1. Is pneumonia indeed as serious a threat as
depicted by international health agencies? Does it really deserve so
much of attention and media galore?
2. What prompted WHO to turn its attention now on
pneumonia after sidelining it for so long?
Is Pneumonia A Serious Threat?
World over, pneumonia kills more children than any
other illness – AIDS, malaria and measles combined and accounts for nearly
1 out of 5 under five deaths in children(2). About 156 million new
episodes occur each year worldwide, of which 151 million episodes are in
the developing world. Of all community cases, 7–13% are severe enough to
be life-threatening and require hospitalization(3). In India also, 410,000
children under 5 years of age die of pneumonia each year. Streptococcus
pneumoniae, Haemophilus influenzae and Respiratory Syncytial
virus (RSV) are the main pathogens associated with childhood pneumonia(3).
These data are sufficient enough to merit a serious fight against
pneumonia on a worldwide basis.
Why Sudden Focus on Pneumonia?
Though WHO had envisaged pneumonia prevention and
control in its ambitious Integrated Management of Childhood Illness (IMCI)
program which is being adopted by many countries, its efforts lacked the
urgency and intensity that were needed to take on pneumonia. It simply
failed to launch a frontal attack against the disease. Why WHO has decided
now to launch a massive drive against this ancient disease? There could be
many reasons-pertaining to both science and commerce.
First the obvious reason to which we all must agree, is
that the progress in the fight against pneumonia needs to be accelerated
if child health goals envisaged in the Millennium Development Goals (MDG)
4 – to reduce under-5 mortality by two-thirds by 2015 – are to be
achieved. It is argued that the real motive behind the invigorated
interest in pneumonia is an attempt to push up the sales of pneumonia
vaccines. The developing world offers a huge market for these vaccines,
and the manufacturers are obviously interested.
How to Tackle Pneumonia?
Pneumonia is not a specific entity but a syndromic
illness, caused by many infectious agents, and sometimes even by
non-infectious processes. Many respiratory illnesses mimic pneumonia in
their clinical presentation. Formulating flawless robust clinical
diagnostic criteria, especially for the community-level health workers is
a very daunting task. The existing WHO age-specific criteria based on
respiratory rates are also quite non-specific. Furthermore, the exact
epidemiological data on prevalence of different major pathogens are
lacking in majority of low and middle income-group (LMI) countries,
including India. For example, even RSV is not a lesser threat than
Streptococcus pneumoniae as far as disease burden is concerned and
newer bacteria like Klebsiella pneumoniae are more frequently
incriminated. Other major barriers to achieve effective control are lack
of availability of health facility at peripheral level, failure of health
workers to recognize the danger signs of the disease, and failure to treat
a case with appropriate antibiotics. Access to treatment is lacking, due
to a shortage of primary care facilities and providers of care – the vast
majority of the children who die of pneumonia die at home without
treatment.
The strategies to control and prevent pneumonia are
well-defined(2). Effective management of a case is as important as
prevention of the disease. Vaccination against pathogens responsible for
the disease is only one aspect of preventive strategy, which includes
improving nutrition and reducing other risk factors like air pollution,
smoking, unhygienic practices, etc. Since vaccines against many pathogens
are not yet fully utilized (measles and pertussis), or not yet available
(RSV, staphylococcal, gram negative pathogens), or not effective due to
serotype mismatch (pneumococcus), the proper management of a case still
remains the cornerstone of pneumonia control, especially in LMI countries.
Hence, to have a credible global strategy to fight this killer, we need to
attack pneumonia from both sides – vaccines to prevent and antibiotics to
treat. Till we have access to effective vaccines, this ‘window period’ can
be utilized to turn our focus on creating awareness amongst masses about
the burden of pneumonia disease, its impact on childhood mortality, simple
preventive measures such as hand washing, persistence with exclusive
breastfeeding, avoidance of diluted animal milk, and healthy nutritious
diet, etc. Devising more specific clinical criteria to diagnose pneumonia
at community level, training /educating health workers on proper case
management, establishing a disease tracking system, preferably a
‘molecular surveillance’ to keep track of prevailing bacterial serotypes,
bolstering our decades-old diagnostic methods with newer diagnostic
techniques to make etiological diagnosis, accelerating the development of
other vaccine products such as RSV with newer ADIPs (accelerated
development and introduction plans) are few other initiatives that can be
sincerely acted upon.
IAP can play a major role by adopting pneumonia control
in its ‘Action Plan’. It can act at different levels of pneumonia control
strategy- with launch of district based awareness campaigns through its
district branches, organizing ‘national consultative meets’ to have
uniform diagnostic and management guidelines, initiating pilots in
collaboration with international health institutions at key centers on
compiling epidemiological data, and advising government on the best
vaccination strategy to prevent the disease. The Academy has already taken
up a great initiative in reducing neonatal mortality through nation-wide
introduction of Neonatal Resuscitation Program. By targeting pneumonia it
can ensure that the major part of the spectrum of diseases responsible for
under-five mortality is taken care of.
