This document discusses information sharing to change policy for child pneumonia treatment in Haiti. It summarizes: 1) In 2000, 40,000 Haitian children under 5 were diagnosed with pneumonia and almost 3,000 died, showing pneumonia was a leading cause of death. 2) Beginning in the 1980s, the Haitian Health Foundation implemented a population-based primary health care program and community-selected village health workers to treat pneumonia. 3) Evaluation found the program reduced pneumonia-specific mortality in children under 5 from 6.2/1000/year to 3.1/1000/year, demonstrating community health workers could effectively diagnose and treat pneumonia with brief training.

1. Judy Lewis
Bette Gebrian
INFORMATION SHARING TO
CHANGE POLICY FOR
CHILD PNEUMONIA
TREATMENT

2.  Pneumonia still leading cause of death <5
 PAHO 1995:
 In 2000, 40,000 children <5 diagnosed
 Almost 3000 died (7.4%)
PEDIATRIC PNEUMONIA IN HAITI
Mortality Rate (Children Under 5 Years)
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Haiti Dominican Republic United States of America
Deathsper100,000livebirths
ARI Mortality Rate (1994)
Total Mortality Rate (1994)

3. Population based primary health care
HHF initial program 1986
Public Health Program 1987
200,000 population
 Village Health Committees
 Community Selected Village Health Workers
 Mobile Health Teams
 Registered Population
 Family Data System
 Epidemiological Profile
HAITIAN HEALTH FOUNDATION

4. DATA DRIVEN PARTICIPATORY
PROGRAM IMPROVEMENT
Assessment
Communities
Providers
Researchers
Feedback Planning
Implementation
Data
Collection
Information
System

5. JEREMIE TOWN AND
VILLAGES

6.  Method: scenarios, video interpretation, card sorts of
symptoms and causal relationships
 Results:
 Rapid breathing and inter-costal retraction believed to be parasites
 Bwonch (pneumonia) vs grip (flu-like)
 Bwonch caused by bathing too late in the day or in cold water, or an
untreated cold
 Knowledge of symptoms low and only 26% identified rapid infant
breathing video as pneumonia
 Everyone knew at least one child who died of pneumonia
Information used by PAHO to launch national
pneumonia program in 1993
1990 WHO ETHNOGRAPHIC STUDY

7.  WHO treatment algorithms and training modules
 Translation to Haitian Creole by JSI 1994
 USAID sponsored pilot implementation
 Tools: battery-operated timer that emitted a sound at 30 and
60 seconds to assess breathing
 Two sequential recordings of rate above age group norm
 Questions and observation to help classify
 Two week training
 Doctors and nurses
 Community health workers –
had to demonstrate competence
 Treatment documentation
 Ongoing supervision
PNEUMONIA TREATMENT AND TRAINING

8.  HHF has regular meetings with community leaders, healers
and members
 Community participation given equal weight in staff training
 seminars for community-based organizations
 creating songs about recognizing and treating pneumonia
 public demonstrations on the use of the timer, counting respiratory
rates
 medicine (cotrimoxazole), cost, first dose, length of rx and home care
 Treatment
 5 days for 5 Haitian gourdes (US$.04)
 Now 8 days for 10 gourdes (WHO)
COMMUNITY MOBILIZATION

9. Refrain
Mothers there is an illness that is called pneumonia
That kills children.
If you see a child with rapid breathing or coughing, go to the dispensary.
I.
Pneumonia is a severe illness.
If you wait to see you will lose your child.
If you see the child gets worse after going to the dispensary you need to
return quickly to the dispensary.
Refrain
II.
Fathers with children, help the mothers!
Its not only mothers who seek care for children
When they have pneumonia or another illness, if they are not treated they
will die more easily.
PNEUMONIA SONG

10.  1997 CDC program impact evaluation
 17,000 cases treated in first 3 years
 CDC concluded:
 HHF ARI program is an important model for Haiti
 Reduction of baseline pneumonia-specific mortality from
6.2/1000/year to 3.1
 CHWs with brief formal training, intensive supervision and regular
continuing education can effectively diagnose and treat ARI in Haiti
 1998 CDC case control study of children with multiple
episodes of pneumonia*
 Wheezing was found to be the significant contributor
CDC EVALUATION/RESEARCH
*Heffelfinger JD, Davis TE, Gebrian B, et al. Evaluation of children with recurrent pneumonia diagnosed by World
Health Organization criteria. Pediatr Infect Dis J. 2002 Feb;21(2):108–12.

11.  In 1993 CHWs in Haiti not allowed to dispense antibiotics
 USAID got MSPP approval for HHF CHWs
 Careful documentation of medication distribution and outcomes
 Based on evidence and discussions with HHF, MSPP approved
CHW cotrimoxazole distribution in USAID sponsored NGOs
 After HHF’s further advocacy and documentation
 Community based treatment of ARI became part of Haiti national
IMCI policy in 2005
 HHF collaborated with
Haitian Pediatric Society
2011 World
Pneumonia Day
GOVERNMENT POLICY

12.  2002 HHF began training other organizations
 FOCAS child survival grant wanted to incorporate community
treatment for pneumonia
 2005 USAID designated HHF as a field training site for
community based treatment of pediatric pneumonia
 6 Haitian NGOs came for one week of training
 Teams of physicians, nurse managers and CHWs—teamwork critical
component
 HHF Community Based ALRI Treatment Manual revised based on
feedback
 Follow up with NGOs found that most had implemented—major
obstacle was timers
 5 additional NGO trainings after USAID
 2 publications and 4 graduate student research projects
DISSEMINATION AND TRAINING

13.  Continue to track pneumonia episodes and treatment—93,000
episodes through 2013
 January 2013 pentavalent vaccine became Haiti protocol
 Problems with stock outs
 Lack of storage space for so many individual vials
 HHF will be able to demonstrate impact of having Hib
vaccination on pneumonia rates and outcomes
 Healthy
children
determining
their future!
PRESENT AND FUTURE