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Health

Pneumonia

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Pneumonia is still a single leading cause of child death, killing 1 child every 35 seconds.

Pneumonia accounts for almost one million deaths every year, 922,000 in 2015 which is 16% of total deaths among children under-five years of age, 5% of which are neonatal. This makes it the single most common cause of child deaths worldwide. Despite having made some progress, a 51% decrease in pneumonia from 2000 to 2015, it is nowhere near the greater than 86% decrease in mortality from malaria-related under five mortality in the same time frame. There is still a significant road ahead to make a marked reduction in the preventable, treatable deaths due to pneumonia.

Pushing the Pace: Progress and Challenges in Fighting Childhood Pneumonia, p. 14 http://www.healthdata.org/policy-report/pushing-pace-progress-and-challenges-fighting-childhood-pneumonia

Pneumonia is the leading infectious disease killer of children worldwide; killing 2,500 children each day - more children than malaria, TB, measles, and AIDS combined. Despite causing 16% of all child deaths, pneumonia receives little attention and a tiny fraction of global public health investment - less than 2% of total global development funding for health. Despite the existence of effective tools to prevent, diagnose and treat pneumonia, most of the countries struggling with high rates of pneumonia-related deaths allocate a tiny portion of their health budgets to fighting child pneumonia. Mortality due to childhood pneumonia is strongly linked to poverty-related factors such as undernutrition, lack of safe water and sanitation, indoor air pollution and inadequate access to health care. An integrative approach to tackle this important public health issue is urgently needed.

UNICEF World Pneumonia Day Infographic, 2015

Timely careseeking with an appropriate health care provider is one of the most important steps to saving the life of a child from pneumonia; yet, worldwide, only 3 in 5 children receive the necessary help and care. In sub-Saharan Africa, where most pneumonia deaths occur, only 2 in 5 children seek care. The fight against pneumonia-related deaths in children relies on the triad of prevention, protection and treatment, laid out in the Global Action Plan for Pneumonia and Diarrhoea (GAPPD), highlighted below.

Source: GAPPD

 

Improved Pneumonia Management to Reduce Child Deaths

-                                      - Prevention:

o   The roll-out of two recent vaccines, the Haemophilus influenzae type B (Hib) vaccine and the pneumococcal conjugate vaccine (PCV) has been the most recent preventive effort. Measles and pertussis (whooping cough) vaccines are also essential for preventing infections that can lead to pneumonia as a complication.

o   Ambient and household air pollution are significant contributing factors to pneumonia mortality. Household air pollution (HAP) leads to 4.3 million deaths globally, and 13% (534,000) of these are deaths of children under 5. (WHO, CCAC, 2015). 12% of which are due to pneumonia. HAP ranks fourth in terms of the risk factors that contribute to disease and death. Exposure to household air pollution almost doubles the risk for childhood pneumonia.

Source: UNICEF APR Report 2015, p.42

 

                   -       Protection:

o   Exclusive breastfeeding for the first six months of life is an effective way to protect children from pneumonia; resulting in a 23% reduction in incidence. There is a 15.1 times greater risk of death from pneumonia if not breastfed in first 6 months.

                  o In addition, good nutrition for older children, adequate Vitamin A supplementation, hand-washing, clean water and good sanitation can also help protect children from pneumonia.

http://www.who.int/maternal_child_adolescent/documents/child-pneumonia-treatment/en/

-                                  - Diagnosis is a key missing element in the triad, which has to be taken into consideration.

o   Childhood pneumonia is very difficult to diagnose, especially in rural settings with limited equipment. The current WHO-recommended diagnostic sign, amongst other symptoms of fever and cough, is a rapid respiratory rate (using an AIR timer, watch or counting beads). Prompt careseeking and early, accurate diagnosis is pivotal to preventing the untimely death of children from pneumonia. Saving children from pneumonia requires urgent action and recognizing danger signs – including chest indrawing –is an important step.

o   UNICEF is currently working on developing the ARIDA project, to identify an Automated Respiratory Infectious Diagnostic Aid. While there are developments on the horizon, appropriate rapid diagnostic tests for point of care application are not currently available on the market. Based on existing technologies, UNICEF is advocating for the development of a tool that could automatically and precisely determine respiratory rates, and hence detect pneumonia, in children under 5. https://www.unicef.org/innovation/innovation_81722.html

Picture of ARI timer

-                                   - Treatment:

o   Early diagnosis and correct treatment saves children from pneumonia. According to the WHO and UNICEF Integrated Management of Childhood Illness (iCCM/IMCI) guidelines, pneumonia cases classified by a health worker should be treated with antibiotics, specifically Amoxicillin dispersible tablets (DT). In settings without adequate diagnostic tools, the WHO/UNICEF guidelines provide a common standard by which health workers can assess and classify bacterial pneumonia illness requiring antibiotic treatment. Despite the disproportionately high pneumonia-related mortality amongst the poor, there is a big gap between the rich and the poor in treatment of symptoms of pneumonia: The poorest children in the poorest countries are least likely to receive treatment when ill. This gap is particularly wide in sub-Saharan Africa and South Asia.

o   The latest WHO recommendations advise for community based management of childhood pneumonia with Amoxicillin DT. Evidence shows that properly trained and supervised community healthcare workers (CHW) are capable of accurately identifying, diagnosing and treating fast breathing and chest indrawing pneumonia with antibiotics. As most primary health facility locations are relatively far apart, enabling CHWs to treat pneumonia within the community enables quicker identification and treatment. If danger signs are identified and referral is necessary, time is of the essence and the presence of oxygen therapy at the referral site is essential to saving a child from severe pneumonia.

See more at: http://data.unicef.org/child-health/pneumonia.html#sthash.tlzz0Dd9.dpuf         

Picture of Amoxicillin dispersible tablets

 

Revised WHO classification and treatment of childhood pneumonia at health facilities detail the benefits of the new recommendations for community based pneumonia management with Amoxicillin DT.

-                             -         Re-Classification to Two Categories of Pneumonia

o   The two new classification categories are: Pneumonia (fast breathing and chest indrawing) treated at the community level, by trained CHWs with oral amoxicillin DT and home care advice. Severe pneumonia requiring injectable antibiotics and oxygen at the facility.

o   The new approach will simplify the management of pneumonia at outpatient level; reduce substantially the number of referrals for hospitalization; and achieve better treatment outcomes.

                -       Oral Amoxicillin DT Replaces Oral Cotrimoxazole as First-line Treatment of Pneumonia

o   For children 2–59 months of age diagnosed with pneumonia and presenting with “fast breathing” and “chest indrawing” clinical signs, oral amoxicillin DT is the first line of treatment, delivered on an outpatient basis.

o   Dosage: New guidance is available on appropriate dosages of oral amoxicillin per age of the child (see table below). Amoxicillin is recommended for use in a child-friendly dispersible tablet formulation that is dissolvable in breast milk or water, making it easy to swallow. The tablets are also easier to distribute, store and dispense than suspension forms.

-                              -          Benefits of change:

o   Oral amoxicillin is the most effective treatment for both fast breathing and chest indrawing pneumonia.

o   Increased access to antibiotic treatment closer to home

o   One oral antibiotic for the treatment of both fast breathing pneumonia and chest indrawing pneumonia

o   Decreased need for referrals to higher level facilities

o   Simplified pneumonia classification and management (two categories instead of three)

o   Simplified training of health workers

o   Cost benefits at individual, household, community and health facility levels

o   Decreased probability of hospitalization and thus the risk of hospital-acquired and injection-borne diseases

o   Reduced probability of increasing antimicrobial resistance, due to better adherence to simplified treatment

For more information:  http://www.who.int/maternal_child_adolescent/documents/child-pneumonia-treatment/en/

 

The revised recommendations emphasize family and community understanding of preventing, recognizing and appropriately managing pneumonia. When they become routine practice, caretakers will act quickly at the first sign of pneumonia, rather than waiting before treating the child.

 

Mothers and other caretakers should:

-       Improve hygiene through hand washing with soap, increase use of improved sources of drinking water and sanitation facilities.

-       Prevent exposure to too much air pollution, ambient and household, especially in children under the age of 2.

-       Provide children with 250 mg Amoxicillin DT per day (one, two or three tablets according to age band) for 5 days as part of the pneumonia treatment. http://www.who.int/maternal_child_adolescent/documents/child-pneumonia-treatment/en/

-       Promote exclusive breastfeeding and adequate feeding afterwards.

-       Recognize prolonged cough, fever or difficulty breathing and take the child to a health care provider for diagnosis and treatment of pneumonia and familiarize themselves with other symptoms requiring medical treatment (danger signs e.g. lethargy)

 

A comprehensive toolkit of adaptable communication materials for the management of Pneumonia have been developed for countries to utilize and are available at www.everybreathcounts.info and http://www.lifesavingcommodities.org/pneumonia. These materials are developed to supplement the iCCM/IMCI training manuals and job aids to help providers council caregivers, as well as help caregivers recognize danger signs. The toolkit also contains job aids and child-friendly product presentations for Amoxicillin DT.

Every Breath Counts

To accelerate progress towards the new global goal to end preventable child deaths, UNICEF with funding from the Bill and Melinda Gates Foundation and the UN Commission on Lifesaving Commodities worked with Speak Up Africa to launch a new global health Campaign, Every Breath Counts (EBC), to raise awareness about, and spur investment in, child pneumonia prevention, diagnosis, and treatment. The Campaign was launched in January 2016 at the Organization for African First Ladies against HIV/AIDS (OAFLA) General Assembly at the African Union. Her Excellency, Toyin Saraki, officially launched the campaign on behalf of Her Excellency, Aisha Muhammadu Buhari, Wife of the President of Nigeria, who is the Every Breath Counts Pioneering Champion.

To ensure the continued success of the Campaign, UNICEF, the UN Environment Programme (UNEP) and WHO have created an Every Breath Counts (EBC) Coalition, which was launched by UNICEF’s Deputy Executive Director Omar Abdi, at a High-Level Ministerial Policy Review at the UN Environmental Assembly (UNEA). The Coalition will mobilize an unprecedented number of partners from a variety of sectors, disciplines and movements to invest more in the fight against childhood pneumonia. Leaders from such diverse sectors as household air pollution, sustainable energy, climate change, education, nutrition, WASH, immunization and child health will combine their respective advocacy, policy development, program delivery and financing assets to dramatically increase access to pneumonia-fighting interventions among the most-affected populations.

 

Every Breath Counts Coalition Concept Note with Her Excellency, Aisha Muhammadu Buhari, Wife of the President of Nigeria, who is the Every Breath Counts Pioneering Champion

 

Health care workers should:

-       Counsel parents on preventative measures, including avoiding air pollution and updating all routine vaccinations, including PCV where available

-       Advise parents on recognizing symptoms of pneumonia and identifying danger signs for timely careseeking

-       Accurately diagnose pneumonia by identifying fast breathing or chest indrawing and treating with Amoxicillin DT, or refer to facility for severe cases

-       Emphasize continued feeding or increased breastfeeding

-       Promote hygiene, sanitation and water and avoidance of ambient and household air pollution (including clean cookstoves or cooking outside of the home)

-       Promote and ensure adequate vitamin A supplementation

-       Ensure that the child has received the PCV vaccine, where available

 

UNICEF, WHO and other partners support these actions by:

-       Leading the Global Diarrhea and Pneumonia Working Group, supporting high mortality countries in their efforts to reduce deaths from diarrhea.

-       Advocating, facilitating and investing resources to ensure country adoption and implementation of the revised WHO recommendations

-       Working with governments and the private sector, including non-governmental organizations and businesses, to rapidly disseminate and implement these recommendations.

-       Ensuring adequate supplies of new Amoxicillin dispersible tablets

-       Helping with communication efforts aimed at enhancing prevention and management of pneumonia, including accurate diagnosis, correct management with Amoxicillin DT and referral and administration of oxygen therapy when necessary.

-       Working with countries to build local capacities to introduce and scale up the use of Amoxicillin DT for community management of pneumonia.

-       Working with governments to introduce PCV vaccines as per GIVS recommendations.

 

Additional materials:

-       Every Breath Counts Coalition

o   www.everybreathcounts.info

-       Pushing the Pace: Progress and Challenges in Fighting Childhood Pneumonia

o   http://www.healthdata.org/policy-report/pushing-pace-progress-and-challenges-fighting-childhood-pneumonia

-       Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD)

o   http://www.who.int/woman_child_accountability/news/gappd_2013/en/

-       Pneumonia and diarrhoea: Tackling the deadliest diseases for the world’s poorest children

o   https://www.unicef.org/publications/index_65491.html

-       Pneumonia & Diarrhea Progress Report

o   http://www.jhsph.edu/research/centers-and-institutes/ivac/resources/IVAC-2015-Pneumonia-Diarrhea-Progress-Report.pdf

 

 


 

 

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