risk factors that suggest need for admission in childhood ... illnesses in kenya...nodding, altered...
TRANSCRIPT
Outline
• Rationale behind WHO pneumonia guidelines
• Study methodology and results
• Interpretation of study findings
Pneumonia Case Management Guidelines
Syndrome
Severe pneumonia
Non severe pneumonia
Clinical Signs (in child with cough/difficulty breathing)
Any one of the following: Cyanosis, grunting (infants), inability to drink, head
nodding, altered consciousness, SPO2 <90%
Lower chest wall indrawing
AND without signs of severe pneumonia
Fast breathi g (RR≥ / i if age - o ths; ≥ / i if age -59
months)
AND without signs of severe pneumonia
Rationale behind WHO pneumonia guidelines
Non severe pneumonia
Severe pneumonia
Low
mortality
High
mortality
Home care
Admit
Objective
To determine if some children categorized as non-severe pneumonia
might have levels of risk warranting hospitalization
Non severe pneumonia
Severe pneumonia
Low
mortality
High
mortality
Home care
Admit
Study methods
• Retrospective cohort study of children aged 2–59 months admitted with pneumonia at 14 hospitals (CIN) in Kenya.
• Associations for inpatient mortality modelled using logistic regression.
• Multiple imputation performed for missing data
• Absolute risks of mortality calculated for o -severe pneumonia
Selection of study population
Aged 2 – 59 months and hospitalized with
pneumonia between 1 March 2014 and 29
February 2016 (n=21832)
Included in analyses (n=16162)
Severe acute malnutrition (n=3287)
Meningitis (n=1180)
Chronic cardiorespiratory illness (n=220)
HIV exposed / infected (n=134)
Born before November 2010 (n=849)
Results: Mortality by WHO severity group
2.7%*
14.2%**
* 322/11930 (95% CI 2·4 to 3·0%) **488/3434 (95% CI 13·1 to 15·4%)
Non severe pneumonia
Severe pneumonia
Low
mortality
High
mortality
Home care
Admit
Independent risk factors for pneumonia mortality Patient characteristic Adjusted risk ratio 95% CI
Non-severe pneumonia ref
Severe pneumonia 4.41 (4.17, 4.66)
Age group 12 - 59 months ref
Age group 2 - 11 months 2.71 (2.56, 2.88)
Male sex ref
Female sex 1.52 (1.44, 1.61)
Low malaria prevalence ref
High malaria prevalence 1.21 (1.14, 1.28)
Respiratory rate <70 breaths/min ref
Respiratory rate ≥70 breaths/ i 1.70 (1.60, 1.80)
Temperature <39ºC ref
Te perature ≥39ºC 1.83 (1.72, 1.95)
WAZ >=-2 SD ref
WAZ <-2 to -3SD 1.96 (1.83, 2.10)
WAZ <-3SD 2.10 (1.93, 2.29)
No pallor ref
Mild/moderate pallor 3.37 (3.15, 3.61)
Severe pallor 5.39 (4.89, 5.92)
No dehydration ref
Some dehydration 2.01 (1.82, 2.23)
Severe dehydration 1.85 (1.70, 2.02)
Patient sub-group Mortality
% LCL UCL
Severe only 14.2 13.1 15.4
Non severe only 2.7 2.4 3.0
Non-severe, no risk factors 0.2 0.0 0.9
2-11 months 4.2 3.7 4.8
Female sex 3.3 2.8 3.8
High malaria prevalence 3.8 3.2 4.4
Immunization not up to date 4.2 2.0 7.6
Resp rate ≥7 / i 4.1 3.1 4.7
Temp ≥ 9C 3.8 2.8 5.1
WAZ <-2 to -3SD 4.4 3.4 5.6
WAZ <-3SD 7.5 4.9 11.8
Mild/moderate pallor 7.8 5.1 11.4
Severe pallor 11.2 7.7 15.6
Moderate dehydration 5.1 3.6 6.9
Mortality (%) 2 4 6 8 10 12 14 16 0
Results
• Pooled analysis of >6398 cases of severe pneumonia from 10 countries
• Mostly clinical trials conducted in Asia
• Mortality rate: 0.3%
• Overall mortality for non-severe pneumonia: 2.7%
• Mortality for children with non-severe pneumonia and without any
of the risk factors: 1/595 (0·2%; 95% CI 0·004 to 0·9%)
Risk factors among children with non-severe
pneumonia
Non severe pneumonia
Severe pneumonia
Low mortality
High mortality
Home care
Admit
Mild/moderate pallor
Severe pallor
WAZ <-3SD
2001
Introduction of
Haemophilus influenzae
type B vaccine
2011
Kenya launches
pneumococcal
conjugate vaccine
Cowgill et al 2006, JAMA
Summary
• Most children hospitalized classified as having non-severe pneumonia (82%) presented with ≥ risk factor associated with an increased risk of death.
• Mortality in children with non-severe pneumonia was substantially higher for those presenting with WAZ <-3SD or pallor
• Current WHO criteria defining pneumonia leave out some important factors associated with poor outcome.
• Findings suggest that clinicians should treat the WHO criteria as but one factor to consider in clinical decision-making.
Thanks to………………..
Clinical Information Network partners include: Vihiga County Hospital, Kakamega County Hospital,
Mbagathi County Hospital, Mama Lucy Kibaki County Hospital, Machakos County Hospital, Nyeri
County Hospital, Kisumu East County Hospital, Embu County Hospital, Karatina County Hospital,
Kerugoya County Hospital, Kitale County Hospital, Busia County Hospital, Kiambu County Hospital,
Mbale RHTC , Pumwani Maternity Hospital