By Laura Costica, Research Associate – ICTPH
Disease prevalence rates were the first elements ICTPH looked at when it began thinking about designing health interventions to improve the lives of individuals in the communities it serves. What immediately became apparent was the high prevalence of respiratory infections, which affected about 70% of patients visiting our clinic in Alakkudi. On this basis, we started looking into ways to reduce incidence. However, further research revealed that ‘respiratory infections’ constituted a disease category with several sub-categories of illness, some of which accounted for a higher disease burden than others, as measured by DALYs (disability adjusted life years) lost or deaths caused. Upper respiratory tract infections, having a very small burden of disease, were therefore ruled out as possible targets of an intervention. Lower respiratory tract infections, on the other hand, result in a large share of child mortality: data from the World Health Organisation ranks them second among the top 10 death causes for the 0-14 age group, with 14% of deaths caused and 12% of DALYs lost (data for 2004); a recent study published in the Lancet series estimates the burden of pneumonia alone to be even higher, accounting for 20% of all deaths in children under five in 2008; a similar result emerged from The Million Deaths study: 17.5% of deaths in children under 4 are caused by pneumonia in states other than EAG states and Assam (that is, in the relatively more advanced states of India).
In the face of such compelling evidence, our attention is now focused on tackling pneumonia in children under five. Evidence shows that these deaths could be largely averted through early detection and appropriate treatment with antibiotics. Recognising the importance of developing easily accessible treatment options, the WHO and UNICEF invested considerable efforts in creating guidelines for the management of pneumonia in community settings. These provide the basis for programmes in which community health workers identify the symptoms of the disease after having been appropriately trained. The effectiveness of this case-management approach has been thoroughly examined and results have been encouraging: one systematic review found a 42% reduction in neonatal pneumonia mortality and a 36% reduction in child pneumonia mortality. These conclusions, corroborated with a record of success in scale up make this approach worth further consideration.
How does community-based management of pneumonia work? The WHO/UNICEF guidelines help CHWs diagnose pneumonia by counting the sick child’s breathing rate; this is then compared to the cut-off point and, if found positive, antibiotics are immediately prescribed. What is more, if lower chest wall indrawing is observed (manifested as an inwards movement or retracting of chest during inhalation), then the case is classified as severe pneumonia and urgently referred to hospital for injectable antibiotics.
There is a variety of intervention models out there, with the main difference stemming from the roles assigned to the health worker. These range from detection, disbursal of antibiotics and follow-up, to detection, disbursal and referral to a health provider. With several options on its plate, ICTPH is currently looking at the best way to implement a community-based management of pneumonia in its field site in Thanjavur.