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Integrated Approach to Pneumonia Prevention and Control in India

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Title: Integrated Approach to Pneumonia Prevention and Control in India


1
Integrated Approach to Pneumonia Prevention and
Control in India
General Presentation
2
Pneumonia 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
3
Yearly Deaths Due to Pneumonia in children under
5
3
4
150 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
5
Pneumonia 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
6
Bacteria Causing Deadly Pneumonia
7
Streptococcus pneumoniae (pneumococcus)andHa
emophilus influenzae type b (Hib)
Most fatal pneumonia is likely caused by two
bacteria
8
Hib 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
9
Pneumonia 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
10
Control Measures
11
A multifaceted approach is needed to prevent and
control childhood pneumonia
12
Pneumonia 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.

13
Proven 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

14
Improving 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

15
Challenges 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

16
Antibiotic Resistance
  • Another barrier to appropriate treatment

17
Hib 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
18
TO 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.
20
Vaccines
  • 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

21
Advantages 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
22
Vaccination 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
23
Routine 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)
25
Pneumococcal 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

26
Pneumococcal 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

27
The way forward
28
Vaccinations 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

29
Vaccines 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

30
Global 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

31
New Vaccine Recommendations
32
The 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
33
In 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

34
Thank You
35
Extra Slides
36
Global 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

37
The 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)

38
Joint 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
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