Fighting for breath: A call to action on childhood pneumonia
THE WORLD’S BIGGEST INFECTIOUS KILLER
Writing in 1901, William Osler, one of the founders of modern medicine, described pneumonia as “the captain of the men of death”. He was writing about the USA, where the disease was a major killer of children – and a source of fear for their parents. Pneumonia remains a “captain of the men of death”. No infectious disease claims the lives of more children. Today, almost all of the victims are in low- and middle-income countries. The vast majority are poor.
The headline statistics on pneumonia point to a global epidemic. The disease claimed 920,000 young lives in 2015. That represents two fatalities every minute of every day – more than diarrhoea, malaria and measles combined.
Most of the deaths happen in South Asia and sub-Saharan Africa. Over 80% occur among children aged less than two years old, many of them in the first weeks of life.
What the statistics cannot capture is the suffering and distress associated with pneumonia. This is a disease that leaves desperately vulnerable children fighting for breath, and their parents coping with anxiety and, all too often, the distress, grief and trauma that comes with loss.
Pneumonia deaths are falling more slowly than other major causes of child mortality.
New research presented in this report shows that, on the current trajectory of progress, there will still be 735,000 pneumonia deaths in 2030.
This is the target date set for the Sustainable Development Goals (SDGs), which include a collective pledge ‘to end preventable child deaths’.
Reducing pneumonia deaths to a level of less than 3/1,000 live births, as envisaged by UNICEF and the World Health Organization (WHO) in their Global Action Plan for Pneumonia and Diarrhoea (GAPPD), would put the world on track for the SDG target.
However, analysis in this report shows only four out of 30 high burden countries are on course to reach this target by 2030. Another 17 – including the Democratic Republic of Congo, Nigeria and Pakistan, which have some of the highest numbers of pneumonia deaths – will not achieve the target until after 2050.
These trends do not define destiny. Other futures are possible. Based on modelling carried out by Johns Hopkins University, we chart a plausible path towards a world where pneumonia deaths are reduced to levels compatible with the SDG commitment. The ‘2030 target scenario’ trajectory would save a cumulative total of 5.3 million lives from pneumonia over the next 15 years. Almost 1 million would be saved over the next five years. Many more lives would be saved as a result of benefits in treating diseases that typically accompany pneumonia, including malnutrition and diarrhoea. We estimate the average annual cost of the interventions required at $4.5bn.
WHY ARE CHILDREN DYING?
Every pneumonia death is one too many. The disease is eminently preventable and treatable.
Effective vaccines are available for immunisation against the most common bacterial strains, including Streptococcus pneumoniae – the deadliest source of pneumonia. Diagnosed accurately and early, pneumonia can be treated with a 3–5 day course of antibiotics costing just $0.40. Severe and complex cases require referral to facilities equipped to deliver more intensive care. But even here the vast majority of lives can be saved, as they are in rich countries.
Children die from pneumonia because they are denied the benefits of prevention, accurate diagnosis and treatment. Support from Gavi, the Vaccine Alliance, has expanded coverage of the pneumococcal conjugate vaccine (PCV), saving many lives. But 170 million children aged 0–2 years in low- and middle-income countries are not immunised against the world’s deadliest disease.
When pneumonia strikes, far too many children are denied access to care. Around 40 million episodes of the disease go untreated each year, placing lives at risk. In sub-Saharan Africa, less than half of children with symptoms are taken to a health care provider.
Reaching a health facility is no guarantee of effective treatment. Inaccurate diagnosis, shortages of frontline antibiotics, and weak referral systems combine to claim lives that could be saved. Surveys of essential medicine availability show that fewer than 60% of facilities in Tanzania, Kenya, the Democratic Republic of Congo and Mauritania have Amoxicillin DT available, the most effective frontline treatment, falling to less than one-quarter in Nepal and Uganda.
One potentially fatal consequence of pneumonia is hypoxaemia, a condition that leaves children with insufficient oxygen in their blood. Some 2 million children are admitted to hospital each year with the condition. These children are left, quite literally, gasping for air. They need basic oxygen therapy that would be taken for granted in any rich country, yet the facilities they are taken to often lack the oxygen that could save their lives.
A DISEASE OF POVERTY
Equity is at the heart of the crisis. Pneumonia today is overwhelmingly a disease of poverty, as it has been throughout history. The risks of contracting the disease are heavily skewed towards the poorest children, while the prospects for receiving accurate diagnosis, effective treatment and appropriate care are skewed towards those who are better off.
Pneumonia powerfully illustrates the lottery of birth that shapes life-chances – including prospects for survival. In rich countries, the disease is a major cause of hospitalisation among children, but fatalities are rare. Being born in a poor country multiplies the risk of pneumonia mortality in the early years. Within countries, social disparities linked to wealth, ethnicity, the rural–urban divide, and gender weigh heavily.
Children who are poor are less likely to be vaccinated, less likely to be taken for treatment when they develop pneumonia symptoms, and more likely to die as a result. A child from a wealthy household in Nigeria is 15 times more likely to be fully immunised than a child from a poor household.
Children from the wealthiest households in countries such as Burkina Faso and Chad are twice as likely to be taken by their parents to a health facility if they have pneumonia symptoms as children from the poorest households.
Gender is another powerful marker for disadvantage. Globally, boys are more likely to contract pneumonia for physiological reasons – but in South Asia girls are far less likely to be treated.
Fatality rates for girls affected by pneumonia in the region are 43% higher than for boys on one estimate.
A COMPLEX CHALLENGE
Failures of prevention, diagnosis and treatment underscore the critical importance of universal health coverage. Currently, some 400 million people lack access to health care, while 100 million are driven into poverty by unaffordable health costs.
Winning the battle against pneumonia will require wider changes that make healthcare accessible and affordable for all.
Pneumonia cannot be treated in isolation. Most fatalities occur because the parents of the children affected are excluded from health systems as a result of cost or distance, or because they see health providers as ineffective, unresponsive and unaccountable. Tackling pneumonia requires a properly financed health system that reaches the most disadvantaged children, delivering effective care through a trained and supported workforce.
Pneumonia presents health planners with a complex challenge because it has such diverse causes – and because it overlaps with other diseases. Prevention is overwhelmingly better than cure, which is why all governments should include pneumococcal conjugate vaccines (PCVs) in their national immunisation schedules. This report highlights the critical importance of building efficient and equitable immunisation infrastructures.
When pneumonia strikes, the first line of defence is the home and community. It is vital that families and carers are equipped with the information they need to recognise symptoms, and that mothers are empowered to make decisions and access care.
Community health workers have a vital role to play in diagnosing pneumonia. Countries with a strong track record in cutting deaths – including Bangladesh and Ethiopia – have invested heavily in community-based care systems.
Slow progress in cutting deaths reflects systemic policy failure. Around 17% of pneumonia deaths occur in the first month of life. Many of these deaths could be prevented through early recognition of the warning signs and antibiotic treatment. Yet many women receive no postnatal care, and the health workers caring for them often lack the diagnostic skills they need.
Guidelines for integrated Community Case Management (iCCM) provided by WHO and UNICEF establish clear guidelines for community health workers on pneumonia diagnosis and treatment. However, misdiagnosis is common. Many children are placed at risk because pneumonia symptoms are routinely mistaken for malaria.
Moreover, primary health care centres often lack frontline antibiotics, including child-friendly Amoxicillin dispersible tablets (DT). The international aid system may have played an unintended role in weakening iCCM systems by under-investing in anti-pneumonia strategies relative to other major killers. Compounding these diagnostic and treatment challenges, many countries make it illegal for community health workers to dispense life-saving antibiotics. Innovative diagnostic tools such as pulse oximeters, a non-invasive mechanism for measuring oxygen levels in blood, are often unavailable.
PNEUMONIA ACTION PLANS – A HEALTH SYSTEM PRIORITY
National governments have the primary responsibility for tackling pneumonia. Political leaders have neglected the disease for far too long. Ensuring that trained community health workers are available, that clinics are properly supplied, and that referral systems are equipped to ensure a swift transition for children with severe pneumonia should be national health priorities.
Every high-burden country should be aiming to achieve universal PCV immunisation over the next five years. The record to date has been mixed. Some high-burden countries – including Indonesia, Chad and Somalia – are still not using the PCV vaccine in routine immunisation programmes. Nigeria has included PCV in its national schedule, but started only recently and coverage rates are just 13%.
More widely, immunisation with PCV is marked by extreme disparities that follow the contours of inequity in health service provision.
This report calls on governments in every highburden country to adopt integrated Pneumonia Action Plans geared towards the GAPPD target.
These plans would cover costings and delivery strategies for achieving universal PCV vaccination, the provision of antibiotics, and supply of pulse oximeters and oxygen to referral facilities.
The condition for successful implementation of such plans is the strengthening of health systems, with accelerated progress towards universal health coverage. The training of community health workers to correctly diagnose and treat pneumonia is critical. However, anti-pneumonia strategies will only succeed if health system coverage extends to the hardest-to-reach children. Governments should be spending around 5% of GDP on health, with a far greater emphasis on equity in the allocation of resources.