- The document analyzes data from 379 pediatric patients under 5 years old seen at a health center in Bangladesh between August-November 2019. - Pneumonia (referred to as ARI) was present in 7.6% of cases. The ratio of pneumonia to no pneumonia to severe pneumonia was 1:0.56. - The analysis aimed to better understand patterns of pneumonia and assess quality of care based on adherence to IMCI guidelines and drug usage. Modern computational tools were used to analyze the complex data from the patient registry.

1. Pneumonia in children
under 5 years of age
An insight from a case based surveillance based on IMCI
from Zagua Union, Barisal Sadar
Akif Ibn Salam
Assistant Surgeon, Barisal Sadar Upazilla

2. Executive summary
Pneumonia being a leading cause of mortality and morbidity worldwide, little is
known about the quality of care in resource constrained settings like Bangladesh.
Due to lack of registered physicians in proportion to the population, the
Government assigned Non Physician Clinicians called Sub Assistant Community
Medical Officers in Upazila and Union level healthcare establishments. Majority of
the clinical care is delivered by them.
The world health organization has developed “the integrated management of
childhood illness (IMCI)” strategy to address a child’s illness in a systematic way.
It is an approach designed to reach a classification rather than a specific diagnosis
[3]. It aims to reduce death, illness, disability, and to promote improved growth and
development among children under the age of five. IMCI also includes both
preventive and curative elements, which are implemented by families,
communities, and health facilities.” [3]
The data from August 2019 to November 2019 contained in the IMCI registry
khata of the outpatient department of Zagua Union Health and Family Welfare
Center in Barisal Sadar, was analyzed. The registry contained a sample of 379
children (under the age of five years old), who presented to the outpatient
department with various childhood illnesses.
The presenting complaints of the caregivers were recorded in the registry along
with details pertaining to age, sex, disease/syndromes, and concomitant presence or
absence of fever for each patient. The data was too complex to decipher and a few
entries were incompletely documented. Conversely, the missing entries were
considered during the analysis. Therefore, various modern software and
computational algorithms were required to provide a comprehensive summary of
the data, so that different groups could be compared during data analysis. The
results were compared according to sex and age groups.
The results demonstrated that a considerable proportion of the OPD patients
presented with fever and pneumonia. The drug usage pattern and the use of

3. combined antibiotics were considered during the analysis of the data.
Unfortunately, there was insufficient information recorded pertaining to drug usage
in the registry. This shortcoming was a limitation towards achieving an
appropriate analysis.
In order to tackle these problems, proper training of health care workers(including
SACMO) with IMCI guided approach to care of pneumonia and an efficient
reporting system that is based on a multi-tiered algorithm should be implemented.
Furthermore, the use of artificial intelligence can be utilized for predictive analysis,
which would aid in the implementation of new strategies with a preceding
epidemic at hand.

4. Introduction
In Bangladesh, the implementation of IMCI has positively impacted children
below the age of five by improving their health and nutrition status. However, there
are numerous areas in the health system that still require development.
The government of Bangladesh officially adopted the IMCI strategy in 1998 but
pilot implementation only began in two sub-districts in late 2001.

5. IMCI concept states that sick children often present with multiple symptoms and
therefore effective management of the pediatric patient population is more of a
syndromic approach rather than a disease specific approach.[2]. Most pediatric
patients that present to the outpatient clinics have multiple symptoms. Therefore,
use of IMCI clinical management guidelines will potentially improve the quality of
care but the effective implementation is difficult due to inconsistencies and
inadequate training of physicians and other allied health care personnels. This
limitation poses a uncertainty in terms of effectiveness of the entire strategy.
Additionally, if surveillance data is not accurate and is not properly recorded, it
emerges as a disadvantage in the system and can present with erroneous results.
Courtesy : IMCI Handbook
In 2014, WHO modified it use of Antibiotics in Pneumonia to Amoxicillin in most
cases except the use of Cotrimoxazole in HIV affected Pneumocystis Jiroveci
patients.(8).
Bangladesh has made notable progress in “digital” health in recent
years.Furthermore, there has been significant growth in budget allocation for

6. children and the ministries have boosted their activities in implementing projects
and programs targeted for children. As a result, child sensitive allocation has gone
up to 43.6% in FY 2018-19 from 41. 4% of FY 2017-18 of the total budget of these
ministries[4]. The proportion of the national budget allocated to children has
increased from 13.97% (FY 2017-18) to 14.13%. Moreover, the allocation for
child-centric activities has increased from 2.50% to 2.59% as a percent of the GDP.
Bangladesh now has a national public sector health data warehouse through one of
the world’s largest deployments to date of the open-source District Health
Information Software 2 (DHIS2).Information from previously incoherent data
systems is now amalgamated in a common database, enabling data exchange for
health information systems and decision-making.
From Upazila Level, 4 types of reporting is done from different levels.
•On a daily basis Sister Supervisor/SSN sends report to statistician of following
diseases
i) Diarrhoea ii) Acute respiratory illness iii) Others diseases.
•A weekly report is sent to DHIS2 and IEDCR in IDS form by statistician and a
copy is kept at the UHFPO and CS office for
i. AWD ii. Bloody dysentery iii.Pneumonia iv. Severe Pneumonia v. SARI vi.
Dengue vii.Kala-azar viii.TB
•Monthly report also sent to DHIS2 for IMCI, EPI, Death number
•Quarterly report is sent for TB to the Civil Surgeon office and National TB
Control Program and vice versa.
The IMCI reports are first collected by the field workers, CHCP,BRAC field
workers at the community level and are sent to the statistician of the upazila.
Similarly reports from community clinics and union subcenters and Upazila Health
complexes are also sent to the statistician on a monthly basis. Later on Compiled
and aggregated data are sent to IEDCR, DHIS2 and vice versa in order to
strengthen the IMCI deliverables.

7. Acute respiratory illness is one of the most common presentations in a pediatric
OPD[5]. ARIs continue to persist as the single largest morbidity contributor among
children, and is responsible for approximately two-thirds of under-five childhood
morbidities in developing countries. It is a greater concern than diarrhea and other
diseases/syndromes among children aged < 5 years.[5] The lack of proper and
timely diagnosis at times can pose health risks to the pediatric population as well as
overall burden to a community, family as well as nation.
No proper data or research were found regarding the expenditure or socio
economic burden of Acute respiratory illness in children of Bangladesh.
This current analysis focused on Acute Respiratory illness and found to be present
in 7.6% of all OPD visits in a UHFWC in Zagua. Zagua Union, being
representative of the demographics of Bangladesh, has a population of 3092
males,3417 females. It has a land area of 15sq.Km . IMCI coverage rate in the
previous years was upto the mark despite lack of authentic data and research.
Infectious etiologies particularly highly virulent mutating strains of influenza and
other viruses might lead to respiratory illness in a number of instances in Children
and Elderly where both are at risk population. Surveillance strategies now should
gradually focus on ascertaining them out though improved laboratory facilities.
This current analysis focuses on the gaps pertaining to the IMCI surveillance on a
single UHFWC representative of other communities and measures required in
management of acute respiratory illness in population aged less than 5.
Objectives
To have a better understanding of Pneumonia in childhood, their frequency, ratios
and proportions based on the comparison of data provided between different age
groups and genders which would aid in the improvement of future policy planning.
To assess the quality of care based on adherence to IMCI guidelines and the drug
usage pattern.

8. Methods
This is a retrospective case based analysis of the surveillance data collected from
the outpatient department registry of Zagua Union Health and Family Welfare
Center in Barisal Sadar. The data contained a sample of 379 children (less than five
years of age) that presented to the OPD with various childhood illnesses between
August 2019 to November 2019.
The presenting complaints of the caregiver were recorded in the registry along with
parameters pertaining to age, sex, disease/syndromes and concomitant presence or
absence of fever. A few of the entries that were recorded in the registry were
incomplete. These incomplete entries were accounted for during the data
analysis.In this Analysis, Pneumonia was taken as a whole considering all its
subclasses under IMCI as synonymous to ARI. The term ARI was used in place of
Pneumonia to avoid confusion.
The raw data was too complex to analyze, thus, google sheets, pivot table, SPSS
for hypothesis testing using chi square analysis of association/independence, and
computation using python was used to produce a comprehensive data and summary
of each variable separately. Each disease was given a separate code name and
blank cells were kept as presented. Most of the data was categorical in nature
mostly with a yes or no answer.
Results:
Analysis of the data related to Pneumonia demonstrated that it was present in 7.6%
cases of OPD visits.The prevalence of Pneumonia patients in OPD were

9. substantially decreased compared to previous years literature(5) and studies thanks
to the upgradement of EPI program in Bangladesh.
Ratio of Pneumonia : No Pneumonia : Severe Pneumonia was 1 : 0.56 : 0.25.

10. Ratio of Female ARI : Male ARI was 1:4.8. There was a trending increase in ARI
cases each month and the peak reached in November. The most affected age group
was 1-5 year childrens(51%).Proportion of Antibiotic coverage in Pneumonia, No
Pneumonia,Severe Pneumonia were 75%, 86% and 0% respectively.
Age Severe Pneumonia Pneumonia No Pneumonia
Total IMCI ARI
cases
1-2 months 0 (0%) 1 (7%) 2 (17%) 3(10.3%)
3 months - 1 year 3(100%) 3 (21%) 6 (50%) 12(41.3%)
1 - 5 years 0 (0%) 10 (71%) 4 (33%) 14(48.2%)
Total 3 (100%) 14 (100%) 12 (100%) 29(100%)
Fig : A table showing total frequency of ARI in children of different ages
under 5 in the OPD of Zagua UHFWC from Aug 19- Nov 19

13. Month Male Female
August 2 (8%) 0 (0%)
September 2 (8%) 1 (20%)
October 8 (33%) 1 (20%)
November 12 (50%) 3 (60%)
Total
24
(100%) 5 (100%)
Fig: A table showing comparison of the frequency and proportion of
Pneumonia cases amongst males and females according to month in Zagua
UHFWC OPD from Aug 19 - Nov 19
Antibiotics were used in 72% of ARI(n=21) cases while in severe pneumonia no
usage of antibiotics was observed.

14. Use of antibiotics in pneumonia cases
Type of
pneumonia Used Not Used Total
No pneumonia 9 (75%) 3 (25%) 12 (100%)
Pneumonia 12 (86%) 2 (14%) 14 (100)
Severe
pneumonia 0 ( 0%) 3 (100%) 3 (100%)
Total 21 (72%) 8 (28%) 29 (100%)
Fig : A table showing frequency and proportion of Antibiotic use vs not
used in Zagua UHFWC OPD from Aug 19- Nov 19
Type of
pneumonia
Use of Multiple
Antibiotic
Use of Only one
antibiotic Total
No pneumonia 4 (67%) 2(33%) 6 (100%)
Pneumonia 8 (67%) 4 (33%) 12 (100%)
Severe
Pneumonia 0 (0%) 0 (0%) 0 (0%)
Total 12(67%) 6(33%) 18(100%)
Fig : A table showing frequency and proportion of Multiple/Single
Antibiotic use in Zagua UHFWC OPD from Aug 19- Nov 19
Multiple Antibiotics were used in 67% of cases in both Pneumonia and No
Pneumonia as opposed to the guidelines of WHO IMCI management(8).On the
contrary, Antibiotic usage was not found in Severe Pneumonia. In Pneumonia
outside medications were advised in 80% cases which we couldn't take into
analysis.

15. Among the total sample of 379 children, the male to female ratio was observed to
be 1.3:1. However, particulars of 126 patients from the sample were insufficiently
recorded in the registry. Additionally, 10 out of the 126 aforementioned entries did
not include information about gender.

16. However,the accuracy of the results were a concern due to missing data (lack of
specific disease entity records), blank cells, and incomplete data. However, all data
were reported in a timely manner to the DHIS2 despite the fact that some entries
were incompletely documented. Measles, malnutrition were uncommon in the
sample population and thus displayed a sporadic number of cases which are
thought to be linked to ARI in some cases(1).The cumulative percentages of blank
cells, age 1-3 months, 3 months to-1 year, and 1-5 years were 2.4%, 14%, 35.6%
and 100% correspondingly.
Most of the drugs were written using their generic name.In terms of Quality of
Care, there was little concordance to adhere with IMCI guidelines for management.
Respiratory rate wasn't written consistently, so the classification of IMCI couldn't
be validated. In a few instances polypharmacy was prescribed. The use of
Cotrimoxazole antibiotic was notable, which perhaps indicated an increased
number of skin/eye problems amongst the infant and toddler populations plus
Cotrim being a part of management of Pneumonia according to previous guidelines
by IMCI.(8)

17. Discussion:
This study has identified key gaps in pneumonia care. For example, our results
demonstrate that the minimum history and physical examination elements needed
to correctly classify pneumonia were performed in very few instances of patients
with respiratory complaints. Determining a patient’s respiratory rate is the
cornerstone of diagnosing non-severe pneumonia, but this was performed in only
very few cases. Other key gaps identified in this study show that SACMOs don't
have a proper knowledge about antibiotic management of IMCI care. These
deficiencies could be addressed with a re-evaluation of pre-service MATS training
and implementing in-service clinical training sessions mandatory for SACMOs to
maintain their certification.
Limitations:
The raw data that was collected, presented with numerous limitations that
contributed to potential inconsistencies in the analysis of the data and the results.
The data was complex in nature and incomplete due to inadequate recording of the
patient details during their visit to the OPD. Furthermore, the data was categorical
and did not have the potential to undergo adequate hypothesis testing. Real life
variabilities may exist because these were data entered by SACMOs who are not
registered physicians and thus they don't have enough training on diagnosing
diseases.
On the other hand, IMCI surveillance is carried out on a standard approach
followed elsewhere around the globe. Slight modifications such as using signs,
symptoms and languages used by the local community under a trained SACMO
would provide a more detailed picture of the scenario.

18. Specific recommendations:
1) To ensure reporting in a timely manner and keeping registries in order by
developing a long term and self sustaining surveillance strategy which would be
strengthened by proofreading mechanisms either by skilled personnel or possibly
by modern computational algorithms. The algorithms would be formulated using
machine learning or neural circuitry, with an aim to providing predictive analysis
that would be utilized in preventing or regulating potential epidemics.
2) To adapt the standard IMCI clinical guidelines to the country’s needs, available
drugs, policies, and to the local foods and language used by the population.
Training of Allied Health care workers including SACMO on data science and
paraclinical training on IMCI and can be a very effective tool in improving the
quality of care(1).
3) To strengthen care at Union/Community levels for 0-5 year children (the at risk
population) that present with Pneumonia to the outpatient clinic by ensuring that
enough of the right low-cost medication and simple equipment are available.
Additionally, the quality of care at the inpatient departments must be upgraded by
training health workers in new methods pertaining to the new guideline given by
WHO(8). Furthermore, at the community level, laboratory facilities require
improvement and should offer a one stop service. The etiologies and economic
burden of Pneumonia in Children Under 5 require further research and study so
that the pediatric age group and caregivers that presents to the OPD can be
effectively examined,treated and adequately counselled to reduce national/global
expenditure.

19. Action:
An immediate meeting was called at the UHFWC including field workers and
other staff to bolster the data entry process properly and eliminate all the gaps that
hinders ideal delivery of service to children under 5 and their proper feedback to
higher authorities.
Facilitation of proper training regarding data entry and training of Allied health
workers on IMCI has been discussed with UHFPO and to be executed in future.
Further planning has been done to carry out long term study in a prospective
manner to delineate the etiology of Pneumonia in our Upazila.
References:
1.Bjornstad E, Preidis GA, Lufesi N et al.Determining the quality of IMCI
pneumonia care in Malawian children.Paediatr Int Child Health. 2014
Feb;34(1):29-36. doi: 10.1179/2046905513Y.0000000070. Epub 2013 Dec
6.
https://www.ncbi.nlm.nih.gov/pubmed/24091151
2.Elena Neri,Egidio Barbi,Samuele Naviglio et al.Fever in Children: Pearls and
Pitfalls.Children (Basel). 2017 Sep; 4(9): 81.
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21. Appendices :
Appendix 1 : Hyperlink to Master Data
Abbreviations:
IMCI: Integrated Management of Childhood Illness
UHFWC: Union Health and Family Welfare Center
OPD: Outpatient Department
COUNTA=COUNT
Cotrim : Cotrimoxazole
ARI: Acute Respiratory Illness
SACMO: Sub Assistant Community Medical Officer
UHFPO: Upazila Health and Family Planning Officer
MATS: Medical Assistant Training Service