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Effect of pneumonia case management on mortality in neonates, infants, and preschool children: a meta-analysis of community-based trials

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Summary

Pneumonia still causes around two million deaths among children annually (20% of all child deaths). Any intervention that would affect pneumonia mortality is of great public health importance. This meta-analysis provides estimates of mortality impact of the case-management approach proposed by WHO. We were able to get data from nine of ten eligible community-based studies that assessed the effects of pneumonia case-management intervention on mortality; seven studies had a concurrent control group. Standardised forms were completed by individual investigators to provide information on study description, quality scoring, follow-up, and outcome (mortality) data with three age groups (<1 month, < 1 year, 0·4 years) and two mortality categories (total and pneumonia-specific). Meta-analysis found a reduction in total mortality of 27% (95% Cl 18–35%), 20% (11–28%), and 24% (14–33%) among neonates, infants, and children 0·4 years of age, respectively. In the same three groups pneumonia mortality was reduced by 42% (22–57%), 36% (20–48%), and 36% (20–49%). There was no evidence of publication bias and results were unaltered by exclusion of any study. A limitation of the included studies is that they were not randomised and, because of the nature of the intervention, could not be blinded. Community-based interventions to identify and treat pneumonia have a substantial effect on neonatal, infant, and child mortality and should be incorporated into primary health care.

Section snippets

Identification and selection of studies

We attempted to locate all published and unpublished community-based intervention trials on case management of pneumonia in preschool children in developing countries. In addition to systematic searching of the bibliographic databases, including Medline, Sci-scimate, Current Contents, and references from the identified papers, potential funding agencies such as the WHO Programme for the Control of Acute Respiratory Infections, the US Agency for International Development, and UNICEF were

Study descriptions

Baseline characteristics of study populations are presented in table 1. The pneumonia case-management studies took place in a range of settings with baseline infant mortality rates (IMR) ranging between 49 and 184 deaths/1000 live births and different levels of health services availability, as reported by the investigators (table 1). Undernutrition was prevalent in all settings for which information was available. Of the nine studies that provided data, seven had concurrent control group data;

Discussion

Our meta-analysis indicates that community-based interventions to identify and treat pneumonia have a considerable effect on child mortality. The diversity of pneumonia interventions and the developing country settings in which these trials took place, along with the consistency of the results, lends credibility to the robustness of the findings and their application to many developing countries. Although not included in meta-analysis estimates, studies with before-and-after comparison designs

Search strategy and selection criteria

We searched Pubmed using the keywords “acute respiratory infections”, “acute lower respiratory infections”, “respiratory infections”, “pneumonia”, and “pneumonia case management strategy”; each term was combined with “and mortality”. The search was restricted to children, all articles, all languages, from 1970 onwards. We also contacted individual authors and the agencies WHO, USAID, and UNICEF for data on unpublished studies.

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