National hospital surveillance of childhood pneumonia in Malawi
Authors: Harry Campbell, Harish Nair
Journal: The Lancet Global Health (2015)

Tim Colbourn and colleagues'1Lazzerini M Seward N Lufesi R et al.Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001–12: a retrospective observational study.Lancet Glob Health. 2015; 4: e57-e68Google Scholar study from Malawi is remarkable in scale. A dataset of 113 154 cases of severe pneumonia in young children, which led to 6903 hospital deaths over a period of more than 10 years, makes this a truly big-data study from Africa. The information system was set up by the International Union Against TB and Lung Disease and the Malawian Ministry of Health and was supported by funding from the Bill & Melinda Gates Foundation and the Scottish Government.2Enarson PM Gie R Enarson DA Mwansambo C Development and implementation of a national programme for the management of severe and very severe pneumonia in children in Malawi.PLoS Med. 2009; 6: e1000137Crossref PubMed Scopus (33) Google Scholar The study included most government and non-governmental organisation hospitals in Malawi and aimed to give a national picture of the effect of child pneumonia over time on hospital inpatient services. At a time when child pneumonia mortality has fallen substantially in almost all low-income and middle-income countries,3Liu L Johnson HL Cousens S et al.for the Child Health Epidemiology Reference Group of WHO and UNICEFGlobal, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000.Lancet. 2012; 379: 2151-2161Summary Full Text Full Text PDF PubMed Scopus (2715) Google Scholar any remaining national inequities, such as disadvantaged communities in which progress has lagged behind, must be identified. Much of our understanding of childhood pneumonia in these countries comes from a relatively limited number of hospitals and research centres. These centres often do not represent the highest mortality settings and the most disadvantaged communities. Routine data collection has to be scaled up to better understand child pneumonia in these settings. In addition to documenting the decrease in case-fatality rate with time (both in children who are HIV-positive and HIV-negative), Colbourn and colleagues point to a number of ongoing challenges: almost half of all deaths occurred within the first 24 h after hospital admission; and the case-fatality rate in children with very severe pneumonia is still very high. If these large-scale data were compared with published4Theodoratou E Zhang JS Kolcic I et al.Estimating pneumonia deaths of post-neonatal children in countries of low or no death certification in 2008.PLoS One. 2011; 6: e25095Crossref PubMed Scopus (12) Google Scholar, 5Rudan I O’Brien KL Nair H et al.for the Child Health Epidemiology Reference Group (CHERG)Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries.J Glob Health. 2013; 3: 10401Crossref Google Scholar, 6Theodoratou E McAllister DA Reed C et al.Global, regional, and national estimates of pneumonia burden in HIV-infected children in 2010: a meta-analysis and modelling study.Lancet Infect Dis. 2014; 14: 1250-1258Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 7Nair H Simoões EA Rudan I et al.Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis.Lancet. 2013; 381: 1380-1390Summary Full Text Full Text PDF PubMed Scopus (492) Google Scholar or population-based estimates by the Ministry of Health, further important questions could be addressed: (1) what percentage of all cases of severe pneumonia (by age group) were admitted to hospital, (2) what percentage of all child deaths (by age group) from pneumonia happened in hospital, and (3) what percentage of the decrease in child pneumonia mortality was due to the decrease in in-hospital pneumonia deaths? The collection of data to answer these questions would improve understanding of how these vary by national regions and so give important information from which to set priorities and plan for the future. As with all big-data projects, the large sample size gives weight to the main descriptive findings, but their detailed interpretation can be complex. In this example, the cause of the decrease in case-fatality rate is not completely clear. Although the authors make a good case for the change being due to improvements in the quality of health services, changes in comorbidities, such as the five-times reduction in associated severe malnutrition, a 67% decrease in the number of new HIV infections in children,8UNAIDS2014 Progress report on the Global Plan.http://www.unaids.org/sites/default/files/documents/JC2681_2014-Global-Plan-progress_en.pdfGoogle Scholar and changes in hospital admission practices probably account for much of the decrease in case-fatality rate. The investigators show that their main conclusion might be robust to missing data bias; nevertheless, the relatively high proportion of missing data, which is higher for girls than for boys, is a concern because children who are discharged and lost to follow-up have an increased risk of mortality in the subsequent few weeks.9Chhibber AV Hill PC Jafali J et al.Child mortality after discharge from a health facility following suspected pneumonia, meningitis or septicaemia in rural Gambia: a cohort study.PLoS One. 2015; 10: e0137095Crossref Scopus (18) Google Scholar Clearly, setting up parallel disease-specific information systems within hospitals is not the best vision for the future. Functional hospital information systems with electronic capture of data on selected major health problems at national scale should be an important part of the future for health services in Africa. However, for now, these findings show what can be achieved with a simple data collection system, providing important information about the child health services, not just in exemplar hospitals, but at a national scale. These data are globally important to help understand how child pneumonia mortality is changing over time. However, the primary audience for these data should not be the international community but the staff of the hospitals in which these data were collected and national and district health-management staff. National data at this scale are needed to ensure that the future design of health services incorporates a true understanding of health needs and the problems with health services, including those serving disadvantaged communities. This information, which should ideally capture associated deaths in the community after discharge from hospital,9Chhibber AV Hill PC Jafali J et al.Child mortality after discharge from a health facility following suspected pneumonia, meningitis or septicaemia in rural Gambia: a cohort study.PLoS One. 2015; 10: e0137095Crossref Scopus (18) Google Scholar should also be discussed in detail by local hospital multidisciplinary groups so that they can seek to understand the main causes of these deaths, identify common problems, take action to improve quality of care, and make services more responsive to local needs.10Bayley O Chapota H Kainja E et al.Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi.BMJ Open. 2015; 5: e007753Crossref Scopus (28) Google Scholar, 11Campbell H Duke T English M Carai S Tamburlini G Weber M Global initiatives for improving hospital care for children: state of the art and future prospects.Paediatrics. 2008; 121: e984-e992Crossref PubMed Scopus (85) Google Scholar That essential child interventions need to be delivered at scale with monitoring of their population coverage is universally agreed. Data on all children with pneumonia who are admitted to hospital should be captured so that we can track outcomes and strengthen efforts to improve the quality of care, echoing the call “everyone counts—so count everyone”.12Bradshaw D Chopra M et al.South Africa Every Death Counts Writing GroupEvery death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa.Lancet. 2008; 371: 1294-1304Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar Once available, these data can help empower local communities to hold health services accountable for the services they provide. Accountability should be an increasingly important driver of improvements in quality of care and reductions in health inequities in the future. HC declares travel grants from the Bill & Melinda Gates Foundation and WHO, outside the submitted work. HN declares travel grants and non-financial support from the Bill & Melinda Gates Foundation and WHO, outside the submitted work. Mortality and its risk factors in Malawian children admitted to hospital with clinical pneumonia, 2001–12: a retrospective observational studyPneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specific subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of sufficient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of effective national systems for data collection. Full-Text PDF Open Access