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| Reducing by one third the deaths due to pneumonia |
The challenge
The 2006 UNICEF/WHO report, Pneumonia: The forgotten killer of children, examines epidemiological evidence on the burden and distribution of pneumonia and assesses current levels of knowledge and treatment.
Pneumonia is the leading killer of children
Pneumonia kills more children than any other illness -- more than AIDS, malaria and measles combined. Nearly 2 million children under five die from the disease each year, accounting for around one in five child deaths globally.
The figure below shows that 17 per cent of under-five deaths are due to pneumonia. But this figure does not include deaths during the neonatal period (the first four weeks of life). It is estimated that 25 per cent of neonatal deaths are caused by severe infections (of which about one third are due to pneumonia, adding another 3 per cent to under-five deaths). Therefore, pneumonia actually accounts for an estimated 20 per cent of total under-five deaths when estimates from the post-neonatal and neonatal periods are combined.
Developing countries bear the greatest burden
More than 150 million episodes of pneumonia are estimated to occur every year among children under five worldwide, with the vast majority of these cases occurring in developing countries (see figure below). Between 11 million and 20 million children with pneumonia will require hospitalization. South Asia and sub-Saharan Africa have the highest incidence of pneumonia cases among children under five. These two regions combined bear the burden of more than half the total number of pneumonia episodes worldwide.
Estimated incidence of childhood pneumonia worldwide, 2004
Source: UNICEF/WHO, 2006, Pneumonia: The forgotten killer of children.
Terminology: Acute respiratory infections, pneumonia and suspected pneumonia
Acute respiratory infection (ARI): This includes any infection of the upper or lower respiratory system, as defined by the International Classification of Diseases. Acute lower respiratory infections (ALRI) affect the airways below the epiglottis and include severe infections, such as pneumonia.
Pneumonia: Pneumonia is a severe form of acute lower respiratory infection that specifically affects the lungs, and accounts for a significant proportion of the ALRI disease burden. The lungs are composed of thousands of tubes (bronchi) that subdivide into smaller airways (bronchioles), which end in small sacs (alveoli). The alveoli contain capillaries where oxygen is added to the blood and carbon dioxide is removed. When a person has pneumonia, pus and fluid fill the alveoli in one or both lungs, which interferes with oxygen absorption, making breathing difficult.
Suspected pneumonia: Since radiography and laboratory tests are largely unavailable in resource-poor settings, childhood pneumonia is diagnosed by its clinical symptoms – cough, and fast or difficult breathing. Therefore, the term 'suspected pneumonia' better describes a large proportion of children diagnosed with pneumonia in developing countries. In addition, data collected through national-level household surveys, such as Multiple Indicator Health Surveys (MICS) and Demographic and Health Surveys (DHS), report pneumonia prevalence based on information regarding whether children have experienced cough and fast or difficult breathing (and due to a problem in the chest) in the two weeks prior to the survey.
Prevention and case management can reduce childhood pneumonia deaths
Preventing children from developing pneumonia is critical to reducing deaths. Efforts include basic child survival interventions such as immunizing children (especially with measles, Hib and pneumococcal conjugate vaccines) and ensuring adequate nutrition, including zinc intake and breastfeeding. Reducing indoor air pollution and washing hands with soap also play a role.
But once a child develops pneumonia, prompt treatment with a full course of effective antibiotics is life-saving because most severe cases are caused by bacterial pathogens. And since access to health services is limited in many developing countries, prompt treatment may also require training health workers to diagnose and treat children with pneumonia in the community.
Studies show that community health workers can effectively manage uncomplicated pneumonia. Case management includes classifying suspected cases based on breathing rates and lower chest wall indrawing (where the chest retracts during inhalation), treating non-severe pneumonia cases with antibiotics and referring severe pneumonia cases to health facilities, where possible.