Early identification and treatment of pneumonia: a call to action
Authors: Karin Kallander, Deborah H Burgess, Shamim A Qazi
Journal: The Lancet Global Health (2015)

On the seventh World Pneumonia Day on Nov 12, 2015, we call for action to improve the early identification and treatment of childhood pneumonia at community and outpatient level to reduce deaths. Of the estimated 5·9 million deaths in children younger than 5 years in 2015, pneumonia was one of the leading killers, causing 16% of deaths.1UNICEFWHOCountdown to 2015: a decade of tracking progress for maternal, newborn and child survival—the 2015 report. WHO/UNICEF, Geneva/New York2015Google Scholar Most of these deaths are readily preventable or treatable with proven, cost-effective interventions.2WHOUNICEFEnding preventable child deaths from pneumonia and diarrhoea by 2025—the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). WHO/UNICEF, Geneva/New York2013Google Scholar Yet treatment is received by half of sick children, and only 54% with symptoms of pneumonia are taken outside the home for care.1UNICEFWHOCountdown to 2015: a decade of tracking progress for maternal, newborn and child survival—the 2015 report. WHO/UNICEF, Geneva/New York2015Google Scholar Therefore, action must be taken immediately to save children's lives by expanding services that allow early identification of symptoms and appropriate treatment. The case–fatality rate in untreated children with pneumonia is high, sometimes reaching 20%,3Pio A Leowski J ten Dam HG The magnitude of the problem of acute respiratory infections.in: Douglas RM Kerby-Eaton E Acute respiratory infections in childhood. University of Adelaide, Adelaide1985: 3-16Google Scholar and death can occur as early as 3 days after illness onset.4Reyes H Perez-Cuevas R Salmeron J Tome P Guiscafre H Gutierrez G Infant mortality due to acute respiratory infections: the influence of primary care processes.Health Policy Plan. 1997; 12: 214-223Crossref PubMed Scopus (71) Google Scholar Early identification of pneumonia and appropriate treatment saves lives. By initiating antibiotic therapy soon after onset of symptoms such as fast breathing in a child with cough, the progression of a pneumonia infection is blunted.5Ghimire M Pradhan YV Maskey MK Community-based interventions for diarrhoeal diseases and acute respiratory infections in Nepal.Bull World Health Organ. 2010; 88: 216-221Crossref PubMed Scopus (42) Google Scholar In the absence of early intervention, pneumonia progresses to a state where even intravenous antibiotics have limited impact, leading to the high hospital case–fatality rates for children.6Berkley JA Ross A Mwangi I et al.Prognostic indicators of early and late death in children admitted to district hospital in Kenya: cohort study.BMJ. 2003; 326: 361Crossref PubMed Google Scholar Of an estimated 15 million hospital admissions for severe and very severe pneumonia globally in 2010, 0·3 million died, approximately 19% in a hospital.7Nair H Simoes 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 (487) Google Scholar Delayed care-seeking behaviour or poor access to hospital care, or both, explained the high number of severe pneumonia cases observed in hospitals. Clinical trials show that children with fast-breathing pneumonia can be effectively treated with oral antibiotics.8Theodoratou E Al-Jilaihawi S Woodward F et al.The effect of case management on childhood pneumonia mortality in developing countries.Int J Epidemiol. 2010; 39: 155-171Crossref PubMed Scopus (115) Google Scholar As a result, many low-income and middle-income countries have now adopted policies for community case management of sick children in underserved communities, as recommended by WHO and UNICEF.9Young M Wolfheim C Marsh DR Hammamy D World Health Organization/United Nations Children's Fund joint statement on integrated community case management: an equity-focused strategy to improve access to essential treatment services for children.Am J Trop Med Hyg. 2012; 87: 6-10Crossref PubMed Scopus (146) Google Scholar Evidence shows that when children are treated in accordance with these standard case management guidelines at health facilities or by community health workers (CHWs), children are treated promptly,10Kalyango JN Alfven T Peterson S Mugenyi K Karamagi C Rutebemberwa E Integrated community case management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms in children under five years in Eastern Uganda.Malar J. 2013; 12: 340Crossref PubMed Scopus (50) Google Scholar antibiotics are used more appropriately,10Kalyango JN Alfven T Peterson S Mugenyi K Karamagi C Rutebemberwa E Integrated community case management of malaria and pneumonia increases prompt and appropriate treatment for pneumonia symptoms in children under five years in Eastern Uganda.Malar J. 2013; 12: 340Crossref PubMed Scopus (50) Google Scholar, 11Gouws E Bryce J Habicht JP et al.Improving antimicrobial use among health workers in first-level facilities: results from the multi-country evaluation of the Integrated Management of Childhood Illness strategy.Bull World Health Organ. 2004; 82: 509-515PubMed Google Scholar and mortality is reduced.8Theodoratou E Al-Jilaihawi S Woodward F et al.The effect of case management on childhood pneumonia mortality in developing countries.Int J Epidemiol. 2010; 39: 155-171Crossref PubMed Scopus (115) Google Scholar Recently, WHO released new guidelines for treatment of lower chest indrawing pneumonia with oral amoxicillin on an outpatient basis.12WHOPocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. 2nd edn. World Health Organisation, Geneva2014Google Scholar The rationale for introducing the new guidelines was not only because they are likely to reduce societal costs (due to less hospitalisation), but because they deliver better outcomes. The WHO pneumonia management guideline is presumptive, based on identification of clinical signs in children with cough or difficult breathing and on treatment with antibiotics. Some argue that CHWs have insufficient capacity to correctly manage pneumonia13Druetz T Siekmans K Goossens S Ridde V Haddad S The community case management of pneumonia in Africa: a review of the evidence.Health Policy Plan. 2015; 30: 253-266Crossref PubMed Scopus (47) Google Scholar and that the evidence of efficacy of antibiotic treatment for fast-breathing pneumonia is questionable, especially when wheeze is present.14Lassi ZS Kumar R Das JK Salam RA Bhutta ZA Antibiotic therapy versus no antibiotic therapy for children aged two to 59 months with WHO-defined non-severe pneumonia and wheeze.Cochrane Database Syst Rev. 2014; 5 (CD009576.)PubMed Google Scholar However, CHWs who have appropriate training, adequate supervision, and availability of drugs and necessary supplies have shown ability to provide quality care for pneumonia.15Kalyango JN Rutebemberwa E Alfven T Ssali S Peterson S Karamagi C Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda.Malar J. 2012; 11: 282Crossref PubMed Scopus (74) Google Scholar Although wheeze is more common in viral infections and often responds well to bronchodilators,14Lassi ZS Kumar R Das JK Salam RA Bhutta ZA Antibiotic therapy versus no antibiotic therapy for children aged two to 59 months with WHO-defined non-severe pneumonia and wheeze.Cochrane Database Syst Rev. 2014; 5 (CD009576.)PubMed Google Scholar a placebo-controlled double blind trial showed higher clinical treatment failure in children with fast-breathing pneumonia and wheeze who received placebo compared to antibiotic.16Awasthi S Agarwal G Kabra SK et al.Does 3-day course of oral amoxycillin benefit children of non-severe pneumonia with wheeze: a multicentric randomised controlled trial.PLoS One. 2008; 3: e1991Crossref PubMed Scopus (32) Google Scholar Mixed viral and bacterial infections are common,17Madhi S Adrian P Kuwanda I Cutland C Albrich W Klugman K Long-term effect of pneumococcal conjugate vaccine on nasopharyngeal colonization by Streptococcus pneumoniae—and associated interactions with Staphylococcus aureus and Haemophilus influenzae colonization—in HIV-infected and HIV-uninfected children.J Infect Dis. 2007; 196: 1662-1666Crossref PubMed Scopus (101) Google Scholar yet efforts to identify other clinical features to better diagnose bacterial pneumonia have not succeeded.18Rambaud-Althaus C Althaus F Genton B D'Acremont V Clinical features for diagnosis of pneumonia in children younger than 5 years: a systematic review and meta-analysis.Lancet Infect Dis. 2015; 15: 439-450Summary Full Text Full Text PDF PubMed Scopus (129) Google Scholar Since it is still impossible to clinically differentiate viral from bacterial pneumonia, prompt treatment of clinical pneumonia with antibiotics will remain a priority for the foreseeable future. Antibiotics can effectively treat pneumonia, but hypoxaemia is a good marker of disease severity and is often associated with adverse outcome.19Subhi R Adamson M Campbell H Weber M Smith K Duke T The prevalence of hypoxaemia among ill children in developing countries: a systematic review.Lancet Infect Dis. 2009; 9: 219-227Summary Full Text Full Text PDF PubMed Scopus (137) Google Scholar It is difficult to clinically identify hypoxaemia but the use of pulse oximetry and management of hypoxaemia with oxygen is associated with improved quality of care and reduced mortality. WHO recommends use of pulse oximetry to identify hypoxaemia and its management with oxygen.12WHOPocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. 2nd edn. World Health Organisation, Geneva2014Google Scholar Pulse oximetry is a reliable and non-invasive method for identifying hypoxaemia in children, yet these devices are rarely available outside the higher-level facilities in resource-constrained countries. To reduce childhood deaths, early identification and prompt treatment of pneumonia is essential. Standard case management of childhood pneumonia (including community case management) is an effective strategy to reduce the burden on hospital services, and improve equity.7Nair H Simoes 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 (487) Google Scholar Identification and management of hypoxaemia are essential along with antibiotics to reduce severe pneumonia mortality. This scale-up will need permissive policies allowing community health workers to detect and treat pneumonia with antibiotics, research and development to improve pneumonia diagnosis, and financial support for introduction and maintenance of pulse oximeters and oxygen therapy in health centres and hospitals. We declare no competing interests.