Title: Integrated Approach to Pneumonia Prevention and Control in India
1Integrated Approach to Pneumonia Prevention and
Control in India
General Presentation
2Pneumonia causes almost 1 in 5 child deathsThe
leading cause of infectious death in children lt5
years of age
Hib and pneumococcus account together for an
estimated 50 of pneumonia deaths
Under-nutrition (underlying cause) 53
Source WHO 2005 World Health Report
3Yearly Deaths Due to Pneumonia in children under
5
3
4150 million cases of child pneumonia /year15
countries account for nearly 75 of child
pneumonia worldwide
India accounts for 40 of childhood pneumonia
cases in the world
4
5Pneumonia death risk factors
- Malnutrition
- Environmental factors (e.g, indoor air pollution)
- Crowded living conditions
- Presence of other illnesses (eg. HIV)
- Distance from health facility
- Access to health facility given poverty, etc.
- More than 95 of new cases worldwide are in
developing countries
Source UNICEF/WHO
6Bacteria Causing Deadly Pneumonia
7 Streptococcus pneumoniae (pneumococcus)andHa
emophilus influenzae type b (Hib)
Most fatal pneumonia is likely caused by two
bacteria
8Hib and Pneumococcal Pneumonia in India
- Hib and pneumococcus most common bacterial causes
of pneumonia - Hib estimated to cause more than 50,000 child
pneumonia deaths in India every year - Pneumococcus estimated to cause more than 120,000
child pneumonia deaths
WHO Global Burden of Disease estimates
9Pneumonia kills 45 children an hour
1095 children a day
7,692 children a week
33,300 children a month
Each year pneumonia kills over 400,000 children
in India 50,000 by Hib 120,000 by pneumococcus
Pneumo
Hib
10Control Measures
11A multifaceted approach is needed to prevent and
control childhood pneumonia
12Pneumonia control requires a multi-pronged
approach
- Pneumonia is caused by several pathogens and
associated with multiple risk factors - Only a multi-pronged approach will fully address
the problem - Case Management facility and community
- Vaccination
- Reducing risk factors indoor air pollution,
nutrition etc.
13Proven Interventions to Reduce Risk Factors
- Improving nutrition
- Breastfeeding can decrease respiratory
disease-related hospitalizations by 15 - Zinc supplementation can significantly reduce
incidence of acute lower respiratory infections - Reduction of household indoor air pollution
- Switching to other fuels, improving combustion
and ventilation
14Improving and scaling up treatment for children
under five
- Community case management (CCM) expands reach
beyond facility-based health care - Policy exists for community treatment of
pneumonia with co-trimoxazole or amoxicillin - ANM (Auxiliary nurse/midwife) and AWW (Anganwadi
workers) can be trained to assess potential
danger signs, count respiratory rates and
classify respiratory illness based on symptoms - 69 children with suspected pneumonia sought care
from health facility or provider - 13 received antibiotics for treatment of
pneumonia
15Challenges in improving treatment
- Estimated treatment gap in India 13,315,000
cases/yr - ANM mostly busy in outreach activity limited
availability for CCM - AWW- Volunteer (small honorarium) - Irregular
supply of co-trimoxazole - ASHA Workers- Role in CCM in early development
- Reported antibiotic use for pneumonia low
- Limited geographical coverage of CCM
16Antibiotic Resistance
- Another barrier to appropriate treatment
17Hib and pneumococcal bacteria becoming resistant
to commonly prescribed antibiotics
- Successful case management relies on effective
antibiotics - Growing resistance raises doubts about the
effectiveness of treatment and leads to use of
more expensive antibiotics, especially in severe
cases - Risk of side effects
Ampicillin
Chloramphenicol
18TO PREVENT
A jumbo jet full of children crashing every 8
hours
19 Vaccines are part of top prevention
interventionsfor children less than five years
of age
No. of deaths prevented
Deaths prevented
as proportion of
Preventive Intervention
all child deaths
(000s)
Breastfeeding
1301
13
Pneumococcal vaccine
617-901
6-9
Insecticide
-treated materials
691
7
Complementary feeding
587
6
Zinc
459
5
H influenzae type b vaccine
403
4
Antiseptic delivery
411
4
Water, sanitation, hygiene
326
3
Range assumes 70-100 Serotype coverage and
88-90 vaccine efficacy
Adapted from Jones G, Lancet 2003.
20Vaccines
- Measles and Pertussis vaccines have already
reduced deaths and cases of childhood pneumonia - Use should be scaled up
- Second dose measles should be introduced
- Hib and pneumococcal vaccines should be an
integral part of a pneumonia prevention program
21Advantages Disadvantages of Immunization for
Pneumonia Control
- ADVANTAGES
- Scheduled intervention required to be given for
free a few times in a life-time - Existing mechanisms for delivery, even to the
difficult to reach - Can be quickly scaled up to reach very high
coverage
- DISADVANTAGES
- Does not cover all known pathogens of pneumonia
- Potential for replacement with other pathogens
- Price supply
Increasing local vaccine supply could resolve
price and supply challenges after 2015
22Vaccination has virtually eliminated Hib disease
when used in routine immunization programs, as it
is in more than 130 countries worldwide.
- GOI has taken decision to introduce Hib
All Indian children, rich or poor, will have
access to Hib vaccine when it is in UIP
23Routine Hib immunization programs 2008
Over 130 countries, including 66 GAVI countries,
have introduced Hib vaccine or are expected to
introduce by 2009-2010
72 GAVI countries
Introduced/plan to introduce (66)
Non-GAVI country introductions
No GAVI application made (6)
Status as of January 2009
Source WHO/Hib Initiative database
February 2009
24(No Transcript)
25Pneumococcal Vaccines in India
- Pneumococcal conjugate vaccines (PCV) have proven
safety and efficacy in both developed and
developing countries - 200 million doses distributed in 90 countries
- Estimates have shown in GAVI-eligible countries
that PCV is highly cost effective most cost
effective in areas with highest child mortality
rates - Can prevent tens of thousands of deaths in
children every year in India
26Pneumococcal vaccine fits into Current Vaccine
Schedule
- It is compatible with the routine immunization
scheduleit can be given at 6, 10, and 14 weeks. - Requires an additional injection but no
additional visits - Although supply is currently too limited for all
of India, it will increase with demand.
Vaccination could begin soon for some parts of
India. - Indian suppliers may have products by 2015
27The way forward
28Vaccinations Save Lives and Reduce Health Care
Costs for Families
- Reduce health inequity
- Improve child health and mental and physical
development - Health improves wealth
- Children less sick perform better in school
- Healthy children grow up to be productive adults
- Saving money on doctor bills enables families to
make other investments
29Vaccines Reduce Burden on Health Systems
- Averting spending of scare resources treating
disease, vaccines prevent needless child death
and disability - Hospital resources and doctors time can be
devoted elsewhere - Avoid problem of increasing drug resistance
- Important for reaching Millennium Development
Goal 4 to reduce lt5 child mortality by 2/3 and
Indias 11th Five-Year Plan child mortality
targets
30Global Action Plan for Pneumonia (GAPP) A Way
Forward
- Strategic, evidence-based approach to coordinate
efforts to reduce pneumonia - Partners pneumonia experts including WHO,
UNICEF, Hib Initiative, PneumoADIP - Comparative impact assessment
- Plan to include further research,
awareness-raising, resource mobilization, policy
activities
31New Vaccine Recommendations
32The World Health Organization recommends that
Hib vaccines be included in all routine infant
immunization programs1and that countries make
inclusion of pneumococcal vaccines in national
routine immunization programs a priority2
1 WHO Position Paper on Haemophilus Influenzae
type B Conjugate Vaccines Weekly Epidemiologic
Review, 23 Nov, 2006 2 WHO Position Paper on
Pneumococcal Conjugate Vaccine Weekly
Epidemiologic Review, March 23, 2007
33In Summary Integrated Approach Needed
- Pneumonia mortality is an urgent child health
crisisneed to raise awareness and act today! - Hib vaccine can prevent more than 70,000 child
deaths / yr in IndiaGoI decided to introduce - Pneumococcal vaccine can prevent tens of
thousands of child deaths/yr in India - Other interventions to reduce risk factors and
scale up community treatment programs should be
implemented simultaneously
34Thank You
35Extra Slides
36Global Action Plan for the Prevention and control
of Pneumonia (GAPP)
- OBJECTIVES
- To accelerate pneumonia control through scaling
up the delivery of interventions of proven
benefit in the context of newborn and child
survival strategies in countries - To identify and implement a set of priority
activities within each area of work in reducing
pneumonia mortality - To develop an approach towards monitoring,
documenting and evaluating the impact of the
action plan
37The process
- Consultative meeting held in March 2007
- Technical consensus on the key interventions for
prevention control of pneumonia - Publication of reviews on epidemiology and on
potential interventions for control - Documentation of the evidence base
- Stakeholder's meeting in 2008
- Broader consensus on priority interventions and
strategies - Draft strategic plan (under development)
38Joint implementation of the interventions
creating a win-win situation
- Scale up delivery of selected interventions
through existing programmes - EPI, IMNCI, Safe Motherhood, Child Nutrition,
Environmental Health - Create synergies between the different programmes
to maximize the benefit and create efficiencies - Joint planning, review and revisions of policies
and strategies - Joint advocacy and social mobilization
- Harmonize processes for procurement stock
management of supplies and for logistics - Develop synergies in processes for monitoring
evaluation