How can children with sepsis receive timely emergency care?

In some cases of acute infection, the body’s own immune response begins to attack its own tissues and organs, leading to a life-threatening condition known as sepsis. With an estimated 30 million cases per year, sepsis is a global public health concern. In the developing world, sepsis accounts for 60-80% of lost lives per year in childhood, killing more than 6 million neonates and children yearly. icddr,b scientists investigate an intervention to reduce delays in seeking timely care for childhood sepsis.

Children with suspected sepsis must be taken to the hospital quickly. Photo: Shehzad Noorani / icddr,b

One of the major reasons that childhood sepsis leads to death is that children are not given professional medical attention in a timely manner. Ultimately, these children are dying of a treatable condition and these deaths could be avoided if there was greater utilisation of health services. According to a previous icddr,b study published in PLoS ONE, the quality of care and management of childhood sepsis could be improved with a well designed need-based and context-specific intervention package, even in the most resource limiting environments. Furthermore, evaluation of the Integrated Management of Childhood Illness (IMCI) programme (launched by the WHO and UNICEF in the mid-90s) in Bangladesh revealed that usage of health facilities for childhood illness has remained low in spite of past interventions.   

These results inspired an icddr,b team to implement an intervention to reduce delays in care- seeking for childhood sepsis among poor families in rural Bangladesh. The team was led by principal investigator Ms Jasmin Khan - a research investigator in the Maternal and Child Health division of icddr,b – alongside international collaborators from the University of British Columbia. The project aimed to identify key reasons for delays in care-seeking for sepsis in rural communities for Bangladesh, and to evaluate communication strategies to encourage greater utilisation of external health services in cases of childhood sepsis.

The team evaluated the intervention over a three year period from August 2012 to August 2015, with two rounds of cross-sectional evaluation before and after the 3-year intervention period. 400 mothers of recently sick children in 26 randomly sampled villages were surveyed, using structured questions about delays in care-seeking. Over the course of the 3 years, four key messages were communicated to households: serious symptoms of suspected sepsis in children, a call-in center number for referral advice, a reliable transport hub, and upgrades to the local hospital.

Ms Khan says, ‘Children with suspected sepsis need to be taken to the hospital as quickly as possible. Consequently it was important to go beyond the improvement of facilities with a community-based communication strategy to inform parents about supports for timely care.’ Hence, communicated messages were designed to inform families about hospital upgrades, convenient referral service and reliable transport.

The results, published in Social Science and Medicine, revealed a significant difference in the total delay between the onset of a child's illness and the decision to seek external care, with families showing shorter delays after the 3-year intervention period. Over 90% of mothers informed someone in the family, mainly the husband, about the sick child before acting to seek care. Using a benchmark of seeking external care within 24 h of onset, only 14.14% of intervention households and 13.40% of control households were “timely” in seeking care. 78% of parents still sought care from a non-formal practitioner (village doctor), in spite of clinical support.

Ms Khan also acknowledges limitations the current study, primarily the lack of random assignment and difficulty in estimating measures of delay.

Delay in seeking care can be life-threatening for young children under 5. Photo: Shehzad Noorani / icddr,b

Despite these constraints, the strength of the study is its comprehensive intervention design and community communication components to inform families of newly available health facilities and clinical supports. More specific data for  exact times of day for the onset of sepsis, recognising the gravity of the illness and decision making will allow more precise estimates of delays.  More specific data for the exact time of day at which sepsis occurs and decision making processes, as well as improved community ability to recognize the gravity of the illness, will allow more precise estimates of delays in the future. Overall, the results demonstrate that the delay in deciding to seek external care is the most critical factor for the treatment of childhood sepsis, and that communication strategies at the community level are needed to increase the uptake of external health services.

Dr Ehsanur Rahman, assistant scientist from maternal and child health division at icddr,b and co-author of this paper says ‘Building on the current study, future interventions coupling with community engagement platforms and evaluations will help address strategies to reduce delays in seeking care and thereby reduce unnecessary child and maternal mortality.’

This study was funded by Global Affairs Canada (GAC)