title: Under treatment of pneumonia among children under 5 years of age in a malaria-endemic area: population-based surveillance study conducted in Manhica district- rural, Mozambique.
abstract: BACKGROUND
  Integrated Management of Childhood Illness (IMCI) guidelines were developed to decrease morbidity and mortality, yet implementation varies across settings. Factors associated with poor adherence are not well understood.
  
  
  METHODS
  We used data from Manhiça District Hospital outpatient department and five peripheral health centers to examine pneumonia management for children <5 years old from January 2008 to June 2011. Episodes of IMCI-defined pneumonia (cough or difficult breathing plus tachypnea), severe pneumonia (pneumonia plus chest wall in-drawing), and/or clinician-diagnosed pneumonia (based on discharge diagnosis) were included.
  
  
  RESULTS
  Among severe pneumonia episodes, 96.2% (2,918/3,032) attended in the outpatient department and 70.0% (291/416) attended in health centers were appropriately referred to the emergency department. Age<1 year, malnutrition and various physical exam findings were associated with referral. For non-severe pneumonia episodes, antibiotics were prescribed in 45.7% (16,094/35,224). Factors associated with antibiotic prescription included age <1 year, abnormal auscultatory findings, and clinical diagnosis of pneumonia; diagnosis of malaria or gastroenteritis and pallor were negatively associated with antibiotic prescription.
  
  
  CONCLUSIONS
  Adherence to recommended management of severe pneumonia was high in a hospital outpatient department, but suboptimal in health centers. Antibiotics were prescribed in fewer than half of non-severe pneumonia episodes, and diagnosis of malaria was the strongest risk factor for incorrect management.
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique. Electronic address: sozinho.acacio@manhica.net.
authors.forename: Sozinho
authors.initials: S
authors.lastname: Acácio
authors.affiliation: Centers for Disease Control and Prevention - 1600 Clifton Road, Atlanta, GA 30329 USA. Electronic address: jverani@cdc.gov.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Verani
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Centre de Recerca en Salut Internacional de Barcelona, Hospital Clínic, Universitat de Barcelona - Rosselló 132, 08036, Barcelona, Spain. Electronic address: miguel.lanaspa@cresib.cat.
authors.forename: Miguel
authors.initials: M
authors.lastname: Lanaspa
authors.affiliation: Centers for Disease Control and Prevention - 1600 Clifton Road, Atlanta, GA 30329 USA. Electronic address: t.fairlie@gmail.com.
authors.forename: Tarayn A
authors.initials: TA
authors.lastname: Fairlie
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique. Electronic address: taciltanha@yahoo.com.
authors.forename: Tacilta
authors.initials: T
authors.lastname: Nhampossa
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Centre de Recerca en Salut Internacional de Barcelona, Hospital Clínic, Universitat de Barcelona - Rosselló 132, 08036, Barcelona, Spain. Electronic address: maria.ruperez@cresib.cat.
authors.forename: Maria
authors.initials: M
authors.lastname: Ruperez
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique. Electronic address: Pedro.Aide@manhica.net.
authors.forename: Pedro
authors.initials: P
authors.lastname: Aide
authors.affiliation: Centers for Disease Control and Prevention - 1600 Clifton Road, Atlanta, GA 30329 USA. Electronic address: bdplikaytis@gmail.com.
authors.forename: Brian D
authors.initials: BD
authors.lastname: Plikaytis
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique. Electronic address: Charfudin.Sacoor@manhica.net.
authors.forename: Charfudin
authors.initials: C
authors.lastname: Sacoor
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique. Electronic address: Eusebio.Macete@manhica.net.
authors.forename: Eusebio
authors.initials: E
authors.lastname: Macete
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Centre de Recerca en Salut Internacional de Barcelona, Hospital Clínic, Universitat de Barcelona - Rosselló 132, 08036, Barcelona, Spain. Electronic address: pedro.alonso@isglobal.org.
authors.forename: Pedro
authors.initials: P
authors.lastname: Alonso
authors.affiliation: Centro de Investigação em Saúde de Manhiça - Road 12. Manhiça, Mozambique; Instituto Nacional de Saúde, Ministério de Saúde - Av. Eduardo Mondlane 1008, Maputo, Mozambique. Electronic address: betuel.sigauque@manhica.net.
authors.forename: Betuel
authors.initials: B
authors.lastname: Sigaúque
mesh_terms: D000553:Ambulatory Care; D002675:Child, Preschool; D060085:Coinfection / Q000175:diagnosis; D011307:Drug Prescriptions; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D008288:Malaria / Q000150:complications* / Q000453:epidemiology; D008297:Male; D009073:Mozambique / Q000453:epidemiology; D011014:Pneumonia / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D011159:Population Surveillance; D012017:Referral and Consultation; D012307:Risk Factors; D012424:Rural Population
keywords: Guideline Adherence; Mozambique; Pneumonia