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2016 Nov; New York, New York, UNICEF, 2016 Nov. 77 p.Pneumonia and diarrhoea are responsible for the unnecessary loss of 1.4 million children each year. This report highlights current pneumonia and diarrhoea related mortality, and illustrates the startling divide between the children being reached and the considerable number of those left behind. By developing key protective, preventative and treatment interventions, collectively we are now equipped with the knowledge and the tools required to preventing child deaths due to these leading childhood killers. The report also provides recommendations to further accelerate progress in effective interventions and bridge the greatest gaps in equity.
Time for new recommendations on cotrimoxazole prophylaxis for HIV-exposed infants in developing countries?
Bulletin of the World Health Organization. 2010 Dec 1; 88(12):949-50.Add to my documents.
Releve Epidemiologique Hebdomadaire. 2013 Apr 26; 88(17):173-80.Add to my documents.
Evidence behind the WHO guidelines: hospital care for children: what is the aetiology of pneumonia in HIV-infected children in developing countries?
Journal of Tropical Pediatrics. 2009 Aug; 55(4):219-24.This clinical review discusses the most common cause of pneumonia in HIV-infected children--bacterial pathogens and includes recommendations for the management of pneumonia in HIV-infected children from World Health Organization (WHO).
Lancet Infectious Diseases. 2008 Jan; 8(1):13.According to new data, the global number of measles deaths fell by 68% from 757 000 to 242 000 between 2000 and 2006. This decrease was a result of a spectacular 91% reduction in Africa, where countries rallied behind concerted immunisation campaigns to achieve a rare success story for a continent blighted by public-health failures. In Africa, deaths were cut from 396 000 to 36 000 by implementing the measles reduction strategy, which includes vaccinating all children before their first birthday and providing a second opportunity for measles vaccination through mass vaccination campaigns. "The clear message from this achievement is that the strategy works", said Julie Gerberding, director of the US Centers for Disease Control and Prevention, which was one of the founding partners of the Measles Initiative, together with WHO, UNICEF, the American Red Cross, and the United Nations Foundation. She said the focus would now move to India, where an estimated 10.5 million children are not immunised. Some178 000 people died of measles in south Asia last year - mostly in India and Pakistan - only 26% down from 2000. (excerpt)
Ambulatory short-course high-dose oral amoxicillin for treatment of severe pneumonia in children: A randomised equivalency trial.
Lancet. 2008 Jan 5; 371(9606):49-56.WHO case management guidelines for severe pneumonia involve referral to hospital for treatment with parenteral antibiotics. If equally as effective as parenteral treatment, home-based oral antibiotic treatment could reduce referral, admission, and treatment costs. Our aim was to determine whether home treatment with high-dose oral amoxicillin and inpatient treatment with parenteral ampicillin were equivalent for the treatment of severe pneumonia in children. This randomised, open-label equivalency trial was done at seven study sites in Pakistan. 2037 children aged 3-59 months with severe pneumonia were randomly allocated to either initial hospitalisation and parenteral ampicillin (100 mg/kg per day in four doses) for 48 h, followed by 3 days of oral amoxicillin (80-90 mg/kg per day; n=1012) or to home-based treatment for 5 days with oral amoxicillin (80-90 mg/kg per day in two doses; n=1025). Follow-up assessments were done at 1, 3, 6, and 14 days after enrolment. The primary outcome was treatmentfailure (clinical deterioration) by day 6. Analyses were done per protocol and by intention to treat. This trial is registered, ISRCTN95821329. In the per-protocol population, 36 individuals were excluded from the hospitalised group and 37 from the ambulatory group, mainly because of protocol violations or loss to follow-up. There were 87 (8.6%) treatment failures in the hospitalised group and 77 (7.5%) in the ambulatory group (risk difference 1.1%; 95% CI -1.3 to 3.5) by day 6. Five (0.2%) children died within 14 days of enrolment, one in the ambulatory group and four in the hospitalised group. In each case, treatment failure was declared before death and the antibiotic had been changed. None of the deaths were considered to be associated with treatment allocation; there were no serious adverse events reported in the trial. Home treatment with high-dose oral amoxicillin is equivalent to currently recommended hospitalisation and parenteral ampicillin for treatment of severe pneumonia without underlying complications, suggesting that WHO recommendations for treatment of severe pneumonia need to be revised. (author's)
Epidemiology and clinical features of pneumonia according to radiographic findings in Gambian children.
Tropical Medicine and International Health. 2007 Nov; 12(11):1377-1385.The objective was to assess the effect of vaccines against pneumonia in Gambian children. Data from a randomized, controlled trial of a 9-valent pneumococcal conjugate vaccine (PCV) were used. Radiographic findings, interpreted using WHO definitions, were classified as primary end point pneumonia, 'other infiltrates / abnormalities' pneumonia and pneumonia with no abnormality. We calculated the incidence of the different types of radiological pneumonia, and compared clinical and laboratory features between these groups. Among children who did not receive PCV, the incidence of pneumonia with no radiographic abnormality was about twice that of 'other infiltrates' pneumonia and three times that of primary endpoint pneumonia. Most respiratory symptoms, reduced feeding and vomiting occurred most frequently in children with primary endpoint pneumonia. These children were more likely to be malnourished, to have bronchial breath sounds or invasive bacterial diseases, and to die within 28 days of consultation than children in the other groups. Conversely, a history of convulsion, diarrhoea or fast breathing, malaria parasitaemia and isolation of salmonellae were commoner in children with pneumonia with no radiographic abnormality. Lower chest wall indrawing and rhonchi on auscultation were seen most frequently in children with 'other infiltrates / abnormalities' pneumonia. Primary endpoint pneumonia is strongly associated with bacterial aetiology and severe pneumonia. Since this category of pneumonia is significantly reduced after vaccination with Hib and pneumococcal vaccines, the risk-benefit of antimicrobial prescription for clinical pneumonia for children with increased respiratory rate may warrant re-examination once these vaccines are in widespread use. (author's)
Introduction of Hib vaccine into national immunization programmes: A descriptive analysis of global trends.
Vaccine. 2007 Oct 10; 25(41):7075-7080.Despite the demonstration of effectiveness and public health impact of Hib conjugate vaccines, the majority of infants from poorest countries do not yet have access to this safe and effective preventive intervention. This paper provides a descriptive analysis of the main characteristics of countries that have included Hib vaccine in their national immunization programmes before 2006. It highlights the importance of regularly analyzing the process of decision-making involved in implementation of public health interventions, in order to learn from cumulative experience and expedite the introduction of future interventions. (author's)
American Journal of Tropical Medicine and Hygiene. 2007 Nov; 77(5):793-794.The World Health Organization (WHO) estimates that Streptococcus pneumoniae is responsible for up to one million deaths annually among children less than five years of age. Pneumococcus is a leading cause of bacterial pneumonia, meningitis, and sepsis. However, due to diagnostic challenges, the burden of pneumococcal disease is largely invisible. In this issue of the journal, Abdullah Brooks and others uncover the substantial disease burden affecting children living in an impoverished urban community in Dhaka, Bangladesh. This is the most rigorous study of the pneumococcal disease burden in an Asian setting. The overall incidence of invasive pneumococcal disease among children less than five 5 years of age was 447 episodes per 100,000 child years, which is comparable to incidence rates found among children coming to hospitals in rural African settings and more than five times higher than rates seen prior to widespread vaccination in the United States, a setting in which blood cultures are frequently performed on febrile children. Before this study, direct evidence for the high pneumococcal disease burden in Asia lagged behind that for Africa, despite the importance of pneumonia as a leading cause of childhood mortality in both regions. (excerpt)
Lancet. 2007 Aug 4; 370(9585):385.We welcome the publication by Lisa McNally and colleagues which provides vitally important information on the causes of pneumonia in a population of HIV-exposed children in sub-Saharan Africa. However, we believe that McNally and colleagues' conclusion that the WHO guidelines are inadequate for all children younger than 1 year, irrespective of HIV prevalence, is ill-founded. Several characteristics of the population in McNally and colleagues' study limit the generalisability of the findings. Unlike the circumstances at the study's referral centre in Durban, South Africa, WHO's pneumonia guidelines provide guidance on the management of acute respiratory infections in facilities with limited diagnostic capabilities. They are also meant to assist first-level workers in the identification of sick or very sick patients for referral and more intense management. Other factors that detract from the generalisability of the findings are the inclusion of a high proportion with very severe disease (71%) and clinical cyanosis (55%), late presentation of disease at enrolment (median 4-5 days), a very high rate of HIV infection or exposure (68% positive, 11% exposed), high previous use of antibiotics (39%), and young median age (4.8 months). Taken together, we believe that these characteristics of the study population identify a highly specialised group of children from whom conclusions about the microbial causes of pneumonia are limited. Furthermore, these data are not sufficient to conclude that (a) the same range of agents causes pneumonia in areas of low or moderate HIV prevalence, or that (b) the WHO recommendations for empirical treatment of pneumonia in infants should be changed at this time. (full text)
Lancet. 2007 Aug 4; 370(9585):385-386.Shamim Qazi and colleagues challenge our conclusion, arguing that our patient population was highly specialised and therefore not representative. We disagree. The HIV epidemic has critically stretched health-care resources in endemic areas, resulting in admission of only the sickest children. Although King Edward Hospital, where our study was done, is a referral centre, children were included in our study only if they fulfilled WHO criteria and were referred directly from primary care. South Africa has implemented the WHO Integrated Management of Childhood Illness guidelines. Children therefore receive a dose of parenteral antimicrobials before referral for secondary-level care, partly explaining why 39% of children in our study had urinary antimicrobial activity. We have compared the characteristics of our study children with those published for children enrolled in similar studies in areas with varying HIV prevalence (table). Graham and colleagues described children admitted to hospital with pneumonia in Blantyre, Malawi-an area of high HIV prevalence. The duration of symptoms, age of children enrolled, and previous antibiotic use were similar to those in our study. Although data are limited, the characteristics of children in our study are also broadly similar to those reported in other paediatric pneumonia studies from medium-prevalence and high-prevalence HIV-endemic areas. Shamim Qazi and Donald Thea have themselves called for a change in first-line WHO therapy in areas of high HIV prevalence, with which we agree. We too recognise the need for studies like ours to be done in areas with moderate or low HIV prevalence. In the meantime, reappraisal of empirical antimicrobial therapy in highly HIV-infected communities is urgently needed. (full text)
Lancet. 2007 Aug; 370(9585):386-387.The important study by Lisa McNally and colleagues challenges the validity of the WHO recommendations for empirical antibiotic treatment of HIV-infected children with pneumonia. It is, however, important to recognise the limited options for improving these recommendations, given the complexity of the causes of pneumonia among children for whom treatment fails. In particular, changes of antibiotic regimen alone would be unlikely to improve treatment failure in children infected with respiratory viruses (33%). Some of the pneumonias caused by both pneumococci and respiratory viruses might, however, be preventable by vaccination with pneumococcal conjugate vaccines. Additionally, the identification of Pneumocystis jirovecii as the most significant pathogen in infants with treatment failure, despite empirical treatment as recommended by WHO, confirms the limited success of treating HIV-infected children with severe P jirovecii pneumonia. The higher prevalence (15%) of Mycobacterium tuberculosis in this study than in three other studies (8% each), might be related to a greater sensitivity of methods used for sample collection and an increasing burden of tuberculosis. Nevertheless, the observation that M tuberculosis was identified in 21.8% of children with treatment failure perhaps merits most attention. Of particular noteworthiness is that all the studies focused on children with an acute illness, challenging the numerous clinical algorithms used for making a clinical diagnosis of pulmonary tuberculosis and the notion that this disorder rarely presents acutely. The management of childhood pulmonary tuberculosis deserves greater priority and is the one issue that can and should be addressed more urgently. We believe tuberculosis should be included in both diagnostic and therapeutic algorithms for acute childhood pneumonia in areas with high HIV and tuberculosis prevalence. (full text)
Potential interventions for the prevention of childhood pneumonia in developing countries: improving nutrition.
American Journal of Clinical Nutrition. 1999 Sep; 70(3):309-320.Acute respiratory infections are the leading cause of childhood death in developing countries. Current efforts at mortality control focus on case management and immunization, but other preventive strategies may have a broader and more sustainable effect. This review, commissioned by the World Health Organization, examines the relations between pneumonia and nutritional factors and estimates the potential effect of nutritional interventions. Low birth weight, malnutrition (as assessed through anthropometry), and lack of breast-feeding appear to be important risk factors for childhood pneumonia, and nutritional interventions may have a sizeable effect in reducing deaths from pneumonia. For all regions except Latin America, interventions to prevent malnutrition and low birth weight look more promising than does breast-feeding promotion. In Latin America, breast-feeding promotion would have an effect similar to that of improving birth weights, whereas interventions to prevent malnutrition are likely to have less of an effect. These findings emphasize the need for tailoring interventions to specific national and even local conditions. (author's)
Geneva, Switzerland, WHO, Department of Child and Adolescent Health and Development, 2005 Jan 10.  p.Acute Respiratory Infections (ARIs) are a major cause of mortality and morbidity in emergencies. About 20% of all deaths in children under 5 years are due to Acute Lower Respiratory Infections (ALRIs - pneumonia, bronchiolitis and bronchitis); 90% of these deaths are due to pneumonia. Early recognition and prompt treatment of pneumonia is life saving. Causative organisms may be bacterial (most commonly Streptococcus pneumoniae and Haemophilus influenzae) or viral. However, it is not possible to differentiate between bacterial and viral ARIs based on clinical signs or radiology. Low birth weight, malnourished and non-breastfed children and those living in overcrowded conditions are at higher risk of getting pneumonia. These children are also at a higher risk of death from pneumonia. (excerpt)
Technical updates of the guidelines on Integrated Management of Childhood Illness (IMCI): evidence and recommendations for further adaptations.
Geneva, Switzerland, WHO, 2005.  p.It is over seven years since IMCI has been introduced and much has been learnt through the adaptation and implementation processes in countries. The Department of Child and Adolescent Health and Development (CAH) and other institutions have undertaken work to evaluate the evidence base for the technical guidelines of the IMCI strategy. Research results are emerging with potential implications for updating the technical guidelines of IMCI. In 2001 CAH, jointly with Roll Back Malaria, organized a technical consultation to examine the evidence base for the IMCI strategy for the management of malaria and other febrile illnesses including measles and dengue haemorrhagic disease. This international consultation came up with recommendations to improve the guidelines, as well as specific recommendations for operational research. Following the technical consultation, CAH held a series of meetings within the Department at HQ in addition to consultations with regional office staff where the updating process was discussed. In 2004 it was recommended that CAH finalize the IMCI updates on the basis of the best available evidence and country programme feedback, prioritizing those updates most likely to reduce child mortality. (excerpt)
Antibiotic treatment of community acquired pneumonia in well-nourished young Nigerian children [letter]
Journal of Tropical Pediatrics. 2005 Oct; 51(5):319-320.Worldwide, Streptococcus pneumoniae and Haemophilus influenzae are reported to be responsible for about 57 per cent of community-acquired pneumonia in children, whereas, Staphylococcus aureus contributes only 14 per cent. Based on this, the WHO has recommended the use of crystalline penicillin and amoxycillin given sequentially for the treatment of severe community-acquired pneumonia. However, this appears not to have been fully accepted in Nigeria, presumably because most aetiological studies of pneumonia in the country have indicated that S. aureus and Klebsiella spp. predominate. However, those in whom S. aureus and Klebsiella spp were isolated were not all cases of community-acquired pneumonia; while a substantial number were malnourished. Therefore, we carried out a retrospective study of the use of the sequentially administered intravenous (i.v.) crystalline penicillin and oral amoxycillin, or i.v. flucloxacillin given simultaneously with intramuscular (i.m.) gentamicin, in the treatment of severe community-acquired pneumonia in well-nourished under-five-year olds in a hospital setting. (excerpt)
Additional markers to refine the World Health Organization algorithm for diagnosis of pneumonia. [Marcadores adicionales para mejorar el algoritmo de diagnóstico de neumonía de la Organización Mundial de la Salud]
Indian Pediatrics. 2005 Aug 17; 42(8):773-781.WHO guidelines for primary care of children with tachypnea indicate that all should receive antibiotics for presumed pneumonia. These guidelines have led to excessive antibiotic use. The objective was to examine the value of history of previous respiratory distress, chest indrawing and fever, and response to bronchodilator(BD) to refine these guidelines. Design: Prospective study. Setting: Urban tertiary care hospital. Subjects: Children, between the ages of 6 and 59 months, presenting with cough and tachypnea. Methods: 182 children were enrolled. Each child had a chest X-ray that was read by two blinded, independent radiologists. Discordance between the two radiologists led to excluding 17 patients. The remaining 165 children were examined for fever and/or chest indrawing, and if they had a history of previous respiratory distress, challenge with a BD. The association of persistent tachypnea after BD and presence of pulmonary infiltrates was recorded. The median age was 22 months (mean 25.1 ± 14.5mo) and 75.8% were aged = 1 year. There were 58.8% males. Previous respiratory distress occurred in 65.0% and 79.2% of children aged < 1 year and = 1 year, respectively. Pneumonia was radiologically diagnosed in 26/165 (15.8%). 2/40 (5%) of children without a history of previous respiratory distress had pneumonia diagnosed. Of 125 children with history of previous respiratory distress, pneumonia was identified in 24 (19.2%). Persistence of tachypnea after BD was associated with pulmonary infiltrate in 14/24 (58.3%), whereas, tachypnea persisted in 32/101 (31.7%) children without pulmonary infiltrates (P = 0.02). The negative predictive value of resolution of tachypnea was 87.3% (95% CI 77.5-93.4). BD nonresponse was most useful in children without fever and/or with chest indrawing to indicate pneumonia as the cause of the tachypnea. This study indicates that by adding the simple procedures of a history of previous respiratory distress, recording of fever and chest indrawing, and observing the response to bronchodilators, pneumonia can be reliably identified in children presenting with tachypnea and cough. It is probable that this approach to management of children with cough and tachypnea could reduce unnecessary use of antibiotics. (author's)
Geneva, Switzerland, WHO, Department of Child and Adolescent Health and Development, 2002. 28 p. (WHO/FCH/CAH/02.23)Although the past 15 years have seen a decline in child mortality due to pneumonia, it remains a very important cause of death in developing countries. In Africa in particular, pneumonia and malaria are by far the most important causes of death for children under 5. The overall aim of this meeting was to help to define practical community approaches which could deliver a rapid reduction in this preventable mortality. WHO has developed and supported the use of case management of pneumonia through the ARI Programme and later as a part of IMCI. The main focus for these initiatives has been the health facility, although much of the demonstration of the efficacy of the clinical interventions was carried out at community level, using community health workers. IMCI uses the same clinical methodology. Although IMCI stresses the promotion of care-seeking by families with sick children, in general, the clinical management of such children is offered at the first level health facility. The importance of providing care without delay for children with malaria has led to the development and introduction, so far on a small scale, of interventions based in the community, either through a community health worker or directly by families, who are provided with packs of antimalarials. These two diseases in childhood, pneumonia and malaria, have major overlaps in terms of clinical presentation, the requirements for their effective management and the feasibility of providing standardised care in the community. Technically sound and operationally manageable community interventions that tackled both conditions would offer a most valuable tool for use in the reduction in child mortality in developing countries. (excerpt)
Technical bases for the WHO recommendations on the management of pneumonia in children at first-level health facilities.
Geneva, Switzerland, WHO, Programme for the Control of Acute Respiratory Infections, 1991.  p. (WHO/ARI/91.20)About 13 million children under 5 years of age die every year in the world, 95% of them in developing countries. Pneumonia is one of the leading causes, accounting for about 4 million of these deaths. Despite this fact, for a combination of technical and operational reasons, pneumonia has been a neglected problem until very recently. Clinicians and epidemiologists thought that the control of respiratory infections did not deserve high priority because of the difficulties involved in preventing and managing these infections; it was said that antibiotics might not be an effective treatment against pneumonia because patients are often weakened by conditions such as chronic malnutrition and parasitic infections, and that a wide variety of viruses and bacteria are associated with pulmonary infections making it impossible to identify the specific etiological agent in each patient (1.) On the other hand, some public health experts felt that a programme aimed at preventing mortality from pneumonia could not succeed because it would be difficult to deliver the available technology (antibiotics) through peripheral health units and community-based health workers. At most, one quarter of the pneumonia cases in children can be prevented by the measles and pertussis vaccines included in the immunization schedule of the Expanded Programme on Immunization. There is a clear need for research to develop and test vaccines against the most frequent agents of pneumonia in children. Such research has been pursued by WHO, notably within the Programe for the Control of Acute Respiratory Infections (ARI) and the Vaccine Development Programme; however, WHO has simultaneously been utilizing current clinical knowledge to formulate a case management strategy to reduce the high mortality from pneumonia in children. The present document is not intended to provide detailed case management guidelines. These are to be found in the manual "Acute respiratory infections in children: Case management in small hospitals in developing countries. A manual for doctors and other senior health workers", document WHO/ARI/90.5 (1990). (excerpt)
Geneva, Switzerland, WHO, Department of Child and Adolescent Health and Development, 2004.  p. (WHO/FCH/CAH/04.06; UNICEF/PD/Pneumonia/01)Pneumonia remains a major killer of children under five years of age. The best way to reduce pneumonia-related mortality is to provide effective treatment promptly. A meeting of experts, national and international agencies, a meta-analysis of trials, and a comprehensive review of community treatment programmes all came to the same conclusion: Pneumonia can be effectively treated in the community. UNICEF and WHO therefore recommend that community-level treatment be carried out by well-trained and supervised community health workers. (excerpt)
Acute respiratory infections in children: case management in small hospitals in developing countries. A manual for doctors and other senior health workers.
Geneva, Switzerland, WHO, Programme for the Control of Acute Respiratory Infections, 1990.  p. (WHO/ARI/90.5)Acute respiratory infections (ARI) are one of the commonest causes of death in children in developing countries. They are responsible for four of the estimated 15 million deaths that occur in children under 5 years of age each year; two-thirds of these deaths are in infants (especially young infants). Lung puncture studies in developing countries indicate that most cases of severe pneumonia in children are caused by bacteria, usually Streptococcus pneumoniae or Haemophilus influenzae. This contrasts with the situation in developed countries, where the great majority are due to viruses. (excerpt)
Standard case management of pneumonia in children in developing countries: the cornerstone of the acute respiratory infection programme.
Bulletin of the World Health Organization. 2003; 81(4):298-300.Widespread acceptance by public health professionals of the simple protocol designed in Papua New Guinea for identifying childhood pneumonia emerged in response to intervention studies conducted in Bangladesh, India, Indonesia, Nepal, Pakistan, the Philippines, and the United Republic of Tanzania. These studies confirmed that the protocol was applicable by properly trained health workers even in the poorest rural areas and that it produced an epidemiological impact despite differences in designs and methods. A significant effect on pneumonia-specific mortality was reflected in reduced overall childhood mortality. (excerpt)