Maternal, newborn, child and adolescent health

Home treatment for children with severe pneumonia just as effective as hospital

9 January 2008

A new study which shows that treating children with severe pneumonia at home is just as effective as treating them in hospitals could significantly change the way the illness is managed in developing countries, saving a significant number of lives every year and taking pressure off health systems.

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The study, conducted by researchers in Pakistan, supported by technical experts from Boston University School of Public Health and WHO with funding from USAID, was published in The Lancet medical journal on 5 January. It involved 2037 children with severe pneumonia who were randomly assigned to get either injectable antibiotics in a hospital or antibiotic pills at home. The trial was the first to compare the outcomes of hospital treatment of severe pneumonia with home-based treatment, and the results demonstrate the safety and efficacy of treating it with oral antibiotics outside of a hospital setting.

Pneumonia is the largest single killer of children under five years old around the world. Almost four children die from pneumonia every minute. About 60% of pneumonia cases in the developing world are caused by bacteria and can be treated with antibiotics, whereas most cases of pneumonia in developed countries are viral.

In the study, there were 87 (8.6%) treatment failures in the hospitalized group, and 77 (7.5%) in the group treated at home. Of the five children (0.2%) who died during the study, four were in the hospitalized group and one was at home.

This study confirmed the findings of three other trials at sites in Africa, Asia, Europe and Latin America, which showed that oral antibiotics were just as effective as injectable antibiotics in treating hospitalized children with severe pneumonia.

The current guidelines advise health workers to provide oral antibiotics for cases of non-severe pneumonia and to refer severe and very severe cases to hospitals for treatment with antibiotics by injection. However, many children with severe pneumonia who are currently referred for admission to a hospital either die before they reach there or are so sick by the time they arrive that nothing more can be done to save them.

"The potential impact of these results is enormous," said the article’s co-author Dr Shamim Qazi, Medical Officer with the WHO’s Department of Child and Adolescent Health and Development. "Effective management of pneumonia is critical to improving child survival. Being able to treat children with severe pneumonia safely and effectively in their own homes would be of huge benefit to both families and health systems, by reducing the need for admission to hospital. We will be updating WHO guidelines in 2008 to reflect this new evidence."

However, there is an important caveat that this treatment strategy for severe pneumonia will not be useful in high HIV prevalence settings, as noted by the authors of the Lancet article, based on another study supported by WHO and Boston University with funding from USAID.

Very severe pneumonia - the most advanced form of the disease - accounts for up to 2-3% of all pneumonia cases. Very severe pneumonia in children under five will still require treatment with injectable antibiotics in a hospital.

The case management strategy for very severe pneumonia, which includes treatment with injectable chloramphenicol followed by oral chloramphenicol, has successfully decreased child deaths as a result of pneumonia. However, until now there has been relatively little evidence about the efficacy of chloramphenicol as compared with other regimens for the treatment of severe pneumonia. WHO supported a study conducted in sites across seven developing countries to gather additional evidence in this area.

On 9 January 2008 the results of the study were published in the British Medical Journal (BMJ). They showed that treatment with injectable ampicillin plus gentamicin was more effective than chloramphenicol.

WHO’s guidelines for the case management of very severe pneumonia have been reviewed based on these findings and those of one previous study. The revised guidelines are now reflected in tools such as the Pocket Book of Hospital Care for Children.

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