Pneumonia: the leading infectious cause of child mortality

1
Pneumonia the leading infectious cause of child
mortality

• Dr. Rana Hajjeh, Hib Initiative
• Dr. Orin Levine, Pneumo ADIP
• Child Survival Camp
• May 11, 2007

2
Every year, Pneumonia causes over two million
deaths in children under 5
Source UNICEF, 2006
3
Under 5 Child Mortality Global Distribution of
Cause Specific Child Deaths
Under-nutrition (underlying cause)
Leading infectious cause of death in children lt 5
Source 2005 World Health Report
4
Epidemiology Of Pneumonia In Developing Countries

• 146 million pneumonia episodes annually Rudan I
  et al. Bull WHO, Dec 2004
• Globally, ?11-20 million hospitalizations/year in
  children lt5 years
• ?1.8 million pneumonia deaths annually Bryce et
  al. Lancet 2005
• ?15-34 of WHO pneumonia cases have evidence of
  consolidation on chest x-ray
• Cutts F et al. Lancet 2005 Klugman KP et al
  NEJM 2003 Magree HC et al. Bull WHO 2005

5
Childhood pneumonia mortality (2005)
Map Source PneumoADIP based on WHO estimates in
Williams BG et al. Lancet ID 2003
6
Pneumonia risk factors

• Environmental factors (e.g, indoor air pollution)
• Crowded living conditions
• Malnutrition
• Presence of other illnesses (eg. HIV)

7
Streptococcus pneumoniaeand Haemophilus
influenzae type b (Hib)
In high mortality areas, most fatal pneumonia is
likely caused by two bacteria
8
Pneumococcus and Hib account for more than half
of all pneumonia deaths in children lt 5
2.0
Deaths attributed to Pneumococcal and Hib
pneumonia
Source 2005 World Health Report and WHO Disease
Burden estimates
9
Prevention of pneumonia mortality

• Case Management
• Risk Modification
• Hand washing, indoor pollution control
• Improved Nutrition
• Exclusive breast feeding, supplements
• Vaccines
• Pertussis, measles, Hib, pneumococcal

10
Case Management

• Integrated Management of Childhood Illness
  (IMCI)
• Educates family and community
• Care seeking, prevention and nutrition, proper
  implementation of prescribed care
• Promotes comprehensive care at health care
  provider level
• accurate diagnosis
• appropriate combined treatment
• referral of severely ill children
• Improved counseling of families
• emphasizes nutrition and vaccination

11
Concurrent Pneumonia Case Management Trials
Effect on Mortality in Children lt 1 Month of Age
Bangladesh
India(G)
Nepal(J)
Pakistan

Tanzania
Summary Estimates
0
0.5
1
1.5
2
2.5
3
Odds Ratio and 95 CI
12
Concurrent Pneumonia Case Management Trials
Effect on Mortality in Children lt 1 Year of Age
Bangladesh
India(G)
Nepal(J)
Pakistan
Philippines
Tanzania
Summary Estimates
0
0.5
1
1.5
2
Odds Ratio and 95 CI
13
Concurrent Pneumonia Case Management Trials
Effect on Mortality in Children 0-4 Years of Age
Bangladesh
India(G)
Nepal(J)
Pakistan
Philippines
Tanzania
Summary Estimates
0
0.5
1
1.5
2
2.5
3
Odds Ratio and 95 CI
14
Vaccines

• Measles and Pertussis vaccines have already
  reduced cases of child pneumonia
• Hib and pneumococcal vaccines should be an
  integral part of a pneumonia prevention program

15
Hib Vaccine Probe Trials X-ray Confirmed
Bacterial Pneumonia Vaccine Efficacy (95 CI)
VE 32 (-2-54)
VE 21 (5-35)
VE 55 (7-78)
VE -5 (NS)
VE 31 (-9-57)
VE 22(-7-43)
Not significant for x-ray confirmed pneumonia,
but significant for clinical pneumonia
16
Pneumococcal Vaccine Trials X-ray Confirmed
Pneumonia Vaccine Efficacy (95 CI)
USA
VE 18 (5-29) WHO Def
26 (7-40)
Philippines
VE 23 (P0.06)
The Gambia
VE 37 (25-48)
South Africa
Overall VE 17(-4-28) HIV - 20
(-7-28) HIV 13 (25-48)
17
Pneumococcal vaccine significantly improves child
survival in the Gambia

• All-cause mortality was decreased by 16 (95
  CI 2-38) in children vaccinated with 9V
  pneumococcal vaccine

That means 7 deaths were prevented for every 1000
children vaccinated
Reference Cutts FT, Zaman SMA, et al. Lancet
2005 365 1139-46.
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The World Health Organization recommends that
Hib vaccines be included in all routine infant
immunization programs1and that countries make
inclusion of pneumococcal vaccines in national
routine immunization programs a priority2
1 WHO Position Paper on Haemophilus Influenzae
type B Conjugate Vaccines Weekly Epidemiologic
Review, 23 Nov, 2006 2 WHO Position Paper on
Pneumococcal Conjugate Vaccine Weekly
Epidemiologic Review, March 23, 2007
19
Challenges to addressing pneumonia

• Documenting epidemiology and etiology
• No good diagnostic tools, costly studies,
  co-morbidity classification challenges
• Measuring impact of interventions
• Cause of disease may be multi-factoral
• Expectations of observable reductions in
  mortality must be managed
• Best results come from integrated approach need
  to reduce competition for resources

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Global Action Plan for Pneumonia A Way Forward
- March 2007

• Strategic, evidence-based approach to coordinate
  efforts to reduce pneumonia
• Partners pneumonia experts
• Epidemiology etiology of pneumonia
• Case Management
• Vaccines (measles, pertussis, Hib, Pneumococcal,
  others (RSV?)
• Nutrition (breast-feeding, macro and micro
  nutrients)
• Indoor air pollution
• Risk assessment
• Comparative impact assessment
• Plan to include further research, advocacy,
  resource mobilization, policy activities

21
Changing world

• Fewer countries with over 90 CMR and more low
  middle income areas
• Greater use of antibiotics and vaccines means
  fewer bacterial infections but more antibiotic
  resistance
• New resources for global health but results
  needed to sustain