Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study

Kanyuka, Mercy; Ndawala, Jameson; Mleme, Tiope; Chisesa, Lusungu; Makwemba, Medson; Amouzou, Agbessi; Borghi, Josephine; Daire, Judith; Ferrabee, Rufus; Hazel, Elizabeth; Heidkamp, Rebecca; Hill, Kenneth; Álvarez, Melisa Martínez; Mgalula, Leslie; Munthali, Spy; Nambiar, Bejoy; Nsona, Humphreys; Park, Lois; Walker, Neff; Daelmans, Bernadette; Bryce, Jennifer; Colbourn, Tim

doi:10.1016/s2214-109x(15)00294-6

Cited by 119 publications

(138 citation statements)

References 21 publications

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“…Malawi is a small landlocked country in southern Africa. Despite being one of the poorest countries in the world [2] it has achieved Millennium Development Goal (MDG) 4, a two-thirds reduction in under-5 child mortality [3]. …”

Section: Introductionmentioning

confidence: 99%

Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

et al. 2016

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BackgroundPneumonia is the leading infectious cause of under-5 mortality in sub-Saharan Africa. Clinical prediction tools may aide case classification, triage, and allocation of hospital resources. We performed an external validation of two published prediction tools and compared this to a locally developed tool to identify children admitted with pneumonia at increased risk for in-hospital mortality in Malawi.MethodsWe retrospectively analyzed the performance of the Respiratory Index of Severity in Children (RISC) and modified RISC (mRISC) scores in a child pneumonia dataset prospectively collected during routine care at seven hospitals in Malawi between 2011–2014. RISC has both an HIV-infected and HIV-uninfected tool. A local score (RISC-Malawi) was developed using multivariable logistic regression with missing data multiply imputed using chained equations. Score performances were assessed using c-statistics, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood statistics.Results16,475 in-patient pneumonia episodes were recorded (case-fatality rate (CFR): 3.2%), 9,533 with complete data (CFR: 2.0%). The c-statistic for the RISC (HIV-uninfected) score, used to assess its ability to differentiate between children who survived to discharge and those that died, was 0.72. The RISC-Malawi score, using mid-upper arm circumference as an indicator of malnutrition severity, had a c-statistic of 0.79. We were unable to perform a comprehensive external validation of RISC (HIV-infected) and mRISC as both scores include parameters that were not routinely documented variables in our dataset.ConclusionIn our population of Malawian children with WHO-defined pneumonia, the RISC (HIV-uninfected) score identified those at high risk for in-hospital mortality. However the refinement of parameters and resultant creation of RISC-Malawi improved performance. Next steps include prospectively studying both scores to determine if incorporation into routine care delivery can have a meaningful impact on in-hospital CFRs of children with WHO-defined pneumonia.

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Section: Introductionmentioning

confidence: 99%

Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

et al. 2016

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“…For example the Integrated Management of Neonatal and Childhood Illness (IMNCI) from the WHO19 is a large-scale algorithm-based strategy, the scale up of which was thought to be a key factor in Malawi reaching Millennium Development Goal 4 20. A recent Cochrane review,21 however, presented only moderate evidence that IMNCI ‘may reduce infant mortality’ and the strategy was difficult to evaluate because it employs multiple interventions across facility, primary care and community settings.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of ‘TRY’: an algorithm for neonatal continuous positive airways pressure in low-income settings

et al. 2018

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“…The incidence of malaria, which can also overlap with pneumonia [31], to the best of our knowledge, did not change during the study period. The coverage of the Hib vaccine also remained high and stable at around 93% during the study period [33]. These two potential confounding factors therefore are unlikely to have contributed to the observed reductions in pneumonia incidence and mortality.…”

Section: Discussionmentioning

confidence: 99%

Impact of the 13-Valent Pneumococcal Conjugate Vaccine on Clinical and Hypoxemic Childhood Pneumonia over Three Years in Central Malawi: An Observational Study

et al. 2017

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BackgroundThe pneumococcal conjugate vaccine’s (PCV) impact on childhood pneumonia during programmatic conditions in Africa is poorly understood. Following PCV13 introduction in Malawi in November 2011, we evaluated the case burden and rates of childhood pneumonia.Methods and FindingsBetween January 1, 2012-June 30, 2014 we conducted active pneumonia surveillance in children <5 years at seven hospitals, 18 health centres, and with 38 community health workers in two districts, central Malawi. Eligible children had clinical pneumonia per Malawi guidelines, defined as fast breathing only, chest indrawing +/- fast breathing, or, ≥1 clinical danger sign. Since pulse oximetry was not in the Malawi guidelines, oxygenation <90% defined hypoxemic pneumonia, a distinct category from clinical pneumonia. We quantified the pneumonia case burden and rates in two ways. We compared the period immediately following vaccine introduction (early) to the period with >75% three-dose PCV13 coverage (post). We also used multivariable time-series regression, adjusting for autocorrelation and exploring seasonal variation and alternative model specifications in sensitivity analyses.The early versus post analysis showed an increase in cases and rates of total, fast breathing, and indrawing pneumonia and a decrease in danger sign and hypoxemic pneumonia, and pneumonia mortality. At 76% three-dose PCV13 coverage, versus 0%, the time-series model showed a non-significant increase in total cases (+47%, 95% CI: -13%, +149%, p = 0.154); fast breathing cases increased 135% (+39%, +297%, p = 0.001), however, hypoxemia fell 47% (-5%, -70%, p = 0.031) and hospital deaths decreased 36% (-1%, -58%, p = 0.047) in children <5 years. We observed a shift towards disease without danger signs, as the proportion of cases with danger signs decreased by 65% (-46%, -77%, p<0.0001). These results were generally robust to plausible alternative model specifications.ConclusionsThirty months after PCV13 introduction in Malawi, the health system burden and rates of the severest forms of childhood pneumonia, including hypoxemia and death, have markedly decreased.

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Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study

Abstract: Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.

Cited by 119 publications

References 21 publications

Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi

Evaluation of ‘TRY’: an algorithm for neonatal continuous positive airways pressure in low-income settings

Impact of the 13-Valent Pneumococcal Conjugate Vaccine on Clinical and Hypoxemic Childhood Pneumonia over Three Years in Central Malawi: An Observational Study

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