Management and outcomes of chest-indrawing pneumonia among children aged 2-59 months in a programme setting in Ethiopia: a prospective observational study.

Background: Pneumonia is a leading cause of morbidity and mortality in children under five years of age. In 2012, the World Health Organization revised its guidelines for managing childhood pneumonia and recommended oral amoxicillin for the outpatient treatment of chest indrawing pneumonia in children aged 2-59 months. While the Ethiopian government subsequently adopted these revised pneumonia guidelines, the level of their implementation and of the related treatment outcomes remains less known. We aimed to determine the outcomes of this approach at primary healthcare facilities in Ethiopia. Methods: We conducted a prospective, observational cohort study at five health centres in Northern Ethiopia from November 2022 to November 2023. Trained health workers screened all children aged 2-59 months who had cough or difficult breathing and managed them according to the integrated management of childhood illness chart booklet. Children with chest indrawing pneumonia who lived in the study catchment area and whose parents or guardians consented were enrolled. An independent data collector conducted a follow-up visit on day 15 to collect information on their survival status and the treatment received after enrolment. The primary outcome was case fatality risk (CFR), calculated as the proportion of children who died by day 15 after enrolment among all enrolled children. Results: We screened 3492 children aged 2-59 months, enrolling 345 with chest indrawing pneumonia. All were prescribed oral amoxicillin. The majority (n = 340, 98.6%), received a five-day prescription, while the remaining five were prescribed a seven-day course. We assessed 333 children on day 15 for study outcomes. Twelve (3.5%) were lost to follow-up. Two children died, resulting in a CFR of 0.6 (95% confidence interval = 0.35, 0.85). Most children (n = 315, 94.6%), adhered to the five-day course of amoxicillin, while 18 (5.4%) did not complete the entire course. Thirteen (3.9%) children were taken to a hospital between days two and 15, six received outpatient treatment, and seven were hospitalised. All 13 were alive and well on day 15. Conclusions: In a programme setting, children aged 2-59 months with chest indrawing pneumonia managed at the primary healthcare facilities on an outpatient basis with oral amoxicillin had low CFR, low hospitalisation rates, and high adherence to treatment. Registration: ISRCTN: 12687253.