Management of chest indrawing pneumonia in children aged 2-59 months by community-level workers compared to standard care on clinical outcomes: systematic review and meta-analysis.

Background: World Health Organization recommends that children aged 2-59 months, with chest indrawing pneumonia, are treated with a five-day course of oral amoxicillin initiated at a health facility. We synthesised the evidence on the effectiveness and safety of community-level health care workers (CLHW)-led management compared to standard care at a hospital or health facility among children aged 2-59 months with chest indrawing pneumonia in terms of clinical outcomes. Methods: We conducted a comprehensive search in PubMed, EMBASE, and Cochrane Central for studies published from January 2000 to August 2024, with no language restriction. The search included quasi and/or randomised controlled trials. We conducted data extraction using the Cochrane checklist, and we used GRADE to assess the quality of the evidence. Given that the included studies were from different settings and used different methods, we applied a random-effects model for data synthesis. The primary outcome was treatment failure by six days of treatment initiation. Secondary outcomes included mortality and other serious adverse events (SAEs) (excluding mortality) by 14 days. Results: Of the 6883 eligible articles, we included three randomised controlled trials involving 11 779 children aged 2-59 months with chest indrawing pneumonia without danger signs. The CLHW-led management significantly reduced the risk of treatment failure by 34% (relative risk (RR) = 0.66, 95% confidence interval (CI) = 0.44, 0.98; low quality evidence). The RR of mortality for CLHW-led management compared to standard care was RR = 0.85 (95% CI = 0.31, 2.30; low quality evidence). The RR for other SAEs was RR = 1.20 (95% CI = 0.34, 4.26; low quality evidence). Conclusions: The findings suggest that CLHW-led management may reduce treatment failure rates by day six without any significant differences in mortality or other SAEs compared to standard care. However, given the low certainty of the evidence, these results should be interpreted with caution and more research is required. Registration: PROSPERO: CRD42023439851.