12th November is World Pneumonia Day. This year, it takes place against the backdrop of the COVID-19 pandemic which, in addition to its own impact on global health, is having a knock-on effect on other diseases, including pneumonia. We spoke to Malaria Consortium’s Research Specialist, Dr Kevin Baker, to hear his views on where we stand in the fight against pneumonia as 2020 draws to a close.

It’s been a significant year for awareness of respiratory illness, due to the COVID-19 pandemic. What’s your assessment of the status of pneumonia as 2020 draws to a close?

Let me mention two points in relation to COVID-19 and pneumonia. Firstly, the direct impact of COVID-19 on the continuity of services across health systems globally. At Malaria Consortium, we have been really concerned that, particularly at community level, health workers are unable to, or restricted from, providing their usual services and to see and be seen by  communities. This is largely due to travel restrictions, but also fear in the community about the transmission risk when seeing health workers or having health workers visit at home. The result is often that people are not bringing sick children to the health centres or health posts, or asking health workers to visit them.

Secondly, due to the pandemic, some initial work has been done looking at the increased potential for a rise in cases of pneumonia and child mortality in general this year and moving forward into 2021. The figures are staggering – up to 2.3 million additional children could die due to COVID-19 health service disruptions, 35 per cent of those from pneumonia or newborn sepsis .

Conversely, has awareness of COVID-19 improved awareness of pneumonia, given the similar symptoms?

Hopefully, yes. It’s true that people are more aware of the symptoms of respiratory illnesses and also thinking more about what course of action they should take, becoming more conscious of the signs of respiratory illness such as cough, difficulty breathing etc. Also, we are seeing how people become more resourceful in these situations. For example, in Cabo Delgado in northern Mozambique, we are seeing more use of our digital health platform, upSCALE, to support community health workers in their roles. It allows them to be more self-sufficient when they can’t have supervisors nearby to provide support as normal. They’re able to use the app on their phone to support their assessments.

What other challenges are occurring in pneumonia diagnosis and treatment?

Access to commodities and supplies. This means access to diagnostic aids, access to treatment, access to training and access to supervision. All of these are a challenge currently, due to the pandemic. We recognise that these are long-standing challenges, but COVID-19 has meant that resources that would have gone towards pneumonia commodities have had to be focused elsewhere, i.e. on the COVID-19 response. So, Malaria Consortium is urging donors to retain their commitments to pneumonia going forward, otherwise, we will see inevitable increases in cases and mortality.

Due to COVID-19 and the similarity in symptoms, it’s difficult for health workers to differentially diagnose pneumonia, versus COVID-19, versus malaria. As we learn more about COVID-19, we have to think about the implications on frontline health workers for example through strategies like  integrated community case management (iCCM) and integrated management of childhood illnesses (iMCI). Do we need to build  COVID-19 into these existing algorithms  to help community health workers to carry out differential diagnosis? Beyond COVID-19, there will still be the threat of antimicrobial resistance (AMR) and the negative impact this could have on the treatment of pneumonia. We will soon be conducting further studies in Bangladesh to assess the use of community dialogues to promote rational use of antibiotics.

You mentioned diagnostic aids and Malaria Consortium has worked to pilot a number of new devices in high-burden countries. What is the future roadmap for new pneumonia diagnostics?

From our perspective, we need  to advocate the scale up of these types of devices. We know that community health workers should be counting respiratory rate every day and we know diagnostic aids are available – that are automated and support health workers well. We want to think about how we can scale up and what we need to do to get to that stage. This relates to Malaria Consortium’s ‘whole system’ view of how health systems can be strengthened to support effective pneumonia case management at every level of the health system. Rather than choosing to focus on community health posts or health centres, we’re taking a more holistic approach – starting at the top of the health system and strengthening throughout.

This aligns well with the COVID-19 response in which a lot of work has been done to increase oxygen availability at higher levels of the health system. This is important because it will also support improved pneumonia treatment for which oxygen is a key tool in the management of severe illness.

Is this increased availability of oxygen likely to continue post-COVID-19 or is there a risk that the gains made here could slip away?

I think the pneumonia community need to be smart about this and work with national governments to build pneumonia action plans in all high-burden countries. Malaria Consortium is working with a number of ministries of health to do that and to build national responses, especially in light of the pandemic. I think there’s a great opportunity to use these recent gains as a catalyst for an improved pneumonia response at all levels of the health system in high burden countries.

The AIRR project seems to be an exciting glimpse to the future of pneumonia diagnostics. Can you tell us more about this project?

As we’ve mentioned, Malaria Consortium has been very focused on improving pneumonia diagnostic aids, either tools to support health workers to count respiratory rate or measure oxygen saturation. As a part of the AIRR project, we have begun to develop and evaluate an artificial intelligence-supported, automated respiratory rate counter. This tool uses video images combined with artificial intelligence to calculate a respiratory rate. This is very exciting as it could be used by any community health worker on their smartphone and it automates the whole process. We see huge potential in this technology, and we are partnering with the Karolinska Institute and Johns Hopkins University to evaluate its feasibility and acceptability. This is the next generation of pneumonia diagnostic aid.

You can find out more about the AIRR project in our new project brief.

With all of these developments in mind, what do you think the roadmap for bringing down pneumonia deaths looks like?

I think we need to really address pneumonia from all sides. We need to come together and promote public-private partnerships, like Every Breath Counts, as much as possible to really consolidate the pneumonia agenda globally. Some of the work we are doing on Every Breath Counts Research Group, where we are defining the research priorities for pneumonia for the next 10 years, will be key. The work aims to clarify the key focal areas for pneumonia research. Hopefully, by having this list of priorities, we can better guide investment decisions and design the next big research studies to effectively address pneumonia. To date, investment in pneumonia has been very low level, so this work is really important. In addition to that, the creation of national pneumonia action plans mentioned earlier is also crucial. This work will hopefully strengthen the pneumonia response in high-burden countries.

You can read more about Malaria Consortium’s position on pneumonia in our advocacy brief.

Dr Kevin Baker is Malaria Consortium’s Research Specialist