Implementation of ARI Control Strategies: Lessons of Experience
The lessons of ARI prevention and control strategies that have been implemented by national programs include the vaccination and case-management strategies discussed below.
Vaccine Strategies
Hib vaccine was introduced into the routine infant immunization schedule in North America and Western Europe in the early 1990s. With the establishment of the Global Alliance for Vaccines and Immunization (GAVI) and the Vaccine Fund, progress is being made in introducing it in developing countries, although major hurdles remain. By 2002, only 84 of the 193 WHO member nations had introduced Hib vaccine. Five countries have since been approved for support from GAVI for Hib vaccine introduction in 2004-5.
The United States added 7-PCV to the infant immunization program in 2000. Several other industrialized countries have plans to introduce the vaccine into their national immunization programs in 2005, whereas others recommend the use of the vaccine only in selected high-risk groups. In some of these last countries, the definition of high risk is quite broad and includes a sizable proportion of all infants. The currently licensed 7-PCV lacks certain serotypes important in developing countries, but the 9-PCV and 11-PCV would cover almost 80 percent of serotypes that cause serious disease worldwide.
Despite the success of Hib vaccine in industrial countries and the generally appreciated importance of LRIs as a cause of childhood mortality, as a result of a number of interlinked factors, uptake in developing countries has been slow. Sustained use of the vaccine is threatened in a few of the countries that have introduced the vaccine. First, the magnitude of disease and death caused by Hib is not recognized in these countries, partly because of their underuse of bacteriological diagnosis (a result of the lack of facilities and resources). Second, because the coverage achieved with traditional Expanded Program on Immunization vaccines remains low in many countries, adding more vaccines has not been identified as a priority. Third, developing countries did not initiate efforts to establish the utility of the vaccine until after the vaccine had been licensed and used routinely for several years in industrialized countries. Consequently, Hib vaccination has been perceived as an intervention for rich countries. As a result of all these factors, actual demand for the vaccine has remained low, even when support has been available through GAVI and the Vaccine Fund.
In 2004, the GAVI board commissioned a Hib task force to explore how best to support national efforts to make evidence-based decisions about introducing the Hib vaccine. On the basis of the task force's recommendations, the GAVI board approved establishment of the Hib Initiative to support those countries wishing either to sustain established Hib vaccination or to explore whether introducing Hib vaccine should be a priority for their health systems. A consortium consisting of the Johns Hopkins Bloomberg School of Public Health, the London School of Hygiene and Tropical Medicine, the Centers for Disease Control and Prevention, and the WHO has been selected to lead this effort.
Case-Management Strategies
Sazawal and Black's (2003) meta-analysis of community-based trials of the ARI case-management strategy includes 10 studies that assessed its effects on mortality, 7 with a concurrent control group. The meta-analysis found an all-cause mortality reduction of 27 percent among neonates, 20 percent among infants, and 24 percent among children age one to four. LRI-specific mortality was reduced by 42, 36, and 36 percent, respectively. These data clearly show that relatively simplified, but standardized, ARI case management can have a significant effect on mortality, not only from pneumonia, but also from other causes in children from birth to age four. Currently, the ARI case-management strategy has been incorporated into the IMCI strategy, which is now implemented in more than 80 countries (see chapter 63).
Despite the huge loss of life to pneumonia each year, the promise inherent in simplified case management has not been successfully realized globally. One main reason is the underuse of health facilities in countries or communities in which many children die from ARIs. In Bangladesh, for example, 92 percent of sick children are not taken to appropriate health facilities (WHO 2002). In Bolivia, 62 percent of children who died had not been taken to a health care provider when ill (Aguilar and others 1998). In Guinea, 61 percent of sick children who died had not been taken to a health care provider (Schumacher and others 2002). Schellenberg and others' (2003) study in Tanzania shows that children of poorer families are less likely to receive antibiotics for pneumonia than children of better-off families and that only 41 percent of sick children are taken to a health facility. Thus, studies consistently confirm that sick children, especially from poor families, do not attend health facilities.
A number of countries have established large-scale, sustainable programs for treatment at the community level:
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The Gambia has a national program for community-level management of pneumonia (WHO 2004b).
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In the Siaya district of Kenya, a nongovernmental organization efficiently provides treatment by community health workers for pneumonia and other childhood diseases (WHO 2004b).
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In Honduras, ARI management has been incorporated in the National Integrated Community Child Care Program, whereby community volunteers conduct growth monitoring, provide health education, and treat pneumonia and diarrhea in more than 1,800 communities (WHO 2004b).
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In Bangladesh, the Bangladesh Rural Advancement Committee and the government introduced an ARI control program covering 10 subdistricts, using volunteer community health workers. Each worker is responsible for treating childhood pneumonia in some 100 to 120 households after a three-day training program.
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In Nepal during 1986-89, a community-based program for management of ARIs and diarrheal disease was tested in two districts and showed substantial reductions in LRI mortality (Pandey and others 1989, 1991). As a result, the program was integrated into Nepal's health services and is being implemented in 17 of the country's 75 districts by female community health volunteers trained to detect and treat pneumonia.
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In Pakistan, the Lady Health Worker Program employs approximately 70,000 women, who work in communities providing education and management of childhood pneumonia to more than 30 million people (WHO 2004b).
