Pakistan acts to reduce child deaths from pneumonia
In Pakistan, the government has introduced WHO's
guidelines for acute respiratory infections (ARI) nationwide after
training doctors and community health workers to use the technique.
In Islamabad, use of these guidelines to improve the diagnosis and
treatment of ARI among hospital outpatients under the age of five
has halved pneumonia death rates among children admitted to hospital,
reduced the inappropriate use of antibiotics, and led to major savings
in health care costs.
Acute respiratory infections (ARI) kill more children
under five than any other infectious disease -- accounting for almost
2 million deaths a year among this age group. Most of these deaths
(99%) occur in developing countries. ARI -- mainly pneumonia -- are
also a major cause of childhood illness.
Among those most vulnerable to infection are children
with low birthweight or those whose immune systems have been weakened
by malnutrition or other diseases. Without early treatment for ARI,
children can die very rapidly. Many deaths are the result of failure
to take the child to a health centre in time or of misdiagnosis by
a health care worker. The problems are compounded by the indiscriminate
use of antibiotics and increasing microbial resistance. In Pakistan,
efforts to improve the diagnosis and treatment of ARI in children
under five and prevent the misuse of antibiotics have led to a major
reduction in child death rates at a children's hospital in the capital
Islamabad. The breakthrough followed the launch in 1990 of new treatment
guidelines for ARI at the hospital. Within three years, ARI death
rates among children under five had been halved and efforts to increase
rational drug use led to a reduction of almost 50% in the inappropriate
use of antibiotics as well as major reductions in health care costs.
The treatment guidelines -- WHO's standardized case management
guidelines for ARI -- were introduced in the outpatients and emergency
departments at the children's hospital in early 1990 after doctors
had been trained in the new technique. Children found to be suffering
from severe pneumonia were admitted to the hospital and given antibiotics
and other treatment if required. Children with non-severe pneumonia
were given oral antibiotics and sent home. Children with upper respiratory
infections -- mainly coughs and colds -- were sent home with oral medication,
and advice on home care (including the use of fluids, feeding, clearing
the nose, and soothing the throat).
The ARI guidelines -- a key component of WHO's Integrated
Management of Childhood Illness (IMCI) -- are designed to help the
health worker identify the signs of pneumonia: fast breathing, chest
indrawing, and other danger signs. The aim is to ensure that children
with pneumonia (and other appropriate conditions) receive urgent treatment
with antibiotics and that children with upper respiratory infections
(mainly coughs and colds) are not prescribed unnecessary antibiotics.
The use of commercial cough remedies containing ineffective or harmful
ingredients is also discouraged.
A study on the impact of the new treatment guidelines
at the Islamabad Children's Hospital from 1990-92 revealed that death
rates among children admitted to hospital with severe pneumonia fell
from about 10% in 1989 to about 5% in 1992. Meanwhile the rational
use of drugs, a key strategy in preventing the overuse of antibiotics
and curbing microbial resistance, led to a major reduction in the
use of antibiotics (from 56% of cases in 1989 to only 30% in 1992).
The study found that eight out of ten ARI cases were
acute upper respiratory infections -- mainly coughs and colds. The
majority of these were viral infections which did not need antibiotics.
Only a small proportion, including inner ear infections, were bacterial
infections that needed treatment with antibiotics.
If appropriate ARI case management guidelines were adopted
throughout Pakistan, it is estimated that there would be a major reduction
in pneumonia deaths among children under five as well as considerable
financial savings through minimizing the use of antibiotics and other
unnecessary drugs. The researchers involved in the study estimated
that government savings on antibiotics would amount to US$ 1.2 million
a year, while a reduction in the indiscriminate use of cough medicines
would save an additional US$ 8.5 million a year.
The Pakistan Government has introduced the standard
ARI management guidelines in first-level health facilities after training
doctors in the technique. In addition, 34 000 community health workers
in villages throughout Pakistan have been trained to use the guidelines
at community level.
The Islamabad study shows how effective use of the ARI
treatment guidelines can have a rapid impact in reducing pneumonia
deaths among children. The challenge now for the Pakistan Government
is to ensure that these guidelines are used in health facilities country-wide
and to monitor the impact.