116
is that these patients were in the process of transformation to a clonal disorder which would not be responsive to antimalarial drugs.
hypothesis
DIAGNOSIS OF PNEUMONIA BY 10 TBAs WITH AND WITHOUT BREATH COUNTER IN CHILDREN WITH BORDERLINE RESPIRATORY RATE (RR)
Department of Cellular and Molecular Sciences, Division of Haematology, St George’s Hospital Medical School, University of London, London SW17 0RE, UK
IMELDA BATES
1. DeCock KM, Hodgen AN, Jupp RA, et al. Immunoglobulin M and malarial antibody levels in hyper-reactive malarial splenomegaly. J Trop Med Hyg 1986; 89: 119-21. 2. Molyneaux M, Hutt MSR, Clear AS, et al. Serum immunoglobulin concentrations, malarial and schistosomal antibodies m patients with massive splenomegaly in Malawi. J Trop Med Hyg 1979; 82: 183-87. 3. Ziegler JL, Voller A, Ponnudurai T. Malarial antibodies m tropical splenomegaly syndrome in Uganda. Trop Geogr Med 1973; 25: 282-85. 4. Fakunle YM, Greenwood BM, Fleming AF, Danon F. Tropical splenomogaly or chronic lymphatic leukaemia? Trop Geogr Med 1979; 31: 353. 5. Ukaejiofo E, Onwukeme KE, Sagoe AS, et al. Chronic lymphocytic leukaemia with raised serum IgM levels. Afr J Med Sci 1987; 16: 113-18. 6. Sagoe AS. Tropical splenomegaly syndrome: long-term proguanil therapy correlated with spleen size, serum IgM and lymphocyte transformation. Br Med J 1970; iii: 378. 7. Hoffman SL, Piessens WF, Ratiwayanto MS, et al. Reduction of suppressor T lymphocytes in the tropical splenomegaly syndrome. N Engl J Med 1984; 310: 337-41.
Breath counter for
diagnosis of childhood pneumonia
SiR,—We reported a field trial in Gadchiroli, India, in which case management of pneumonia by trained health workers reduced pneumonia childhood deaths by 54%.’ To improve the casemanagement service, we trained traditional birth attendants (TBAs) to diagnose and treat childhood pneumonia.’ Since almost all TBAs were illiterate and usually could not count to more than twelve they could not use WHO criteria based on respiratory rate .2 Hence they were trained to diagnose pneumonia by visual judgment of whether the child looked tachypnoeic (Lahak or Dhapa). Training included visual inspection of children with pneumonia and a film on childhood pneumonia. We undertook a pilot study to ascertain the diagnostic accuracy of 46 TBAs by comparing their visual judgment with the WHO criteria for respiratory rate (RR). These two matched in 91 % of cases when RR was extreme (< 30 or > 70) but only 59% when RR was borderline (± 10 of WHO criteria). To improve TBAs’ diagnostic accuracy, a simple aid was developed and tested. The device consisted of an abacus, a 1-minute sand-timer, and two rows of beads—one for infants up to 2 months of age (five green and one red bead, RR 60), and one for infants aged 2-11 months, (four green and one red bead, RR 50). Using the sand-timer, the TBA counted breaths and moved one bead for every ten breaths. If within 1 minute the red bead was moved, it denoted the presence of pneumonia. The counter also had pictures of a baby and a young child alongside the relevant rows to guide the user to the correct row for age. TBAs were invited to volunteer to use this device, and the first 10 to do so were selected for training. Their training and practice included three sessions of about 1 h. Diagnostic accuracy of these TBAs was tested first without and then with the use of the breath counter on the same 5 children. These children were selected for their borderline RR to test accuracy in more difficult situations. A physician (A. T. B.) also counted the RR at the same time and classified children according to WHO criteria.2 The table shows diagnostic accuracy of the TBAs without and with the aid of the breath counter. The use of this device significantly improved the diagnosis of pneumonia (chi-square test, p < 0-05). The proportion of correct diagnoses with the breath counter in borderline cases improved to 82%. Since RR alone is not 100% reliable,3,4 the diagnosis by TBAs may be less accurate than medical diagnosis. However, it is possible that in some instances the TBAs’ unaided judgment rather than their diagnosis based on count, might be correct.3,4 Since RR is the diagnostic criterion recommended by WHO the purpose of the breath counter was to bring TBAs diagnosis close to one based on RR. Our breath counter combines two traditional methods of measuring time and counting. Moreover, it overcomes the inability
of TBAs to count to more than twelve, helps arrive at a definite decision when the red bead is moved, and decisions can be related to age. The counter is cheap (US$4); mass production would lower this price. It could be improved by replacement of the sand-timer by an electronic timer that sounds an alarm at 1 minute. The ability of parents and health workers to differentiate upper respiratory tract infection from pneumonia is the most crucial skill in the control of deaths due to pneumonia with case-management approach. We suggest that the breath counter can become a household diagnostic aid and contribute much in the reduction of childhood mortality due to pneumonia. SEARCH was supported by the Indian Council of Medical Research and the Ford Foundation. We thank the TBAs, Miss Maya Bujone, Mr Vilas Morankar, and Mr Digambar Deotale for their help. Shri Ashok Kanoje of Vidarbha Wood Craft Industries, Gadchiroli, made the breath counter designed by A. T. B. SEARCH Gadchiroli 442 605, India
ABHAY T. BANG RANI A. BANG
Tale O, et al. Reduction in pneumonia mortality and total childhood mortality by means of community based intervention trial in Gadchiroli, India. Lancet 1990; 336: 201-06. 2. World Health Organisation. Acute respiratory infections in children: case management m small hospitals in developing countries. WHO/ARI/90.5. 3. Shann F, Hart K, Thomas D. Acute lower respiratory tract infection in children; possible criteria for selection of patients for antibiotic therapy and hospital admissions. Bull WHO 1984; 62: 749-53 4. Cherian T, John TJ, Simoes E, Steinhoff MC, John M. Evaluation of simple clinical signs for diagnosis of acute lower respiratory tract infection. Lancet 1988; ii: 125-28. 1.
Bang AT, Bang RA,
Schizophrenia and influenza SIR,-On the basis of an apparent excess of births, between Feb 15 and March 14,1958, of individuals in whom schizophrenia later developed Dr O’Callaghan and colleagues (May 25, p 1248) suggest that prenatal exposure in the 1957 influenza epidemic predisposed to
schizophrenia.
We have studied the admissions to psychiatric hospitals of individuals in the National Child Development Study,1.2 whose antenatal and perinatal histories including infections were documented at the time of birth. All children born in England, Scotland, and Wales in the week March 3-9, 1958, were included. The sample consisted of those whom O’Callaghan et al suggest are at greatest risk of subsequent psychotic illness as a result of exposure to influenza in the supposedly critical fifth month of pregnancy. Cases were identified (with the help of statisticians in the sixteen regional health authorities) by a search in Mental Health Enquiry records for individuals born in that week. Patients born abroad were excluded. Psychiatric diagnoses were established by retrieving the case notes and applying Present State Examination criteria. Influenza during pregnancy was documented by an interview with the mother conducted by the midwife, who was also required to consult medical records relating to the period of pregnancy. The table shows rates of influenza in 16 179 mothers whose children by 1985 had not been admitted to psychiatric units, and those in mothers whose children had been so admitted and who acquired a diagnosis either of schizophrenia, by a broad or a narrow definition, or of affective disorder. The findings suggest that mothers who were exposed to influenza in the fifth month (or at other times) in their pregnancies did not
is that these patients were in the process of transformation to a clonal disorder which would not be responsive to antimalarial drugs.
hypothesis
DIAGNOSIS OF PNEUMONIA BY 10 TBAs WITH AND WITHOUT BREATH COUNTER IN CHILDREN WITH BORDERLINE RESPIRATORY RATE (RR)
Department of Cellular and Molecular Sciences, Division of Haematology, St George’s Hospital Medical School, University of London, London SW17 0RE, UK
IMELDA BATES
1. DeCock KM, Hodgen AN, Jupp RA, et al. Immunoglobulin M and malarial antibody levels in hyper-reactive malarial splenomegaly. J Trop Med Hyg 1986; 89: 119-21. 2. Molyneaux M, Hutt MSR, Clear AS, et al. Serum immunoglobulin concentrations, malarial and schistosomal antibodies m patients with massive splenomegaly in Malawi. J Trop Med Hyg 1979; 82: 183-87. 3. Ziegler JL, Voller A, Ponnudurai T. Malarial antibodies m tropical splenomegaly syndrome in Uganda. Trop Geogr Med 1973; 25: 282-85. 4. Fakunle YM, Greenwood BM, Fleming AF, Danon F. Tropical splenomogaly or chronic lymphatic leukaemia? Trop Geogr Med 1979; 31: 353. 5. Ukaejiofo E, Onwukeme KE, Sagoe AS, et al. Chronic lymphocytic leukaemia with raised serum IgM levels. Afr J Med Sci 1987; 16: 113-18. 6. Sagoe AS. Tropical splenomegaly syndrome: long-term proguanil therapy correlated with spleen size, serum IgM and lymphocyte transformation. Br Med J 1970; iii: 378. 7. Hoffman SL, Piessens WF, Ratiwayanto MS, et al. Reduction of suppressor T lymphocytes in the tropical splenomegaly syndrome. N Engl J Med 1984; 310: 337-41.
Breath counter for
diagnosis of childhood pneumonia
SiR,—We reported a field trial in Gadchiroli, India, in which case management of pneumonia by trained health workers reduced pneumonia childhood deaths by 54%.’ To improve the casemanagement service, we trained traditional birth attendants (TBAs) to diagnose and treat childhood pneumonia.’ Since almost all TBAs were illiterate and usually could not count to more than twelve they could not use WHO criteria based on respiratory rate .2 Hence they were trained to diagnose pneumonia by visual judgment of whether the child looked tachypnoeic (Lahak or Dhapa). Training included visual inspection of children with pneumonia and a film on childhood pneumonia. We undertook a pilot study to ascertain the diagnostic accuracy of 46 TBAs by comparing their visual judgment with the WHO criteria for respiratory rate (RR). These two matched in 91 % of cases when RR was extreme (< 30 or > 70) but only 59% when RR was borderline (± 10 of WHO criteria). To improve TBAs’ diagnostic accuracy, a simple aid was developed and tested. The device consisted of an abacus, a 1-minute sand-timer, and two rows of beads—one for infants up to 2 months of age (five green and one red bead, RR 60), and one for infants aged 2-11 months, (four green and one red bead, RR 50). Using the sand-timer, the TBA counted breaths and moved one bead for every ten breaths. If within 1 minute the red bead was moved, it denoted the presence of pneumonia. The counter also had pictures of a baby and a young child alongside the relevant rows to guide the user to the correct row for age. TBAs were invited to volunteer to use this device, and the first 10 to do so were selected for training. Their training and practice included three sessions of about 1 h. Diagnostic accuracy of these TBAs was tested first without and then with the use of the breath counter on the same 5 children. These children were selected for their borderline RR to test accuracy in more difficult situations. A physician (A. T. B.) also counted the RR at the same time and classified children according to WHO criteria.2 The table shows diagnostic accuracy of the TBAs without and with the aid of the breath counter. The use of this device significantly improved the diagnosis of pneumonia (chi-square test, p < 0-05). The proportion of correct diagnoses with the breath counter in borderline cases improved to 82%. Since RR alone is not 100% reliable,3,4 the diagnosis by TBAs may be less accurate than medical diagnosis. However, it is possible that in some instances the TBAs’ unaided judgment rather than their diagnosis based on count, might be correct.3,4 Since RR is the diagnostic criterion recommended by WHO the purpose of the breath counter was to bring TBAs diagnosis close to one based on RR. Our breath counter combines two traditional methods of measuring time and counting. Moreover, it overcomes the inability
of TBAs to count to more than twelve, helps arrive at a definite decision when the red bead is moved, and decisions can be related to age. The counter is cheap (US$4); mass production would lower this price. It could be improved by replacement of the sand-timer by an electronic timer that sounds an alarm at 1 minute. The ability of parents and health workers to differentiate upper respiratory tract infection from pneumonia is the most crucial skill in the control of deaths due to pneumonia with case-management approach. We suggest that the breath counter can become a household diagnostic aid and contribute much in the reduction of childhood mortality due to pneumonia. SEARCH was supported by the Indian Council of Medical Research and the Ford Foundation. We thank the TBAs, Miss Maya Bujone, Mr Vilas Morankar, and Mr Digambar Deotale for their help. Shri Ashok Kanoje of Vidarbha Wood Craft Industries, Gadchiroli, made the breath counter designed by A. T. B. SEARCH Gadchiroli 442 605, India
ABHAY T. BANG RANI A. BANG
Tale O, et al. Reduction in pneumonia mortality and total childhood mortality by means of community based intervention trial in Gadchiroli, India. Lancet 1990; 336: 201-06. 2. World Health Organisation. Acute respiratory infections in children: case management m small hospitals in developing countries. WHO/ARI/90.5. 3. Shann F, Hart K, Thomas D. Acute lower respiratory tract infection in children; possible criteria for selection of patients for antibiotic therapy and hospital admissions. Bull WHO 1984; 62: 749-53 4. Cherian T, John TJ, Simoes E, Steinhoff MC, John M. Evaluation of simple clinical signs for diagnosis of acute lower respiratory tract infection. Lancet 1988; ii: 125-28. 1.
Bang AT, Bang RA,
Schizophrenia and influenza SIR,-On the basis of an apparent excess of births, between Feb 15 and March 14,1958, of individuals in whom schizophrenia later developed Dr O’Callaghan and colleagues (May 25, p 1248) suggest that prenatal exposure in the 1957 influenza epidemic predisposed to
schizophrenia.
We have studied the admissions to psychiatric hospitals of individuals in the National Child Development Study,1.2 whose antenatal and perinatal histories including infections were documented at the time of birth. All children born in England, Scotland, and Wales in the week March 3-9, 1958, were included. The sample consisted of those whom O’Callaghan et al suggest are at greatest risk of subsequent psychotic illness as a result of exposure to influenza in the supposedly critical fifth month of pregnancy. Cases were identified (with the help of statisticians in the sixteen regional health authorities) by a search in Mental Health Enquiry records for individuals born in that week. Patients born abroad were excluded. Psychiatric diagnoses were established by retrieving the case notes and applying Present State Examination criteria. Influenza during pregnancy was documented by an interview with the mother conducted by the midwife, who was also required to consult medical records relating to the period of pregnancy. The table shows rates of influenza in 16 179 mothers whose children by 1985 had not been admitted to psychiatric units, and those in mothers whose children had been so admitted and who acquired a diagnosis either of schizophrenia, by a broad or a narrow definition, or of affective disorder. The findings suggest that mothers who were exposed to influenza in the fifth month (or at other times) in their pregnancies did not
