Point-of-care diagnostics are needed to improve childhood pneumonia case management and survival in low-resource settings
Dr Ayobami Adebayo Bakare, University College Hospital, Ibadan, Nigeria and Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
Pneumonia remains the leading infectious cause of death among children despite increasing coverage of pneumococcal vaccines and proven therapeutic interventions, including antibiotics and oxygen. The reasons for this may be complex—but an important factor was recently highlighted by Pui-Ying et al who observed that children hospitalized with pneumonia in settings where vaccine coverage, HIV, and chronic malnutrition rates are high did not present with typical signs and symptoms. This made accurate diagnosis with existing tools including risk scores difficult increasing the risk of missed diagnosis and inappropriate antibiotic use. The authors concluded that the absence of more specific diagnostics hinder both the rational application of treatments and appropriate antimicrobial stewardship.
The study assessed 1,139 children admitted to Queen Elizabeth Central Hospital in Malawi and found that those fulfilling the WHO Integrated Management of Childhood Illness criteria for clinical pneumonia presented with heterogeneous features. No single clinical feature was present in more than 55% of children. While just over half had crackles (54.7%), nasal flaring (53.5%), and lower chest wall in-drawing (53.2%), less than half had fever (45.7%), and 25% had hypoxaemia (SpO2<90%). Only 10% of the children were given the highest Respiratory Index of Severity in Children (RISC) score of 3-6.
This study underscores the challenge of accurate and timely diagnosis of pneumonia in low-resource settings where access to affordable, high-level diagnostics is limited. Current efforts to improve caregiver recognition of symptoms and careseeking rates may fuel distrust in healthcare if accurate and timely diagnosis of illnesses like pneumonia on presentation to facilities is not guaranteed. In Nigeria, where I work, pneumonia is rarely diagnosed at primary health care level, and self-referral to a higher level of care is common due to distrust in primary care.
However, in our study of 12 hospitals in Nigeria, we found that almost half of the admitted children with documented signs of severe pneumonia were not actually given a pneumonia diagnosis. Changing this narrative requires a holistic approach, nevertheless, the availability of point-of-care diagnostics to help healthcare workers accurately identify children with pneumonia is a step in the right direction and ranked high in a recent publication on pneumonia research priorities.
In Nigeria, caregivers express trust and satisfaction in healthcare when their child is subjected to simple diagnostics. Given that adherence to recommended medical treatment such as referral, antibiotics, and medical oxygen remains a challenge, simple point-of-care diagnostics may improve trust in healthcare and motivate caregivers to adhere to recommended treatments including referral advice.
Moreover, wider effects of better point-of-care diagnostics may include judicious use of antibiotics, early diagnosis of childhood illnesses, and indirectly, protection against catastrophic health care expenditure. With a delayed diagnosis, caregivers too often spend a lot of time and money visiting healthcare yet without improvement. Worsening of the child’s condition results in presentation/admission at a higher level of care and this is associated with increased direct and indirect medical costs.
In conclusion, the availability of point-of-care diagnostics for childhood pneumonia may reduce sickness and death, but to support their adoption and integration into healthcare delivery, more studies are needed to validate diagnostic accuracy, assess feasibility, and usability in real-time settings as well as cost-effectiveness and health system benefits.