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1 : Childhood Pneumonia World’s biggest killer Situation analysis & Future directions
2 : ARI is the most common acute affliction of human Most ARI deaths occur due to Pneumonia (Bhutta ZA, 2007) Denny FW et al. Am J Trop Med Hyg 1986;35:1-2 Bhutta ZA. Arch Dis Child 2007; 92:286-288)’ ARI?? Childhood Pneumonia
3 : Highlight current state of Pnm morbidity & mortality in U5 child globally and in the country Address clinico-epidemiological insights of Pnm, based on data generated over the past decade Plan future directives in reducing Pnm disease burden & prevent child deaths Objectives of the presentation BPPF Conference’2007
4 : Methodology : Review Current Literatures WHO : Management of ARI in Children’1995. WHO : IMCI Guidelines’2001 National Asthma Bronchiolitis COPD Guidelines. Asthma Association Bangladesh’ 2005.
5 : Magnitude of pneumonia Wardlaw T et al. Pneumonia… killer of children. Lancet 2006; 368: 1048-50 Among 19 million annual U5 deaths, Pneumonia alone is responsible for 28-34% of all deaths Global scenario
6 : ….and 95% of pneumonia deaths occur in L D C countries, mostly of S E A Bellamy C. Healthy environments for children. Bull WHO 2003;81:157
7 : Pneumonia: Annual incidence ~151million new cases, of which 11-20 million requires hospitalization1 Rudan I et al. Global estimate of the incidence of pneumonia among children under 5 years. Bull WHO 2004; 82:895-903 2. Bhutta ZA. Dealing.... pneumonia..difference? Arch Dis Child 2007;92:286-8 Magnitude contd… Treatment Failure rate still 2-20%2
8 : Insignificant change in mortality !! GBD = Global Burden of Disease : CHERG = Childhood Epidemiology Ref. Group Bhutta Z. A. Dealing…childhood pneumonia …Arch Dis Child 2007: 92:286-288 2.58 2.15 1.94 1.88
9 : Pneumonia incidence persists high Attributes to 47% of all U-5 illness Claims a high death toll of ~ 23% Pneumonia… Bangladesh ………………………………………………………………………………………. Brooks WA, et al, Lancet, 2005 Bangladesh Health & Injury Survey (BHIS), ICMH, UNICEF & TASK, 2005 Shams El- Arifeen, et al. Causes of death in children U-5 of age, ICDDR’2004 Bangladesh Demographic & Health Survey (BDHS), 2004
10 : Source: BDHS 1996/97 BHIS’2005, NO change in ARI / pneumonia deaths over a decade !
11 : Why mortality remains unchanged despite a structured WHO-IMCI guideline? Is it contributed by hypoxic deaths of bronchiolitis, who diagnosed as pneumonia?
12 : No of reported pneumonia cases at DGHS(1993-2006)
13 : Case fatality of Pneumonia Plateau??
14 : Bronchiolitis study: RSV IgM Results (n=279)
15 : Why mortality remains unchanged despite a structured WHO-IMCI guideline? Is it related to any risk factors?
16 : Pneumonia : inappropriate infant & young children feeding (IYCF) Non breast feeding enhances mortality by 3.6 times1 Mixed feeding enhances mortality by 1.6 times1 Prelacteal feeding & early weaning significanly increases chance of pneumonia 2 Victora C G et al. Evid…strong… effect of B F .. In Brazil. Lancet’1987 Broor S et al. Risk factor…severe ARI under 5 children. Ind Pediatr’2001
17 : Poor environment
18 : In 77% of households of Bangladesh, 4-5 persons live in a single room
19 : 1. Anwar KS et al et al. Usefulness…abstract ’2001 2. Savitha MR et al. Modifiable risk factors of ALRTI. Ind J Paediatr’ 2007 Pneumonia : Overcrowding Overcrowding significantly (2.5 times) enhances pneumonia attacks
20 :
21 : Indoor Air Pollution (I A P) (mud, cow dung, kerosin lamp,biomass fuel, tobacco smoke) IAP Hampers mucocilliary functions & Cellular immunity of respiratory tract and increases pneumonia morbidity & mortality Savitha MR et al. Modifiable risk factors of ALRTI. Ind J Paediatr’ 2007
22 : In Bangladesh, Malnutrition is identified among 78% of children with pneumonia 1 Anwar KS et al. Proj Min of Sci Tech, GoB’ 2002
23 : Malnutrition & Pneumonia 1. Rice A L et al. Malnutrition….countries. Bull WHO 2000; 78(10): 1207-21 2. Yoon PW et al. The effect of malnutrition on the risks…Am J Clin Nutr’ 1997 Malnutrition increases pneumonia mortality by 3 times 1,2
24 : Pneumonia : Less care seeking Pneumonia mortality was found significantly lower among children who were consulted health workers earlier In Bangladesh, early care seeking was noted among mothers who were SSC passed 1. Bangladesh Demography and Health Statistics’2004 2. Savitha MR et al. Modifiable risk factors of ALRTI. Ind J Paediatr’ 2007
25 : Risk Factors : Summary Pneumonia Inappropriate I Y C F Overcrowding Indoor Pollution Malnutrition ~Micronutrient def Less care seeking behaviour
26 : Changing microorganism and drug sensitivity / Resistance pattern Why mortality remains unchanged despite a structured WHO-IMCI guideline?
27 : Bacteria, the commonest pathogen Brooks, W.A. et al. Lancet, 2005, Zaman K et al. J Trop Pediatr, 1997 Mastumura K, Anwar KS, Mollah MAH. J Diarrhoeal Dis Res’ 1998;16: 96 Hassan K et al. Scand J Infect Dis. 2006 Despite variation in study results, S. Pneumoniae ,Staph aureus, H influenzae Identified as major pathogens in developing countries Pneumonia : Microorganisms
28 : Pneumonia : microorganisms Mixed infection : 8-40% (Viral / bacterial or more than 1 bacteria) Most common combination S pneumoniae + RSV or S pneumoniae + Mycoplasma Kabir ARML. Aetiology of ALRTI in infancy’2003
29 : Organism isolation rate : 11.69% Staph aureus (42%) Strep Pneumoniae (20%) H Influenzae (7%) P aeroginosa (5.3%) coming up- previously not recognized Severe pneumonia Evaluation Antimicrobial Research (SPEAR)’2007 All were susceptible to 3rd gen cephalosporin
30 : Viruses in pneumonia in Bangladesh Total cases : 67 & NPA for viral antigens + ve in 45% cases Hasan K et al. Viral etiology….Bangladesh. J Infectious Dis 2006;38 : 690-95
31 : Chlamydia pneumonia, isolated among 20.3% of U5 pneumonia cases in Bangladesh Matsumoto T, Anwar KS, Mollah MAH, et al. Prevalence..atypical ..among Bang… U5 children with ARI. J Inf Chemotherapy 2006 Pneumonia Atypical Microorganisms in Bangladesh
32 : Pneumonia… Neonate: E coli, Kl. pneumoniae, Pseudomonas, cl trachomatis Infancy to 5 yrs : Strep. Pneumoniae, H Influenzae , Staph aureus, RSV, p aeroginosa >5 years: str pneu, s aureus, M Pneumoniae, Cl Pneumoniae 1.Bryan A et al. CAP…Hosp Physician’2000 2.http/ CAP’2007 3.Current Paediatrics’ 2006 : Summary : Microorganisms
33 : Micro organism: Antibiotic resistance pattern Severe pneumonia Evaluation Antimicrobial Research (SPEAR)’2007 Saha S K et al. Survillence of pneumococccus…Health & Science Bull ’2007 ISCAP Study Group. BMJ 2004 ; 328 : 791.
34 : Pneumonia : Clinical trial 1. ISCAP Study Group. BMJ 2004 ; 328 : 791 2. Hazir T et al. Comparison…. Pakistan. Arch Dis Child 2007 ; 92 : 291-97 Amoxicillin (30-50 mg/kg/day) found effective & recommended for 5 days at OPD despite growing resistance
35 : Severe pneumonia Evaluation Antimicrobial Research (SPEAR)’2007 P<0.02 Children of 2mo-59 mo ; severe pneumonia
36 : Summary: Antibiotic trials Amoxicillin is effective for non severe pneumonia Both combined Ampicillin+Gentamicin and chlroamphenical are effective for severe pneumonia but the former combination is more effective.
37 : Lozano JM. Epid of hypox in ALRTI. Int.J.Tuberc.Lung Dis 2001 ;5(6):496-04 Dyke T et al. Hypoxia in childhood pneumonia... BMJ 1994;308(6921):119-20 Onyango FE et al Hypoxaemia …. BMJ 1993;306(6878):612-5 Pneumonia deaths & HYPOXIA Risk of death is 4 times more when pneumonia has associated hypoxia
38 : Sensitive to identify/ classify pneumonia at community.
39 : ….Many doctors not diagnosing the cases with any case definition (n=246)
40 : Pneumonia : Summary The leading cause of U5 deaths though hypoxic deaths from bronchiolitis, not recognized. Microorganism isolation rate is very poor. S. Pneumoniae, commonest in all ages. Staph aureus, H. Influenzae is next common RSV & Atypical organisms, other agents.
41 : Improper feeding, overcrowding, I A P, Malnutrition etc identified as risk factors Common organisms showing high rate of resistance to Cotrimoxazole Hypoxia, an important mortality determinant Pneumonia cases, mostly remain classified even in hospitals Pneumonia : Summary
42 : How to address this issue? At hospitals Classification ~ Diagnosis by comprehensive clinical evaluation & chest X Ray Diagnosis of pneumonia
43 : Pneumonia : Case definition WHO ’2000 A child with cough & difficult breathing having Fever Coarse crackles on auscultation Nasal flaring Grunting Head nodding X Ray chest: Patchy opacity / consolidation Management…care at first ref…dev..countries. WHO’2000
44 : Pneumonia : Case definition
45 : Reviewing Treatment Based on current research findings .…how to address?
46 : Non severe pneumonia Duration of treatment: 5 days
47 : severe pneumonia (0-2months) Duration of treatment: 5-10 days
48 : severe pneumonia (2mo-5 yrs)
49 : Pneumonia (>5 years)
50 : Oxygen saturation monitoring &O2 therapy
51 : How to prevent pneumonia? Ensuring optimum nutrition by breast feeding & proper complementary feeding Incorporation of Hib & Peumococcal vaccines in EPI Elimination of other risk factors.
52 : Research to generate national database on childhood respiratory illnesses to guide public health &Clinical management of pneumonia Future Actions
53 : Integrated journey
54 :


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