Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study

Background: Guidelines on integrated management of childhood illness (IMCI) for severe pneumonia recommend referral to hospitals. However, in many settings, children who are referred do not actually attend hospital, which severely limits appropriate care. We aimed to assess the safety and effectiveness of modified guidelines that allowed most children with severe pneumonia to be treated locally in first-level facilities, with referral only for those with danger signs or other severe classifications. Methods: We did an observational cohort study in ten first-level health facilities in Matlab, rural Bangladesh that had implemented IMCI guidelines. We assessed children with severe pneumonia who were aged between 2 and 59 months, and for whom we could obtain complete information, in two cohorts: 261 children who presented to these facilities between May, 2003, and April, 2004 (before implementation of the modified guidelines) and 1271 children between September, 2004, and August, 2005 (after full implementation). We obtained information about the characteristics and management of their illness, including referrals and admissions to hospital, from facility records. Staff visited households to obtain details of treatment, socioeconomic information, and final outcome, including mortality data. Findings: 245 (94%) of 261 children who had severe pneumonia were referred to hospital before the guidelines were modified, compared with 107 (8%) of 1271 after implementation (p<0·0001). 94 (36%) children with severe pneumonia received correct management before the guidelines were modified, compared with 1145 (90%) children after implementation (p<0·0001). Before modification of the guidelines, three children with severe pneumonia who presented at first-level facilities died, with a case-fatality rate of 1·1%; after modification, seven children died, with a case-fatality rate of 0·6% (p=0·39). Interpretation: Local adaptation of the IMCI guidelines, with appropriate training and supervision, could allow safe and effective management of severe pneumonia, especially if compliance with referral is difficult because of geographic, financial, or cultural barriers. Funding: Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, US Agency for International Development.