Explorer Measuring Coverage in MNCH

Background: Antibiotic treatment for pneumonia as measured by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) is a key indicator for tracking progress in achieving Millennium Development Goal 4. Concerns about the validity of this indicator led us to perform an evaluation in urban and rural settings in Pakistan and Bangladesh. Methods and Findings: Caregivers of 950 children under 5 y with pneumonia and 980 with ‘‘no pneumonia’’ were identified in urban and rural settings and allocated for DHS/MICS questions 2 or 4 wk later. Study physicians assigned a diagnosis of pneumonia as reference standard; the predictive ability of DHS/MICS questions and additional measurement tools to identify pneumonia versus non-pneumonia cases was evaluated. Results at both sites showed suboptimal discriminative power, with no difference between 2or 4-wk recall. Individual patterns of sensitivity and specificity varied substantially across study sites (sensitivity 66.9% and 45.5%, and specificity 68.8% and 69.5%, for DHS in Pakistan and Bangladesh, respectively). Prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, increasing to 72% and 82% in Pakistan and Bangladesh, respectively, using a drug chart and detailed enquiry. Conclusions: Monitoring antibiotic treatment of pneumonia is essential for national and global programs. Current (DHS/ MICS questions) and proposed new (video and pneumonia score) methods of identifying pneumonia based on maternal recall discriminate poorly between pneumonia and children with cough. Furthermore, these methods have a low yield to identify children who have true pneumonia. Reported antibiotic treatment rates among these children are therefore not a valid proxy indicator of pneumonia treatment rates. These results have important implications for program monitoring and suggest that data in its current format from DHS/MICS surveys should not be used for the purpose of monitoring antibiotic treatment rates in children with pneumonia at the present time. Please see later in the article for the Editors’ Summary. Citation: Hazir T, Begum K, el Arifeen S, Khan AM, Huque MH, et al. (2013) Measuring Coverage in MNCH: A Prospective Validation Study in Pakistan and Bangladesh on Measuring Correct Treatment of Childhood Pneumonia. PLoS Med 10(5): e1001422. doi:10.1371/journal.pmed.1001422 Academic Editor: David Osrin, Wellcome Trust Senior Research Fellow in Clinical Science, UCL Reader in International Child Health, Honorary Consultant, Great Ormond Street Hospital for Children, United Kingdom Received September 18, 2012; Accepted March 4, 2013; Published May 7, 2013 Copyright: 2013 Hazir et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This work was supported by a sub-grant ‘‘MA13 project: careseeking and coverage of child health interventions’’ from the Child Health Epidemiology Reference Group (CHERG; www.cherg.org) grant from The Bill & Melinda Gates Foundation grant no. 50140 (www.gatesfoundation.org). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: DHS, Demographic and Health Survey/s; MICS, Multiple Indicator Cluster Survey/s; WHO, World Health Organization. * E-mail: tabishhazir@hotmail.com . These authors contributed equally to this work. PLOS Medicine | www.plosmedicine.org 1 May 2013 | Volume 10 | Issue 5 | e1001422 This paper is part of the PLOS Medicine ‘‘Measuring Coverage in MNCH’’ Collection.