Acute Respiratory Infection and Pneumonia in India: A Systematic Review of Literature for Advocacy and Action: UNICEF-PHFI Series on Newborn and Child Health, India.

Background: Scaling up of evidence-based management of childhood acute respiratory infection/pneumonia, is a public health priority in India, and necessitates robust literature review, for advocacy and action. Objective: To identify, synthesize and summarize current evidence to guide scaling up of management of childhood acute respiratory infection/pneumonia in India, and identify existing knowledge gaps. Methods: A set of ten questions pertaining to the management (prevention, treatment, and control) of childhood ARI/ pneumonia was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. Results: Childhood ARI/pneumonia is a significant public health problem in India, although robust epidemiological data is not available on its incidence. Mortality due to pneumonia accounts for approximately one-fourth of the total deaths in under five children, in India. Pneumonia affects children irrespective of socioeconomic status; with higher risk among young infants, malnourished children, non-exclusively breastfed children and those with exposure to solid fuel use. There is lack of robust nation-wide data on etiology; bacteria (including Pneumococcus, H. influenzae, S. aureus and Gram negative bacilli), viruses (especially RSV) and Mycoplasma, are the common organisms identified. In-vitro resistance to cotrimoxazole is high. Wheezing is commonly associated with ARI/pneumonia in children, but difficult to appreciate without auscultation. The current WHO guidelines as modified by IndiaCLEN Task force on Penumonia (2010), are sufficient for case-management of childhood pneumonia. Other important interventions to prevent mortality are oxygen therapy for those with severe or very severe pneumonia and measles vaccination for all infants. There is insufficient evidence for protective or curative effect of vitamin A; zinc supplementation could be beneficial to prevent pneumonia, although it has no therapeutic benefit. There is insufficient evidence on potential effectiveness and cost-effectiveness of Hib and Pneumococcal vaccines on reduction of ARI specific mortality. Case-finding and community-based management are effective management strategies, but have low coverage in India due to policy and programmatic barriers. There is a significant gap in the utilization of existing services, provider practices as well as family practices in seeking care. Conclusion: The systematic review summarizes current evidence on childhood ARI and pneumonia management and provides evidence to inform child health programs in India.

Acute Respiratory Infection: Boston University’s Collaborative Research Work in the Last Decade.

In the last decade, Boston University, in collaboration with the Child and Adolescent Health Division of the World Health Organization (WHO), has conducted a number of multi-center clinical trials aimed at reducing the childhood mortality associated with acute respiratory infections (ARI). These studies have addressed questions of program relevance and challenges faced by implementing WHO case management guidelines. The spectrum of research studies has extended from endorsing WHO guidelines for using antibiotics in all children with fast breathing to evaluation of ARI guidelines for management of severe pneumonia. Research priorities have included assessing the capacity of community health workers to provide appropriate early treatment to children with pneumonia and to manage both pneumonia and malaria in countries with a dual burden of these childhood illnesses. These contributions are likely to have a long lasting impact on reducing the mortality and morbidity associated with childhood pneumonia.