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Pneumonia leads causes of Pneumonia leads causes of childhood deathschildhood deaths
Source: WHO estimates of the causes of death in children, 2000-03 Bryce, Lancet, 26 March 2005
Where do 10 million children die Where do 10 million children die each year?each year?
WHO estimates of the causes of death in children, Lancet, 2005
Percentage of children that die from pneumonia, by country
From Williams et al. Lancet Infect Dis, 2002.
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0-5 6-11 12-23 24-35 36-47 48-59
Age (months)
Ep
iso
des
per
ch
ild
/yr
Philippines
Age-specific incidence / mortality of Age-specific incidence / mortality of pneumoniapneumonia
0
20
40
60
80
100
120
140
160
1-5 6-11 12-23 24-35 36-59
Age (months)
Dea
ths/
1000
Bangladesh
Is pneumonia a problem in Is pneumonia a problem in emergencies?emergencies?
Examples of pneumonia deathsExamples of pneumonia deaths
• 63% among Nicaraguan refugees in 198963% among Nicaraguan refugees in 1989
• 30% of under-5 deaths in Kabul in 199330% of under-5 deaths in Kabul in 1993
• 80% when combined with malaria and diarrhea 80% when combined with malaria and diarrhea among Congolese refugees in 1999among Congolese refugees in 1999
Most data limited to mortalityMost data limited to mortality
• Few studies of morbidityFew studies of morbidity
Major Causes of Death in emergencies for <5 Years
Sudan: Wad Kowli CampFebruary, 1985
Somalia: Gedo Region 7 Camps, January, 1980
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.
MeaslesARIMalariaDiarrheaOther
Risk factors for pneumoniaRisk factors for pneumonia
• Low birth weight
• Malnutrition
• Bottle feeding
• Vitamin A deficiency
• HIV infection
• Indoor air pollution
• Household crowding
• Cold exposure
What causes Pneumonia: What causes Pneumonia: VirusesViruses
Respiratory Syncytial Respiratory Syncytial VirusVirus
AdenovirusAdenovirus
RhinovirusRhinovirus
Parainfluenza/InfluenzaParainfluenza/Influenza
What causes Pneumonia: What causes Pneumonia: BacteriaBacteria
Streptococcus Streptococcus pneumoniaepneumoniae
Source: CF. Laine, T Sugishita, J Rabke-Verani , M Cavicchia
Haemophilus Haemophilus influenzaeinfluenzae
Approaches to Preventing Approaches to Preventing Pneumonia MortalityPneumonia Mortality
• Prompt diagnosis • WHO algorithm
• Treat cases of pneumonia AntibioticsSupportive care
• Prevent cases of pneumonia Modify risk factors Vaccinate
Case Definition 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
WHO focuses on the reduction of mortality requiring:
Early/adequate diagnosisCorrect case management
Hospitalize for danger signsAccess to health careTrained health staffSimple treatment protocolsImmunization
May increase transmission risk for meningitis
Control of Lower Respiratory Infections Control of Lower Respiratory Infections
MSF book, p. 178
Clinical management of a sick child with Clinical management of a sick child with cough or difficult breathingcough or difficult breathing
Danger signs*YES
Refer to hospitalGive antibiotics
NO
Assess for chest indrawingYES
NO
Refer to hospitalGive antibiotics
VERY SEVERE DISEASE
* Danger signs include cyanosis, convulsions, severe malnutrition, difficult to wake, not able to drink
SEVERE PNEUMONIA
Assess for fast breathing
(RR>50/40 breaths/minute) YES
NO=NO PNEUMONIA; COUGH OR COLD
Give antibiotics
PNEUMONIA
Recommended Antibiotics for Recommended Antibiotics for PneumoniaPneumonia
Antibiotic Doses/day Relative cost
Cotrimoxazole 2 PO Lowest
Amoxicillin 3 PO Highest
Procaine penicillin 1 IM Middle
Antibiotic dose needs to be calculated by the weight of the child
Results of community case management Results of community case management interventions on mortality, by ageinterventions on mortality, by age
Sazawal and Black. Lancet ID, 2003
-50%
-40%
-30%
-20%
-10%
0%
<1 month <1 year <5 years
% m
ort
alit
y v
s c
on
tro
ls
All-cause
Pneumonia
Potential Barriers to Effective Case Potential Barriers to Effective Case ManagementManagement
• 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
Pneumonia: Pneumonia: PreventionPrevention
• 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
Existing vaccines to prevent Existing vaccines to prevent pneumoniapneumonia
Routinely usedRoutinely used• MeaslesMeasles• PertussisPertussis• DiphtheriaDiphtheria• Haemophilus influenzae Haemophilus influenzae type b (In some type b (In some
countries)countries) FutureFuture
• PneumococcalPneumococcal• RSVRSV
Efficacy of Efficacy of Haemophilus influenzaeHaemophilus influenzae type type b (Hib) vaccine on pneumonia outcomesb (Hib) vaccine on pneumonia outcomes
-10%
0%
10%
20%
30%
X-ray pospneumonia
Severepneumonia
Clinicalpneumonia
% e
ffic
acy Indonesia
Gambia
Chile
Tuberculosis in EmergenciesTuberculosis in Emergencies
Not cause of significant mortalityNot cause of significant mortality Post emergency setting: affects morbidity & Post emergency setting: affects morbidity &
mortalitymortality Depending on the epidemiology of the Depending on the epidemiology of the
diseasedisease• Need for continuation of treatment for those Need for continuation of treatment for those
patients who already are on treatmentpatients who already are on treatment
• Need for effective control program Need for effective control program
Tb ControlTb Control Conditions for implementing TB Conditions for implementing TB
Program:Program:• Basic health priorities already addressedBasic health priorities already addressed• Long term commitment - 1 year from last Long term commitment - 1 year from last
casecase• Stable population - patients complete Stable population - patients complete
treatmenttreatment• Adequate drug supplyAdequate drug supply• Knowledge of baseline drug resistanceKnowledge of baseline drug resistance• Laboratory confirmationLaboratory confirmation• Appropriate treatment algorithmAppropriate treatment algorithm