Preventing the number one infectious cause of death in children

November 12th is World Pneumonia Day. To mark this occasion, Malaria Consortium interviewed Dr Phanuel Habimana, adviser on child and adolescent health for the World Health Organisation’s Africa region. 

What effect does pneumonia have in Africa economically and in terms of mortality? 

Pneumonia continues to be the biggest killer worldwide of children under five years of age. In 2013, it claimed the lives of close to one million children under five worldwide, 50 percent of them in the WHO African region.

Pneumonia is a disease of poverty. Poverty-related factors such as lack of access to safe water, poor access to health care and inadequate sanitation all increase the likelihood and amplify the effects of pneumonia. Children with deficiencies such as malnourishment, particularly those who are not breastfed or do not consume enough zinc, are at a higher risk of developing pneumonia.

Research has shown that prevention and proper treatment of pneumonia could avert one million deaths in children every year globally. With proper treatment alone, 600 000 deaths could be avoided.

The cost of treating all children with pneumonia in 42 of the world’s poorest countries is estimated at around US$600 million per year. Treating pneumonia in South Asia and sub-Saharan Africa – which account for 85 percent of deaths – would cost a third of this total, at around US$200 million. The price includes the antibiotics themselves, as well as the cost of training health workers, which strengthens the health systems as a whole.

What is the single biggest obstacle to reducing the burden of pneumonia?

The single most important obstacle to reducing the burden of pneumonia is low coverage of essential interventions for the prevention and control of pneumonia due to inadequate care seeking behaviour, access, availability and cost of diagnosis and treatment. Evidence shows that children are dying from pneumonia because effective interventions are not provided equitably across all communities.

Do you think that integrated community case management initiatives, such as those run by Malaria Consortium, are effective?

The integrated community case management initiatives have been very effective in training members of communities to identify treat and/or refer cases of pneumonia. With adequate training and supervision, community health workers can retain the skills and knowledge necessary to provide appropriate care for pneumonia, malaria and diarrhoea. For example:

  • In Malawi, 68 percent of classifications of common illnesses by health surveillance assistants were in agreement with assessments done by physicians, and 63 percent of children were prescribed appropriate medication.
  • In Zambia, a community case management (CCM) study on pneumonia and malaria found that 68 percent of children with pneumonia received early and appropriate treatment from community health workers.
  • In Ethiopia, the health extension workers (HEWs) performed better in terms of doing assessment tasks correctly – 84 percent compared to 70 percent by health facility health workers. HEWs treated the child with pneumonia correctly 72 percent of the time compared with 65 percent by facility health workers.

If pneumonia is an easy disease to both diagnose and treat, why does it cause so many deaths every year, especially among children? 

Many of the reasons, which are associated with poverty conditions, are:

  • Delayed care-seeking: Recognising the symptoms of pneumonia and seeking appropriate care from a health care facility is the first step in reducing deaths from pneumonia. However, sub-Saharan Africa has the lowest care-seeking for pneumonia – 48 percent. Nearly half of early childhood pneumonia is estimated to result from lack of or delay in appropriate diagnosis and treatment.
  • Lack of access to health facilities with well trained staff and essential medicines:  Most vulnerable communities do not have access to health facilities with well-trained health workers and essential medicines to get lifesaving interventions in time. Currently in the African region, only 24 percent children with suspected pneumonia are given proper antibiotic treatment. Stock out of essential antibiotics to treat pneumonia is a major problem.
  • Low coverage of vaccines:  Many countries have not yet introduced pneumococcal vaccines to prevent pneumococcal pneumonia.
  • Low exclusive breastfeeding rate:  Exclusive breastfeeding and continued breastfeeding with complementary feeding reduces pneumonia illness and death in children. However, only 35 percent of infants less than six months are exclusively breastfed.
  • Lack of simple and standardised guidelines in every health facility: The World Health Organisation (WHO) and UNICEF have developed guidelines for the integrated management of childhood illness to improve the quality of care provided to under-five children. However, the training in the use of these guidelines has not been scaled up to reach every health worker managing sick children under five in every health facility in most of the countries in Africa. Therefore, millions of children are still dying because those most at risk are not reached and services are provided piecemeal.

What does the WHO recommend in order to reduce the prevalence of pneumonia in rural and low-resource communities?

WHO and UNICEF, in collaboration with other partners, have developed an integrated plan entitled Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea.  This plan emphasises that the prevention and control of pneumonia and diarrhoea should not be dealt with separately but must be addressed together. Both are caused by a range of pathogens, and no single intervention alone will be adequate to prevent, treat or control either disease. Further, they share several common causes and risk factors, common prevention strategies and interventions, and similar delivery platforms in health facilities and communities.

What can be done at community level to help limit pneumonia?

In most high-mortality countries, facility-based services alone do not provide adequate access to treatment within the crucial window of 24 hours after onset of symptoms. If child mortality is to be adequately dealt with, the challenge of access must be addressed.  Community health workers – appropriately trained, supervised and provided with an uninterrupted supply of medicines and equipment – can identify and correctly treat most children who have pneumonia. A recent review by the Child Health Epidemiology Reference Group estimated that community management of all cases of childhood pneumonia could result in a 70 percent reduction in mortality from pneumonia in children less than five years old. Furthermore, community health workers can empower families and communities to improve care seeking practices and care for the child at home during sickness and wellness.

How has technology contributed to reducing the burden of pneumonia?

The use of vaccines against streptococcus pneumonia and haemophilus influenzae type b, the two most common bacterial causes of childhood pneumonia plus vaccinations against measles and pertussis, substantially reduces the disease burden and deaths caused by pneumonia.  Furthermore, the development of evidence-based simplified Integrated Management of Childhood Illnesses’ (IMCI) guidelines for the identification and treatment of pneumonia at facility and community levels has greatly contributed to the reduction of the burden of pneumonia. At hospital level, the availability and use of pulse oximetry has been a great technological advance to assess the saturation of oxygen in the blood. Oxygen concentrators have been very critical in providing care to very sick children. All those technological advances have enabled health workers to give appropriate lifesaving interventions.