% (69/90) CXRs were abnormal. Various radiological abnormalities, according to the WHO classification, were as follows: (1) end-point consolidation-56.5% (39/69); (2) other infiltrates (non end-point consolidation)-37.6% (26/69); (3) Pleural effusion-1.4%(1/69); and (4) non-significant infiltrates-4.3% (3/69)
Treatment
During their management, 23.5% (27) children received intravenous fluids because of severe respiratory distress (mainly inability to drink, drowsiness, or marked grunting) and/or dehydration. Parenteral antimicrobials (penicillin/ampicillin + chloramphenicol) were administered (at least for 48 hours or more) to 58.3% (67) patients. Severe shortage of oxygen limited its use to only those 2 infants who had obvious cyanosis. Children were also monitored for defervescence of their respiratory illness. The results revealing mean time taken for fever, cough, anorexia and tachypnea to decrease and become normal are shown in table2.
Discussion
The wide breadth of community-based epidemiological data strongly implicates important "extra pulmonary" factors primarily related to nutritional status, sociocultural variables and general healthcare practices involved in either delayed or inappropriate treatment of pneumonia. [12],[13] The uncertainty over pneumonia diagnosis and its management is further clouded by a substantial gap between recommended guidelines for diagnosis and treatment and actual clinical practice.[14], [15] Wide variations in WHO guidelines' use exist in resource- limited settings.[16],[17] Findings of the present study provide useful insights of all 3 components of IMCI that cannot be ignored when addressing the pertinent issue of lowering burden of illness due to pneumonia in children of developing countries.[18]
First component of training of field health workers assumes great importance in the backdrop of the present finding, that involvement of health care workers is of inconsequential benefit in remote areas, as prior treatment in the present study participants was never based on WHO guidelines and was ineffective. Feeding malpractices, vaccination inconsistencies, exposure hazards to smoking, micronutrient as well as macronutrient deficiencies are widely prevalent, therefore making them prone to acute infective illnesses including pneumonia. Suboptimal vaccination coverage in the present study demonstrates the inadequacy of healthcare workers in meeting the basic health needs of children that is deemed necessary to lower their susceptibility to respiratory tract infections. The results of this study have also broken the myth that breast-feeding is universal in rural areas. At least half of the studied children with acute LRTI were not given breast feeds, and use of top feeds with bottle was unexpectedly high in the present study. Therefore IMCI guidelines' emphasis to provide nutritional counseling needs to be considered with earnest. Also, it is imperative to improve the skills of health workers in managing micronutrient deficiencies, particularly iron (anemia 82.6%), vitamin D/calcium (rickets 36.5%), and vitamin A (2.7% in the present study participants) that can further aggravate the vulnerability of rural children to various respiratory pathogens, modify response to antimicrobial agents, and influence outcome from illness. [19] Study of pattern of resolution of symptoms and signs of pneumonia as in the present study will further provide useful insights for training health workers to decide improvement in attacks of severe pneumonia.
A second component of IMCI aims to improve health system support for child health service delivery. Implicit here is the concern that mean time taken to report to hospital in the present study was 5.8 days, suggesting that parents do not recognize the signs and symptoms of disease earlier that puts additional constraint on the effectiveness of ongoing management strategy. So there is an urgent need for health education to enable parents to recognize respiratory disease and seek an appropriate care. Moreover, local private and unqualified practitioners also need to be active participants in the program. Studies of health facility utilization patterns have shown that self-employed general practitioners working in the community see and treat the largest proportion of ARI patients. [4],[5],[6] This ground reality indicates the necessity of involving the public-private partnership in any national child survival program, including IMCI. Administration of oxygen to only 2 children with obvious cyanosis highlights the resource-constrained environment, where even minimal essential guidelines for administrating oxygen therapy in developing countries cannot be met.[20] Problems of accessibility and fragmented health service delivery, with some parents of affected children traveling a distance of 25 km or more by bus (10% approximately) or 5 km or more on foot (3%) to reach the present study hospital, are other major barriers to the successful implementation of IMCI strategy. About 39% of children with severe pneumonia reported to the civil hospital directly without receiving prior treatment. This widely prevalent practice of self-referral to higher levels of health care system points to either lack of faith on health care personnel in dispensary or subcenter, or their inaccessibility at the time of need. These issues warrant a serious advocacy for improving the health system support as envisaged in 2nd component of IMCI guidelines.
The third component focuses on a set of family practices that encourage the development and implementation of community-and household-based interventions that are important for child health. In this regard, the issue of accompanier also needs an insight particularly for various program managers involved in planning for care of sick children. Brunt of care of ALRTI in children was mainly borne out by already overburdened mothers (46% of children were accompanied to the hospital by mothers alone as compared to fathers who accompanied only 6% of children alone). A study by Lye et al had shown lack of concurrence between mother's perception of severity of respiratory illness and that of clinicians.[13] It is, therefore, deemed imperative that educational and training strategies be targeted specifically to the mothers in rural areas so that their ability to decipher the sickness of their children is enhanced further.
Conclusion
To conclude, despite disturbing epidemiological trend of mortality in childhood pneumonia in developing countries, recent evidence on Integrated Management of Childhood Illness (IMCI) strategy points to its effectiveness in managing childhood pneumonia. Therefore, efforts to expand the evidence base for such a policy must continue in parallel with its implementation, with necessary adaptation on the basis of local epidemiology, health system characteristics, and social and cultural influences. In this context, this study lays emphasis on improving family and community practices, and health care systems as well as case management skills of health workers. Finally, by highlighting the clinical and nonclinical correlates of severe childhood pneumonia that influence and affect the development or management of respiratory illness, the present study offers practical insights that can be useful for the process and outcome of IMCI implementation in resource-limited settings.
References
1. Programme for the control of acute respiratory infections. Acute respiratory infections in children: case management in small hospitals in developing countries. Geneva; World Health Organization; 1991.
2. Sazawal S, Black RE. Pneumonia Case Management Trials Group. Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials. Lancet Inf Dis 2003; 3 : 547-556.
3. Bang AT, Bang RA, Tale O et al . Reduction in pneumonia mortality and total childhood mortality by means of community-based intervention trial in Gadchiroli, India. Lancet 1990; 336 : 201-206.
4. Cherian T. The lingering problem of acute respiratory infections. Natl Med J India 2003; 16(suppl 2): 11-14.
5. Kumar S. Much health care in rural India comes from unqualified practitioners (news). BMJ 2004; 328 : 975 .
6. Nagaraj A, Nagaraj VK, Lobo J. Perception of severity of acute respiratory tract infections and diarrhea in children under the age of five in rural India: utilization pattern of health services. Trop Doct 2004; 34: 222-223.
7. Khan TA, Madni SA, Zaidi AKM. Acute respiratory infections in Pakistan: have we made any progress J Coll Physicians Surg Pak 2004; 14: 440-448.
8. Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated the Sick Child. Bull World Health Organ 1997; 75 (Suppl 1): 7-24.
9. Tulloch J. Integrated approach to child health in developing countries. Lancet 1999; 354 (suppl 2): S II 16-20.
10. Bhatia V. Normal growth. In Desai MP, Bhatia V, Menon PSN, eds. Pediatric Endocrine disorders . Orient Longman Limited, 2001; 43-52.
11. World Health Organization Pneumonia Vaccine Trial Investigators' Group. Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. Geneva: World Health Organization, 2001.
12. I0 nternational Institute for population sciences (IIPS) and ORC Macro. 2002. National Family Health Survey (NFHS-2), India, 1998-99: Himachal Pradesh. Chapter 9, 193-204, Mumbai; IIPS.
13. Lye MS, Deavi U, Lai KPF, Kaur H, Nair RC, Choo KE. Acute respiratory infection in Malaysian Children. J Trop Paediatr 1994; 40 : 334-340.
14. Lakhanpaul M, Atkinson M, Stephenson T. Community acquired pneumonia in children: a clinical update. Arch Dis Child-Education and Practice Edition 2004; 89: ep 29-34.
15. Cherian T. Acute respiratory infections in developing countries: current status and future directions. Ind Pediatr 1997; 34: 877-884.
16. Adegbola RA, Obaro SK. Diagnosis of childhood pneumonia in tropics. Ann Trop Med Parasitol 2000; 94: 197-207.
17. Hadi A. Management of acute respiratory infections by community health volunteers: experience of Bangladesh Rural Advancement Committee (BRAC). Bull World Health Organ 2003; 81: 183-189.
18. Bryce J, Victora CG, Habicht JP, Vaughan P, Black RE. The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions. Am J Pub Health 2004; 94 : 406-415.
19. Banajeh SM, al-Sunbali NN, al-Sanahani SH. Clinical characteristics and outcome of children aged 5 years hospitalized with severe pneumonia in Yemen. Ann Trop Paediatr 1997; 17 : 321-326.
20. Qazi S. Oxygen therapy for acute respiratory infections in young children. Ind Pediatr 2002; 39 : 909-913.(Bharti Bhavneet, Bharti S)