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Pneumonia Sapna Bamrah, MD CDC

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1 Pneumonia Sapna Bamrah, MD CDC
Acute Lower respiratory infections- include pneumonia, bronchiolitis, and bronchitis. In this talk we will focus mainly on the morbidity, mortality, diagnosis, treatment, prevention and control of pneumonia. I do use the term lower respiratory infection and pneumonia synonymously… Sapna Bamrah, MD CDC

2 Pneumonia leads causes of childhood deaths
Pneumonia accounts for ~20% of under 5 mortality (more including neonatal deaths). Exact contribution is difficult to determine because most deaths occur in areas where it is hard to assign a cause. Note: Not shown in this graph is the proportion of deaths attributable to malnutrition, >50% of all childhood deaths have undernutrition as an underlying cause (You may wish to note that measles mortality is low, mainly as a result of successful efforts to control measles worldwide) Source: WHO estimates of the causes of death in children, Bryce, Lancet, 26 March 2005

3 Where do 10 million children die each year?
The size of the pie is proportional to the number of deaths. The African and South Asian regions account for 70% of worldwide deaths annually among children <5 years. Pneumonia is shown in green. Notice that the size of the wedge is relatively constant in the highest mortality regions. In complex emergencies, the distribution of causes of deaths is likely to reflect the main causes of death in high mortality settings in the same geographic area, with some increased risk of diseases of epidemic potential. WHO estimates of the causes of death in children, Lancet, 2005

4 Source: World Health Report, 2005
High mortality regions are often associated with complex emergencies. This figure shows in dark blue countries that have made no progress towards reducing childhood mortality since Stars denote countries with recent humanitarian crises. These tend to be countries with high under-5 mortality rates to begin with (remember the size of the pie charts in the previous graph). Source: World Health Report, 2005

5 Percentage of children that die from pneumonia, by country
Finally, here’s one more graph to set the stage for discussions of lower respiratory illness and pneumonia. In general, the higher the under 5 mortality rate, the greater the percentage of these deaths are due to pneumonia. From Williams et al. Lancet Infect Dis, 2002.

6 Age-specific incidence / mortality of pneumonia
When we think of pneumonia, we may think of older children. However, the highest risk of severe pneumonia and death actually occurs before the age of two years, as shown in this graph of age-specific incidence of pneumonia in a community based study in the Philippines. Note that the y-axis goes up to 1 case of pneumonia per child year. The distribution of cases in refugee populations is likely to be very similar, with highest risk of severe illness and death among the youngest children, as shown in this study completed in Bangladesh.

7 Is pneumonia a problem in emergencies?
Examples of pneumonia deaths 63% among Nicaraguan refugees in 1989 30% of under-5 deaths in Kabul in 1993 80% when combined with malaria and diarrhea among Congolese refugees in 1999 Most data limited to mortality Few studies of morbidity

8 Somalia: Gedo Region 7 Camps, January, 1980
Major Causes of Death in emergencies for <5 Years Somalia: Gedo Region 7 Camps, January, 1980 Sudan: Wad Kowli Camp February, 1985 Measles ARI Malaria Diarrhea Other With the elimination of measles, lower respiratory infections are the second highest cause of death– second to diarrhea. Plus, its important to remember that the mortality associated with measles is often due to respiratory complications. 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.

9 Risk factors for pneumonia
Low birth weight Malnutrition Bottle feeding Vitamin A deficiency HIV infection Indoor air pollution Household crowding Cold exposure What are the risk factors for pneumonia? When you look at the individual– the risk factors include– low birth weight, malnutrition, bottle feeding, Vitamin A deficiency, HIV. Environmental causes include indoor air pollution, household crowding, and cold exposure.

10 What causes Pneumonia: Viruses
Respiratory Syncytial Virus Adenovirus Rhinovirus Parainfluenza/Influenza Before talking about control strategies in emergencies, we need to talk for a moment about what are the main causes of acute respiratory infections. These are the main viral causes of pneumonia in children.

11 What causes Pneumonia: Bacteria
Streptococcus pneumoniae Haemophilus influenzae These are two main bacterial pathogens. We can’t tell the difference clinically between viral and bacterial pneumonias, and both may be involved, so we often treat with antibiotics. Source: CF. Laine, T Sugishita, J Rabke-Verani , M Cavicchia

12 Approaches to Preventing Pneumonia Mortality
Prompt diagnosis WHO algorithm Treat cases of pneumonia Antibiotics Supportive care Prevent cases of pneumonia Modify risk factors Vaccinate What approaches can be taken in emergencies? Here’s a simple list.

13 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

14 Control of Lower Respiratory Infections
WHO focuses on the reduction of mortality requiring: Early/adequate diagnosis Correct case management Hospitalize for danger signs Access to health care Trained health staff Simple treatment protocols Immunization May increase transmission risk for meningitis MSF book, p. 178

15 Clinical management of a sick child with cough or difficult breathing
VERY SEVERE DISEASE Danger signs* YES Refer to hospital Give antibiotics NO SEVERE PNEUMONIA Assess for chest indrawing YES Refer to hospital Give antibiotics NO Who should be treated with antibiotics? Many field clinics follow this clinical algorithm from the WHO which recommends antibiotics for children with cough or difficulty breathing in the presence of danger signs (1st box), chest wall in-drawing (2nd box) or rapid respiratory rate (3rd box). You might say that this could over diagnose pneumonia and lead to overuse of antibiotics, but remember the focus is on decreasing mortality. Assess for fast breathing (RR>50/40 breaths/minute) PNEUMONIA YES Give antibiotics NO=NO PNEUMONIA; COUGH OR COLD * Danger signs include cyanosis, convulsions, severe malnutrition, difficult to wake, not able to drink

16 Recommended Antibiotics for Pneumonia
Doses/day Relative cost Cotrimoxazole 2 PO Lowest Amoxicillin 3 PO Highest Procaine penicillin 1 IM Middle Note here that antibiotics are a cheap strategy. There are concerns about resistance to these first line antibiotics among the main bacterial pathogens, but alternative antibiotics are still much more expensive. Antibiotic dose needs to be calculated by the weight of the child

17 Results of community case management interventions on mortality, by age
And here are some data to support this approach. These aggregated data are from community trials in settled populations—a trial in a emergency would not have been feasible and is not ethical based on these results. The community case management approach with early administration of antibiotics reduced all-cause mortality (shown here in blue) by 20-30% and pneumonia-specific mortality by 35-40% among children at highest risk. If children can be reached early and antibiotics are effective, this is a very successful strategy for reducing mortality. Sazawal and Black. Lancet ID, 2003

18 Potential Barriers to Effective Case Management
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 What are the barriers to consider in relation to complex emergencies and displaced populations?

19 Pneumonia: Prevention
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

20 Existing vaccines to prevent pneumonia
Routinely used Measles Pertussis Diphtheria Haemophilus influenzae type b (In some countries) Future Pneumococcal RSV

21 Efficacy of Haemophilus influenzae type b (Hib) vaccine on pneumonia outcomes
This graph shows data from three clinical trials of vaccines against Hib pneumonia in developing countries. Hib vaccine prevented more than 20% of the most severe, chest x-ray confirmed pneumonia in two trials, and a lower percentage of pneumonias among children with negative x-ray findings or with clinical signs of pneumonia alone. None of the trials estimated the impact of Hib vaccination on all-cause mortality, but based on some assumptions, the Lancet article by Jones estimates that 4% of childhood deaths could be prevented with widespread Hib vaccination. Should we be using Hib vaccine?

22 Tuberculosis in Emergencies
Not cause of significant mortality Post emergency setting: affects morbidity & mortality Depending on the epidemiology of the disease Need for continuation of treatment for those patients who already are on treatment Need for effective control program

23 Tb Control Conditions for implementing TB Program:
Basic health priorities already addressed Long term commitment - 1 year from last case Stable population - patients complete treatment Adequate drug supply Knowledge of baseline drug resistance Laboratory confirmation Appropriate treatment algorithm

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