Managing children with pneumonia symptoms in malaria endemic Uganda

Background: Pneumonia is one of the leading killers of children under five years of age. In sub-Saharan Africa, symptoms of pneumonia often overlap with those of malaria. While many countries have made public commitments to improve malaria management, similar efforts for pneumonia are lacking. The overlap of symptoms between pneumonia and malaria, in combination with more efforts for appropriate malaria management, raises worries that pneumonia cases are being mismanaged. More information is needed on how caretakers and health workers respond to children with pneumonia symptoms. Main objective: To explore caretakers and health care providers understanding and response to children with symptoms of pneumonia in order to identify issues that need to be addressed for improved management of children with acute febrile illness. Methods: A triangulation of a qualitative community study with mothers, traditional healers and health workers (I), two hospital based studies with structured interviews with caretakers of children with symptoms or diagnosis of severe pneumonia (II, IV) and a mixed qualitative-quantitative community study with verbal and social autopsies with caretakers of children deceased in acute febrile illness (III) was done. To compare stated drug use with blood drug concentrations, blood samples were collected on filter papers (IV). Qualitative interviews were analyzed using content analysis (I, III). Blood drug concentrations of sulfamethoxazole, chloroquine and sulfadoxine were analyzed using high performance liquid chromatography methods (IV). Results: Many terminologies were used to refer to symptoms of pneumonia (I). Mothers tended to interpret any febrile condition as malaria and stated differing preferred care-seeking actions for difficult/rapid breathing in their children (I). Severe pneumonia developed two days after first recognition of difficult/rapid breathing (II). Half of the children diagnosed with severe pneumonia had seen another health care provider prior to arrival at a hospital (II). Barriers to adequate management of a child with fatal acute febrile illness (III) included: Illness interpretation barriers - when care was delayed or inappropriate due to caretakers interpretation of illness; Barriers to seeking care involving gender roles and household financial constraints; and Barriers to receiving adequate treatment revealing caretakers discontents with providers and possible deficiencies in quality of care. Positive and negative predictive values for caretakers reports of drug intake for the child s acute illness were 67% and 64% for sulfamethoxazole, 69% and 52% for chloroquine and 85% and 62% for sulfadoxine, respectively (IV). Many caretakers could not name the drug given to the child, and more so if treated in a health facility than in the home (RR 2.6 (1.2-5.6)) (IV). Discussion: There is a need to find ways to encourage caretakers to seek immediate and appropriate care after recognition of key pneumonia symptoms. Ideally, adequate antibiotic treatment should be provided close to where people live and one option is to allow community health workers to diagnose and treat pneumonia in addition to malaria. Quality of care must be improved in the whole health care chain, public as well as private. Health care providers need to be aware of key pneumonia symptoms, appropriate biomedical treatment for these symptoms, and the common co-existence of pneumonia and malaria symptoms