Childhood pneumonia

Journalist-to-Journalist Lung Health Programme

Berlin, Germany
November 12, 2010
Penny Enarson
The Union, Paris France
WHAT IS PNEUMONIA?
ARI Clinical Syndromes
 ARI in Children
Is any infection of It ranges from the
acute onset,
affecting the:
• ear • common cold
• nose • ear infection
• throat • sore throat
• larynx
• bronchitis
• trachea
• bronchi • bronchiolitis
• bronchioles • pneumonia
• lungs
 Categories of pneumonia
Pneumonia:
– very sever
– severe
– non-severe

• The lungs are made up of

small sacs called alveoli,
which fill with air when a
healthy person breathes.
When an individual has
pneumonia, the alveoli are
filled with pus and fluid, which
makes breathing painful and
limits oxygen intake.
WHO DOES PNEUMONIA
AFFECT?
 UNDER-FIVE CLINIC AT DISTRICT HOSPITAL

Pneumonia is the single biggest killer of children <5 years in the developing world
 ARI Burden
on Health Services
• 5-8 episodes per child year in urban areas
• 3-5 in rural areas
• Overall ARI incidence same for low-income
and industrialized countries
• ARI is very often the most common
- acute illness amongst children
- reason for visit to a health worker
- reason for admission to hospital
WHERE?
Disease profiles

Diarrhea +
pneumonia

Malaria
Neonatal Malaria + AIDS

AIDS
Child Mortality: Geographic Distribution
 Major Causes of Child Death
(2005)
Total deaths:
10.8 million Perinatal (23.1%) Majority from pneumonia
Pneumonia (19.1%)
Diarrhoeal diseases (15.2%)
These seven
Malaria (10.7%)
communicable
Measles (5.4%)
diseases account
HIV/AIDS (3.6%)
for 60% of all
Pertussis (2.9%)
child deaths
Tetanus (1.8%)
All other (19.2%)

Malnutrition is estimated to
contribute to around 50% of
all childhood deaths.

EIP/WHO
Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.
Pneumonia:The forgotten killer of children New York: UNICEF/WHO 2006.
 Incidence of Pneumonia

• Pneumonia is more frequent & severe in

children in low-income countries than in
children in industrialized countries
• Mortality rate for pneumonia is 10 to 50
times higher than in developed countries
 WHY?
It’s not just the disease.
The incidence and mortality due to
pneumonia must be understood in the
broader context of the child’s environment
and the care he or she receives.
Those that are most disadvantaged are at
highest risk of exposure to these risks and
at highest risk of death.
 Significant Risk Factors
Pneumonia in Children
• Lack of immunization
• Poor nutrition
• Environmental pollution
• Poor case management/prophylaxis
• Social/behavioural issues
• Poverty
• Malaria
• HIV/AIDS
 Child Survival: Determinants
Proximate Determinants
 Feeding and nutrition
 Hygiene and indoor air pollution
 Other preventive activities
Socio-economic
 Care during illness
differences

Underlying Determinants
For each of these
 Financial barriers determinants:
 Health care provision
 Maternal education The poor are
 Water, sanitation, and the home
environment
disadvantaged
 Other underlying determinants

Source: Wagstaff, Bryce, Bustreo, Claeson. Child health: reaching the poor. AJPH
 Is the MDG 4 for child survival
achievable globally?

The limiting factors/obstacles in reducing

child mortality by two-thirds by 2015?

– Scaling up health delivery

– Lack of funds
 Child Survival:The Obstacles
Implementation Challenges
Health Systems Constraints Community Constraints

Underfunded
Poverty

Over-crowded
The reality of HIV/AIDs
 Monthly health expenditure per capita, deaths at age under 5 years per
1000 livebirths,6 and “preventable” component of under-5 mortality*

*Deaths from pneumonia, diarrhoea, malaria, and measles.

Six WHO regions: AFR=sub-Saharan Africa, SEAR=southeast Asia,
EMR=eastern Mediterranean, WPR=western Pacific, EUR=Europe,
AMR=Americas.

Byass P, Ghebreyesus TA. Making the world’s children count Lancet 2005; 365 1114
 Estimated proportion of children < 5 years who received survival prevention
interventions in 42 countries accounting for 90% of under-5 deaths, 2003

Bryce J, et.al. Reducing child mortality: can public health deliver? Lancet 2003; 362: 159–64
 Percent of per capita GNP needed to
buy primary series of Hib vaccine
7
6
Percent of Per capita GNP

6
5
4
3 2.3
2
1 0.5
0.06
0
USA South Africa Egypt Niger
The cost of scaling-up interventions

• US$5·1 billion in new resources is needed

annually to save 6 million child lives in the
42 countries responsible for 90% of child
deaths in 2000.
• This cost represents $1·23 per head in
these countries, or an average cost per
child life saved of $887.
 Coverage estimates for child survival treatment interventions for
the 42 countries with 90% of worldwide child deaths in 2000

Data source: State of the World’s Children 2003. *Where available. For interventions with no country-level
coverage data a single estimate was used for all countries.

Jones G, et al How many deaths can we prevent this year? Lancet 2003; 362: 65-71
 Cost of scaling-up pneumonia interventions

• More than 1 million lives could be saved if

both prevention and treatment
interventions for pneumonia were
implemented universally.
• Around 600,000 children’s lives could be
saved each year through universal
treatment with antibiotics alone, costing
around $600 million

Bryce, J., et al., ‘Can the World Afford to Save the Lives of 6 Million Children Each Year?’, The Lancet, vol. 365, 2005, pp. 2193-2200;
Jones, G., et al., ‘How Many Child Deaths Can We Prevent This Year?’, The Lancet, vol. 362, 2003, pp. 65-71.
Cost of scaling-up pneumonia interventions
This investment is not only critical for expanding
treatment coverage with antibiotics but is also
necessary for strengthening the broader Health
system. The cost includes
• The purchase price of antibiotics,
• Scaling up treatment coverage to universal
levels:
– training
– supervising staff
– funding hospital stays for children with severe
pneumonia
Reaching MDG 4
Child Survival: The Opportunities

• Taking Known Interventions to Scale

– Preventive interventions
– Care of the sick child
• Pneumonia Standard Case
Management – a proven intervention
 Child survival interventions with sufficient or limited evidence of effect on reducing
mortality from the major causes of under-5 deaths

Jones G, et. al. How many child deaths can we prevent this year? Lancet 2003; 362: 65–71
Community-based implementation of
standard case management
of pneumonia
Sazawal S, Black RE. Lancet Infect Dis 2003

Reduced pneumonia-specific mortality

– 35-40% reduction

• Reduced all cause under 5 mortality

– 20-25% reduction
Child Lung Health Programme (CLHP)
MALAWI

Making a Difference in Child Survival

The Union’s Health Service Delivery Model
for Lung Health Goal:
• To promote better lung health in children
through the development of a cost-
effective, sustainable project for the
surveillance, diagnosis, and management
of severe respiratory disease in children
• The building of sustainable management
and technical capacity for these activities
in the target country, and
• The ultimate establishment of national
self-sufficiency for this model of health
services delivery for severe childhood
respiratory disease.
Basis of case management strategy
• Value of simple clinical signs
– Ability of health workers to utilize the
signs
• Most pneumonia deaths in high burden
countries due to bacteria
– Effective antibiotics will reduce CFR
• Avoids unnecessary use of antibiotics
– Minimize development of MDR
pathogens
• Rational use of oxygen
 Achievements of the CLHP Malawi
• Total number of children admitted between
October 2000-December 2005 48 285
• Baseline pneumonia CFR 18.6%
• Pneumonia CFR December 2005 8.4%
• Reduction over the baseline 54.8%
• There was a significant statistical intervention
effect OR .79 p> 0.037 95% Conf Interval .
63 to.99
• Total number lives saved 2000-2005 4357
Lack of funding
 20 diseases graded by disability-adjusted life-years (DALYs)

*Countries classified by the World Health Organization as having very high or high
child and adult mortality. Data from WorldHealth Report 2001 (WHO 2001).

Shiffman J. Donor funding priorities for communicable diseases. The Author 2006.
Disease burden in the developing world versus share
of donor funding, direct grants only*

*Donor funding is considered for the years 1996–2003 in deflated dollars, with 2002 as the base year. Burdens are
measured in DALYs for theyear 2000 for developing countries. Percentages are of the total for the
20 diseases considered, not of all developing world diseases.
Shiffman J. Donor funding priorities for communicable diseases. The Author 2006.
 Percentage of developing world burden and percentage of donor funding
for selected diseases For the period 1996-2003

Shiffman J. Donor funding priorities for communicable diseases. The Author 2006.
 Conclusion
• Pneumonia remains the major cause of mortality
in children
• Standard case management has been shown to
be effective in reducing mortality rates but is
expensive in relation to other interventions
• If MGD 4 is to be achieved there is an urgent
need for a major increase in funding for
universal coverage of SCM for pneumonia in the
developing world
• There needs to be a more balanced allocation
of the resources already being provided
What You Can Do As Journalists

• Generate a new “buzz” about

pneumonia and its role in child
survival
• Track and report on progress of
MDG 4
• Become a champion yourself
THANK YOU