WHO PSBI guidelines Summary of evidence from 11 demonstration sites - PowerPoint PPT Presentation

Implementation research on WHO PSBI guidelines Summary of evidence from 11 demonstration sites PSBI Community of Practice Webinar 28 Feb 2019 1 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

Questions 1. Can we achieve up to 80% of coverage of appropriate treatment for all young infants with PSBI irrespective of place of treatment? (Coverage) 2. Compared to the previous referral refusal rates to the hospital, did the referral refusal rates increase when offered OPD treatment? (unintended consequences) 3. Did the death rate increase after implementation of WHO PSBI guideline in programme setting compared to the death rate in systematic review? (safety) 2 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

Implementation research ⚫ 11 sites in six countries – 6 sites in Africa – DRC (1 site), Ethiopia (2 sites), Malawi (1 site) and Nigeria (2 sites). – 5 sites in Asia – Pakistan, India (4 sites) ⚫ Implemented in programme setting at district or sub-district level ⚫ Technical support (as TSU ) was provided either by academic institute or by NGOs at each site. ⚫ Based on TSU involvement in implementation of PSBI guidelines, sites are stratified into two groups for this analysis – high and low 3 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

1. Can we achieve up to 80% of coverage of appropriate treatment for all young infants with PSBI irrespective of place of treatment? (Coverage*) % % site ES (95% CI) ES (95% CI) Weight Weight High TSU involvement DRC 0.95 (0.93, 0.96) 0.95 (0.93, 0.96) 10.33 10.33 No Ibadan 0.91 (0.89, 0.93) 0.91 (0.89, 0.93) 10.32 10.32 21% Zaria 0.96 (0.94, 0.98) 0.96 (0.94, 0.98) 10.32 10.32 Subtotal (I^2 = .%, p = .) 0.94 (0.91, 0.97) 0.94 (0.91, 0.97) 30.97 30.97 Low TSU involvement Jimma 0.78 (0.75, 0.81) 0.78 (0.75, 0.81) 10.21 10.21 Mekelle 0.63 (0.61, 0.66) 0.63 (0.61, 0.66) 10.25 10.25 Pakistan 0.82 (0.81, 0.84) 0.82 (0.81, 0.84) 10.34 10.34 Yes HP 0.67 (0.57, 0.75) 0.67 (0.57, 0.75) 9.00 9.00 79% Pune 0.70 (0.61, 0.77) 0.70 (0.61, 0.77) 9.24 9.24 Lucknow 0.73 (0.70, 0.76) 0.73 (0.70, 0.76) 10.23 10.23 Palwal 0.71 (0.65, 0.77) 0.71 (0.65, 0.77) 9.76 9.76 Subtotal (I^2 = 96.52%, p = 0.00) 0.72 (0.66, 0.79) 0.72 (0.66, 0.79) 69.03 69.03 Heterogeneity between groups: p = 0.000 Overall (I^2 = 98.79%, p = 0.00); 0.79 (0.72, 0.86) 0.79 (0.72, 0.86) 100.00 100.00 -.5 0 .5 1 1.5 *Malawi data was excluded from this analysis 4 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

2. Compared to the previous referral refusal rates to the hospital, did the referral refusal rates increase when offered OPD treatment? (unintended consequences) In high TSU involvement countries referral refusal rate Study Refusal was 86% rate Refused all treatment Bhandari et al India, Lancet 1996 76% 3% Bang et al India, Lancet 1999 98% Baqui et al Bangladesh, Lancet 2008 68% Zaidi et al Pakistan: PIDJ 2012 78% Refused referral & accepted OPD treatment Accepted referral 71% Baqui et al SATT Bangladesh Lancet GH 84% 26% 2015 DR Congo AFRINEST, Lancet 2015 71% Kenya AFRINEST, Lancet 2015 89% Nigeria AFRINEST, Lancet 2015 78% Young infants 7-59 d with fast breathing cases were excluded from this analysis 5 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

3. Did the death rate increase after implementation of WHO PSBI guideline in programme setting compared to the death rate in AFRINEST/SATT studies? (safety) Study Death rates Died 2% AFRINEST Lancet 2015 1.3% SATT Pakistan, LANCET GH 2016 1.5% SATT Bangladesh Lancet GH 2015 1.6% Survived 98% 6 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

Questions related to programmatic issues 4. What proportion of identified livebirths were visited by CHWs at least once in their first week of life? 5. What proportion of sick young infants brought to PHC were identified by CHWs at home? 6. What proportion of young infants with PSBI treated on OPD basis had day 4 follow up? 7 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

4. What proportion of identified livebirths were visited by CHWs at least once in their first week of life? % % site ES (95% CI) ES (95% CI) Weight Weight High TSU involvement DRC 0.91 (0.90, 0.92) 0.91 (0.90, 0.92) 9.11 9.11 Ibadan 0.75 (0.74, 0.77) 0.75 (0.74, 0.77) 9.11 9.11 No postnatal visit Zaria 0.95 (0.94, 0.96) 0.95 (0.94, 0.96) 9.12 9.12 in first week of life Subtotal (I^2 = .%, p = .) 0.87 (0.76, 0.98) 0.87 (0.76, 0.98) 27.34 27.34 22% Low TSU involvement Jimma 0.39 (0.37, 0.40) 0.39 (0.37, 0.40) 9.10 9.10 Mekelle 0.94 (0.93, 0.94) 0.94 (0.93, 0.94) 9.12 9.12 Malawi 0.60 (0.56, 0.64) 0.60 (0.56, 0.64) 8.95 8.95 Pakistan 0.98 (0.97, 0.98) 0.98 (0.97, 0.98) 9.12 9.12 At least 1 postnatal visit in first HP 0.91 (0.89, 0.92) 0.91 (0.89, 0.92) 9.09 9.09 week of life Pune 0.86 (0.85, 0.88) 0.86 (0.85, 0.88) 9.09 9.09 78% Lucknow 0.79 (0.78, 0.79) 0.79 (0.78, 0.79) 9.12 9.12 Palwal 0.49 (0.46, 0.51) 0.49 (0.46, 0.51) 9.07 9.07 Subtotal (I^2 = 99.90%, p = 0.00) 0.74 (0.62, 0.86) 0.74 (0.62, 0.86) 72.66 72.66 Heterogeneity between groups: p = 0.121 Overall (I^2 = 99.88%, p = 0.00); 0.78 (0.69, 0.87) 0.78 (0.69, 0.87) 100.00 100.00 -.5 0 .5 1 1.5 8 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

5. What proportion of sick young infants brought to PHC were identified by CHWs at home? % % site ES (95% CI) ES (95% CI) Weight Weight High TSU involvement DRC 0.77 (0.75, 0.79) 0.77 (0.75, 0.79) 9.14 9.14 Ibadan 0.94 (0.93, 0.95) 0.94 (0.93, 0.95) 9.15 9.15 Zaria 0.89 (0.87, 0.91) 0.89 (0.87, 0.91) 9.14 9.14 Subtotal (I^2 = .%, p = .) 0.87 (0.77, 0.96) 0.87 (0.77, 0.96) 27.43 27.43 Low TSU involvement Identified by Identified by family Jimma 0.11 (0.08, 0.15) 0.11 (0.08, 0.15) 9.12 9.12 CHWs member Mekelle 0.28 (0.23, 0.34) 0.28 (0.23, 0.34) 9.07 9.07 52% 48% Malawi 0.11 (0.04, 0.22) 0.11 (0.04, 0.22) 8.98 8.98 Pakistan 0.40 (0.37, 0.42) 0.40 (0.37, 0.42) 9.14 9.14 HP 0.32 (0.25, 0.40) 0.32 (0.25, 0.40) 9.00 9.00 Pune 0.75 (0.67, 0.82) 0.75 (0.67, 0.82) 9.02 9.02 Lucknow 0.91 (0.89, 0.93) 0.91 (0.89, 0.93) 9.14 9.14 Palwal 0.22 (0.18, 0.27) 0.22 (0.18, 0.27) 9.09 9.09 Subtotal (I^2 = 99.73%, p = 0.00) 0.39 (0.14, 0.64) 0.39 (0.14, 0.64) 72.57 72.57 Heterogeneity between groups: p = 0.001 Overall (I^2 = 99.80%, p = 0.00); 0.52 (0.34, 0.70) 0.52 (0.34, 0.70) 100.00 100.00 -.5 0 .5 1 1.5 9 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

6. What proportion of young infants with PSBI treated on OPD basis had day 4 mandatory follow up? Day 4 follow up % % was not done site ES (95% CI) ES (95% CI) Weight Weight 7% High TSU involvement DRC 0.97 (0.95, 0.99) 0.97 (0.95, 0.99) 13.31 13.31 Zaria 0.86 (0.81, 0.89) 0.86 (0.81, 0.89) 10.72 10.72 Ibadan (Excluded) (Excluded) . . Subtotal (I^2 = .%, p = .) 0.95 (0.93, 0.97) 0.95 (0.93, 0.97) 24.03 24.03 Low TSU involvement Jimma 0.96 (0.95, 0.98) 0.96 (0.95, 0.98) 13.66 13.66 Mekelle 0.99 (0.98, 1.00) 0.99 (0.98, 1.00) 14.06 14.06 Malawi 0.98 (0.95, 0.99) 0.98 (0.95, 0.99) 13.31 13.31 Pakistan 0.90 (0.88, 0.92) 0.90 (0.88, 0.92) 12.99 12.99 HP 0.63 (0.45, 0.79) 0.63 (0.45, 0.79) 2.29 2.29 Day 4 follow up was done Pune 0.86 (0.42, 1.00) 0.86 (0.42, 1.00) 0.97 0.97 93% Lucknow 0.98 (0.97, 0.99) 0.98 (0.97, 0.99) 13.99 13.99 Palwal 0.72 (0.60, 0.81) 0.72 (0.60, 0.81) 4.71 4.71 Subtotal (I^2 = 93.36%, p = 0.00) 0.94 (0.91, 0.97) 0.94 (0.91, 0.97) 75.97 75.97 Heterogeneity between groups: p = 0.495 Overall (I^2 = 93.53%, p = 0.00); 0.93 (0.91, 0.96) 0.93 (0.91, 0.96) 100.00 100.00 -.5 0 .5 1 1.5 10 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

Association of mortality with clinical signs assessed at home and at facility In-depth analysis of AFRINEST data 11 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

Prevalence and mortality rates by clinical signs: CHWs ’ assessment Clinical sign Mortality Chest (%) Fast breathing High body indrawing, 9% in 0-6 days, Local infection 0.2% temperature , 18% Low body 11% temperature, Fast breathing 7-59 days 0.4% 7% High body temperature 0.9% Feeding poorly Chest indrawing 0.9% or no feeding at all, 2% Fast breathing 0-6 days 1.0% Movement Low body temperature 4.3% only when stimulated or Not able to feed at all or not feeding well 6.5% no movement at all, <1% Movement only when stimulated or no 8.7% Convulsions, movement at all <1% Convulsions - ≥ 2/7 signs of > 2/7 signs of PSBI (Excluding fast 13.8% PSBI, 7% breathing 7-59 days & local infection) Local infection, 21% 12 | TITLE from VIEW and SLIDE MASTER | 01 March 2019

Prevalence and mortality rates by clinical signs: IMCI trained workers ’ assessment (1) Clinical sign Mortality Chest (%) Fast breathing indrawing Low body only in 0-6 days Fast breathing 7-59 days 0.2% 19% temperature 18% 3% High body temperature 0.8% Chest indrawing 0.9% Not able to feed at all or not feeding well Fast breathing 0-6 days 1.9% 4% Low body temperature 11.0% High body Movement only Not able to feed at all or not feeding 6.3% temperature when stimulated well 20% or no movement at all Movement only when stimulated or no 9.3% 1% movement at all Fast breathing only Convulsions Convulsions 11.3% in 7-59 d 1% 26% ≥2/7 signs of > 2/7 signs of PSBI (Excluding fast 6.5% PSBI breathing 7-59 days) 8% 13 | TITLE from VIEW and SLIDE MASTER | 01 March 2019