PRIMARY LEVEL CARE
OF PNEUMONIA
Eric Macharia
Aggrey Amwoga
OBJECTIVES
Definition and Classification: no pneumonia,
pneumonia and severe pneumonia
Distribution
Risk factors
Burden of illness caused by pneumonia with
regard to morbidity and mortality
Global Action Plan for the Prevention and
Control of Pneumonia (GAPP) Strategy
Definition
Pneumonia is a form of acute respiratory
infection that affects the lungs (WHO)
An infection of the lower respiratory tract that
involves the airways and parenchyma with
consolidation of the alveolar spaces (Nelson
Essentials of Paediatrics)
When an individual has pneumonia, the alveoli
are filled with pus and fluid, which makes
breathing painful and limits oxygen intake.
Causes of Pneumonia
These include bacteria, viruses and fungi
Most common causes of pneumonia:
◦ Streptococcus pneumoniae
◦ Haemophilus influenza
◦ RSV (most common viral cause)
Pneumocystis jiroveci is a common cause in
HIV and contributes to 25% of deaths in HIV
infected infants
WHO Pneumonia Fact sheet. 2016.
CLASSIFICATION
.
Risk Factors
Age
◦ Young age 2 years and below
◦ Old age 65 years and above
Pre-existing illnesses such as symptomatic HIV infection
Malnutrition and failure to exclusively breastfeed.
Zinc and Vitamin A deficiency.
Lack of immunization (pneumococcal, hib, pertussis,
measles)
Environmental factors:
◦ Indoor pollution from cooking fuels such as wood, charcoal or
kerosene
◦ Overcrowding
◦ Parental smoking
WHO Pneumonia Fact sheet. 2016.
Other Factors
Preexisting lung disease or other chronic
disease: asthma, COPD, cystic fibrosis, sickle cell
disease
Hospitalization, especially in ICU and using
ventilator
Gastroesophageal reflux
Neurologic impairment (higher risk of aspiration)
Anatomic abnormalities of the respiratory tract
such as TEF (Tracheo-Esophageal Fistula) and
Immotile Cilia Syndrome.
Pneumonia. National Heart, Lung, and Blood Institute.
Burden of Illness
Pneumonia is the leading cause of deaths of children
under 5 years old worldwide and accounts for about
16% of all deaths of children under 5 years old.
There are an estimated 120 million cases of
pneumonia in children <5 years annually, 10% of
which progress to severe forms
It caused 920,000 deaths of children under 5 in 2015
(100 deaths/hour) – 7/1000 live births
This was more than diarrhea, malaria and HIV
combined
More than 90% of the deaths occur in LMICs in Africa
and South Asia
Sub Saharan Africa accounts for half of these deaths
(half a million deaths)
80% of deaths is in children aged two years or younger
Percentage of deaths among children under age 5 attributable to pneumonia, 2015
Source: WHO and Maternal and Child Epidemiology Estimation Group (MCEE) provisional estimates 2015
Burden of Illness in Kenya
In KDHS 2014, prevalence of children with
symptoms of ARI was estimated at 9%
Lowest incidence was in less than 6 months
(4%) and highest at 6-11 months (11%)
Only 66% of these visited a health facility
Under 5 death rate from ARI was estimated to
be 7 per 1000 live births in 2015 translating
to over 10,000 deaths (UNICEF)
This accounted for 14% of all under 5 deaths
KDHS 2014
UNICEF 2015
Global Action Plan for the
Prevention and Control of
Pneumonia (GAPP)
This was developed by WHO and UNICEF in 2009
This was in response to the the huge toll caused
by pneumonia and the few global resources
dedicated to tackling it
It was seen as vital in achieving MDG 4 (reducing
child mortality by 2/3)
Aims
◦ Increase awareness of pneumonia as a major cause of
child mortality
◦ Spur action to deal more effectively with the problem
Vision
Every child is protected against pneumonia
through a healthy environment, and should
have access to preventive and treatment
measures.
Goals
Reduce mortality from pneumonia in children
under 5yrs, by 65% by the year 2015
compared to the year 2000.
Reduce incidence of severe pneumonia in
children <5yrs, by 25% by the year 2015,
compared to the year 2000.
Targets
90% coverage of each relevant vaccine (with
80% coverage in every district)
90% access to appropriate pneumonia case
management
90% coverage of exclusive breastfeeding
during the first six months of life
Measurement of progress
Data collection through national health
information systems, demographic and health
surveys, and multiple indicator surveys, as
appropriate
Framework for pneumonia control
Recommendations for major actions
to be taken by countries
Designation of a national action group for
pneumonia control
Generating political will
Developing a situation analysis for pneumonia
Involving other programmes
Identifying areas of harmonization and collaboration
Increasing coverage for vaccination, access to case
management and promotion of exclusive
breastfeeding
Tracking progress
Engaging the United Nations agencies and donors
within the countries
Recommendations for Research
Main barriers to health care seeking and health
care access for children with pneumonia in
different contexts and settings
Finding more effective methods of diagnosing
pneumonia and its causes in the community and
first level facilities
Investigating new treatment regimens in the
face of increasing antimicrobial resistance and
shifts in prevalent pathogens post hib and
pneumococcal vaccine introduction and HIV
prevalence
Continued and expanded vaccine development
to produce improved versions of existing
Achievement of targets
Global decline in under 5 mortality due to
pneumonia was 47% between 2000 and 2015
(target was 65%)
In Kenya the decline was 65% between 2008
(30000 deaths) and 2015 (10000 deaths)
Vaccination coverage-79% (KDHS 2014)
Pneumococcal vaccine – 86%
Pentavalent vaccine – 90%
Measles – 87%
EBF for 6 months was estimated at 61%
66% had reported to a healthcare facility after
presenting with symptoms of ARI. 53% of these
received treatment
KDHS 2014
UNICEF 2015
Kenya: Pneumonia and pneumococcal disease. GAVI Alliance. 2011
Integrated Global Action Plan for the Prevention
and Control of Pneumonia and Diarrhoea (GAPPD)
Developed in 2013 by WHO and UNICEF with
the aim of fighting the two diseases in an
integrated approach
The two diseases account for 29% of all under
5 deaths globally
The integrated plan is to ensure more efficient
and effective use of often scarce resources
Target dates – 2025 and 2030
Goals (by 2025):
Reduce deaths from pneumonia to <3/1000
Reduce deaths from diarrhea to <1/1000
Reduce the incidence of severe pneumonia by
75% compared to 2010 levels
Reduce the incidence of severe diarrhoea by
75% compared to 2010 levels
Reduce by 40% the global number of children
less than 5 years of age who are stunted
compared to 2010 levels
Coverage targets (by 2025):
90% full-dose coverage of each relevant
vaccine (with 80% coverage in every district)
90% access to appropriate pneumonia and
diarrhea case management (with 80%
coverage in every district)
at least 50% coverage of exclusive
breastfeeding during the first 6 months of life
virtual elimination of paediatric HIV
Targets (by 2030):
universal access to basic drinking water in
health care facilities and homes
universal access to adequate sanitation in
health care facilities by 2030 and in homes by
2040
universal access to handwashing facilities
(water and soap) in health care facilities and
homes
universal access to clean and safe energy
technologies in health care facilities and
homes
References
WHO/UNICEF Global Action Plan For Prevention and
Control of Pneumonia (GAPP), 2008.
Integrated Global Action Plan for the Prevention and
Control of Pneumonia and Diarrhoea (GAPPD). 2016.
[Link]/Pneumonia.
Primary Health Care (A Manual For Medical Students
and Other Health Workers), 3rd Edition, pg 118-120.
Kliegman et al, (2007) Nelsons Textbook of
Paediatrics, 18th Ed.
Ministry of Health, Republic of Kenya, Basic
Paediatric Protocols for ages up to 5yr, July 2013 Ed,
pg 32.