Risk factors that suggest need for

admission in childhood pneumonia Ambrose Agweyu

Outline

• Rationale behind WHO pneumonia guidelines

• Study methodology and results

• Interpretation of study findings

Pneumonia Case Management Guidelines

Syndrome

Severe pneumonia

Non severe pneumonia

Clinical Signs (in child with cough/difficulty breathing)

Any one of the following: Cyanosis, grunting (infants), inability to drink, head

nodding, altered consciousness, SPO2 <90%

Lower chest wall indrawing

AND without signs of severe pneumonia

Fast breathi g (RR≥ / i if age - o ths; ≥ / i if age -59

months)

AND without signs of severe pneumonia

Rationale behind WHO pneumonia guidelines

Non severe pneumonia

Severe pneumonia

Low

mortality

High

mortality

Home care

Admit

Objective

To determine if some children categorized as non-severe pneumonia

might have levels of risk warranting hospitalization

Non severe pneumonia

Severe pneumonia

Low

mortality

High

mortality

Home care

Admit

Study methods

• Retrospective cohort study of children aged 2–59 months admitted with pneumonia at 14 hospitals (CIN) in Kenya.

• Associations for inpatient mortality modelled using logistic regression.

• Multiple imputation performed for missing data

• Absolute risks of mortality calculated for o -severe pneumonia

Selection of study population

Aged 2 – 59 months and hospitalized with

pneumonia between 1 March 2014 and 29

February 2016 (n=21832)

Included in analyses (n=16162)

Severe acute malnutrition (n=3287)

Meningitis (n=1180)

Chronic cardiorespiratory illness (n=220)

HIV exposed / infected (n=134)

Born before November 2010 (n=849)

Results: Mortality by WHO severity group

2.7%*

14.2%**

* 322/11930 (95% CI 2·4 to 3·0%) **488/3434 (95% CI 13·1 to 15·4%)

Non severe pneumonia

Severe pneumonia

Low

mortality

High

mortality

Home care

Admit

Independent risk factors for pneumonia mortality Patient characteristic Adjusted risk ratio 95% CI

Non-severe pneumonia ref

Severe pneumonia 4.41 (4.17, 4.66)

Age group 12 - 59 months ref

Age group 2 - 11 months 2.71 (2.56, 2.88)

Male sex ref

Female sex 1.52 (1.44, 1.61)

Low malaria prevalence ref

High malaria prevalence 1.21 (1.14, 1.28)

Respiratory rate <70 breaths/min ref

Respiratory rate ≥70 breaths/ i 1.70 (1.60, 1.80)

Temperature <39ºC ref

Te perature ≥39ºC 1.83 (1.72, 1.95)

WAZ >=-2 SD ref

WAZ <-2 to -3SD 1.96 (1.83, 2.10)

WAZ <-3SD 2.10 (1.93, 2.29)

No pallor ref

Mild/moderate pallor 3.37 (3.15, 3.61)

Severe pallor 5.39 (4.89, 5.92)

No dehydration ref

Some dehydration 2.01 (1.82, 2.23)

Severe dehydration 1.85 (1.70, 2.02)

Patient sub-group Mortality

% LCL UCL

Severe only 14.2 13.1 15.4

Non severe only 2.7 2.4 3.0

Non-severe, no risk factors 0.2 0.0 0.9

2-11 months 4.2 3.7 4.8

Female sex 3.3 2.8 3.8

High malaria prevalence 3.8 3.2 4.4

Immunization not up to date 4.2 2.0 7.6

Resp rate ≥7 / i 4.1 3.1 4.7

Temp ≥ 9C 3.8 2.8 5.1

WAZ <-2 to -3SD 4.4 3.4 5.6

WAZ <-3SD 7.5 4.9 11.8

Mild/moderate pallor 7.8 5.1 11.4

Severe pallor 11.2 7.7 15.6

Moderate dehydration 5.1 3.6 6.9

Mortality (%) 2 4 6 8 10 12 14 16 0

Results

• Pooled analysis of >6398 cases of severe pneumonia from 10 countries

• Mostly clinical trials conducted in Asia

• Mortality rate: 0.3%

• Overall mortality for non-severe pneumonia: 2.7%

• Mortality for children with non-severe pneumonia and without any

of the risk factors: 1/595 (0·2%; 95% CI 0·004 to 0·9%)

Risk factors among children with non-severe

pneumonia

Non severe pneumonia

Severe pneumonia

Low mortality

High mortality

Home care

Admit

Mild/moderate pallor

Severe pallor

WAZ <-3SD

2001

Introduction of

Haemophilus influenzae

type B vaccine

2011

Kenya launches

pneumococcal

conjugate vaccine

Cowgill et al 2006, JAMA

Pneumonia aetiology pre-vaccine era

True p eu o ia

Malaria

Dehydration

Bronchiolitis

Anaemia

Pneumonia aetiology pre-vaccine era

True p eu o ia

Malaria

Dehydration

Bronchiolitis

Anaemia

Summary

• Most children hospitalized classified as having non-severe pneumonia (82%) presented with ≥ risk factor associated with an increased risk of death.

• Mortality in children with non-severe pneumonia was substantially higher for those presenting with WAZ <-3SD or pallor

• Current WHO criteria defining pneumonia leave out some important factors associated with poor outcome.

• Findings suggest that clinicians should treat the WHO criteria as but one factor to consider in clinical decision-making.

Thanks to………………..

Clinical Information Network partners include: Vihiga County Hospital, Kakamega County Hospital,

Mbagathi County Hospital, Mama Lucy Kibaki County Hospital, Machakos County Hospital, Nyeri

County Hospital, Kisumu East County Hospital, Embu County Hospital, Karatina County Hospital,

Kerugoya County Hospital, Kitale County Hospital, Busia County Hospital, Kiambu County Hospital,

Mbale RHTC , Pumwani Maternity Hospital