Treating children with severe pneumonia at home is just as effective as treating them in hospitals

The study results could significantly change the way the illness is managed in developing countries, saving a significant number of lives every year and taking pressure off health systems.

The research, conducted in Pakistan by researchers from the Boston University School of Public Health and supported by WHO and the U.S. Agency for International Development (USAID), is published this week in The Lancet medical journal. It involved 2037 children with severe pneumonia who were randomly assigned to get either injectable antibiotics in a hospital or antibiotic pills at home. The trial was the first to compare the outcomes of hospital treatment of severe pneumonia with home-based treatment, and the results demonstrate the safety and efficacy of treating it with oral antibiotics outside of a hospital setting.

Pneumonia is the largest single killer of children under five around the world. Almost four children die from pneumonia every minute. About 60% of pneumonia cases in the developing world are caused by bacteria and can be treated with antibiotics, whereas most cases of pneumonia in developed countries are viral.

In the study, there were 87 (8.6%) treatment failures in the hospitalized group, and 77 (7.5%) in the group treated at home. Of the five children (0.2%) who died during the study, four were in the hospitalized group and one was at home.

This study confirmed the findings of three other trials in Africa, Asia, Europe and Latin America, which showed that oral antibiotics were just as effective as injectable antibiotics in treating hospitalized children with severe pneumonia.

Far-reaching implications

"The potential impact of these results is enormous," said the article's co-author Dr Shamim Qazi, Medical Officer with the WHO's Department of Child and Adolescent Health and Development. "Effective management of pneumonia is critical to improving child survival. Being able to treat children with severe pneumonia safely and effectively in their own homes would be of huge benefit to both families and health systems, by reducing the need for admission to hospital. We will be updating WHO guidelines in 2008 to reflect this new evidence."

“This confirmatory research in Pakistan, when implemented into programmes around the globe, will increase access to critical care in disadvantaged communities and support the potential to diagnose and treat severe pneumonia by community health workers,” said Dr Alfred Bartlett, Senior Advisor for Child Survival, USAID. “These findings promise to build upon an existing approach endorsed by WHO and UNICEF, for treatment of non-severe pneumonia, that is already contributing to the achievement of the Millennium Development Goals.”

The current guidelines advise health workers to provide oral antibiotics for cases of non-severe pneumonia and to refer severe and very severe cases to hospitals for treatment with antibiotics by injection. However, many children with severe pneumonia who are currently referred for admission to a hospital either die before they reach there or are so sick by the time they arrive that nothing more can be done to save them.

A small number of cases of very severe pneumonia (around 2-3% of all pneumonia cases) will still require treatment with injectable antibiotics in a hospital.

Families in the poorest countries, where the majority of children are affected by pneumonia, may not have easy access to hospitals. In-patient treatment may not be an option for parents who cannot leave their homes to accompany the sick child. In addition, children with severe pneumonia are vulnerable to infections as a result of weak immunity and could be at increased risk in crowded hospital wards. A community-based approach would bring treatment to people's homes, so that children with pneumonia can be identified and begin treatment before the onset of life-threatening complications.