PNEUMONIA AMONG HOSPITALIZED CHILDREN AGED 1-9 YEARS - A prospective and retrospective study at a referral hospital in Northern Tanzania ________________________________________________________ Peter Forsberg, medical student at the Sahlgrenska Academy at Gothenburg University, Sweden 2012 [email protected]

Supervisors Rune Andersson, Professor in Global Health, MD, PhD Sahlgrenska Academy at Gothenburg University Raimos Olomi, Professor in Paediatric Medicine, MD, PhD Kilimanjaro Christian Medical Center, Moshi, Tanzania

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Index Abstract Introduction Epidemiology Pathophysiology Etiology Diagnostics Risk factors HIV Treatment Tanzania Method Results The patients Investigations Malaria Underlying disease Social/environmental factors Relapsing infections Treatment Outcome and evaluation of diagnosis The fatal cases Discussion Case-fatality Underlying/concomitant disease Social/environmental factor WHO case-management Treatment and severity of pneumonia Girls and boys Vaccine Conclusions Limitations/improvements Acknowledgements References Appendix I

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Abstract Objective The aim was to study epidemiological aspects and identify risk factors for incidence and casefatality of pneumonia among children aged 1-18 years treated as in-patients at a hospital in northern Tanzania. Methods Using the clinical definition and severity assessment of childhood pneumonia by WHO, 140 patients were identified among the 209 children aged 1-9 years treated for pneumonia during June 2010 – July 2011. Patients admitted June 2010 – May 2011 were included in a retrospective study solely based on information in their medical files. The patients admitted during June – July 2011 were included in a prospective study, where information was obtained from the caregiver present regarding socio-economic status, crowding, indoor airpollution and socioeconomic status. Results More patients were diagnosed having non-severe pneumonia at KCMC (67.6%; CI 57.877.5%) than would have been according to WHO (40.9%; 95% CI 32.1-49.7), while less many patients were diagnosed as severe and very severe pneumonia at KCMC (32.3%; 95% CI 18-46.6) than would have been according to WHO (59.1%; CI 48-70.2%). The clinical definition and severity assessment of pneumonia in children aged >1 years only identified about 75% of the patients with radiologically confirmed pneumonia. Relapsing infections seemed to be more common among boys (40%; 95% CI 29-51) than girls (21.5%; CI 11.631.5). Underlying diseases tended to be more common among relapsing cases (43.2; 95% CI 28.6-57.8) than first-time infections (25%; 95% CI 16.3-33.7). Treatment with parenteral ampicilline and gentamycine was the most common treatment in all the different severity subgroups of pneumonia as defined by WHO. Although malnutrition tended to be more common both among the cases of severe and very severe pneumonia than non- severe pneumonia and among the fatal than the non-fatal cases, there were no risk factors significantly associated with a more severe infection or case-fatality. Crowding was common in the study; however the mean number of family members at home was only slightly higher than the average number in Tanzania. No conclusions regarding possible risk factors for pneumonia and case-fatality inquired in the questionnaire could be drawn due to the low number of participants. Conclusions No significant risk factors for pneumonia and case-fatality were identified. Relapsing pneumonia tended to be more common in boys than girls. Underlying disease tended to be more common among the relapsing cases than the first-time infections. Cases of pneumonia were often considered less severe at KCMC than they would have been according to WHO.

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INTRODUCTION Epidemiology Pneumonia is the leading cause of mortality in children aged less than five years worldwide (Sazawal and Black 2003; Black, Cousens et al. 2010). The incidence of pneumonia in this group is estimated to about 156 million episodes each year, of which approximately 151 million are in developing countries and 35 million in Africa (Rudan, Boschi-Pinto et al. 2008). Estimates indicate that 7-13% of these episodes are possibly life-threatening and require hospitalization (Rudan, Boschi-Pinto et al. 2008). Pneumonia is responsible for about 1.6 million deaths among children aged