Evaluation of Interventions to Reduce Child Mortality From Acute Respiratory Infections in a Remote Community in North Eastern Afghanistan, and the Implications for the Emergence of Antibiotic Resistance in Streptococcus pneumoniae

Duncan, Alexander Charles Weeks (2011). Evaluation of Interventions to Reduce Child Mortality From Acute Respiratory Infections in a Remote Community in North Eastern Afghanistan, and the Implications for the Emergence of Antibiotic Resistance in Streptococcus pneumoniae. PhD thesis The Open University.

DOI: https://doi.org/10.21954/ou.ro.0000f1cc

Abstract

There are many remote regions of the world where there are no data about the health of the community. This thesis reports on the implementation of a community health programme in Wakhan District, a remote valley in Afghanistan. This programme trained illiterate women to educate mothers to feed their children appropriately, to treat dehydration and to manage acute respiratory infections (ARI) with co-trimoxazole. The programme covered 6000 people in 28 communities, and took five years to establish. Data about births and deaths were collected in 2002, before the programme began, and during its implementation from 2005-8.

ARI was a leading cause of death in children under five. Standard case management of ARI in children, using co-trimoxazole, was effective in significantly reducing mortality. A simple algorithm for appropriate use of co-trimoxazole, based on counting respiratory rate, can be implemented by health workers with limited training. Comparing data collected in 2002, before the programme was implemented, with data collected 2005-8, mortality in children under two years fell by 40%, from 262 to 158 per 1000 live births.

There is little data on the consequences of using standard case management of ARI by health workers with limited training on the reduction of antibiotic susceptibility, or the clinical consequences of reduced antibiotic susceptibility. Isolating invasive Streptococcus pneumoniae, (the most common pathogen causing ARI in children) to examine its antibiotic susceptibilities is difficult. Two sets of nasopharyngeal samples were collected from healthy children to give an estimate of the proportion of Streptococcus pneumoniae with reduced antibiotic susceptibility. Streptococcus pneumoniae isolates were tested for antibiotic susceptibility in a purpose-built laboratory in Wakhan. Streptococcus pneumoniae was isolated from 47% of the children sampled. 17% of samples showed resistance to penicillin, 70% to co-trimoxazole, 9% to erythromycin and 40% to tetracycline. 16 isolates were sent back to the UK. Six of the 11 which survived were of serotypes not included in the commercially available protein conjugate vaccines. Three were novel strains of Streptococcus pneumoniae on multi-locus sequence typing, displaying two different strain types.

The conclusion of this research programme is that health workers with very limited training can successfully implement a simple algorithm to treat ARI in children. It is possible to monitor antibiotic susceptibility in a remote area, with limited equipment, facilities and supplies. In vitro reductions in susceptibility to co-trimoxazole are noted, but the clinical significance of this is unclear. Unusual strains of Streptococcus pneumoniae are circulating in this community, which are not covered by vaccines currently available.

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