Management of severe pneumonia in young children

1
Management of severe pneumonia in young children
2
Context

• Lancet CS Series PN 19 u 5 mort
• Renewed global effort to promote community
  management non-severe PN and CCM
• WHO, UNICEF,USAID, BASICS and CORE)
• Est. 2 million acute infections in young children
• WHO guidelines children with lower chest
  in-drawing/severe PN sent to hospital and general
  danger signs Refer and TX with IM AMP or PEN

3
Research

• Oral injectable for Severe Pneumonia (SP) in
  hospital setting
• Addo-Yobo et al 364 Lancet 2004
• WHO Expert Consultation (Oct 2003)
• However, before it (oral therapy) can be
  recommended on a general basis.
• Studies in several centres around the world
  should be conducted in a public health setting to
  evaluate clinical outcome to oral amoxicillin in
  children 2-59 months old presenting with lower
  chest indrawing.

4
Why change regimens?

• Practical benefits of switching-over to oral
  amoxicillin
• simplify treatment of severe pneumonia
• minimize the need for referral or hospitalization
  
• decrease treatment administration costs
• reduce transport, food and lost income costs for
  the family
• reduce the pressure on already overburdened
  hospitals
• reduce the risk of needle-associated
  complications such as needle-borne infections
• reduce the risk of nosocomial infection during
  hospital stay.

5
APPIS II Safety Studyto be completed early 2009

• Multi-center one-arm intervention study
• Home management with 5 days of oral amoxicillin
  for
• WHO-defined severe pneumonia in children 3 -
  59 mo of age
• Sites
• Bangladesh
• Egypt
• Ghana
• Vietnam (Ho Chi Minh City and Haiphong)

6

• 7 Site Pakistan RCT
• Children 3-59 mo with WHO-defined severe
  pneumonia
• IV Ampicillin/hospitalization VS
• Home management/oral amoxicillin

LANCET JAN 2008

• FINDING
• Home therapy with oral amoxicillin is equivalent
  to initial hospitalization and parenteral
  ampicillin for treatment of WHO-defined severe
  pneumonia in children 3-59 mo of age
• Shorter course of high-dose amoxicillin (80-90
  mg/kg/day administered twice a day for 5 days) is
  safe and efficacious

7
Provisios

• Certain populations may require closer monitoring
  or hospitalization
• Very young infants (3-5 mo old)
• Very fast breathing
• Underweight for age (WAZ lt -2)
• May need Research in HIV populations

8
Cumulative treatment failure (TF) by specific
causes by Day 6
9
Cumulative treatment failure (TF) by specific
causes relapse by Day 14
10
Community based management of Severe
Pneumoniacompletion by Fall 2009

• CHW manage severe pneumonia in children at the
  community level
• train Lady Health Workers in Pakistan in
  management of severe pneumonia under careful
  supervision and document the outcomes

11
Research to policy potential road map

• Public health policy and programmatic
  implications and benefits
• Reduce, referrals and hospitalizations
• Improve access and reduce costs
• Reduce mortality from pneumonia and nosocomial
  risks
• Modify WHO ARI/IMCI guidelines
• Country Level Programming
• New treatment approach for programs
• Ongoing discussions in Pakistan potential program
  pilots even before completion of community trials
  
• Opens policy question where to shift from COTRIM
  to AMOX