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Clinical features to diagnose pneumonia in children under 5: A systematic review

Author(s) Clotilde Rambaud-Althaus1, Amani Shao2, Blaise Genton3, Valerie Dacremont 4
Affiliation(s) 1Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Geneva, Switzerland, 2Amani research center, National Institute of Medical Research, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania, 3Department of Ambulatory Care and Community Medicine – Infectious Disease Service, University Hospital, Lausanne, Switzerland, Lausanne, Switzerland, 4Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Lausanne, Switzerland.
Country - ies of focus Global
Relevant to the conference tracks Infectious Diseases
Summary Pneumonia is the leading cause of child mortality. In low income countries only the clinical diagnosis is available. We undertook a systematic literature review to assess the diagnostic accuracy of WHO non-severe pneumonia case definition for children less than 5 years of age to identify which clinical features best predict pneumonia. Our preliminary results indicate that chest in-drawing and fast breathing appeared to be rule-in signs in the selected studies. The specificity of the WHO pneumonia case definition remained low, resulting in over-treatment of non-pneumonia cases.
Background Pneumonia is the leading cause of child mortality. Early identification and treatment of pneumonia in primary health care facilities is essential to decrease the number of deaths. In low income countries, primary care health workers have access to neither radiology nor laboratory support, and pneumonia diagnosis relies on simple clinical features. In the context of antibiotics resistance, the accuracy of the diagnosis is fundamental. The more accurate the diagnostic test will be, the more pneumonia cases will be identified and the less non-pneumonia conditions will be prescribed unnecessary antibiotics. The current WHO definition of pneumonia relies on cough, chest indrawing and fast breathing. Recent published studies suggest that antibiotics may not be beneficial to children with WHO non-severe pneumonia (cough + fast breathing), and that severe (but not very severe) pneumonia (cough + chest indrawing without general danger signs) may be safely managed at home with oral antibiotics.
Objectives Our aim was to review the accuracy of WHO non-severe pneumonia clinical case definition, and to identify which clinical features have value in predicting the diagnosis of pneumonia in children younger than 5 years presenting in outpatient facilities.
Methodology We undertook a systematic review, searching electronic databases (Medline, Embase, Cochrane database of systematic reviews) and reference lists of relevant studies. 1296 potentially relevant articles were identified. Studies were selected on the basis of 6 criteria: design (studies assessing diagnostic accuracy), targeted disease (pneumonia), participants (children aged 2 to 59 months), setting (ambulatory care), index tests assessed (clinical features), and sufficient data reported. Quality assessment was done using the Quality Assessment of Diagnostic Accuracy Studies criteria. In each individual study, we only considered for analyses the index tests that were not part of participants’ inclusion criteria. For each clinical feature, we calculated sensitivity, specificity, and positive and negative likelihood ratio (LR+ and LR-). Clinical features were considered as a rule-in sign if the positive likelihood ratio was above 5.0, and the rule-out sign was if the negative likelihood ratio was less than 0.2.
Results We included 14 studies in the analysis, assessing a total of 14 different clinical features. Likelihood ratios were highly varied in the included studies. Within the included studies, chest indrawing (1 study, LR+ 30.32), respiratory rate above 50 breaths/min in children aged 1 to 5 years (2 studies, LR+ 5.17 and 19.83), and caretaker reported breathlessness (1 study, LR+ 9.50) were identified as rule-in sign in individual studies. Only 2 studies reported clinical features with LR-
Conclusion No single clinical feature accurately predicted the diagnosis of pneumonia. The current WHO definition of non-severe pneumonia lead to substantial overtreatment of non-pneumonia cases, which is an issue with regards to the rapid spread of antibiotic resistance. Point-of-care tests identifying bacterial pneumonia are highly desirable to further improve diagnosis accuracy.

Smartphones to improve health workers performance and rational drug use for management of childhood illnesses in low resource settings.

Author(s) Clotilde Rambaud-Althaus1, Amani Shao2, Ndeniria Swai3, Seneca Perri 4, Marc Mitchell 5, Judith Kahama-Maro6, Valerie D'acremont7, Blaise Genton8
Affiliation(s) 1Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Geneva, Switzerland, 2Amani Research Center, National Institute of Medical Research, Dar es Salaam, Tanzania, 3City Medical Office of Health, Dar es Salaam City council, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania, 4Nursing informatics, University of Utah, Salt Lake city, USA, Salt Lake City, United States, 5Department of Global Health and Population, Harvard School of Public Health, Boston, United States, 6City Medical Office of Health, Dar es Salaam City council, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania, 7Infectious Diseases Service and Department of Ambulatory care and Community Medicine, University Hospital, Lausanne, Switzerland, Lausanne, Switzerland, 8Epidemiology and Public Health department, Swiss Tropical and Public Health department, Lausanne, Switzerland
Country - ies of focus Tanzania
Relevant to the conference tracks Innovation and Technologies
Summary In low resource settings, where childhood mortality is high, health workers (HWs)’ compliance to guidelines is essential to improve management of childhood illness. We developed paper and electronic versions of an algorithm for the management of childhood illness (ALMANACH) combining clinical elements with rapid tests for malaria and urinary infection. We assessed HWs’ compliance to guidelines when using paper versus electronic ALMANACH. The electronic clinical decision supports improved HWs performance in terms of symptoms assessment and rational use of drugs. However, it did not improve the accuracy of bacterial diseases diagnoses, which is essential to ensure quality of child care.
Background In low resource settings, where qualified health workers (HWs) are scarce and childhood mortality due to infectious diseases is high, the overuse of antimicrobial drugs is fastening the emergence of drug resistance. HWs’ compliance to evidence-based guidelines has the potential to improve the rational use of drugs and ensure quality of health care for children. Available new mobile technology, through smartphones and tablets, offers new perspectives in the delivery of evidence-based clinical guidelines to remote ambulatory health workers.
Objectives Our aim was to assess whether the use of smartphones to deliver a clinical ALgorithm for the MANAgement of CHildhood illnesses (ALMANACH) improves health workers diagnostic performance and rational use of drugs through a better compliance to the clinical chart.
Methodology ALMANACH, a decision chart combining clinical elements with a rapid test for malaria and a urine dipstick, was developed both on paper and electronic version. Nine Primary Health Care Facilities (PHCF) in Dar es Salaam, Tanzania (United Republic of), were randomized into 3 arms. Three PHCF were allocated an intervention using Paper ALMANACH, 3 other PHCF used Smartphone ALMANACH, the remaining 3 followed routine practice. The intervention, in Paper and Smartphone arms, consisted in a 2 days training on ALMANACH for all HWs attending to children below 5 years of age in outpatient departments (OPDs). The training was followed for each HW by one day of on-site supervision, and monthly supervision visits to the PHCF. Smartphones running ALMANACH algorithm were provided to the PHCF in the phone arm. The same ALMANACH algorithm printed as a paper booklet was provided to the PHCF in the Paper arm. Control PHCF did not receive any algorithm nor training or supervision and thus managed patients as usual. From September to November 2011, we conducted a cross sectional consultation process observational survey in the 9 PHCFs. Children aged 2-59 months, coming for the first visit for an acute medical ailment, were enrolled. All consultations were observed by a surveyor who collected data on a standardized form. An expert re-examined each child to establish the ‘gold standard’ assessment and treatments needed. We compared HWs’ performance between the 3 arms using indicators of child’s assessment, and appropriateness of diagnosis and treatment as outcome variables. Indicators (proportions) were compared using the Fischer’s exact test and 95% confidence interval (95%CI). The expert consultation was the reference.
Results A total of 504 children were enrolled. The mean age was 19.7 months (interquartile range 8-29) and 261 (52%) were males. The most frequent symptoms at presentation were: fever (71%), cough (66%), diarrhoea (20%) and skin problems (8%). The use of smartphones was associated with better child assessment indicators. The proportion of children checked for 3 dangers signs (unable to drink, vomits everything, and history of convulsion) was 74% (95%CI, 67-81%) when using smartphones, 41% (34-49%) when using paper ALMANACH and only 3% (0.4-6%) in the control arm. The proportion of children checked for main symptoms (fever, cough, and diarrhoea) was 99% (98-100%) when using smartphones, 75% (68-81%) when using paper ALMANACH and 77% (71-84%) in controls. The proportion of children with reported fever tested for malaria was 72% (63-80%), 92% (77-90%), and 84% (77-90%) in smartphones, paper and control arm respectively. The proportions of children with reported fever and cough who had their respiratory rate measured (for diagnose pneumonia) were 38% (27-49%), 53% (42-65%) and 3% (0-7%) in smartphones, paper and control arm respectively. With regards to diagnostic appropriateness, the proportion of expert-validated viral diseases identified by HWs (diagnostic sensitivity) was 74% (65-82%) with smartphones, 35% (26-44%) with paper and 45% (37-56%) in control arm. On the other hand, identification of expert-validated bacterial diseases (pneumonia and dysentery clinically diagnosed, and urinary tract infection using dipstick urinalysis) remained low in all 3 arms, with the proportion of validated bacterial infections identified by HWs at 41% (21-61%), 33% (20-65%), and 36% (15-58%) respectively. Nevertheless, the use of ALMANACH was associated with an important decrease in unnecessary antibiotic prescriptions. The proportion of children not needing antibiotics who were still prescribed antibiotics by HWs was: 20% (13-27%) in the smartphone arm, 25% (19-33%) in the paper arm and 66% (58-74%) in controls. Seven among 12 children in the paper arm and 14 among 26 children in the phone arm who needed antibiotics according to the expert, were not prescribed antibiotics by the HW. All these 21 cases were diagnosed as non-severe pneumonia by the expert, based on a respiratory rate above 50 breaths/min. For 10 (1 in paper, 9 in phone arm) of these patients, HWs did not measure the respiratory rate and did not consider pneumonia diagnosis. In the remaining 11 patients, HWs’ respiratory rate measures were below the threshold of 50 breaths/min. This difference could be due to inaccurate measurement by the HW or alternatively, to natural fluctuation of the respiratory rate between the two assessments.
Conclusion The use of ALMANACH compared to control arm was associated with better child’s assessment and considerable reduction of unnecessary antibiotic prescription. The use of smartphones running ALMANACH software versus the use of the paper ALMANACH was associated with better symptoms assessment and better identification of viral diseases. However, the discriminative clinical and lab tests available (i.e. respiratory rate for pneumonia, and malaria test) remained underutilized after our intervention, with no significant difference between smartphones and paper arm. This resulted in missed antibiotic prescription for about half of the children in need of it according to ALMANACH, both in the smartphone and the paper arm. The use of smartphones, a powerful tool to guide HWs during the consultation, is not enough to convince them to use the key clinical and lab tests in all children. Devices that would directly measure the respiratory rate, or point-of-care tests identifying pneumonia or severe disease, are highly desirable. A supportive working environment, with iterative supervision is necessary to ensure the rational use of antimicrobials by HWs.