Conclusions: Promises and Pitfalls
The evidence clearly shows that the WHO case-management approach and the wider use of available vaccines will reduce ARI mortality among young children by half to two-thirds. The systematic application of simplified case management alone, the cost of which is low enough to be affordable by almost any developing country, will reduce ARI mortality by at least one-third. The urgent need is to translate this information into actual implementation.
The case-management strategy has to be applied and prospectively evaluated so that emerging problems of antimicrobial resistance, reduced efficacy of current treatment with the recommended antimicrobials, or emergence of unexpected pathogens can be detected early and remedial steps can be taken rapidly. If community-level action by health workers is supplemented by the introduction of the IMCI strategy at all levels of primary care, then both applying and evaluating this strategy will be easier. Such synergy may also help in gathering information that will help further fine-tune clinical signs, so that even village health workers can better distinguish bronchiolitis and wheezing from bacterial pneumonia. The criticism that the case-management steps may result in overuse of antimicrobials should be countered by documenting their current overuse and incorrect use by doctors and other health workers. Although there is a resurgent interest in basing interventions at the community level, our analysis suggests that doing so may not be cost-effective. Indeed, ARI case management at the first-level facility may still be the most cost-effective when coupled with better care-seeking behavior interventions.
The international medical community is only beginning to appreciate the potential benefits of Hib and pneumococcal vaccines. They are currently expensive compared with Expanded Program on Immunization vaccines, but the price of Hib vaccine may fall with the entry of more manufacturers into the market in the next few years. Nevertheless, convincing evidence of the vaccines' cost-effectiveness is required to facilitate national decisions on introducing the vaccine and using it sustainedly. In low-income countries, positive cost-benefit and cost-effectiveness ratios alone appear to be insufficient to enable the introduction of these vaccines into national immunization programs.
