Performance of Four Respiratory Rate Counters to Support Community Health Workers to Detect the Symptoms of Pneumonia in Children in Low Resource Settings: A Prospective, Multicentre, Hospital-Based, Single-Blinded, Comparative Trial

Kevin Baker; Tobias Alfvén; Akasiima Mucunguzi; Alexandra Wharton-Smith; Emily Dantzer; Tedila Habte; Lena Matata; Diana Nanyumba; Morris Okwir; Monica Posada; Anteneh Sebsibe; Jill Nicholson; Madeleine Marasciulo; Rasa Izadnegahdar; Max Petzold; Karin Källander

doi:10.1016/j.eclinm.2019.05.013

Performance of Four Respiratory Rate Counters to Support Community Health Workers to Detect the Symptoms of Pneumonia in Children in Low Resource Settings: A Prospective, Multicentre, Hospital-Based, Single-Blinded, Comparative Trial

EClinicalMedicine. 2019 Jun 10:12:20-30. doi: 10.1016/j.eclinm.2019.05.013. eCollection 2019 Jul.

Authors

Kevin Baker^{1

2}, Tobias Alfvén^{2

3}, Akasiima Mucunguzi⁴, Alexandra Wharton-Smith⁵, Emily Dantzer⁵, Tedila Habte⁶, Lena Matata⁷, Diana Nanyumba⁴, Morris Okwir⁷, Monica Posada⁵, Anteneh Sebsibe⁶, Jill Nicholson¹, Madeleine Marasciulo⁸, Rasa Izadnegahdar⁹, Max Petzold^{10

11}, Karin Källander^{1

2}

Affiliations

¹ Malaria Consortium, London, United Kingdom.
² Karolinska Institutet, Stockholm, Sweden.
³ Sachs' Children and Youth Hospital, Stockholm, Sweden.
⁴ Malaria Consortium, Kampala, Uganda.
⁵ Malaria Consortium, Phnom Penh, Cambodia.
⁶ Malaria Consortium, Addis Ababa, Ethiopia.
⁷ Malaria Consortium, Juba, South Sudan.
⁸ Malaria Consortium, Raleigh, USA.
⁹ Bill & Melinda Gates Foundation, Seattle, USA.
¹⁰ Gothenburg University, Gothenburg, Sweden.
¹¹ University of the Witwatersrand, Johannesburg, South Africa.

Abstract

Background: Pneumonia is one of the leading causes of death in children under-five globally. The current diagnostic criteria for pneumonia are based on increased respiratory rate (RR) or chest in-drawing in children with cough and/or difficulty breathing. Accurately counting RR is difficult for community health workers (CHWs). Current RR counting devices are frequently inadequate or unavailable. This study analysed the performance of improved RR timers for detection of pneumonia symptoms in low-resource settings.

Methods: Four RR timers were evaluated on 454 children, aged from 0 to 59 months with cough and/or difficulty breathing, over three months, by CHWs in hospital settings in Cambodia, Ethiopia, South Sudan and Uganda. The devices were the Mark Two ARI timer (MK2 ARI), counting beads with ARI timer, Rrate Android phone and the Respirometer feature phone applications. Performance was evaluated for agreement with an automated RR reference standard (Masimo Root patient monitoring and connectivity platform with ISA CO₂ capnography). This study is registered with ANZCTR [ACTRN12615000348550].

Findings: While most CHWs managed to achieve a RR count with the four devices, the agreement was low for all; the mean difference of RR measurements from the reference standard for the four devices ranged from 0.5 (95% C.I. - 2.2 to 1.2) for the respirometer to 5.5 (95% C.I. 3.2 to 7.8) for Rrate. Performance was consistently lower for young infants (0 to < 2 months) than for older children (2 to ≤ 59 months). Agreement of RR classification into fast and normal breathing was moderate across all four devices, with Cohen's Kappa statistics ranging from 0.41 (SE 0.04) to 0.49 (SE 0.05).

Interpretation: None of the four devices evaluated performed well based on agreement with the reference standard. The ARI timer currently recommended for use by CHWs should only be replaced by more expensive, equally performing, automated RR devices when aspects such as usability and duration of the device significantly improve the patient-provider experience.

Funding: Bill & Melinda Gates Foundation [OPP1054367].

Keywords: Childhood pneumonia; Diagnostic tools; Health worker performance; Low-income country; Respiratory rate counting.