ARI guidelines in Pakistan reduce child pneumonia deaths in hospital by 50%

 

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.