Proceedings Report

National Consultation on
Childhood ARI Case Management:
Translating Research to
Policy and Program
 Proceedings Report

National Consultation on
Childhood ARI Case Management:
Translating Research to
Policy and Program
New Delhi
February 25, 2009
Design and Print:
New Concept Information Systems Pvt. Ltd
E-mail: communication@newconceptinfosys.com
Website: www.newconceptinfosys.com
 PREFACE
The burden of childhood pneumonia, particularly in India, is undeniably and unacceptably
high. Preventing children from contracting pneumonia is essential for reducing child deaths. Key
prevention measures include promoting exclusive breastfeeding and appropriate complementary
feeding, improving immunization rates, reducing indoor air pollution, etc. Recognition of the
signs and symptoms of pneumonia at the peripheral level, coupled with an equitable and timely
access to a full-course of appropriate antibiotic therapy are life-saving measures. Because
pneumonia kills more children than any other illness, any effort to improve overall child survival
must address the reduction of pneumonia-related death toll on a priority basis.

Globally, and at the national level, a number of research studies are yielding evidence for
improving the case management of childhood acute respiratory infections. This report
summarizes the discussions from a technical consultation organized by IndiaCLEN, with support
from USAID’s MCH-STAR initiative to share the latest evidence on ARI case management so as to
inform program and policy. The technical consultation draws upon the collective technical and
programmatic wisdom of researchers, policymakers, program managers and academics to review
the available research findings in light of the existing policy framework and technical guidelines.

USAID/India and MCH-STAR are committed to supporting efforts that contribute to evidence-
based policy development and dialogue. We hope that the discussions and conclusions from
this meeting will play a useful role in identifying a research agenda for the country on ARI case
management. We also hope that this consultation will facilitate the development of a coalition to
play a sustained leadership role through research and dialogue for reducing pneumonia-related
deaths among children in our country.

Dr. Rajiv Tandon

USAID/India

iii
Contents
Acronyms 4

I. Background 6

II. Proceedings 7

Introductory Session 7

Presentations: Evidence from Global and National Research on Childhood ARI 7

Pneumonia Case Management Guidelines: Evidence from Multi-centric Studies,

Dr. Ashok Patwari, Boston University 8

Preventing Severe Bacterial Pneumonia in South Asian Region,

Dr. Kurien Thomas, Christian Medical College, Vellore 9

Advances on the Treatment of Non Severe Pneumonia (NSP),

Dr. Shally Awasthi, King George’s Medical University, Lucknow 11

Care Seeking Behavior of Mothers: Findings from the IMNCI Baseline

Assessment of Childhood Morbidity and Mortality in Selected Districts in India,
Dr. Narendra Kumar Arora, IndiaCLEN, New Delhi 12

Panel Discussion: Translating Research Finding to Policy and Program 14

1. Possible Evidences that Need to be Incorporated into the Program 14

2. Issues Related to ARI Case Management 14
3. Role of ASHA in ARI Case Management 15
4. Role of the Indian Academy of Pediatrics (IAP) in Improving Treatment of
Pneumonia 16

5. Operations Research Areas and the Pathways to Plug Evidence Gaps 16

III. Next Steps on Taking the Recommendations Forward 17

Annex 1
IV. Agenda 18

Annex 2
V. Participants 19

v
 Acronyms
CEU Clinical Epidemiology Network
CSSM Child Survival and Safe Motherhood Programme
Hib Haemophilus influenzae Type B (vaccine)
IAP Indian Academy of Pediatrics
IndiaCLEN India Clinical Epidemiology Network
IPEN IndiaCLEN Program Evaluation Network
ISCAP IndiaCLEN Short Course Amoxicillin Therapy for Pneumonia
MDGs Millennium Development Goals
NNF National Neonatology Forum
NSP Non-severe pneumonia
UIP Universal Immunization Programme
IMNCI Integrated Management of Neonatal and Childhood Illnesses
USAID United States Agency for International Development
WHO World Health Organization
UNICEF United Nations Children’s Fund
MCH-STAR Maternal Child Health Sustainable Technical Assistance
and Research Initiative
APPIS Amoxicillin Penicillin Pneumonia International Study
NO-SHOTS New Outpatient Short- Course Home Oral Therapy
for Severe Pneumonia
SPEAR Severe Pneumonia Evaluation Antimicrobial Research
SAPNA South Asian Pneumococcal Alliance
IBIS Invasive Bacterial Infections Surveillance
EAG Empowered Action Group
CIHD Centre for International Health and Development
ANM Auxiliary Nurse Midwife
AWW Anganwadi Worker
RCH Reproductive and Child Health
ASHA Accredited Social Health Activist

vi
I. Background
World over, pneumonia kills more children
than AIDS, malaria and measles combined
together, states a report `Pneumonia – The
Forgotten Killer of Children,’ brought out
by the United Nations Children’s Fund
(UNICEF) and World Health Organization
(WHO). The incidence in this age group is six
times higher in developing countries (0.29
episodes per child per year) as compared to
the developed countries (0.05 episodes per
child per year). This translates into about 156
million new episodes each year worldwide,
of which 151 million episodes are in the
developing world. India ranks first in the list,
with around 43 million cases followed by
China (21 million) and Pakistan (10 million)1.
However, of all the cases, only around 7–13%
are severe enough to be life-threatening and
require hospitalization. Substantial evidence
also reveals that the leading risk factors
contributing to pneumonia incidence are lack
of exclusive breastfeeding, undernutrition,
indoor air pollution, low birth weight,
crowding and lack of measles immunization.
While estimates say that pneumonia has
been the single leading cause of childhood
mortality, there is conflicting evidence for
effective childhood acute respiratory infection
(ARI) case management, pertaining to large
differences in case definition of pneumonia
between studies, low specificity of verbal
autopsies in community-based studies,
difficulties in distinguishing pneumonia from
1
Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World
Health Organ. 2008;86:408–16
sepsis in neonates, and the co-existence of
several morbidities leading to a single death,
etc.
In India, ARIs contribute to approximately
40% of all childhood illnesses in India, and
approximately 30% of all childhood deaths.
A number of research studies and pilots
have been conducted or are underway that
can provide strong scientific evidence for
the modification and improvement of case
management of ARIs in children, and thereby
save children’s lives. The India Clinical
Epidemiology Network (IndiaCLEN), with
assistance from USAID’s Maternal and Child
Health Sustainable Technical Assistance and
Research (MCH-STAR) Initiative, organized
a National Consultation on Childhood ARI
Management: Translating Research into
Policy and Programme, in Delhi on February
25, 2009 to deliberate on the latest policy-
relevant evidence on childhood ARI in India
and globally.
The objectives of the national consultation
were:
• To share the latest research findings
pertaining to ARI case management
• To identify and build consensus on
specific research findings with policy and
program implications
• To develop a roadmap for incorporating
specific research findings into the policy
framework.
1
II. Proceedings
Introductory Session
The consultation began with a welcome
note by Dr. Kurien Thomas, President,
IndiaCLEN. He noted the wide participation
at the meeting, representing a range of
stakeholders from the multilateral agencies
(WHO, UNICEF), bilateral agencies and
development partners (USAID, DFID,
and others), academics and researchers
representing a number of medical colleges
and research institutions (ICMR, AIIMS, CMC,
LHMC, UCMS, MAMC, Safdarjung Hospital,
and others), representatives from professional
associations (IAP, NNF) and Government
(Government of India, Government of
Uttar Pradesh).
Dr. Kurien, in his opening speech, reiterated
that the burden of pneumonia2 worldwide
is estimated at 156 million cases per year,
2
Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and Etiology of Childhood Pneumonia. Bull World
Health Organ. 2008;86:408–16
of which 151 million cases occur in the
developing world. Half of these cases are in
India. Of all cases, 7-13% are severe and life
threatening, contributing to nearly 19% of all
deaths in children below five years of age. He
summarized that there is an urgent need to
evaluate global and Indian evidence for case
management of ARIs, which could help in
revisiting existing national policies.
Presentations: Evidence from Global
and National Research on Childhood
ARI
Dr. Rajiv Tandon, Division Chief, Maternal,
Child Health and Nutrition, and Urban
Health, USAID/India, moderator of the
session, congratulated this effort of reviewing
research evidence at this juncture. He
remarked that though there is insufficient
evidence from India to conclusively
3
National Consultation on Childhood ARI Case Management: Translating Research to Policy and Program
determine the best approach for ARI case
management, it is necessary to accept the
available global evidence and contextualize
it within the prevailing diversity of India.
He also stressed that the countdown for the
Millennium Development Goals (MDGs) has
already begun, and there is an urgent need to
move rapidly to achieve them. He highlighted
that every fifth child dies of pneumonia,
which calls for refinement of the existing
policies and an increased program thrust.
Dr. Vijay Kumar from WHO-SEARO served as
Chair of the session. He began by highlighting
the importance of ‘communitization’ of
programs. He emphasized the pertinence
of the third “P” for “People” while striving to
translate policy to programs. He also pointed
that most of the deaths occur among poor
children in urban slum and rural areas and
continue to be a serious impediment to
the achievement of MDG 4 – reduced child
mortality. He shared a few interventions on
standard case management implemented
for more than 20 years on the basis of which
Haemophilus influenza B and pneumococci
conjugate vaccines were added. He also
stressed that much of childhood pneumonia
and ARIs are preventable through exclusive
breastfeeding and complementary feeding,
micronutrient supplementation (vitamin A
and zinc) and reducing indoor air pollution.
4
Pneumonia Case Management
Guidelines: Evidence from
Multi-centric Studies
Dr. Ashok Patwari, Research Professor in
International Health at the School of Public
Health in Boston University (BU) and Senior
Technical Advisor with MCH-STAR Initiative,
briefed about the engagement of the Centre
for International Health and Development
(CIHD), Boston University, in conducting
the policy research pertaining to pneumonia
case management. He gave an overview
of the multi-center clinical trials done at
CIHD to improve ARI case management and
reduce childhood mortality associated with
pneumonia. Dr. Patwari summarized the
evolution of the ARI control program, launched
in late 80s to respond to alarming under-five
mortality on account of pneumonia, the case
classification and choice of anti-microbial
agents based on available evidence followed by
incorporations in guidelines of Child Survival
and Safe Motherhood (CSSM) program, and
later in Reproductive and Child Health (RCH)
and Integrated Management of Neonatal and
Childhood Illnesses (IMNCI). He then raised
some of the common issues pertaining to
Pneumonia Case Management guidelines
which Boston University has addressed by
conducting multi-centric studies in some of
the developing countries.
Dr. Patwari referred to the Boston University
study published in Lancet (Lancet 2004, 363:

1141-48) to address the question of “Can
we replace injections by oral medications
for severe pneumonia?” This randomized
multi-center equivalency study, conducted
by Amoxicillin Penicillin Pneumonia
International Study (APPIS) group, included a
sample size of 1702 children from nine study
sites (8 countries, 3 continents) to look into
oral amoxicillin versus injectable penicillin
for severe pneumonia in children aged
3-59 months. The results showed an equal
treatment failure of 19% and 22% in both the
groups at 48 hours and 5 days respectively.
Thus, the study concluded that injectable
penicillin and oral amoxicillin are equivalent
for severe pneumonia treatment in controlled
settings and there are certain potential
benefits of oral treatment when compared to
injectables, like reduced risk of needle-borne
diseases, need for hospitalization and referral
costs.
With regard to ambulatory treatment for
severe pneumonia, he mentioned that
hospitalization and referrals are issues
of concern in India and in many of the
developing countries. Apart from the
difficulties faced in hospitalization and
referral, risk of pneumococcal infection and
even the inadequacy of the health system
in providing needles and syringes are issues
of concern. The study, “New Outpatient
Short-Course Home Oral Therapy for Severe
Pneumonia (NO-SHOTS)”3, published in
Lancet in 2008, looked at 2037 children, aged
3-59 months, with severe pneumonia at seven
study sites in Pakistan. The study concluded
that home treatment with high dose oral
amoxicillin is equivalent to parenteral
ampicillin for severe pneumonia without
underlying complications.
3
Hazir T, Fox LM, Nisar YB, Fox MP, Ashraf YP, MacLeod WB, et al. Ambulatory short-course high-dose oral amoxicillin for treatment
of severe pneumonia in children: a randomised equivalency trial. Lancet 2008; 371:49-56.
4
Asghar R, Banajeh S, Egas J, Hibberd P, Iqbal H, et al. Chloramphenicol versus ampicillin plus gentamicin for community acquired
very severe pneumonia among children aged 2-59 months in low resource settings: multicentre randomised controlled trial (SPEAR
study). BMJ 2008; 336: 80 - 84.
Proceedings
The third issue he posed to the audience was,
“Whether to continue with chloramphenicol
as the first line treatment for very severe
pneumonia?” The Severe Pneumonia
Evaluation Antimicrobial Research (SPEAR)
study, a collaboration between Boston
University, WHO and Johns Hopkins
University, was an open label randomized
controlled trial with 958 children from tertiary
care hospitals in seven countries.4 The study
results showed more treatment failures with
chloramphenicol on day 5 as well as by days
10 and 21 and isolation of S. pneumoniae
associated with increased risk of treatment
failure in the chloro-group on day 21,
thus, concluding that injectable ampicillin
plus gentamicin is superior to injectable
chloramphenicol for community-acquired
pneumonia.
Summarising the findings from the studies,
Dr. Patwari concluded that there is a need
for targeted research to improve ARI case
management guidelines and simultaneously
update current WHO guidelines for
management of severe pneumonia. The
growing resistance pattern of S. pneumoniae
and the risk of treatment failures need
to be seriously considered and evidence
needs to be built to support switching
over from parenteral to oral therapy in
severe pneumonia. In addition, the risk of
hypoxaemia and need for oxygen therapy also
need to be considered.
Preventing Severe Bacterial
Pneumonia in South Asian Region
Dr. Kurien Thomas, Christian Medical
College, Vellore began his presentation by
highlighting the global and national burden
5
National Consultation on Childhood ARI Case Management: Translating Research to Policy and Program
of childhood pneumonia. He also presented
the geographic variation and concentration
of pneumonia, wherein it is estimated that
85% of childhood pneumonia deaths occur
in Sub-Saharan Africa and South Asia where
47% of children reside. Improved nutrition,
reduction of risk factors (such as indoor
air pollution, crowding, etc.), appropriate
vaccination and improved case management
and treatment constitute the child survival
package to prevent pneumonia in children.
After breastfeeding, which is estimated to
prevent 13% of all child deaths, vaccination
is considered one of the top preventive
interventions for children less than five
years of age, with the pneumococcal vaccine
estimated at saving 6-9% of all child deaths.
He also mentioned the South Asian
Pneumococcal Alliance (SAPNA) and
Invasive Bacterial Infections Surveillance
(IBIS) studies, in which the sample included
children in the age group of 2 months to 5
years, with high fever ( >38°C) of less than five
days duration and having clinical syndrome
of pneumonia, meningitis or severe illness
(i.e. sepsis). The clinical outcome of children
less than 12 years showed that 95% had
normalized, 3% had worsened, and 2% died.
He observed that though the case fatality was
not very high at the tertiary level, the absolute
number of cases was very high, reflecting the
extent of child mortality.
5
World Health Organization. Pneumococcal conjugate vaccine for childhood immunization (WHO position paper). Weekly Epid.
Record 2006; 82: 93-104.
6
Based on surveillance data collected from
1993 to 2008, Dr. Kurien Thomas shared the
level of anti-microbial resistance in 718
S. pneumoniae isolates, with cotrimoxazole,
the first choice of drug for respiratory diseases
till recently, showing increasing resistance
over the years and reaching 82% resistance
in 2008. Though the data is from tertiary
settings, it may be a useful consideration in
recommending an alternate to cotrimoxazole.
In India, fortunately the penicillin resistance
continues to be low at approximately 12%,
but a few high level resistant organisms have
begun to emerge over the last two years.
Additionally, neighboring countries are
experiencing high levels of resistance, which
is bound to penetrate into India, calling
for continued surveillance and a focus on
preventive strategies. Dr. Kurien then showed
the case of the drug chloramphenicol, to
which resistance dipped around the year
1996, corresponding to the emergence of
the multi-drug resistant S.typhi infections.
Practitioners stopped prescribing
chloramphenicol due to poor response,
leading to a fall in resistance over the years
including for S.pneumoniae. The case of
irrational prescription of antibiotics by
practitioners and its effect on drug resistance
was highlighted.
Through the sero-type distribution data
and the levels of anti-microbial resistance
seen in other countries (particularly in Sri
Lanka), Dr. Thomas recommended that
pneumococcal vaccine should be viewed
as an important strategy to save children’s
lives. He also quoted the WHO position
statement – “Recognizing the heavy burden
of pneumococcal disease in children and the
safety and efficacy of PCV7 in this age group,
WHO considers the inclusion of this vaccine
in national immunization programmes as a
priority.5”

In conclusion, Dr. Thomas cited the example
of Sri Lanka, where policy level changes have
been achieved by introducing pneumococcal
conjugate vaccine in national program with
much higher levels of penicillin resistance
and different serotype distribution. Raising
the context of India, he mentioned that
Hib vaccine has been introduced in India,
primarily as a vaccine against meningitis in
children as part of Universal Immunization
Program (UIP) in eight states from 2009.
While the National Technical Group on
Immunization has recommended the
introduction of an appropriate conjugate
vaccine (PCV-10 or PCV-13), there is a need
to evaluate the operational issues associated
with the introduction of the vaccine.
Advances on the Treatment of
Non-Severe Pneumonia (NSP)
In her presentation, Dr. Shally Awasthi,
King George’s Medical University, Lucknow
chronologically shared results from three
studies. The first study, “ISCAP Study-Double
Blind, Placebo Controlled Trial of 3 Versus 5
days’ Amoxicillin for Non-Severe Pneumonia
(NSP),” 6 compared the proportion of children
(2-59 months) presenting with non-severe
pneumonia, who achieve clinical cure
on day 5 with 3 days versus 5 days of oral
amoxicillin therapy. The study also compared
the proportion of enrolled children who
were judged to be clinically cured on day 5 of
6
ISCAP Study Group. Three day versus five day treatment with amoxicillin for non-severe pneumonia in young children: a
multi-centre randomized controlled trial. BMJ 2004; 328:791.
Proceedings
enrolment, but relapse within the next 7 days
of observation with 3 days versus 5 days oral
amoxicillin therapy and also the proportions
who had resistant strains of S. pneumoniae or
H. influenzae in NSP cultures on day 0 and 14.
The study was conducted in the context
of cotrimoxazole being recommended as
the first line drug for NSP under India’s ARI
Control Programme, significant in vivo and
in-vitro resistance to cotrimoxazole being
reported, and clinical studies showing
high treatment failure with cotrimoxazole.
Therefore, there was a need to switch to the
next recommended drug, amoxycillin. Since
the cost of treatment with amoxycillin is high,
the other option was to investigate whether
a shorter course of treatment would be as
effective as conventional treatment, as seen
in cases of urinary tract infections. Inferring
from the study, Dr. Awasthi concluded that
oral amoxicillin for three days is as effective
clinically as five days in the treatment of
children 2-59 months old suffering from
NSP and in the nasopharyngeal isolates of
S. pneumonia on days 12-14, an increase in
in-vitro resistance to cotrimoxazole was seen
with 5-day treatment.
Dr. Awasthi next discussed a second study
published in an online scientific journal
PLoSONE titled, “Does Three-Day Course
of Oral Amoxycillin Benefit Children of
Non-Severe Pneumonia with Wheeze: A
Multi-centric Randomised Control Trial?”
It was based on the rationale that the
current IMCI algorithm prescribes that
children with wheeze and fast breathing
that present to first level health facilities
should be given antibiotics if they continue
to have fast breathing, which is above the
age dependent respiratory rate cut-off of
WHO defined pneumonia, after two doses of
bronchodilator. While the primary purpose
of the algorithm is to prevent mortality
due to bacterial pneumonia, an unknown
7
National Consultation on Childhood ARI Case Management: Translating Research to Policy and Program
proportion of children managed in this
fashion could have a viral-related wheezing
illness or asthma rather than pneumonia.
Further, about 20% children with WHO
criterion of non-severe pneumonia have
wheeze on auscultation, with nearly half of
them having a history suggestive of asthma
and the remaining half have bronchospasm
as a presentation of bronchial asthma,
bronchiolitis or bronchopneumonia. In all of
these conditions, with the possible exception
of bronchopneumonia, there is no role of
antibiotics.
The study concluded that treating children
with non-severe pneumonia with wheeze
with a placebo is not equivalent to treatment
with oral amoxicillin. The study also found
that among cases of non-severe pneumonia
and wheeze, the respiratory rate came back
below age specific cut-offs in 46% children
after nebulization with salbutamol and thus,
there was no need to prescribe antibiotic.
The IMCI guideline also recommends the use
of bronchodilators among wheezers before
deciding to treat them as cases of pneumonia
with antibiotics. The final conclusion was
that the implementation of IMCI guidelines
in ambulatory care settings in India as well
as other developing countries will result in
a substantial reduction in prescription of
antibiotics for non-severe pneumonia.
The third study was on “Effectiveness of 3-
Day Amoxicillin Versus 5-Day Cotrimoxazole
in the Treatment of Non-Severe Pneumonia
in Children Aged 2-59 Months of Age: A
Multi-centric Open Labeled Trial.” 7 This
study was based on the rationale that the
emergence of resistance in S. pneumoniae
or H. influenzae to cotrimoxazole warrants
a change in the case management of non-
severe pneumonia. An alternative could be
amoxicillin. However, use of amoxicillin at the
peripheral level would incur huge expenses to
7
Awasthi S, Girdhar A, Singh JV, Kabra SK, Pillai RM, et al. Effectiveness of 3-Day Amoxicillin vs. 5-Day Cotrimoxazole in the
Treatment of Non-severe Pneumonia in Children Aged 2–59 Months of Age: A Multi-centric Open Labeled Trial. Journal of Tropical
Pediatrics 2008; 54(6):382-389.
8
the government. An alternative to this could
be a shorter course of amoxicillin with the
dual advantage of being less expensive and
arresting the emergence of drug resistance.
The inferences from this open labeled trial
3 showed no difference in treatment of NSP
with either cotrimoxazole or Amoxicillin
but were not tested for equivalence. The
recommendations from this study were that:
 There is no need to change the existing
national guidelines of treating non-severe
pneumonia with cotrimoxazole twice in a
day for five days.
 It is essential to nebulise NSP (~13%
cases) with wheeze prior to giving
amoxicillin, since this averts antibiotic
use in almost 40% cases. Further,
appropriate bronchodilator therapy is
needed in those with NSP with wheeze.
 It is recommended that in all healthcare
set-ups, provision to nebulise children
presenting with wheezing should be
provided as this is a simple, cost-effective
strategy.
 Lastly, continuous monitoring is
required as anti-microbial resistance
pattern changes, and further changes
are anticipated with the introduction of
Hemophilus vaccine.
Care-seeking Behavior of Mothers:
Findings from the IMNCI Baseline
Assessment of Childhood Morbidity
and Mortality in Selected Districts in
India
Dr. Arora echoed Dr. Vijay Kumar’s
views about the importance of people’s
participation. His presentation focused on
the IndiaCLEN Program Evaluation Network
(IPEN) study conducted in 2007-08, the
objective of which was to assess the extent to
which IMNCI improves the management of
childhood illnesses, health system logistics,

and community involvement for child
survival activities in India. The study helps
provide baseline estimates of mortality: Infant
Mortality Rate (IMR), Neonatal Mortality
Rate (NMR), Under-five Mortality Rate
(U5MR); baseline estimates of morbidity:
cough, fever & diarrhea, existing health and
care seeking practices of community for
children under five; and existing practices of
care providers for management of illnesses
less than five years. Two districts each from
four Empowered Action Group (EAG) states,
namely Uttar Pradesh, Rajasthan, Orissa, and
Madhya Pradesh and from non-EAG states,
namely Meghalaya, Karnataka, Maharashtra
and Haryana, were included in the study.
A period prevalence range of 20-40% with
some symptoms of illness (cough, fever and
diarrhea) was found. Out of those children
who had illness, 50 to 60% had fever. There
was a district to district variation for children
who sought care outside home for any illness,
varying between 17% in Mewat district of
Haryana which is the poorest performing
district in the country and 45 to 47% in Orissa,
Maharashtra and UP. Healthcare seeking
outside the home for cough was 35-40%,
except in Meghalaya which goes up to 55%.
Care seeking outside the home was 80-90%
when the mother perceived it to be a serious
illness. Agreement between perceived severity
of the illness by the mother and objective
severity (indicators – fast breathing, decrease
Proceedings
in breathing and decrease in drinking) was
75-80%. Between 50-80% of the times,
mothers were not able to perceive less feeding
and less drinking as symptoms of severity,
when child had definite severe illness.
In the context of home treatment, whether
it was a mild or severe illness, across all the
states, 35-40% mothers gave some kind of
home treatment, which could have delayed
taking the child to the facility. The confidence
in the quality of care and prescriber
characteristics determined the decision to
seek outside care in 65-70% cases, urgency to
seek care in 30-40% cases, and accessibility
and affordability in around 20% cases.
Verbal autopsies revealed that of the
714 neonatal deaths, 45% never visited any
health facility before dying. Of those who did
not visit any health facility, two-thirds received
home treatment. On the other hand, only
one-third of the newborns who visited the
health facility received any home treatment.
In the case of post-neonatal deaths, 40% never
visited any health facility, 60% visited a health
facility. Again, two-thirds of those who never
visited the health facility got home therapy
and 40% those who visited got home therapy.
Expectedly, in the case of children less than five
years who had recovered, recovery was higher
(78%) for those who visited a health facility
compared to those who never visited (22%).
Home-based treatment in all children was
approximately 40%.
In conclusion, approximately 40-45% of those
who died were never taken to a health facility,
and two-thirds of these children received
some form of home therapy (compared
to one-third of those who were taken to
health facility). Perceived severity of illness
by the mother was a predictor for seeking
care outside the home. Most mothers did
not perceive “less drinking and less eating”
in the presence of other symptoms, as an
indicator of severity. Prescriber characteristics
and quality of care were the dominant
9
National Consultation on Childhood ARI Case Management: Translating Research to Policy and Program
determinants in choosing a particular
health facility/care provider versus issues
related to access and affordability. Transport,
finance and social support emerged as major
difficulties for care providers when they
decided to take their children to a health
facility.
Panel Discussion: Translating
Research Finding to Policy and
Program
Dr. Sangeeta Saxena, Assistant Commissioner
(Child Health), MoHFW, Government of
India, emphasized that with the MDGs in
place and international advocates striving to
put maternal and child health at the center
stage, the role of such workshops is pivotal
to draw attention to evidence for advocacy of
cost-effective interventions. Along with the
information available from the monitoring
system and the evaluation studies, research
evidence on what can work at scale in
our country will be useful in accelerating
progress towards maternal and child health.
She welcomed the consultation as a timely
10
discussion, and requested closer involvement
with the Government of India to take the
recommendations forward.
Dr. Vinod Paul, Head of the Pediatrics
Department and IndiaCLEN Clinical
Epidemiology Unit, AIIMS, moderated
the panel discussion on assessing the
policy implications of the research studies.
The expert discussants and the audience
responded to the issues emerging out of
research evidence shared in the previous
session.
The main issues that came out of the panel
discussion and recommendations from the
panelists and the audience are summarized
below:
1. Possible evidence that need to be
incorporated into the program
a. Pneumonia can be recognized at
the community and facility level. Its
treatment exists and is affordable. There
is overwhelming evidence that standard
case management works. However,

delay in getting treatment is a major
constraint.
b. Measles and pertussis immunization
coverage rates need to be increased to
levels that eliminate it as a public health
threat. This is an unfinished agenda
requiring greater rigor, and NRHM
provides an opportunity to strengthen
the health system to deliver the routine
immunization programme.
c. Additional vaccines such as Hib and
pneumococcal vaccine need to be
reviewed with caution, and perhaps more
evidence needs to be garnered before a
policy decision can be made.
d. We need to further explore the
relationship between ARIs and protein
energy malnutrition, micronutrient
deficiencies, exposure to smoke and
overcrowding, and equity and access to
health services.
2. Recommendations related to ARI case
management
a. Non-severe pneumonia
While there is evidence from tertiary care
settings, there is little information on
the etiology and micro-organisms from
community settings. More information will
need to be generated on the etiological agent
and anti-microbial susceptibility, and changes
over time. Existing evidence does not greatly
support a change from cotrimoxazole to
amoxicillin or any other antibiotic. Therefore,
status-quo should be maintained, while
continuing to be vigilant and keeping the
program and policy informed of the latest
research developments. Research gaps need
to be addressed by generating community-
based data.
b. Severe pneumonia
There are two issues for discussion – whether
a short course can be given at the hospital,
and if these cases can be treated at home.
Short course seems an attractive proposition,
once the data is firm and defendable. Oral
therapy can be given for pneumonia, but not
Proceedings
severe pneumonia. Till there is more India
specific data, treatment with injectables
needs to be continued for severe pneumonia.
Results from the IndiaCLEN’s multi-centric
Severe Pneumonia Oral Therapy (ISPOT)
study on use of oral amoxicillin, currently
underway, may be useful, once available. Lady
Hardinge Medical College’s to-be-published
research on treatment with antibiotics in a
scenario of viral pneumonia will also provide
important evidence in the treatment of
severe pneumonia. For severe pneumonia,
the decision for the treatment drug should
be based on whether referral to a hospital is
possible or not. If referral is not possible, oral
amoxicillin (high dose 80-90 mg/kg/day) for
five days should be prescribed. If referral is
feasible, injectable penicillin or ampicillin
should continue as drug of choice for severe
pneumonia. This is so because of paucity of
evidence for home-based treatment of severe
pneumonia. Where referral is not possible, the
capacity of the health worker needs to be built
to recognize severe pneumonia and manage
the case. However, a caveat is that ANMs are
not allowed to administer amoxicillin and
thus, this would require a policy change.
c. Wheezing
Dr. Awasthi’s study provides good evidence
towards nebulization of children with
lower ARI. The feasibility of using spacing
devices is not an issue; rather, the issue is
of capacity and acceptance of program,
and empowerment of health worker. We
need to revise the protocol for wheezing
management in the IMNCI algorithm with
the need to incorporate wheezing box as
an essential equipment for facility settings.
At the Primary Health Centre (PHC) level,
metered-dose inhalers with spacers should be
made available. Urgent feasibility studies are
required in community settings.
3. Role of ASHA in ARI case management
The issue of Accredited Social Health
Activist (ASHA) being allowed to administer
11
National Consultation on Childhood ARI Case Management: Translating Research to Policy and Program
cotrimoxazole, as being done by Auxiliary
Nurse Midwifes (ANMs) and Anganwadi
Worker (AWWs), was discussed. In
Chhattisgarh, ‘Mitanins’ (ASHA equivalents)
have been equipped with training and
supplies to administer cotrimoxazole, but
there has not been any assessment so far.
Participants cautioned that while the issue of
equity is critical, the issue of accountability
and capacity of other health workers also
needs to be kept in mind rather than putting
responsibility on ASHA. Everyone agreed
that ASHAs could possibly manage ARI
cases in the communities. While the idea of
empowering ASHA to manage ARIs seems
like a practical solution, it is important to test
the effectiveness through a pilot study before
taking to scale.
4. Role of IAP in improving treatment of
pneumonia
Dr. Panna Choudhury, President, IAP,
described IAP as the only official body of
ediatricians with 17,000 members and
300 branches across the country. IAP frames
guidelines for its members, which are also
widely utilized by other professional bodies
and the government. For instance, the zinc in
diarrhea policy was first framed by IAP. These
guidelines are updated time and again. Three
clear opportunities for partnership with IAP on
the issue of ARI case management emerged:
a. Under the aegis of its respiratory chapter,
IAP can set up a task force to review the
literature and the evidence and bring out
guidelines for ARI case management,
particularly at the facilities.
b. IAP can also be involved in the training of
providers on ARI management protocol
due to its large presence throughout the
country.
c. Guidelines are required for when not
to use antibiotics. IAP can write a white
paper on rational use of antibiotics and
publish it within four months in the
Indian Pediatrics (official journal of the
Indian Academy of Pediatrics).
12
5. Operations research areas and the
pathways to plug gaps in the evidence
The following areas of operations research
were identified as priorities:
a. There is sparse information from
community settings, both in terms of
etiology and organisms, and therefore,
more information on etiological agents
and anti-microbial susceptibility, and the
change over time and community based
data is essential.
b. Urgent feasibility studies are required in
community settings for incorporating
metered dose inhalers at PHC level
facilities.
c. Review and further analyze NFHS-3 and
IMNCI baseline data on health seeking
behavior for ARI management.
d. Look at antibiotic use in well-nourished
children from Dr. Awasthi’s study and
BU studies.
e. Review data on children with chest
indrawing since they are seldom taken to
hospital.
i. Further in-country research on oral
therapy for severe pneumonia. Is
ambulatory treatment possible for severe
pneumonia?
f. Conduct research on increasing the
utilization of facilities by communities,
and operational issues of how to improve
the outcomes of children brought to the
system by strengthening the facility and
increasing the credibility of the provider
in the community.
g. Bringing improvement in the home-
based care by the parents whose child is
suffering from pneumonia.
h. The use of antibiotics for children who
reported fever, cough and rapid breathing
is about close to 20% in the country
as a whole. Therefore, there is a gross
under-utilization of antibiotics when it
is required. How to optimize the use of
antibiotics for severe ARI is an important
research question.

Dr. Reeta Rasaily from the Indian Council
of Medical Research (ICMR) pointed that
the basic mandate of ICMR is to promote
research in the country and provide useful
evidence for incorporation into the program.
Pneumonia, with its high morbidity and
mortality burden, is a priority for ICMR. She
indicated that the research priorities were
Proceedings
well-listed and ICMR would be happy to
support research activity in this regard. ICMR
is in the process of having expert group
meetings to finalize priorities to take up for
achieving MDG 4, and the recommendations
very much fit into ICMR priorities. She
concluded that ICMR welcomed research
proposals in this regard.
13
 III.Next Steps on Taking the
Recommendations Forward
Dr. N.K. Arora pointed out that there is a need
to engage with the Ministry more closely to
take the recommendations forward. A brief
document with rationale and justification can
be prepared as a background document and
shared with the MoHFW. The development
partners, researchers and academicians
present in the meeting should contribute
to that document. Two additional exciting
opportunities are available for taking the
recommendations to policy and program. The
adaptation group of IMNCI and draft child
14
health policy are in the process of finalization;
the deliberations from this consultation could
be incorporated in both.
The consultation concluded with a synthesis
of the discussions by Dr. Vinod Paul, a vote
of thanks by Dr. Marta Levitt-Dayal, Chief
of Party, MCH-STAR, and presentation of
partnership plaques to representatives from
IAP, ICMR, and Government of Uttar Pradesh
on behalf of IndiaCLEN, MCH-STAR and
USAID.
Annex 1

IV. Agenda

National Consultation on
Childhood ARI Case Management: Translating Research to Policy
and Programme

Gulmohar, India Habitat Centre, Lodhi Road, New Delhi

February 25, 2009 from 10:00 am to 2:00 pm

Program

9:45 am – 10:00 am Registration with tea

10:00 am – 10:10 am Welcome, Dr. Kurien Thomas, IndiaCLEN
10:10 am – 11:45 am Presentations : Evidence from Global and National Research on
Childhood ARI

Chair:
Dr.Vijay Kumar, WHO/SEARO

Moderator:
Dr. Rajiv Tandon, USAID

Presenters:
Dr. Ashok Patwari, Boston University
Dr. Kurien Thomas, IndiaCLEN
Dr. Shally Awasthi, IndiaCLEN
Dr. N.K. Arora, IndiaCLEN
11:45 am – 1:30 pm Panel Discussion: Translating Research Findings to Policy and
Programme

Moderator:
Dr Vinod Paul, AIIMS

Panelists:
Dr. Sangeeta Saxena, MoHFW, Government of India
Dr. Panna Choudhury, IAP
Dr. Reeta Rasaily, ICMR
Dr. Vijay Kumar, WHO/SEARO
Dr. N.K. Arora, IndiaCLEN
1:30 pm Vote of thanks, Dr. Marta Levitt-Dayal, MCH-STAR
1:40 pm onwards LUNCH

15
 Annex 2

V. Participants

National Consultation on
Childhood ARI Case Management: Translating Research to Policy and Program

February 25, 2009, New Delhi

List of Participants

S. No. Name Organization E-mail

1 Dr. Rajiv Tandon USAID rtandon@usaid.gov
2 Dr. Kurien Thomas IndiaCLEN, Vellore kurien123@hotmail.com
3 Dr. Shally Awasthi IndiaCLEN, Lucknow sawasthi@sancharnet.in
4 Dr. Vinod Paul IndiaCLEN, AIIMS vinodpaul@hotmail.com
5 Dr. Reeta Rasaily ICMR rasailyreeta@rediffmail.com
6 Dr. Vijay Kumar WHO-SEARO kumarv40@gmail.com
7 Dr. N. K. Arora INCLEN nkaraora@inclentrust.org
8 Dr. Rajmohan Pillai IndiaCLEN,Trivandrum drrajamohanan@sancharnet.in
9 Dr. Shamim Haider IndiaCLEN drshamimhaider@yahoo.com
10 Dr. Pancholi IndiaCLEN rpancholi@tatamotors.com
11 Dr. Rajiv Sharan IndiaCLEN rajiv.sharan@tatamotors.com,
12 Dr. Najam IndiaCLEN najam_km@yahoo.com
13 Dr. Sudhansh Malhotra WHO-SEARO drsmalhotra@rediffmail.com
14 Dr. V. K. Anand WHO, India anandv@searo.who.int
15 Dr. Pavitra Mohan UNICEF pmohan@unicef.org
16 Dr. Manoj Kar NHSRC manoj.nhsrc@gmail.com
17 Dr. G. R. Sethi MAMC
18 Dr. Panna Choudhary MAMC and IAP pannachoudhury@gmail.com
19 Dr. R.N. Mandal MAMC
20 Dr. Satinder Aneja LHMC drsaneja@gmail.com
21 Dr. Arvind Saili LHMC sailiarvind@gmail.com
22 Dr. Sushama Nangia LHMC drsnangia@yahoo.com
23 Dr. Umesh Kapil AIIMS kapilumesh@hotmail.com
24 Dr. Shinjini Bhatnagar AIIMS
25 Dr. Sriram Krishnamurthy INCLEN drsriramk@yahoo.com
26 Vaishali Deshmukh INCLEN vaishali@inclentrust.org
27 Jyoti Dhavan INCLEN jyoti@inclentrust.org
28 Dr. A. K. Patwari MCH-STAR akpatwari@mchstar.org
29 Anju Dadhwal Singh MCH-STAR adadhwal@mchstar.org

16
 Participants

30 Dr. Indrajit Hazarika MCH-STAR ihazarika@mchstar.org

31 Dr. Sangeeta Saxena MoHFW, Govt. of India drsangeetasaxena@gmail.com
32 Rashmi Kukreja DFID r.kukreja@dfid.gov.uk
33 Dr. Hanimi Reddy Vistaar Project hreddy@intrahealth.org
34 Dr. Sunil Kumar
35 Dr. Luke Ravi MMC Chennai drlukeravic@gmail.com
36 Rachna Sujay Hope Foundation rachnasujay@gmail.com
37 Dr. Rais Ahmed MoHFW, Govt. of UP Rais.ahmed19@yahoo.com
38 Dr. Anand Lakshman Micronutrient alakshman@micronutrient.org
Initiative
39 Dr. Melina Thakur INCLEN milithakur078@yahoo.co.uk
40 Dr. Marta Levitt-Dayal MCH-STAR mlevitt-dayal@mchstar.org
41 Tapati Dutta MCH-STAR tdutta@mchstar.org
42 Dr. Avinash Ansingkar MCH-STAR aansingkar@mchstar.org
43 Dr. Sanjeev Upadhyaya USAID supadhyaya@usaid.gov
44 Manoj Kohli CEDPA mkohli@cedpaindia.org

17
“This report is made possible by the support of the American People through the
United States Agency for International Development (USAID). The contents of
this document are the sole responsibility of Emerging Markets Group Ltd. and do
not necessarily reflect the views of USAID or the United States Government.”