Publications

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.

The challenge

Pneumonia is the leading killer of children

Pneumonia kills more children than any other illness – more than AIDS, malaria and measles combined. Nearly 1.5 million children under five die from the disease each year, accounting for nearly one in five child deaths globally.

Currently, 18 per cent of under-five deaths are due to pneumonia, including deaths during the neonatal period (the first four weeks of life).

Global distribution of under-five deaths by cause, 2008

Source: WHO/Child Health Epidemiology Reference Group (CHERG) estimates presented in The Lancet, June 2010.

East Asia and the Pacific and sub-Saharan Africa have the highest pneumonia mortality rates among children under five
Percentage of deaths among children under five years of age attributed to pneumonia (neonatal deaths not included), 2008

Source: WHO/Child Health Epidemiology Reference Group (CHERG) estimates presented in The Lancet, June 2010.

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. With pneumonia, pus and fluid fill the alveoli in one or both lungs, which interfere with oxygen absorption, making breathing difficult.

Suspected pneumonia: Since radiography and laboratory tests are largely unavailable in poor areas, childhood pneumonia is diagnosed by its clinical symptoms – coughing, 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 household surveys, such as Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS), report pneumonia prevalence based on information regarding whether children have experienced coughing and fast or difficult breathing (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 lifesaving 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.

Too few children with pneumonia are receiving appropriate care

Prompt treatment with effective antibiotics is critical for reducing deaths from pneumonia. Yet, slightly more than half of children (59 per cent) with pneumonia in the developing world (excluding China) are taken to an appropriate health-care provider. The highest levels of care seeking for pneumonia are found in the Middle East and North Africa (76 per cent), East Asia and the Pacific (excluding China, 66 per cent) and South Asia (65 per cent), while sub-Saharan Africa lags behind at 46 per cent. The proportion of children receiving antibiotics to treat pneumonia is even lower.

Coverage of care seeking and treatment for children with pneumonia is still falling short
Proportion of children under five with suspected pneumonia taken to an appropriate health-care provider, 2005–2009

Proportion of children under five with suspected pneumonia receiving antibiotics, 2005–2009

Note: Analysis is based on 106 and 62 developing countries with data on care seeking and antibiotics treatment for suspected pneumonia respectively.
*Excludes China.
Source: UNICEF global databases 2010, from MICS, DHS and other national surveys.

In 37 countries with available data, less than half of children with suspected pneumonia are taken to an appropriate health provider
Percentage of children under five with suspected pneumonia who are taken to an appropriate health provider, 2005–2009*

Source: UNICEF global databases 2010, from MICS, DHS and other national surveys.
Note: *For the following countries, data refer to a previous year other than specified but not before 2000: Azerbaijan, Botswana, Chad, Comoros, Democratic People’s Republic of Korea, Eritrea, Gabon, Guatemala, Iran, Lebanon, Maldives, Myanmar, Namibia, Nicaragua, Occupied Palestinian Territory, South Africa, Turkey, Venezuela and Yemen.

References

UNICEF, Pneumonia: The forgotten killer of children, UNICEF and World Health Organization, New York and Geneva, 2006.

‘Global, regional, and national causes of child mortality: A systematic analysis’, in The Lancet, vol. 375, no. 9730, 5 June 2010, pp. 1969-1987.