Child Pneumonia (Penny Enarson)

Childhood pneumonia

Journalist-to-Journalist Lung Health ProgrammeBerlin, Germany

November 12, 2010

Penny EnarsonThe Union, Paris France

WHAT IS PNEUMONIA?

ARI Clinical Syndromes

ARI in ChildrenIs any infection ofacute onset, affecting the:• ear• nose• throat• larynx• trachea• bronchi• bronchioles• lungs

It ranges from the

• common cold

• ear infection

• sore throat

• bronchitis

• bronchiolitis

• pneumonia

Categories of pneumoniaPneumonia:

– 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

Neonatal

AIDS

MalariaMalaria +

AIDS

Diarrhea +

pneumonia

Child Mortality: Geographic Distribution

Major Causes of Child Death (2005)

EIP/WHO

All other (19.2%)

HIV/AIDS (3.6%)

Pertussis (2.9%)

Tetanus (1.8%)

Malaria (10.7%)

Measles (5.4%)

Diarrhoeal diseases (15.2%)

Pneumonia (19.1%)

Perinatal (23.1%) Majority from pneumonia

Total deaths: 10.8 million

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

for 60% of all

diseases account

child deaths

These seven

communicable

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

Proximate Determinants Feeding and nutrition Hygiene and indoor air pollution Other preventive activities Care during illness

Underlying Determinants Financial barriers Health care provision Maternal education Water, sanitation, and the home

environment Other underlying determinants

Socio-economic Socio-economic differencesdifferences

For each of theseFor each of thesedeterminants:determinants:The poor areThe poor are

disadvantageddisadvantaged

Source: Wagstaff, Bryce, Bustreo, Claeson. Child health: reaching the poor. AJPH

Child Survival: Determinants

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 ObstaclesImplementation Challenges

Health Systems Constraints Community Constraints

Underfunded

Over-crowded

Poverty

The reality of HIV/AIDs

Byass P, Ghebreyesus TA. Making the world’s children count Lancet 2005; 365 1114

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.

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

0.060.5

2.3

6

0

1

2

3

4

5

6

7

USA South Africa Egypt Niger

Per

cen

t o

f P

er c

apit

a G

NP

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.

Jones G, et al How many deaths can we prevent this year? Lancet 2003; 362: 65-71

Coverage estimates for child survival treatment interventions forthe 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.

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 expandingtreatment coverage with antibiotics but is alsonecessary 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 pneumoniaSazawal 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.


Percentage of developing world burden and percentage of donor funding for selected diseases For the period 1996-2003


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

Child Pneumonia (Penny Enarson)

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