Acute respiratory infections in children: a case management intervention in Abbottabad District, Pakistan.

Acute respiratory infections in children: a case management intervention in Abbottabad District, Pakistan A.J. Khan,1 J.A. Khan,2 M. Akbar,3 & D.G. Addiss4 Between 1985 and 1987, a community-based case-management programme for acute lower respiratory infection (ALRI) was conducted in a rural district of northern Pakistan. The impact on infant and child mortality of this programme, which included active case-finding and maternal health education, was evaluated. In 1985-86, the ALRI-specific mortality rate among children <5 years old in 31 intervention villages was 6.3 deaths per 1000 children per year, compared with 14.4 in seven control villages (P =0.0001). Within one year of the interventions being extended to the control villages in 1987, the ALRI- specific mortality rate in these villages dropped by 55% to 6.5 per 1000 children per year (P =0.06). The total child mortality rate in 1985-86 was 29.0 per 1000 children per year in the intervention villages and 39.4 per 1000 children in the control villages, a difference of26% (P =0.01). With the interventions in 1987, the total child mortality rate in the control villages declined by 29% to 27.8 per 1000 children per year (P =0.09). Similar intervention-associated declines in the infant mortality rate were also observed. Case management of acute respiratory infection by village-level community health workers backed up by local health centre staff appeared to significantly reduce both ALRI-specific and total infant and child mortality rates in this setting. Introduction Acute respiratory infections (ARI) are responsible for about 4 million deaths annually in children under 5 years of age (1). Most cases of ARI involve the upper respiratory tract and are mild and self-limiting; how- ever, in developing countries the mortality rate from acute lower respiratory infection (ALRI), principally pneumonia, is approximately 10-50 times higher than in developed countries (2). WHO has proposed a programme of ARI case management to reduce mortality from childhood pneumonia in developing countries (2,3). In this programme, peripheral health workers are trained using recognizable signs, such as increased res- piratory rate and the presence of chest retractions, to detect pneumonia that requires treatment with anti- biotics at home or referral to hospital. Recent studies suggest that these signs are sensitive indicators of ' Professor, Ayub Medical College, Abbottabad, Pakistan. 2 Research Director, Pakistan Medical Research Centre, Ayub Medical College, Abbottabad, Pakistan. Requests for reprints should be sent to Dr J.A. Khan at this address or to Dr Addiss at the Centers for Disease Control. 3 Principal, Ayub Medical College, Abbottabad, Pakistan. 4 Medical Epidemiologist, Parasitic Diseases Branch, Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333, USA. Reprint No. 5111 lower respiratory infection (4, 5). The programme also includes efforts to educate mothers to recognize pneumonia and to provide appropriate supportive measures, and emphasizes the importance of timely immunization and good nutrition. The extent to which these measures can reduce mortality in children has been examined in several settings.' For example, in Haryana, India, the ALRI- specific mortality among low-birth-weight infants in several intervention villages was 30 per 1000 live births, compared with 71 in control villages (6). A study in Bagamayo, United Republic of Tanzania, demonstrated a 27% reduction in mortality among under-5-year-olds (7), and ALRI-specific mortality in infants in Nepal was reduced in one year from 53 to 20 per 1000 live births.' We report here the impact on childhood mor- tality of a primary health care programme of ARI case management in the rural Abbottabad District of northern Pakistan. This area is characterized by severe winters, rugged terrain at 1500-2000 m, a traditional agricultural economy, and a low level of formal maternal education. Methods The study population included all children aged < 5 years who lived in 38 villages (population, 37 245) in * Case management of acute respiratory infections in children: intervention studies. Unpublished document WHO/ARI/88.2. Bulletin of the World Health Organization, U (5): 577-585 (1990) © World Health Organization 1990 577 A.J. Khan et al. three distinct clusters. Each cluster included all the villages in the catchment area of an existing basic health unit or civil dispensary. In the health units, outpatient medical care is provided by a doctor and one or two medical technicians; public health services include immunization, antenatal care, maternal nutri- tional supplementation, health education, and malaria control. In the dispensaries, medical technicians provide basic medical and public health services. Mortality data were collected from January 1985 to December 1987. A total of 31 "intervention" villages received the full range of interventions de- scribed below, from March 1985 to December 1987. Over this period, the seven "control" villages received only improved immunization coverage in addition to services already provided by the basic health unit or civil dispensary. All intervention strategies were ex- tended to the seven control villages from January to December 1987; the control area therefore became a "phase-IT intervention area" during the third year of the study. Control villages were selected non- randomly to be representative of other villages in the area, and were similar to the intervention villages with respect to the following characteristics: height above sea level, house construction materials (mud and brick), time to walk to the health unit or dispen- sary (mean, 30 minutes), age distribution and number of residents per village, maternal education level, proportion of mothers who breast-fed (90%), mean household income (approximately US$ 90 per month), and occupation of the male head of house- hold (farming, 45%; government service, 40%; busi- ness, 15%). Five (71%) control villages, compared with two (6%) intervention villages, were inaccessible by road. Interventions Seventeen community health workers (CHWs), each with a minimum of 10 years' schooling, were re- cruited from the villages and trained in Abbottabad in the autumn of 1984. After training, the CHWs lived in the intervention villages, where they were available to evaluate and treat symptomatic children with ARI who were brought to their attention. Each CHW also systematically visited approximately 200 households every 10-14 days in active ARI case- finding. If access to the basic health unit was not possible, the CHWs administered oral trimethoprim/ sulfamethoxazole for suspected pneumonia or acute otitis media before referral to the health unit (Table 1). Four qualified nurses monitored and supervised CHW activities in the villages, administered oral trimethoprim/sulfamethoxazole and with the assis- tance of the CHWs, conducted frequent, informal, interactive health education programmes. Table 1: Protocol used for acute respiratory Infection (ARI) case management In the study Symptoms and signs Cough, with respirations <50/minute and no chest indrawing Blocked or runny nose Cough, with respirations 50-70/minute and no chest indrawing Ear pain or discharge for <2 weeks Cough, with respirations >70/minute or chest indrawing Unable to drink Treatment Supportive measures: Give paracetamol for fever Continue breast-feeding Give adequate food and fluids Clear nasal secretions Administer home-prepared herbal tea Refer to basic health unit or civil dispensary Administer trimethoprim/ sulfamethoxazole or procaine penicillin Refer to hospital Give chloramphenicol or benzyl penicillin Administer oxygen if cyanotic Maternal health education included instruction on signs of severe illness, such as rapid respiratory rate and the inability to drink, the importance of childhood immunization, general hygenic measures, including use of soap and water, preparation and use of oral rehydration salts (ORS), and simple suppor- tive measures for children with mild ARI. The sup- portive measures included provision of adequate food and fluids, continued breast-feeding, para- cetamol for fever, and a neutral environmental tem- perature, use of home-prepared herbal teas for coughs, clearing of nasal secretions, removal of dis- charge from the ear with absorbent paper, humidi- fication of household air, and avoidance of household smoke. The doctors and medical technicians at the health units and dispensaries served patients from both intervention and control villages. Children from intervention villages who had signs or symptoms suggestive of pneumonia or acute otitis media were treated according to the protocol with antibacterials, primarily oral trimethoprim/sulfamethoxazole (Table 1) (15). Children from control villages were treated at the health units, dispensaries, or by private prac- titioners on an individual, nonstandardized basis, and did not receive antibacterials provided by the study. Other services, including distribution of pack- ets of ORS, immunizations, and nutritional sup- plements for pregnant and lactating women were provided uniformly to persons from both interven- tion and control villages. Collection of data From November 1984 to January 1985 the CHWs conducted an initial census of the entire study area in WHO Bulletin OMS. Vol. 68 1990.578 ARI In children: a case management intervention in northern Pakistan which child immunization status was verified; in the intervention villages, parents were also questioned about any children aged less than 5 years who had died in the previous year. Additional censuses were conducted in September-November of each year of the study to determine the "mid-year" population. In the intervention villages, the CHWs maintained active surveillance and recorded all known births, deaths, and migrations. The control villages were surveyed quarterly to ascertain the number of child deaths in the previous 3 months. Supervising nurses conducted standardized annual surveys of adult females in the intervention villages to determine their knowledge, attitudes and practices (KAP) towards ARI. The nurses also per- formed verbal autopsies using an algorithm of stan- dardized questions that suggested a single primary cause of death (Fig. 1); additional information was obtained in open-ended interviews with the parents of deceased children. Each case was also reviewed by a doctor at Ayub Medical College, Abbottabad, to confirm the most probable cause(s) of death identi- fied by the nurses; the doctor was aware of the study hypothesis, but did not know the identity Fig. 1. Algorithm used by supervising nurses to assign cause of death In children, Abbottabad, Pakistan, 1985-87. Signs and symptoms Child born with no signs of life 4no Child born more than one month before expected date, with weight less than 2200 g at birth 4no 7-10 days after birth, refuses breast-feeding, spasms with body arched like a bow 4no High fever with chills and rigors 4no Breathing difficulty, fast breathing or air hunger, noisy breathing, cough, fever 4no Rash all over, runny nose, cough, sneezing, red eyes, with fever 4no Loose stools, sunken eyes, excessive thirst 4 no Face sunken, "skin and bones" appearance, or may be swollen all over 4no Road accident, severe burns, had taken drugs, other accident no -I yes yes yes yes yes yes yes yes yes Primary cause of death Stillborn Prematurity Neonatal tetanus Malaria Acute respiratory infection Measles Diarrhoea Malnutrition Accident Died of other causes WHO Bulletin OMS. Vol. 68 1990. , 579 A.J. Khan et al. of the child's village. In the intervention area, interviews were conducted as soon as possible after notification of death; in the control area, verbal autopsies were conducted every 3 months. In 1985, the cause of death in the control villages was re- corded only as ALRI or non-ALRI. StatlIstkal methods Records of migrations, which were as high as 15% in the severe winter months, were incomplete, especially for the control villages. The number of child-months at risk could not be accurately calculated, and apnual mortality rates were therefore determined using the September-November "mid-year" population as the denominator. Significance levels were determined using x2 tests; the two-tailed P values include Yates' correction. Taylor series 95% confidence intervals were calculated around the risk ratios. The terms "child mortality" and "infant mortality" refer to deaths of children aged < 5 years and < 1 year, respec- tively. Results In 1985, a total of 4665 and 1194 children aged < 5 years lived in the intervention and control villages, respectively. At the beginning of the study, 5% of these children were found to have been immunized appropriately for their age; after an intensive immunization campaign in both the intervention and control areas, this proportion increased to 77% by December 1985 and to 87% by 1987. Little econo- mic or social change, and no known outbreaks of measles, pertussis, or influenza occurred during the study. A total of 508 deaths were reported among children aged <5 years; 361 (71%) deaths were re- ported in infants. The baseline child mortality rate, both in the intervention area (determined retrospec- tively for 1984) and in the control area (determined prospectively in 1985-86) was 39 deaths per 1000 children per year; the child mortality rate was not assessed for 1984 in the control area. ALRI and diarrhoeal disease were the leading causes of death in both the intervention and control areas (Table 2). The causes of 50 (10%) deaths that occurred outside the study area could not be adequately ascertained by verbal autopsy. A bimodal seasonal pattern of mortality was noted, with deaths from ALRI being more frequent in the winter, and those from diarrhoea more common in the summer. The female:male mortality risk ratios were vir- tually identical among children from both the inter- vention and control villages. Compared with that for males, the ALRI-specific mortality rate for females was 16% higher among under-5-year-olds and 25% higher among infants, but these differences were not statistically significant. The total annual mortality rate for girls aged < 5 years in all villages was 31.6 per 1000, compared with 24.8 per 1000 for boys (risk ratio (RR), 1.28; 95% confidence interval (CI), 1.07- 1.51). Among infants, the total annual mortality rate for females was 78.4 per 1000, compared with 60.3 for males (RR, 1.30; 95% CI, 1.06-1.59). ALRI-speclflc mortality In 1985-86, the ALRI-specific child mortality rate was 6.3 deaths per 1000 children per year in the intervention villages and 14.4 in the control villages Table 2: Primary causes of death In children aged <5 years In the Intervention and control villages, as determined by verbal autopsy Intervention villages Control villages Cause of death No. in 1985-87 No. in 1985 No. in 1986' ALRI' 78 (21)b 17 (36) 18 (37) Diarrhoea 131 (35) - 11(22) Malaria 9 (2) - 4 (8) Malnutrition 2 (1) - 0 Measles 11 (3) - 3 (6) Neonatal tetanus 25 (7) - 1 (2) Prematurity 32 (8) - 3 (6) Stillbirth 12 (3) - 3 (6) Accident/injury 4 (1) - 0 Unknown or other cause 74 (20) 30 (64) 6 (12) Total ' ALRI= acute lower respiratory infection. b Figures in parentheses are percentages. 378 47 49 WHO Bulletin OMS. Vol. 68 1990.580 ARI In children: a case management Intervention In northern Pakistan Table 3: Infant and child mortality In the control and Intervention villages Infant mortality (aged < 1 year): Child mortality (aged <5 years): ALRI'-specific No. Rate' Total No. Rate ALRI-specific No. Rate Total No. Rate Control villagesc C: 1985 C: 1986 I: 1987 Intervention villages l: 1985 I: 1986 I: 1987 " ARLI =acute lower respiratory infection. b Rate= per 1000 per year. c C= control (received only improved immunization coverage-see text for details); = intervention. Fig. 2. ALRI (acute lower respiratory infection) and total Infant and child mortalty rates In the intervention and control villages by year, Abbottabad District, Pakistan. (a) ALRI mortality rate In under-5-year-olds. (b) ALRI mortality rate In Infants. (c) Total mortality rate In under-5-year-olds. (d) Total Infant mortality rate. I 1984 1985 1986 1987 1985 1988 1987 EI Control rvnUm * s pIbd Ineo_I_ (Table 3, Fig. 2), a difference of 56% (P=0.0001). (P=0.006). Afte] After the introduction of interventions in the control villages in 1987 villages in 1987, the ALRI mortality rate dropped by rate dropped to 55% to 6.5 per 1000 per year (P=0.06). Similarly, the ALRI-specific infant mortality rate in the intervention villages was 15.5 per 1000 live Total mortality births per year in 1985-86, compared with 32.5 per In 1985-86, the 1000 per year in the control villages, a 52% difference per 1000 childre r interventions began in the control , the ALRI-specific infant mortality ,15.0 per 1000 per year (P=0.12). e total child mortality rate was 29.0 n per year in the intervention villages WHO Bulletin OMS. Vol. 68 1990. 12 10 6 29 13 14 36.8 28.5 15.0 21.9 9.4 9.7 31 32 22 108 92 76 95.1 91.2 54.9 81.5 66.4 52.7 17 18 8 40 19 19 14.4 14.5 6.5 8.6 4.0 3.8 47 49 34 149 124 105 39.4 39.4 27.8 31.9 26.2 21.0 (b)(a) 181 14] 12] 10] 8- 4- 2 O _It I (C) s81 A.J. Khan et al. and 39.4 in the control villages, a difference of 26% (P=0.01). In 1987, the total child mortality rate in the control villages declined by 29% to 27.8 per 1000 children per year (P=0.09). The total infant mortality rate in the interven- tion area during the first two years of the study was 73.8 per 1000 per year, compared with 93.1 per 1000 in the control area, which was not a significant difference, although the numbers were small. The total infant mortality rate in the control villages declined to 54.9 per 1000 children per year in 1987 (P = 0.03). To determine whether these reductions in mor- tality rate were associated with increased use of the health units or dispensaries, we reviewed the health unit records from a control village for January, February, and July in both 1986 and 1987. In 1986, 107 visits (49 for ARI) were recorded for children aged < 5 years, compared with 80 visits (36 for ARI) in 1987. The non-ALRI mortality rate did not change appreciably during the study; the diarrhoea-specific child mortality rate appeared to decline slightly, from 11.1 to 8.2 per 1000 in the intervention villages and from 8.8 (1986) to 5.7 (1987) per 1000 in the control villages, but these differences were not statistically significant. If the death rate in the control villages in 1985-86 is accepted as the baseline "expected" rate, an estimated 97 child deaths were averted in the intervention villages during the first two years of the study; 76 (78.4%) of these deaths would be expected to be due to ALRI. The results of the annual KAP surveys in the intervention villages suggest that maternal practices and attitudes towards ARI changed during the study. The proportion of mothers who indicated they would contact the health facility or CHW when their child had a cough and fever increased from 5% in 1985 to 58% in 1987, while the proportion who stated that they would seek help from a traditional or religious healer decreased from 60% to 16%. In 1987, 78% of mothers stated they would contact the CHW and go to the basic health unit or civil dispensary if their child had difficulty in breathing, compared with 34% in 1985. The proportion of mothers with knowledge of ARI symptoms also increased; the proportion of women who identified fever as a symptom of ARI increased from 35% in 1985 to 71% in 1987, while the proportion of those who considered "difficulty in breathing" as a symptom of ARI increased from 3% to 25% over this period. Before interventions began in 1985, the proportions of women who correctly identified a cough and a running nose as symptoms of ARI were 83% and 78%, respectively. Discussion The programme appeared to reduce ALRI-specific infant and child mortality rates by 50% within 1-2 years. It was also associated with a 20-30% decrease in total child mortality; a "compensatory" increase in deaths from other causes, as noted elsewhere with other interventions such as measles vaccination (8), was not observed. Similar declines in mortality rates have been reported in previous ARI intervention studies in India, Nepal, and the United Republic of Tanzania (6, 7),b but our study demonstrates the impact of adding active case-finding and ARI case management by CHWs to a functioning basic health unit system. In some previous studies, it has been difficult to distinguish the effect of ARI case management from that of other interventions, such as improved immun- ization (6).b In Abbottabad, both vaccination coverage and access to ORS improved during the study, but these changes occurred simultaneously and to a comparable degree in both the intervention and control areas. The factor considered to be most probably res- ponsible for the reduction in child mortality was ARI case management by CHWs, including education of mothers to recognize ARI and seek appropriate care. Maternal education appeared to result in improved health-seeking behaviour and knowledge of ARI, as determined by KAP surveys. Health education also addressed several other reported risk factors for severe ARI, including malnutrition (9, 10), indoor air pollution (11), parental smoking (12), and bottle- rather than breast-feeding (13). Our impression is that these changed little during the study period, but comparable pre- and post-intervention data were not collected on smoking, breast-feeding, or other house- hold practices, and nutritional status was not system- atically measured. Instruction in ORS use and general hygiene was felt to contribute to community acceptance of the programme, but the impact of this on the overall mortality is unclear. Improved management of pneumonia at the basic health units/civil dispensaries may also have played an important role in reducing mortality, since antibacterials and ARI treatment protocols were standardized for children from the intervention, but not from the control villages. Although data are limited, the decline in mortality does not appear to be due to an increase in the number of children referred to the health units or dispensaries for ARI. b See footnote a, p. 577. 582 WHO Bulletin OMS. Vol. 68 1990 ARI In children: a case management Intervention In northern Pakistan A gradual reduction in mortality was observed in the 31 intervention villages over the 3-year study period; this may have been partly because only 10 months of intervention occurred in 1985, but as the CHWs and programme staff gained experience, their efficacy may also have increased. Both the ready acceptance of interventions by control villagers in 1987 and the improved coverage of fewer villages by experienced CHWs probably contributed to the more rapid decline in mortality in the control villages after intervention strategies had been introduced there. This study has several limitations. Cause of death was based on verbal autopsy, an approach that has limited accuracy.c The interval between death and verbal autopsy was up to 3 months longer in the control than in the intervention area, and recall of some details may therefore have been more difficult for parents in the control area. Although intervention and control villages were comparable in most res- pects, they were not selected randomly, and may have had different baseline mortality rates and other risk factors for death. For example, data on the incidence of low birth weight and malnutrition, both of which are risk factors for ALRI (9, 10), were not obtained. Once interventions began, however, similar declines in mortality were observed in the villages in both areas. Finally, because the programme was imple- mented at the village level rather than that of the individual, use of the X2 test may have overestimated the statistical significance of the observed differences in mortality (14).C In the study, active case-finding by CHWs was a central component of the ARI case-management strategy. Because household visits were scheduled every 2 weeks, it is likely that some episodes of ARI, including severe ones, were not detected. However, the CHWs lived and worked in the villages where they taught mothers to recognize signs and symp- toms of ARI and encouraged them to seek assistance and notify the CHW. The proportion of cases iden- tified by systematic CHW case-finding, as opposed to maternal recognition and referral, is not known. In summary, both the total and ALRI-related mortality rates among infants and children were substantially reduced after introduction of a pro- gramme of ARI case management in a mountainous area of northern Pakistan. The degree to which these same interventions would be effective in other geo- graphical settings or in other populations served by different health care systems is not known, although similar community-based ARI intervention trials c See footnote a, p. 577. elsewhere have demonstrated 27-62% reductions in ALRI mortality (6, 7).c Baseline data suggest that ALRI-specific mortality was particularly high in the study area, where a basic health clinic infrastructure already existed that was able to support CHW activities. Active case-finding by CHWs, which was a central component of the ARI case-management strategy used in this study, may not be feasible in other settings, particularly on a regional or national level. ARI intervention strategies could be expected to be less effective where case-finding is primarily dependent on maternal recognition of signs of pneumonia and appropriate care-seeking. None the less, the findings of this study support efforts cur- rently underway in Pakistan and other developing countries to establish national ARI programmes and to standardize ARI case management within the primary health care system. Acknowledgements This study could not have been carried out without the generous financial support of the Arab Gulf Programme for United Nations Development Organizations (AGFUND) and of WHO. The authors thank Dr A. Pio for his inspira- tion, encouragement, and continued support of the study; Dr S. Gove, Dr J. Kaleta, and Dr 1. Riley, for their invaluable assistance; and the staff of Ayub Medical College, Pakistan Medical Research Centre, and DHQ Teaching Hospital, Abbottabad. The authors are indebted to Mr Rizwan-Ullah and Mr M. Ajmal for data manage- ment and statistical support; Mr S. Khan for adminis- trative assistance; Ms P. Tyson for assistance with gra- phics; and Dr S. Redd and Dr J. Spika for helpful reviews of earlier drafts of the manuscript. R6sum6 Les Infections respiratoires algues chez l'en- fant: r6sultats d'un programme d'Interventlon dans le district d'Abbottabad, au Pakistan Les infections aigues des voies respiratoires inferieures sont responsables d'environ 4 millions de deces par an parmi les enfants ages de moins de 5 ans. La prise en charge de ces infections a fait l'objet d'un programme communautaire de 1985 a 1987 dans 38 villages (population totale: 37 245 habitants) d'un district rural du nord du Pakistan. Dans le cadre de ce programme, des agents de sante communautaires bases dans les villages procedaient ci une recherche active des cas et WHO Bulletin OMS. Vol. 68 1990. 583 A.J. Khan et al. donnaient des conseils de sante aux meres des enfants. Au cours des 2 premikres annees de l'etude, le taux de mortalite sp6cifique des infections aigues des voies respiratoires inferieures, parmi les 4802 enfants ages de moins de 5 ans vivant dans les 31 villages de la zone d'intervention, a ete de 6,3 d6c6s par 1000 enfants et par an, alors qu'il at- teignait 14,4 pour 1000 parmi les 1221 enfants des 7 villages temoins (P=0,0001). En 1987, les interven- tions ont Wte 6tendues aux villages temoins; moins d'un an plus tard, le taux dans ces villages avait baisse de 55%, passant a 6,5 deces par 1000 enfants et par an (P=0,06). Quant au taux global de mortalite des enfants de moins de 5 ans, il a et en 1985-1986 de 29,0 deces par 1000 enfants et par an dans la zone d'intervention et de 39,4 pour 1000 dans les villages t6moins, soit une difference de 28% (P=0,01). A la suite de 1'extension des interventions en 1987, le taux dans les villages temoins a baisse de 29% pour s'etablir a 27,8 deces par 1000 enfants et par an (P=0,09). Les interventions se sont accompagnees d'un declin analogue dans la mortalite des enfants de moins d'un an. Au cours de la periode 1985-1986, le taux de mortalite specifique des infections aigues des voies respiratoires inferieures dans cette tranche d'age a ete de 15,5 deces par 1000 naissances vivantes et par an dans la zone d'in- tervention, contre 32,5 pour 1000 dans les villages temoins, ce qui represente une difference de 52% (P=0,006). Apres le debut des interventions en 1987, le taux dans les villages temoins est tombe a 15,0 par 1000 naissances vivantes et par an (P= 0,12). Le principal facteur responsable de la reduc- tion de la mortalite chez les enfants de moins de 5 ans semble avoir ete la prise en charge des cas par les agents de sante communautaires et les efforts d'education entrepris aupres des meres pour leur apprendre a reconnaltre les sympt6mes des infections aigues des voies respiratoires inferieures et a faire soigner correctement leurs enfants. II semble que ces efforts d'education aient am6lior6 le comportement des meres en matiere de sante et leur connaissance des infections res- piratoires aigues, si l'on en juge par le resultat des enquetes effectuees a ce sujet. La couverture vac- cinale et la disponibilit6 des solutions de rehydratation orale ont egalement ete am6liorees au cours de l'etude, mais ces changements sont survenus simultanement et a un degre comparable dans la zone d'intervention et dans la zone temoin. Une meilleure prise en charge de la pneumonie dans les dispensaires existants peut aussi avoir contribue de facon importante a reduire la mor- talite. Les resultats de l'etude montrent que la recherche active des cas et leur prise en charge par les agents de sante communautaires peuvent ameliorer le fonctionnement d'un systeme de sant6 de base. Dans une region montagneuse du nord du Pakistan, ces interventions ont r6duit de fac,on significative le taux global de mortalite et le taux de mortalite du aux infections respiratoires aigues, tant chez les enfants de moins de 5 ans que chez les enfants de moins d'un an. Le degre d'efficacite de ces interventions dans d'autres situations ou dans d'autres populations desservies par des systemes de soins de sante diff6rents est inconnu, mais des experiences communautaires analogues menees ailleurs se sont traduites par des reductions de 27 a 62% de la mortalite due aux infections aigues des voies respiratoires inferieures. Les donnees recueillies avant le debut de l'etude montrent que la mortalite due a ces maladies etait particulierement elevee dans la region, mais qu'il existait une infrastructure sani- taire de base sur laquelle pouvaient s'appuyer les agents de sante communautaires. La recherche active des cas par ces derniers, qui a ete un element essentiel de la strategie de prise en charge des infections aigues des voies res- piratoires inferieures dans cette etude, peut etre irrealisable dans d'autres situations, surtout au niveau regional ou national. On peut aussi s'atten- dre a ce que les strategies d'interventions soient moins efficaces lorsque la decouverte des cas depend principalement de I'aptitude des meres a reconnaltre les signes de pneumonie et a recher- cher un traitement approprie pour leurs enfants. Neanmoins, les resultats obtenus justifient les efforts actuellement entrepris au Pakistan et dans d'autres pays en d6veloppement pour etablir des programmes nationaux de lutte contre les infec- tions aigues des voies respiratoires inf6rieures et normaliser la prise en charge de ces cas dans le cadre du systeme de soins de sant6 primaires. References 1. The work of WHO 1986-1987: biennial report of the Director-General. 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