PNEUMONIA IN CHILDREN LIVING AT HIGH ALTITUDES IN PAKISTAN
Khan, Aamir Javed
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Pneumonia is responsible for an estimated 44% of deaths in children under 5 years of age in the Himalayan communities of the Northern Areas, Pakistan. The objectives of the three papers included in this thesis were to 1) determine the incidence of pneumonia in children using the World Health Organization Integrated Management of Childhood Illness (IMCI) criteria; 2) evaluate the impact of intensive follow-up training for Community Health Workers (CHWs) on pneumonia recognition and referral; and 3) compare health center staff classification of pneumonia based on IMCI criteria with evaluation by pediatricians. Children 2-35 months were followed at home every two weeks by CHWs and surveillance was simultaneously established at 15 health centers for pneumonia. CHW performance was evaluated at six-weekly intervals using pre- and post-tests, by measuring the proportion of children with severe disease they referred correctly to health centers, and by comparing the incidence rates for pneumonia among children in their coverage area. Misclassification of disease was measured by determining overall agreement between health center staff classification of disease with a pediatrician’s evaluation at a referral hospital in Gilgit. The incidence rate was 29.9 per 100 child years of observation (CYO) for pneumonia and 8.1 per 100 CYO for severe pneumonia. The proportion of children that were correctly referred for severe disease by CHWs increased from zero at baseline to above 80% over one year. Significant improvements were reported between the pre- and post-test results of CHW in all 10 tests conducted (paired sample t-test p-value <0.001). Using the pediatrician’s diagnosis as reference, health center staff correctly classified 125 (74.9%) of the children with severe pneumonia, and failed to identify 42 (25.1%) of children with the disease. Staff incorrectly labeled 328 (72.4%) children from the 453 they classified as children with severe pneumonia. Fewer children with pneumonia were missed (11.5%) or labeled incorrectly (2.8%). The pneumonia incidence rates in this Himalayan region are among the highest reported, even after adjustments for over-diagnosis of severe pneumonia. Sustained improvements in pneumonia referral were achieved following intensive training for CHWs. These findings warrant consideration of new intervention strategies in this region.