WHO PSBI guidelines Summary of evidence from 11 demonstration sites - - PowerPoint PPT Presentation

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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Implementation research on WHO PSBI guidelines

Summary of evidence from 11 demonstration sites

PSBI Community of Practice Webinar 28 Feb 2019

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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Questions

• 1. Can we achieve up to 80% of coverage of appropriate treatment for all

young infants with PSBI irrespective of place of treatment? (Coverage)

• 2. Compared to the previous referral refusal rates to the hospital, did the

referral refusal rates increase when offered OPD treatment? (unintended consequences)

• 3. Did the death rate increase after implementation of WHO PSBI guideline

in programme setting compared to the death rate in systematic review? (safety)

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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Implementation research

⚫ 11 sites in six countries

– 6 sites in Africa – DRC (1 site), Ethiopia (2 sites), Malawi (1 site) and Nigeria (2 sites). – 5 sites in Asia – Pakistan, India (4 sites)

⚫ Implemented in programme setting at district or sub-district level ⚫ Technical support (as TSU) was provided either by academic institute or by NGOs at each site. ⚫ Based on TSU involvement in implementation of PSBI guidelines, sites are stratified into two groups for this analysis – high and low

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• 1. Can we achieve up to 80% of coverage of appropriate

treatment for all young infants with PSBI irrespective of place

• f treatment? (Coverage*)

Yes 79% No 21%

*Malawi data was excluded from this analysis

Heterogeneity between groups: p = 0.000 Overall (I^2 = 98.79%, p = 0.00); site HP DRC Subtotal (I^2 = 96.52%, p = 0.00) Low TSU involvement Lucknow Subtotal (I^2 = .%, p = .) Palwal Mekelle Jimma Pune Ibadan High TSU involvement Pakistan Zaria 0.79 (0.72, 0.86) ES (95% CI) 0.67 (0.57, 0.75) 0.95 (0.93, 0.96) 0.72 (0.66, 0.79) 0.73 (0.70, 0.76) 0.94 (0.91, 0.97) 0.71 (0.65, 0.77) 0.63 (0.61, 0.66) 0.78 (0.75, 0.81) 0.70 (0.61, 0.77) 0.91 (0.89, 0.93) 0.82 (0.81, 0.84) 0.96 (0.94, 0.98) 100.00 Weight 9.00 10.33 69.03 10.23 30.97 9.76 10.25 10.21 9.24 % 10.32 10.34 10.32 0.79 (0.72, 0.86) ES (95% CI) 0.67 (0.57, 0.75) 0.95 (0.93, 0.96) 0.72 (0.66, 0.79) 0.73 (0.70, 0.76) 0.94 (0.91, 0.97) 0.71 (0.65, 0.77) 0.63 (0.61, 0.66) 0.78 (0.75, 0.81) 0.70 (0.61, 0.77) 0.91 (0.89, 0.93) 0.82 (0.81, 0.84) 0.96 (0.94, 0.98) 100.00 Weight 9.00 10.33 69.03 10.23 30.97 9.76 10.25 10.21 9.24 % 10.32 10.34 10.32

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Accepted referral 26% Refused referral & accepted OPD treatment 71% Refused all treatment 3%

• 2. Compared to the previous referral refusal rates to the

hospital, did the referral refusal rates increase when offered OPD treatment? (unintended consequences)

Study Refusal rate Bhandari et al India, Lancet 1996 76% Bang et al India, Lancet 1999 98% Baqui et al Bangladesh, Lancet 2008 68% Zaidi et al Pakistan: PIDJ 2012 78% Baqui et al SATT Bangladesh Lancet GH 2015 84% DR Congo AFRINEST, Lancet 2015 71% Kenya AFRINEST, Lancet 2015 89% Nigeria AFRINEST, Lancet 2015 78%

Young infants 7-59 d with fast breathing cases were excluded from this analysis

In high TSU involvement countries referral refusal rate was 86%

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• 3. Did the death rate increase after implementation of WHO

PSBI guideline in programme setting compared to the death rate in AFRINEST/SATT studies? (safety)

Survived 98% Died 2% Study Death rates AFRINEST Lancet 2015 1.3% SATT Pakistan, LANCET GH 2016 1.5% SATT Bangladesh Lancet GH 2015 1.6%

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Questions related to programmatic issues

• 4. What proportion of identified livebirths were visited by CHWs at least
• nce in their first week of life?
• 5. What proportion of sick young infants brought to PHC were identified

by CHWs at home?

• 6. What proportion of young infants with PSBI treated on OPD basis had

day 4 follow up?

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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• 4. What proportion of identified livebirths were visited

by CHWs at least once in their first week of life?

At least 1 postnatal visit in first week of life 78% No postnatal visit in first week of life 22%

Heterogeneity between groups: p = 0.121 Overall (I^2 = 99.88%, p = 0.00); Zaria Malawi DRC Subtotal (I^2 = .%, p = .) Subtotal (I^2 = 99.90%, p = 0.00) High TSU involvement Lucknow Pakistan HP Palwal Jimma Low TSU involvement Mekelle Ibadan Pune site 0.78 (0.69, 0.87) 0.95 (0.94, 0.96) 0.60 (0.56, 0.64) 0.91 (0.90, 0.92) 0.87 (0.76, 0.98) 0.74 (0.62, 0.86) 0.79 (0.78, 0.79) 0.98 (0.97, 0.98) 0.91 (0.89, 0.92) 0.49 (0.46, 0.51) 0.39 (0.37, 0.40) 0.94 (0.93, 0.94) 0.75 (0.74, 0.77) 0.86 (0.85, 0.88) ES (95% CI) 100.00 9.12 8.95 9.11 27.34 72.66 9.12 9.12 9.09 9.07 9.10 9.12 9.11 9.09 Weight % 0.78 (0.69, 0.87) 0.95 (0.94, 0.96) 0.60 (0.56, 0.64) 0.91 (0.90, 0.92) 0.87 (0.76, 0.98) 0.74 (0.62, 0.86) 0.79 (0.78, 0.79) 0.98 (0.97, 0.98) 0.91 (0.89, 0.92) 0.49 (0.46, 0.51) 0.39 (0.37, 0.40) 0.94 (0.93, 0.94) 0.75 (0.74, 0.77) 0.86 (0.85, 0.88) ES (95% CI) 100.00 9.12 8.95 9.11 27.34 72.66 9.12 9.12 9.09 9.07 9.10 9.12 9.11 9.09 Weight %

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TITLE from VIEW and SLIDE MASTER | 01 March 2019

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• 5. What proportion of sick young infants brought to

PHC were identified by CHWs at home?

Identified by CHWs 52% Identified by family member 48%

Heterogeneity between groups: p = 0.001 Overall (I^2 = 99.80%, p = 0.00); DRC Ibadan HP site Jimma Low TSU involvement Subtotal (I^2 = 99.73%, p = 0.00) Malawi Lucknow Mekelle Pune High TSU involvement Subtotal (I^2 = .%, p = .) Pakistan Zaria Palwal 0.52 (0.34, 0.70) 0.77 (0.75, 0.79) 0.94 (0.93, 0.95) 0.32 (0.25, 0.40) ES (95% CI) 0.11 (0.08, 0.15) 0.39 (0.14, 0.64) 0.11 (0.04, 0.22) 0.91 (0.89, 0.93) 0.28 (0.23, 0.34) 0.75 (0.67, 0.82) 0.87 (0.77, 0.96) 0.40 (0.37, 0.42) 0.89 (0.87, 0.91) 0.22 (0.18, 0.27) 100.00 9.14 % 9.15 9.00 Weight 9.12 72.57 8.98 9.14 9.07 9.02 27.43 9.14 9.14 9.09 0.52 (0.34, 0.70) 0.77 (0.75, 0.79) 0.94 (0.93, 0.95) 0.32 (0.25, 0.40) ES (95% CI) 0.11 (0.08, 0.15) 0.39 (0.14, 0.64) 0.11 (0.04, 0.22) 0.91 (0.89, 0.93) 0.28 (0.23, 0.34) 0.75 (0.67, 0.82) 0.87 (0.77, 0.96) 0.40 (0.37, 0.42) 0.89 (0.87, 0.91) 0.22 (0.18, 0.27) 100.00 9.14 % 9.15 9.00 Weight 9.12 72.57 8.98 9.14 9.07 9.02 27.43 9.14 9.14 9.09

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TITLE from VIEW and SLIDE MASTER | 01 March 2019

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• 6. What proportion of young infants with PSBI treated
• n OPD basis had day 4 mandatory follow up?

Day 4 follow up was done 93% Day 4 follow up was not done 7%

Heterogeneity between groups: p = 0.495 Overall (I^2 = 93.53%, p = 0.00); DRC Jimma Lucknow Low TSU involvement Ibadan Pakistan Pune Mekelle Subtotal (I^2 = .%, p = .) site Malawi High TSU involvement Palwal Zaria HP Subtotal (I^2 = 93.36%, p = 0.00) 0.93 (0.91, 0.96) 0.97 (0.95, 0.99) 0.96 (0.95, 0.98) 0.98 (0.97, 0.99) (Excluded) 0.90 (0.88, 0.92) 0.86 (0.42, 1.00) 0.99 (0.98, 1.00) 0.95 (0.93, 0.97) ES (95% CI) 0.98 (0.95, 0.99) 0.72 (0.60, 0.81) 0.86 (0.81, 0.89) 0.63 (0.45, 0.79) 0.94 (0.91, 0.97) 100.00 13.31 13.66 13.99 . 12.99 0.97 14.06 24.03 Weight 13.31 4.71 % 10.72 2.29 75.97 0.93 (0.91, 0.96) 0.97 (0.95, 0.99) 0.96 (0.95, 0.98) 0.98 (0.97, 0.99) (Excluded) 0.90 (0.88, 0.92) 0.86 (0.42, 1.00) 0.99 (0.98, 1.00) 0.95 (0.93, 0.97) ES (95% CI) 0.98 (0.95, 0.99) 0.72 (0.60, 0.81) 0.86 (0.81, 0.89) 0.63 (0.45, 0.79) 0.94 (0.91, 0.97) 100.00 13.31 13.66 13.99 . 12.99 0.97 14.06 24.03 Weight 13.31 4.71 % 10.72 2.29 75.97

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Association of mortality with clinical signs assessed at home and at facility

In-depth analysis of AFRINEST data

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Prevalence and mortality rates by clinical signs: CHWs’ assessment

Local infection, 21% High body temperature , 18% Chest indrawing, 9% Fast breathing in 0-6 days, 11% Low body temperature, 7% Feeding poorly

• r no feeding

at all, 2% Movement

• nly when

stimulated or no movement at all, <1% Convulsions, <1% ≥2/7 signs of PSBI, 7% Clinical sign Mortality (%) Local infection 0.2% Fast breathing 7-59 days 0.4% High body temperature 0.9% Chest indrawing 0.9% Fast breathing 0-6 days 1.0% Low body temperature 4.3% Not able to feed at all or not feeding well 6.5% Movement only when stimulated or no movement at all 8.7% Convulsions

• > 2/7 signs of PSBI (Excluding fast

breathing 7-59 days & local infection) 13.8%

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Fast breathing only in 7-59 d 26% High body temperature 20% Chest indrawing 19% Fast breathing

• nly in 0-6 days

18% Low body temperature 3% Not able to feed at all or not feeding well 4% Movement only when stimulated

• r no movement at

all 1% Convulsions 1% ≥2/7 signs of PSBI 8%

Prevalence and mortality rates by clinical signs: IMCI trained workers’ assessment (1)

Clinical sign Mortality (%) Fast breathing 7-59 days 0.2% High body temperature 0.8% Chest indrawing 0.9% Fast breathing 0-6 days 1.9% Low body temperature 11.0% Not able to feed at all or not feeding well 6.3% Movement only when stimulated or no movement at all 9.3% Convulsions 11.3% > 2/7 signs of PSBI (Excluding fast breathing 7-59 days) 6.5%

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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Fast breathing in 7- 59 d 26% High body temperarure 20% Chest indrawing 19% Fast breathing in 0-6d 18% Low body temperature 3% Not feeding well 4% Not able to feed at all 1% Movement

• nly when

stimulated 0% No movement at all 0% Convulsions 1% ≥2/7 signs of PSBI 8% Clinical sign Mortality (%) Fast breathing 7-59 days 0.2% High body temperature 0.8% Chest indrawing 0.9% Fast breathing 0-6 days 1.9% Movement only when stimulated 3.2% Not feeding well 4.0% Low body temperature 11.0% Convulsions 11.3% Not able to feed at all 22.9% No movement at all 25.0% > 2/7 signs of PSBI (Excluding fast breathing 7-59 days) 6.5%

Prevalence and mortality rates by clinical signs: IMCI trained health workers’ assessment (2)

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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Fast breathing in 7-59 d High body temperarure Chest indrawing Fast breathing in 0-6d Movement

• nly when

stimulated Not feeding well Low body temperature ≥2/6 signs of clinical severe infection ≥1/3 signs of critical illness

Interpretation of findings of IMCI trained workers’ assessment

Mortality 0.2% Mortality 16.9% Mortality 1.2% Mortality 3.9% Mortality 6.5% Mortality 11.0%

Mortality Prevalence

6 signs of clinical severe infection:

• 1. High body temperature
• 2. Chest indrawing
• 3. Fast breathing 0-6d
• 4. Movement only when stimulated
• 5. Not feeding well
• 6. Low body temperature

3 signs of critical illness:

• 1. Convulsions
• 2. No movement at all
• 3. Not feeding at all

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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Fast breathing in 7-59 d High body temperarure Chest indrawing Fast breathing in 0-6d Movement

• nly when

stimulated Not feeding well ≥2/5 signs of clinical severe infection ≥1/4 signs of critical illness

Moving low body temperature to critical illness

Mortality 12.3% Prevalence: 8% Mortality 3.8% Prevalence: 5%

Prevalence Mortality

5 signs of clinical severe infection:

• 1. High body temperature
• 2. Chest indrawing
• 3. Fast breathing 0-6d
• 4. Movement only when stimulated
• 5. Not feeding well
• 6. Low body temperature

4 signs of critical illness:

• 1. Convulsions
• 2. No movement at all
• 3. Not feeding at all
• 4. Low body temperature

Mortality 0.2% Mortality 1.2% Mortality 3.9%

TITLE from VIEW and SLIDE MASTER | 01 March 2019

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Conclusions

Based on IMCI trained workers’ assessment:

– Fast breathing in 7-59 days old young infants had the highest prevalence and the lowest mortality rate – Among seven signs of PSBI, high body temperature had the lowest mortality rate, followed by chest indrawing and fast breathing in 0-6 days old young infants. – Signs of critical illness (convulsions, no movement at all or not feeding at all) had the lowest prevalence and the highest mortality rate. – Among six signs of clinical severe infection, low body temperature had the highest mortality rates.