PROGNOSTIC FACTORS FOR THE OUTCOME OF THE MANAGEMENT OF SEVERE PNEUMONIA IN CHILDREN UNDER FIVE YEARS ADMITTED AT PLATEAU STATE SPECIALIST HOSPITAL, JOS

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PROGNOSTIC FACTORS FOR THE OUTCOME OF THE MANAGEMENT OF SEVERE PNEUMONIA IN CHILDREN UNDER FIVE YEARS ADMITTED AT PLATEAU STATE SPECIALIST HOSPITAL, JOS

SUMMARY

Severe pneumonia is a major cause of morbidity and mortality in Nigeria and the world over.  It takes most of its toll in children under five years of age.  While several studies have investigated the occurrence of childhood pneumonia, very little is known of childhood pneumonia in under fives in north central Nigeria.  This study aims at elucidating the clinical features of severe pneumonia in under-fives in Jos and to identify some prognostic factors affecting the outcome of its management in this age group.  The study was carried out in Plateau State Specialist Hospital, Jos.

One hundred and seventy six under-five children admitted with severe pneumonia were analyzed during the study period.

The main symptoms of severe pneumonia in the study subjects were fever, cough, breathlessness and poor feeding.  The main clinical signs were dyspnoea, lower chest in drawing, tachypnoea, crepitations and grunting respirations.  The commonest complication was cardiac failure.  The associated illnesses in this study were PEM, malaria, measles, sickle cell disease, HIV/AIDS and aspiration.

Severe pneumonia occurred more in children less than two years with slight male preponderance. The male to female ratio was 1.5:1.

Twenty six (15.0%) subjects died before discharge. The case fatality varies depending on the exposed risk factors. Children less than 2 years were 4 times more likely to die than children with none of this factor. Malnourished children and non-exclusive breastfed children had more than 2 times risk of dying from severe pneumonia when compared with those without these risk factors. Children exposed to wood smoke had 2.5 times the risk of dying from severe pneumonia compared to unexposed children. Delay in presentation to hospital, cyanosis, grunting respiration, hepatomegaly and oxygen saturation level less than 90% increase the risk of dying from severe pneumonia 2-11 fold compared to those without these risk factors. The occurrence of heart failure as complication of severe pneumonia increased the risk of dying from this disease by more than 6 times. Predictors of death from severe pneumonia in children under-five in this study were delayed presentation to hospital (OR 1.43) and hepatomegaly

(OR 33.66).

TABLE OF CONTENTS

 

Title page    –        –        –        –        –        –        –        –        –        i

Declaration –         –        –        –        –        –        –        –        –        ii

Certificate –           –        –        –        –        –        –        –        –        iii

Dedication –           –        –        –        –        –        –        –        –        iv

Acknowledgement –        –        –        –        –        –        –        –        v

Table of contents –          –        –        –        –        –        –        –        vi

List of tables/Figures       –        –        –        –        –        –        –        x

Abbreviations        –        –        –        –        –        –        –        –        xi

Summary (Abstract)        –        –        –        –        –        –        –        xiii

 

CHAPTER ONE: INTRODUCTION

1.1     Background Information –         –        –        –        –        –         1

1.2     Statement of the problem         –        –        –        –        –         4

1.3      Objectives of the study –          –        –        –        –        –         7

1.4     Significance of the study          –        –        –        –        –         8

CHAPTER TWO:  LITERATURE REVIEW

2.1     Definition of Pneumonia –         –        –        –        –        –         9

2.2     Epidemiology        –        –        –        –        –        –        –         10

2.3     Pathogenesis and Pathology of pneumonia  –        –        –         12

2.4     Pathogens Associated with pneumonia       –        –        –         13

2.5     Diagnosis of pneumonia  –        –        –        –        –        –         16

2.5.1 Clinical Evaluation           –        –        –        –        –        –         16

2.5.2 Radiological diagnoses –           –        –        –        –        –         21

2.5.3 Etiological diagnoses       –        –        –        –        –        –         22

2.6     Prognostic factors in childhood pneumonia  –        –        –         23

2.6.1 Household factors –         –        –        –        –        –        –         23

2.6.2 Child factors           –        –        –        –        –        –        –         28

2.6.3 Child care practices         –        –        –        –        –        –         30

2.6.4 Illness factors         –        –        –        –        –        –        –         33

2.6.5 Health care factors-         –          –        –        –         –          –        40

2.7     Treatment of Childhood pneumonia – –        –        –        –         41

2.8     Outcome of management of childhood pneumonia         –         43

2.9      Prevention of childhood pneumonia –         –        –        –         44

CHAPTER THREE: METHODOLOGY

3.1     Study environment         –        –        –        –        –        –         47

3.2     Study hospital       –        –        –        –        –        –        –         48

3.3      Ethical clearance –         –        –        –        –        –        –         48

3.4     Study period         –        –        –        –        –        –        –         49

3.5     Sample size          –        –        –        –        –        –        –         49

3.6      Study population –         –        –        –        –        –        –         50

3.6.1 Inclusion criteria  –           –        –        –        –        –        –         50

3.6.2 Exclusion criteria –           –        –        –        –        –        –         50

3.7     Recruitment into the study        –        –        –        –        –         51

3.8     Investigations       –        –        –        –        –        –        –         52

3.9     Antibiotics/supportive care        –        –        –        –        –         53

3.10 Treatment outcome variables  –            –        –        –        –         54

3.11 Data collection form          –        –        –        –        –        –         54

3.12 Statistical method –           –        –        –        –        –        –         54

CHAPTER FOUR: RESULTS

4.1     Demographic and household factors among the study

subjects-       –        –        –        –        –        –        –                  55

4.2      Subjects’ month of presentation to hospital –         –        –         57

4.3     Distribution of subjects by duration of symptoms before

presentation to hospital  –         .         –        –        –        –         58

4.4     Distribution of subjects by reasons for delay in seeking

Healthcare –      –        –        –     –        –        –        –        –         59

4.5     Health workers’ ability to diagnose severe pneumonia    –         59

4.6     Distribution of subjects by presenting symptoms

and signs-    –        –        –        –        –        –        –        –         60

4.7     Distribution of associated complications/illness     –        –         62

4.8     Radiological diagnoses in study subjects     –        –        –         63

4.9     Duration of hospital stay in days        –        –        –        –         63

4.10 Treatment outcome in study subjects-           –        –        –         64

4.11 Relationship between age group and treatment outcome –          65

4.12 Relationship between maternal factors and treatment

outcome      –        –        –        –        –        –        –        –         66

4.13 Relationship between child care factors and treatment

outcome      –        –        –        –        –        –        –        –         67

4.14 Relationship between exposure to wood smoke and

treatment outcome         –        –        –        –        –        –         68

4.15 Relationship between illness factors and treatment outcome      69

4.16 Relationship between associated illnesses/complications

and treatment outcome –         –        –        –        –        –         71

4.17 Predictors of death in children under-five years admitted

with severe pneumonia –         –        –        –        –        –         72

 

CHAPTER FIVE: 

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1      Discussion –         –        –        –        –        –        –        –         73

5.2     Conclusion/Recommendations –        –        –        –        –         78

5.3      Limitations –         –        –        –        –        –        –        –         80

5.5    Suggestion for further study-    –        –        –        –        –             80

REFERENCES     –        –        –        –        –        –        –        –         81

CHAPTER ONE

INTRODUCTION

1.1     BACKGROUND INFORMATION

Close to 11 million children under the age of five died in 2003. Most of these children (98 percent) lived in developing countries.1 Levels of underfive mortality vary widely across countries from 3 to over 280 deaths per 1000 live births1.  Forty-three countries account for 90 percent of the world’s deaths in children under-five.1

The biggest killers of children under-five are pneumonia, diarrhoea, and neonatal causes2. Global distribution of cause specific mortality among children under five in 2004 revealed that pneumonia accounted for 19 percent of all under-five deaths.3 Others were; diarrhoeal diseases 17 percent, malaria 8 percent, measles 4 percent, injuries 3 percent, AIDS 3 percent, severe neonatal infections 10 percent, other neonatal causes 27 percent and other causes 10 percent.3

Pneumonia remains one of the major child health and survival challenges despite the identification of risk factors, which can be addressed, and the availability of preventive and curative measures of proven efficacy and effectiveness.2

Although the child survival revolution of the 1980s greatly reduced child mortality, the tasks of preventing child deaths and addressing inequalities remain unfinished.4 Children who are poor had more than their share of this tragedy.5 The child survival revolution left large inequalities in child health.5 For example, a child born in the poorest fifth of Indonesia’s population is four times more likely to die before reaching 5 years than one born in the wealthiest fifth.6

Currently, the integrated management of childhood illness (IMCI) developed by WHO and UNICEF is a form of child survival strategy aimed at addressing the challenges of the five major preventable killers of children under-five in developing countries.7 IMCI strategy promotes the accurate identification of childhood illnesses in out-patient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counseling of caretakers and speeds up the referral of severely ill children.7 In the home setting, it promotes appropriate care seeking behaviours, improved nutrition and preventive care and the correct implementation of prescribed care.7

The IMCI approach to pneumonia is training health workers to learn the importance of determining the severity of the disease by observing the child for two key signs of pneumonia (chest in-drawing and fast

breathing).7

In its effort to reduce childhood mortality in Nigeria,8 the National Health Policy (NHP) was officially launched and became operative in October

  1. NHP aims at a level of health that will enable all Nigerians to achieve socially and economically productive lives. The National Health Policy adopts the Primary Health Care (PHC) concept as the main engine by which the goal of health for all Nigerians can be attained.8 Of recent, the government has established an agency called the National Primary Health Care Development Agency (NPHCDA) charged with responsibility for the development of health care facilities at the local government level nationwide. The agency has conducted training programmes for upgrading the skills of the PHC personnel in the local government areas.  More village health workers and Traditional Birth Attendants (TBAs) have also been trained and made available at the community level in order to assist in reducing child mortality.8

Furthermore, there have been awareness campaigns against common childhood diseases. The government has provided vaccinations at no cost for the children in the country. The government has also embarked upon routine immunization days in which workers go from house to house to immunize the children against the killer diseases. In her effort to make immunization effective, the Nigerian government recently reviewed the EPI (Expanded Programmes on Immunization) and renamed it National Programme on Immunization (NPI) today, the Nigerian government is striving towards reducing mortality, morbidity and incapacitation caused by the childhood killer diseases to the barest minimum.8

 

 

1.2     STATEMENT OF THE PROBLEM

It is estimated that more than 150 million episodes of pneumonia occur every year among children under-five in developing countries accounting for more than 95 percent of all new cases world wide.3

Between 11 million and 20 million children under-five years with pneumonia will require hospitalization and more than 2 million will die from the disease.3 It is also important to note that incidence of pneumonia among children decreases with age.9

South Asia and sub-saharan Africa combined bear the burden of more than half of the total number of pneumonia episodes among children under-five.3 Worldwide three quarters of all pneumonia episodes among children under five occur in just 15 countries including Nigeria.3 (Table 1a).

Table 1a

15 countries accounting for three quarters of childhood pneumonia cases worldwide.3

Countries No. of cases
India 44 million
China 18 million
Nigeria 7 million
Pakistan 7 million
Bangladesh 6 million
Indonesia 6 million
Brazil 4 million
Ethiopia 4 million
Congo, Democratic Republic 3 million
Philippines 3 million
Afghanistan 2 million
Egypt 2 million
Mexico 2 million
Sudan 2 million
Vietnam 2 million
Total
 
113
 million
 

 

Note:  Country level estimates do not add up to the total due to rounding.

Table 1b

Incidence of pneumonia cases and pneumonia deaths among children under-five, by UNICEF region, 2004.3

 

UNICEF Region                No. of                No. of           Incidence of         Total No. of

children           childhood         pneumonia           pneumonia

under-five         pneumonia            cases               episodes

years of age          deaths            (episodes         (in thousand)

( in (in thousand) per child per thousand) year)

South Asia                   169,300 702 0.36 61,300
Sub-saharan Africa      117,300 1,022 0.30 35,200
Middle     East      and 43,400

North Africa

82 0.26 11,300
East       Asia        and 146,400

Pacific

158 0.24 34,500
Latin America and 56,500

Caribbean

50 0.22 12,200
CEE/CIS                      26,400 29 0.09 2,400
Developing                  533,000

countries

2,039 0.29 154,500
Industrialize                 54,200

countries

1 0.03 1,600
World                           613,600 2,044 0.26 158,500

 

Of recent HIV pandemic has sharply increased the incidence, severity and mortality of childhood pneumonia in developing countries10. This situation is worsened by lack and inaccessibility to conjugate vaccines that prevent pneumonia due to Streptococcus penumoniae and Haemophilus influenza

type b.10

The prevalence of severe pneumonia in under-five urban Nigerian children admitted for Acute lower respiratory infections (ALRI) in Ibadan was 12.7% with a mortality of 10.5%.11 The previous mortality rate of childhood pneumonia in Jos was 14 percent.12

A look at the unpublished admission and discharge records for children under-five years admitted in Plateau State Specialist Hospital with severe pneumonia over a 3-month period revealed eighty five patients among which 12 patients died. This later figure is high and thus motivated the decision for this research with an aim to find out factors that determine the outcome of management of this illness.

 

1.3     OBJECTIVES OF THE STUDY

General Objectives

To identify prognostic factors for the outcome of management of severe pneumonia in children under-five years admitted at Plateau State Specialist Hospital Jos in order to map out strategies to reduce morbidity and mortality from this illness.

Specific objectives

  1. To identify the symptoms and signs among the study population.
  2. To identify factors that influences the outcome of management of severe pneumonia among the study population.

 

1.4     SIGNIFICANCE OF THE STUDY

  1. i) Pneumonia is a major cause of morbidity and mortality among children under-five years in Nigeria and other developing countries especially with the present HIV

pandemic.3,11-16   ii) The study shall bring to light the prognostic factors that adversely affect the outcome of management of severe pneumonia in the study population in Jos to help plan appropriate measures to reduce the morbidity and mortality from this disease.

iii) The study will serve as an important contribution to the body of knowledge already existing on this health problem.

 

 

PROGNOSTIC FACTORS FOR THE OUTCOME OF THE MANAGEMENT OF SEVERE PNEUMONIA IN CHILDREN UNDER FIVE YEARS ADMITTED AT PLATEAU STATE SPECIALIST HOSPITAL, JOS

 

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