PneumoniaPneumonia

Pneumonia leads causes of Pneumonia leads causes of childhood deathschildhood deaths

Source: WHO estimates of the causes of death in children, 2000-03 Bryce, Lancet, 26 March 2005

Where do 10 million children die Where do 10 million children die each year?each year?

WHO estimates of the causes of death in children, Lancet, 2005

Source: World Health Report, 2005

Percentage of children that die from pneumonia, by country

From Williams et al. Lancet Infect Dis, 2002.

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0-5 6-11 12-23 24-35 36-47 48-59

Age (months)

Ep

iso

des

per

ch

ild

/yr

Philippines

Age-specific incidence / mortality of Age-specific incidence / mortality of pneumoniapneumonia

0

20

40

60

80

100

120

140

160

1-5 6-11 12-23 24-35 36-59

Age (months)

Dea

ths/

1000

Bangladesh

Is pneumonia a problem in Is pneumonia a problem in emergencies?emergencies?

Examples of pneumonia deathsExamples of pneumonia deaths

• 63% among Nicaraguan refugees in 198963% among Nicaraguan refugees in 1989

• 30% of under-5 deaths in Kabul in 199330% of under-5 deaths in Kabul in 1993

• 80% when combined with malaria and diarrhea 80% when combined with malaria and diarrhea among Congolese refugees in 1999among Congolese refugees in 1999

Most data limited to mortalityMost data limited to mortality

• Few studies of morbidityFew studies of morbidity

Major Causes of Death in emergencies for <5 Years

Sudan: Wad Kowli CampFebruary, 1985

Somalia: Gedo Region 7 Camps, January, 1980

Source: Centers for Disease Control and Prevention, Famine-Affected, Refugee, and Displaced Populations: Recommendations for Public Health Issues. MMWR, 1992;41(No. RR-13):8.

MeaslesARIMalariaDiarrheaOther

Risk factors for pneumoniaRisk factors for pneumonia

• Low birth weight

• Malnutrition

• Bottle feeding

• Vitamin A deficiency

• HIV infection

• Indoor air pollution

• Household crowding

• Cold exposure

What causes Pneumonia: What causes Pneumonia: VirusesViruses

Respiratory Syncytial Respiratory Syncytial VirusVirus

AdenovirusAdenovirus

RhinovirusRhinovirus

Parainfluenza/InfluenzaParainfluenza/Influenza

What causes Pneumonia: What causes Pneumonia: BacteriaBacteria

Streptococcus Streptococcus pneumoniaepneumoniae

Source: CF. Laine, T Sugishita, J Rabke-Verani , M Cavicchia

Haemophilus Haemophilus influenzaeinfluenzae

Approaches to Preventing Approaches to Preventing Pneumonia MortalityPneumonia Mortality

• Prompt diagnosis • WHO algorithm

• Treat cases of pneumonia AntibioticsSupportive care

• Prevent cases of pneumonia Modify risk factors Vaccinate

Case Definition Case Definition Moderate – Severe Lower Respiratory Infection in children:

1) Fever +2) Cough +3) Rapid breathing (more than 50 breaths/minute)

A child has tacypnoea if Respiratory rate >60/min in children <2 months Respiratory rate >50/min in children 2-11 months Respiratory rate >40/min in children 12-59months

WHO focuses on the reduction of mortality requiring:

Early/adequate diagnosisCorrect case management

Hospitalize for danger signsAccess to health careTrained health staffSimple treatment protocolsImmunization

May increase transmission risk for meningitis

Control of Lower Respiratory Infections Control of Lower Respiratory Infections

MSF book, p. 178

Clinical management of a sick child with Clinical management of a sick child with cough or difficult breathingcough or difficult breathing

Danger signs*YES

Refer to hospitalGive antibiotics

NO

Assess for chest indrawingYES

NO

Refer to hospitalGive antibiotics

VERY SEVERE DISEASE

* Danger signs include cyanosis, convulsions, severe malnutrition, difficult to wake, not able to drink

SEVERE PNEUMONIA

Assess for fast breathing

(RR>50/40 breaths/minute) YES

NO=NO PNEUMONIA; COUGH OR COLD

Give antibiotics

PNEUMONIA

Recommended Antibiotics for Recommended Antibiotics for PneumoniaPneumonia

Antibiotic Doses/day Relative cost

Cotrimoxazole 2 PO Lowest

Amoxicillin 3 PO Highest

Procaine penicillin 1 IM Middle

Antibiotic dose needs to be calculated by the weight of the child

Results of community case management Results of community case management interventions on mortality, by ageinterventions on mortality, by age

Sazawal and Black. Lancet ID, 2003

-50%

-40%

-30%

-20%

-10%

0%

<1 month <1 year <5 years

% m

ort

alit

y v

s c

on

tro

ls

All-cause

Pneumonia

Potential Barriers to Effective Case Potential Barriers to Effective Case ManagementManagement

• Depends on care seeking and access

•recognition of illness

•access to care

•acceptability of care

• Depends on training and supervising health care workers

• Depends on availability of antibiotics

Pneumonia: Pneumonia: PreventionPrevention

• Avoid overcrowding• Provide alternatives to open indoor fires• Provide adequate shelter and blankets/heating• Prevent malnutrition

• Encourage breastfeeding

• Vitamin A supplementation• Vaccinate

• Reduce Pneumonia

• Reduce secondary bacterial infections

Existing vaccines to prevent Existing vaccines to prevent pneumoniapneumonia

Routinely usedRoutinely used• MeaslesMeasles• PertussisPertussis• DiphtheriaDiphtheria• Haemophilus influenzae Haemophilus influenzae type b (In some type b (In some

countries)countries) FutureFuture

• PneumococcalPneumococcal• RSVRSV

Efficacy of Efficacy of Haemophilus influenzaeHaemophilus influenzae type type b (Hib) vaccine on pneumonia outcomesb (Hib) vaccine on pneumonia outcomes

-10%

0%

10%

20%

30%

X-ray pospneumonia

Severepneumonia

Clinicalpneumonia

% e

ffic

acy Indonesia

Gambia

Chile

Tuberculosis in EmergenciesTuberculosis in Emergencies

Not cause of significant mortalityNot cause of significant mortality Post emergency setting: affects morbidity & Post emergency setting: affects morbidity &

mortalitymortality Depending on the epidemiology of the Depending on the epidemiology of the

diseasedisease• Need for continuation of treatment for those Need for continuation of treatment for those

patients who already are on treatmentpatients who already are on treatment

• Need for effective control program Need for effective control program

Tb ControlTb Control Conditions for implementing TB Conditions for implementing TB

Program:Program:• Basic health priorities already addressedBasic health priorities already addressed• Long term commitment - 1 year from last Long term commitment - 1 year from last

casecase• Stable population - patients complete Stable population - patients complete

treatmenttreatment• Adequate drug supplyAdequate drug supply• Knowledge of baseline drug resistanceKnowledge of baseline drug resistance• Laboratory confirmationLaboratory confirmation• Appropriate treatment algorithmAppropriate treatment algorithm