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Recent advances in child survival have often been at the expense of increasing inequity. Successive interventions are applied to the same population sectors, while the same children in other sectors consistently miss out, leading to a trend towards increasing inequity in child survival. This is particularly important in the case of pneumonia, the leading cause of child death, which is closely linked to poverty and malnutrition, and for which effective community-based case management is more difficult to achieve than for other causes of child death. The key strategies for the prevention of childhood pneumonia are case management, mainly through Integrated Management of Childhood Illness (IMCI), and immunization, particularly the newer vaccines against Haemophilus influenzae type b (Hib) and pneumococcus. There is a tendency to introduce both interventions into communities that already have access to basic health care and preventive services, thereby increasing the relative disadvantage experienced by those children without such access. Both strategies can be implemented in such a way as to decrease rather than increase inequity. It is important to monitor equity when introducing child-survival interventions. Economic poverty, as measured by analyses based on wealth quintiles, is an important determinant of inequity in health outcomes but in some settings other factors may be of greater importance. Geography and ethnicity can both lead to failed access to health care, and therefore inequity in chiid survival. Poorly functioning health facilities are also of major importance. Countries need to be aware of the main determinants of inequity in their communities so that measures can be taken to ensure that IMCI, new vaccine implementation and other child-survival strategies are introduced in an equitable manner. Les recents progres dans la survie des enfants ont souvent ete obtenus au prix d'une inequite grandissante. Des interventions successives ont ete appliquees aux memes secteurs demographiques sans jamais beneficier a certains enfants d'autres secteurs et ont genere une tendance de plus en plus forte a l'inequite dans la survie des enfants. Ce phenomene est particulierement notable dans le cas de la pneumonie, principale cause de mortalite de l'enfant et fortement liee a la pauvrete et a la malnutrition, pour laquelle une prise en charge communautaire des cas est plus difficile a obtenir que pour d'autres causes de mortalite infanto-juvenile. Pour prevenir la pneumonie chez l'enfant, les principales strategies sont la prise en charge des cas, principalement par le biais de la Prise en charge integree des maladies de I'enfance (PCIME), et la vaccination, notamment par les nouveaux vaccins contre Haemophilus influenzae type b (Hib) et pneumococcus. Il existe une tendance a introduire l'une et l'autre interventions dans des communautes ayant deja acces aux soins de sante de base et a des services de prevention, d'ou un desavantage relatif accru pour les enfants sans acces a ces prestations. Il est pourtant possible de mettre en oeuvre ces deux strategies de facon a diminuer plutot qu'a augmenter l'inequite. Il importe de surveiller l'aspect equite Iorsqu'on introduit des interventions en faveur de la survie des enfants. La pauvrete economique, telle que mesuree par des analyses reposant sur les quintiles de richesse, est un determinant important de l'inequite dans les evenements sanitaires, mais dans certains pays, d'autres facteurs peuvent revetir une importance plus grande encore. Les conditions geographiques et l'appartenance ethnique peuvent aussi empecher d'acceder aux soins et donc conduire a des inequites dans la survie des enfants. Le mauvais fonctionnement des etablissements de soins joue aussi un role majeur. Les pays doivent connaitre les principaux determinants de l'inequite dans leurs communautes de maniere a pouvoir prendre des mesures pour garantir une introduction equitable de la PCIME, des nouveaux vaccins et d'autres strategies en faveur de la survie des enfants. Los recientes progresos en materia de supervivencia infantil se han conseguido a menudo a expensas de un aumento de la inequidad. Las sucesivas intervenciones se centran en Ios mismos sectores de la poblacien, mientras en otros sectores Ios ninos son ignorados sistematicamente, Io que se refleja en una tendencia al aumento de la inequidad en Io referente a la supervivencia infantil. Esa tendencia es harto patente en el caso de la neumonia, que constituye la principal causa de mortalidad en la ninez, esta estrechamente asociada a la pobreza y la malnutricien, y plantea mas dificultades que cuaiquier otra causa de mortalidad en la ninez para lograr un manejo de casos comunitario eficaz. Las estrategias clave para la prevencien de la neumonia en la ninez son el manejo de casos, principalmente mediante la Atencion Integrada a las Enfermedades Prevalentes de la lnfancia (AIEPI), y la inmunizacien, en particular con las nuevas vacunas contra Haemophilus influenzae tipo b (Hib) y contra el neumococo. Se tiende a emprender ambas intervenciones en comunidades que ya tienen acceso a Ios servicios de atencien basica y preventiva, Io que acentua la desventaja relativa que padecen Ios ninos que carecen de ese acceso. Sin embargo, ambas estrategias pueden apticarse de manera que reduzcan la inequidad, en lugar de aumentarla. Es importante vigilar la equidad cuando se Ilevan a cabo intervenciones de fomento de la supervivencia infantil. La pobreza econemica, determinada mediante analisis basados en Ios quintiles de riqueza, es un determinante importante de la inequidad en Ios resultados sanitarios, pero en algunos entornos hay otros factores que pueden ser mas relevantes. La geografia y el grupo etnico pueden ambos entorpecer el acceso a la atencien de salud, y favorecer por consiguiente la inequidad en materia de supervivencia infantil. El mal funcionamiento de Ios centros de salud es tambien un factor de gran importancia. Los paises deben saber cuales son les principales factores determinantes de la inequidad en sus comunidades a fin de potier adoptar medidas que garanticen que la aplicacien de la AIEPI, de la inmunizacien con nuevas vacunas y de otras estrategias de supervivencia infantil se realice de forma equitativa. [TEXT NOT REPRODUCIBLE IN ASCII], Introduction In human rights law, the term "equity" is used to represent equality with fairness. This is synonymous with the notion of distributive justice, or fair distribution of good things [...]

Objective To calculate the incidence and document the clinical features of chest X-ray- (CXR-) confirmed pneumonia in children aged between 1 month and 5 years living in Greater Suva, Fiji. Methods A retrospective review was undertaken of children aged between 1 month and 5 years with a discharge diagnosis suggesting a lower respiratory tract infection (LRTI) admitted to the Colonial War Memorial Hospital in Suva, Fiji, in the first 10 days of each month from 1 January 2001 to 31 December 2002. Clinical data were collected and CXRs were reread and classified according to WHO standardized criteria for CXR-confirmed pneumonia. Findings Two hundred and forty-eight children with LRTI met the inclusion criteria. CXRs were obtained for 174 (70%) of these cases, of which 59 (34%) had CXR-confirmed pneumonia. The annual incidence of CXR-confirmed pneumonia was 428 cases per 100 000 children aged between 1 month and 5 years living in Greater Suva. If a similar proportion of the children for whom CXRs were unavailable were assumed to have CXR-confirmed pneumonia, the incidence was 607 per 100 000. The incidence appeared to be higher in Melanesian Fijian than Indo-Fijian children. The case-fatality rate was 2.8% in all children with LRTI, and 6.8% in those with CXR-confirmed pneumonia. Conclusion This is the first study to document the incidence of CXR-confirmed pneumonia in a Pacific Island country, and demonstrates a high incidence. A significant proportion of hospital admissions of children with LRTI are likely to be preventable by the introduction of pneumococcal conjugate vaccine. Keywords Pneumonia, Pneumococcal/diagnosis/epidemiology; Lung/radiography; Respiratory tract infections/classification/ epidemiology; Child; Retrospective studies; Fiji (source MeSH, NLM). Mots cles Pneumopathie a pneumocoque/diagnostic/epidemiologie; Poumon/radiographie; Moles aeriennes superieures, Infection/ classification/epidemiologie; Enfant; Etude retrospective; Fidji (source: MeSH, INSERM). Palabras clave Neumonia neumococica/diagnostico/epidemiologia; Pulmon/radiografia; Infecciones del tracto respiratorio/ clasificacion/epidemiologia; Estudios retrospectivos; Nino; Fiji (fuente: DeCS, BIREME). Bulletin of the World Health Organization 2005;83:427-433. Voir page 432 le resume en francais. En la pagina 432 figura un resumen en espanol., Introduction Each year, more than 10 million children worldwide die before their fifth birthday, and more than 97% of these deaths occur in developing countries (1, 2). Almost two million [...]

Anaemia associated with malaria is a major public health problem in African countries. Since most primary health facilities have to rely on physical signs and not laboratory tests to detect anaemic patients who need referral for blood transfusion, we have assessed the reliability of simple clinical signs to predict severe anaemia. A trained field assistant examined 368 children admitted to a tertiary care hospital, assessing the pallor of their eyelids (conjunctiva), palms and nailbeds, counting the respiratory rate, and looking for signs of respiratory distress. After the children's admission, their packed cell volume (PCV) was measured, and the need for transfusion and the outcomes were noted. A second observer examined 173 of these children so that interobserver variability in the detection of clinical signs could be assessed. A total of 27% of the 368 children had a PCV of [is less than] 15%. In a multiple regression analysis, definite pallor of the conjunctiva, definite pallor of the palms, and a "sick" appearance of the child were identified as independent significant predictors of a PCV of [is less than] 15%. The best predictor was a combination of definite pallor of the conjunctiva and pallor of the palms, with a sensitivity of 80% and a specificity of 85%. Inclusion of signs of respiratory distress did not improve the prediction. Pallor was a reproducible sign (weighted kappa statistic for the comparison between two observers: [Kappa] = 0.6 for conjunctival pallor). We conclude that pallor can be used as a sign for referring children who may require blood transfusion., Introduction Anaemia is a major health problem in the Gambia and many other African countries (1), most cases in children being related to malaria. Although the pathogenesis of malarial anaemia [...]

Most of the 12.4 million deaths occurring every year among under-5-year-olds in developing countries could be prevented by the application of simple treatment strategies. So that health professionals who have had limited training can identify and classify the common childhood diseases, WHO developed a treatment algorithm (the Integrated Management of Childhood Illness (IMCI) or Sick Child algorithm), a prototype of which was tested in 440 Gambian children aged between 2 months and 5 years. The children were first assessed by a trained field worker using the algorithm, and then by a paediatrician whose clinical diagnosis was supported by laboratory Investigations and, when indicated, a chest X-ray. Compared with the paediatrician's diagnosis, the sensitivity and specificity of the draft IMCI algorithm were, respectively, 81% and 89% for the detection of pneumonia, 67% and 96% for dehydration, 87% and 8% for malaria parasitaemia (any level), 100% and 9% for malaria parasitaemia (above 5000 parasites/[micro]l), 100% and 99% for measles, 31% and 97% for otitis media, and 89% and 90% for malnutrition. Among the children admitted by the physician, 45% had been recommended for admission by the algorithm. Intermittent fever, chills and sweats did not help in discriminating between malaria and non-malarious fevers; shivering or shaking of the body had a sensitivity of only 35%. While the algorithm dealt with the majority of presenting complaints, the most common problems not addressed by the chart were skin rashes (21%), mouth problems (8%), and eye problems (6%). The draft IMCI algorithm proved to be effective in the diagnosis of pneumonia, gastroenteritis, measles and malnutrition, but not malaria where its use without microscopy would result in considerable overtreatment, especially in a low transmission area or during a low transmission season in countries with seasonal malaria. The current algorithm would benefit from expansion to cover management of localized infections as well as skin, mouth and eye problems., Introduction About 12.4 million children under the age of 5 years die every year in developing countries (1). The main causes of death, after the neonatal period, are respiratory infections, [...]

The current WHO recommendations for the case management of acute respiratory infections (ARI) in children aged 2 months to 5 years in developing countries use fast breathing (respiratory rate of [greater than or equal to]50 per minute in children under 12 months and [greater than or equal to]40 in children aged 12 months to 5 years) and lower chest wall indrawing to determine which child is likely to have pneumonia and should therefore receive antibiotics. We have evaluated these and other physical signs in 487 malnourished children and 255 well nourished children who presented with a cough or breathing difficulty. Pneumonia, defined as definite radiological pneumonia or probable radiological pneumonia associated with crackles on auscultation, was present in 145 (30%) of the malnourished children and 68 (26%) of the well nourished children. The respiratory rate predicted pneumonia equally well in the two groups, but to achieve an appropriate sensitivity and specificity the respiratory rate cut-off required in malnourished children was approximately 5 breaths per minute less than that in well nourished children. Intercostal indrawing was more common and lower chest wall indrawing was less common in the malnourished children, with or without pneumonia. These results suggest that fast breathing, as defined at present by WHO, and lower chest wall indrawing are not sufficiently sensitive as predictors of pneumonia in malnourished children. As the latter are a high-risk group, we should like to recommend that children with malnutrition who present with a cough, fast breathing or difficult breathing should be treated with antibiotics., Introduction Acute respiratory infections (ARI) are estimated to be responsible for about 4 million childhood deaths per year, most of them in developing countries[1]. Malnutrition is common in most developing [...]

Acute lower respiratory infections (ALRI) are the main cause of death in young children worldwide. We report here the results of a study to determine the long-term survival of children admitted to hospital with severe pneumonia. The study was conducted on 190 Gambian children admitted to hospital in 1992-94 for ALRI who survived to discharge. Of these, 83 children were hypoxaemic and were treated with oxygen, and 107 were not. On follow-up in 1996-97, 62% were traced. Of the children with hypoxaemic, 8 had died, compared with 4 of those without. The mortality rates were 4.8 and. 2.2 deaths per 100 child-years of follow-up for hypoxaemic and non-hypoxaemic children, respectively (P = 0.2). Mortality was higher for children who had been malnourished (Z-score [is less than] -2) when seen in hospital (rate ratio = 3.2; 95% confidence interval (CI) = 1.03-10.29; P = 0.045). Children with younger siblings experienced less frequent subsequent respiratory infections (rate ratio for further hospitalization with respiratory illness = 0.15; 95% CI = 0.04-0.50; P = 0.002). Children in Gambia who survive hospital admission with hypoxaemic pneumonia have a good prognosis. Survival depends more on nutritional status than on having been hypoxaemic. Investment in oxygen therapy appears justified, and efforts should be made to improve nutrition in malnourished children with pneumonia., Voir page 147 le resume en francais. En la pagina 147 figura un resumen en espanol. Introduction Acute lower respiratory infections (ALRI) in children of less than 5 years of [...]