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