Ahead of World Pneumonia Day on Saturday 12 November, a study published Online First by the Lancet shows that, in Pakistan, use of Lady Health Workers (LHWs) to treat severe pneumonia with amoxicillin in the community reduces treatment delays and failures compared with standard care. The article is by Dr Salim Sadruddin, Save the Children, USA, and colleagues in Pakistan and worldwide.
The authors carried out their study in Haripur district, northern Pakistan. They randomly assigned 28 clusters to intervention or control groups. Children were included in the study if they were aged 2 months with WHO-defined severe pneumonia and living in the study area. In the intervention clusters, community-based LHWs provided mothers with oral amoxicillin, with specific guidance on its use and the dose given that was dependent on the child's age/weight. In control clusters, LHWs gave the first dose of oral co-trimoxazole (as is standard in the LHW programme in Pakistan), with dose again varying with age of the child, and they then referred the children to a health facility for standard care. The primary outcome was treatment failure by day 6.
The final analysis included 1857 children in intervention clusters and 1354 in control clusters. Cluster-adjusted treatment failure rates by day 6 were significantly reduced in the intervention clusters (165 [9%] intervention vs 241 [18%] control). Only two deaths were reported in the control clusters and one in the intervention cluster. Adverse events were rare and not serious in each group.
The authors say: "Although this study was designed and powered to detect equivalence, our findings show that the study intervention was better than the current practice."
They conclude: "The results of our study have shown that well trained and supervised community health workers can also manage WHO-defined severe pneumonia. Community case management could result in standardised treatment for severe pneumonia, reduce delay in treatment initiation, and reduce costs for families and health systems."
In a linked Comment, Professor Elizabeth M Molyneux, Queen Elizabeth Central Hospital, Blantyre, Malawi and Dr Stephen M Graham, Centre for International Child Health, University of Melbourne and Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, VIC, Australia, say: "Not all community health workers (CHWs) are supervised as well as the LHWs in Pakistan and the HIV infection rate in Haripur is very low, so the implications of this study for HIV-endemic settings with a higher rate of mortality and treatment failure, and where the current recommendations for severe pneumonia are broad-spectrum injectable antibiotics, need to be assessed with caution."
They conclude: "A reduction in the childhood mortality rate of 25% could be achieved by well trained and motivated CHWs. Sadruddin and colleagues have given an example of how effective CHWs can be. Further phase 4 studies to monitor the effect of large-scale deployment of CHWs in this way might be needed to show whether their results can translate into an important reduction in infant and child mortality rates."
For Dr Salim Sadruddin, Save the Children, USA, please contact Tanya Weinberg, Director, Media and Communications T) 1-202-640-6647 / 1-202-247-6610 E) Tweinberg@savechildren.org
Dr Elizabeth M Molyneux, Queen Elizabeth Central Hospital, Blantyre, Malawi. T) 265-88-88-44-517 E) emmolyneux@gmail.com
**Note: there is an embargoed telephone media briefing to discuss the findings of this paper, details below**
Journal
The Lancet