1. CDI Module 17: Community Management of Pneumonia
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on Community-Directed Intervention (CDI) to Improve Access to Essential Health Services

2. Module 17 Objectives By the end of this module, learners will:
Describe the global burden of pneumonia and reasons it cannot be neglected
Describe the signs and symptoms of pneumonia and its relationship to other acute respiratory infections (ARIs)
Define pneumonia
Describe methods for prevention and treatment of pneumonia

3. Why We Cannot Ignore Pneumonia in Efforts to Control Malaria
Pneumonia kills more children than any other illness
Any effort to improve overall child survival must make the reduction of pneumonia’s death toll a priority
More than 35 million childhood pneumonia episodes occur in African children each year
More than one million of these children die

4. Pneumonia Is Common in Africa

5. Relation Between Pneumonia and Other ARIs
Pneumonia and other ARIs share similar clinical features such as presence of:
Fever
Cough
Vomiting (sometimes)
Chest pain/indrawing
Rapid breathing
Zinc and vitamin A are useful in managing both pneumonia and ARI, especially lower ARI
Co-trimoxazole and amoxicillin are effective drugs against pneumonias caused by some bacterial pathogens, but these do not cure ARI caused by viruses

6. Recognizing Pneumonia
Bacterial pneumonia usually causes children to become severely ill, with high fever and rapid breathing
Viral infections, however, often come on gradually and may worsen over time
Some common symptoms of pneumonia in children and infants include rapid or difficult breathing, cough, fever, chills, headaches, loss of appetite and wheezing
Children under five with severe cases of pneumonia may struggle to breathe, with their chests moving in or retracting during inhalation (known as “lower chest wall indrawing”)
Young infants may suffer convulsions, unconsciousness, hypothermia, lethargy and feeding problems

7. Two Most Important Signs of Pneumonia
Difficult Breathing
Fast Breathing
Photo by WHO/M. Weber at

8. Framework for Pneumonia Control
PROTECT
PREVENT
children by providing a healthy environment
children from becoming ill with pneumonia
Exclusive breastfeeding for six months
Adequate nutrition
Prevent low birth weight
Reduce indoor air pollution
Handwashing
Vaccination against measles,
pertussis, Spn* and Hib**
Prevention of HIV in children
Co-trimoxazole prophylaxis for
HIV-infected and exposed children
Zinc supplementation for
children with diarrhea
REDUCE PNEUMONIA MORTALITY AND MORBIDITY
*Streptococcus pneumoniae
**Hemophilis influenzae b
TREAT
children who become ill with pneumonia
Case management in community, health center and hospital

9. Protecting Children from Pneumonia
Protect children by providing a healthy environment
Reduce indoor air pollution
Encourage handwashing
Promote exclusive breastfeeding for six months

10. Protecting Children from Pneumonia (continued)
Reduce low birth weight (LBW)—defined as weight at birth <2.5kg—by:
Preventing malaria in pregnancy
Provide long-lasting insecticide-treated nets (LLINs) and intermittent preventive treatment in pregnancy (IPTp)
Ensuring good maternal nutrition
Provide food that contains zinc (e.g., vegetables, eggs, meat and fish) and iodine (e.g., fish, iodized salt and okra).
Using a hematinic (to prevent anemia)
Optimizing maternal health

11. Preventing Pneumonia in Children
Preventing children from developing pneumonia in the first place is essential for reducing child deaths
Key prevention measures include:
Promoting adequate nutrition (including breastfeeding and zinc intake)
Raising immunization rates
Reducing indoor air pollution
Recent research also suggests that handwashing may play a role in reducing the incidence of pneumonia

12. Preventive Measures: Breastfeeding and Handwashing with Soap

13. Countries That Have Introduced Hib Vaccine against Pneumonia
Vaccines can prevent some forms of pneumonia
Only around half of 193 countries worldwide have adopted Hib3 vaccine and implemented it up to 80% coverage
We still have a long way to go with this strategy

14. Status of Global Pneumococcal Conjugate Vaccine Introduction (2008)
Here we see slow progress with a vaccine to prevent another form of pneumonia
On the slide above, GAVI refers to the GAVI Alliance (formerly known as the Global Alliance for Vaccines and Immunization.

15. Preventing HIV in Children
Routine assessment for signs/symptoms of HIV (persistent diarrhea, failure to thrive)
HIV testing
Pneumocystis carinii pneumonia (PCP) prophylaxis (starting at six months)
Prevention and treatment of TB or malaria
Specific interventions to reduce mother-to-child transmission (MTCT) of HIV include antiretroviral (ARV) treatment and prophylaxis, safe delivery procedures, counseling and support for safe infant feeding

16. Treatment

17. Chart for Classifying and Treating Respiratory Illness
Signs
Classify As
Treatment
Fast breathing (see below)
Lower chest wall indrawing
Stridor in calm child
Severe pneumonia
Refer urgently to hospital for injectable antibiotics and oxygen, if needed
Give first dose of appropriate antibiotic
Non-severe pneumonia
Prescribe appropriate antibiotic
Advise mother about other supportive measures and when to return for a follow-up visit
No fast breathing
Other respiratory illness
Advise mother about other supportive measures and when to return if symptoms persist or get worse
What is fast breathing?
If the child is…
2 months to 12 months old
12 months to 5 years old
The child has fast breathing if you count…
50 breaths or more per minute
40 breaths or more per minute

18. Treatment
Co-trimoxazole and amoxicillin are effective drugs against bacterial pathogens and are often used to treat children with pneumonia in developing countries
Infants under two months of age, with signs of pneumonia/sepsis:
Are at risk of suffering severe illness and death more quickly than older children, and
Should be immediately referred to a hospital or clinic for treatment

19. Medicine for Cough, Fast Breathing, Fever
Give an appropriate oral antibiotic
For pneumonia, acute ear infection, severe classifications requiring first dose of antibiotics:
First-line antibiotic co-trimoxazole
Adult tablet = trimethoprim (80 mg) + sulfamethoxazole (400 mg)
Pediatric tablet = trimethoprim (20 mg) + sulfamethoxazole (100 mg)
Syrup/per 5 ml = 40 mg trimethoprim mg sulfamethoxazole
Second-line antibiotic amoxicillin
Tablet 250 mg; syrup 125 mg per 5 ml
In all the children on co-trimoxazole prophylaxis, give amoxicillin

20. Cough, Fast Breathing, Fever Give Appropriate Dosage by Age or Weight
Co-Trimoxozole
Give two times daily
for five days
Amoxicillin
Give three times daily
Adult Tablet
80 mg trimethoprim mg sulfamethoxazole
Pediatric Tablet
20 mg trimethoprim mg sulfamethoxazole
Syrup/per 5 ml
40 mg trimethoprim mg sulfamethoxazole
Tablet
250 mg
Syrup
125 mg per 5 ml
Two months up to 12 months (4kg to <10kg)
1/2 2
5 ml
12 months up to five years
(10kg‒19kg) 1 3
7.5 ml
10 ml
This is a sample schedule and dose table for oral antibiotics
Users will need to confirm and comply with specific country treatment guidelines

21. Summary Points
Infants under two months of age with signs of pneumonia/sepsis:
Are at risk of suffering severe illness and death more quickly than older children, and
Should be immediately referred to a hospital or clinic for treatment
Research evidence has shown that handwashing and breastfeeding may prevent pneumonia
Use an appropriate oral antibiotic for treatment