Pneumonia, the silent killer of children in India

Illness and death from pneumonia happen all over India; however, some groups of children are at higher risk because they are systematically disadvantaged: suffering from poverty, malnutrition, illness, and low access to health care. A child’s risk of dying from pneumonia in Bihar is far greater than a child in Tamil Nadu. In India there are great disparities in access to life-saving interventions –from prevention measures, like vaccines, to care management and treatment. Barriers to preventive and treatment measures turn pneumonia from a common, preventable or treatable childhood illness into a death sentence.

An annual report published by the International Vaccine Access Center (IVAC) at Johns Hopkins Bloomberg School of Public Health begins to examine disparities by adding to its analysis this year a look at the sub-national coverage indicators for two of the countries with the highest burden of child mortality, India and Nigeria. The “Pneumonia and Diarrhea Progress Report” published annually on World Pneumonia Day, documents the progress of the 15 highest-burden countries by calculating a score based on an average of coverage of child health interventions suggested in the WHO/UNICEF Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD). Pneumonia and diarrhea are the two leading infectious killers of children and can be addressed with many of the same interventions, which is why they are integrated in GAPPD.

The subnational results for India, while limited by availability of data, start to tell a story of stark contrasts between states. In the top performing state, Goa. the GAPPD score (66%) was nearly double the score of Meghalaya (38%), the lowest performing state. Several high mortality states did not have sufficient data to be included and probably would have fared even worse. In addition, eight states showed large disparities between urban and rural populations, with differences of more than 20% for at least one of the GAPPD interventions. These inequities are concerning because, as the report demonstrates, states with lower overall GAPPD scores tend to have higher rates of under-five mortality. We also know that if you look more deeply into one state, for example on a district or block level, you find even greater inequities which are often masked by average data. Unfortunately, many Indian children simply do not have a fair chance at a healthy life because of the conditions into which they were born: poverty, malnutrition, illness, and lack of access to preventive and therapeutic measures.

The good news, however, is that immunization has the potential to address some of these health inequities. With vaccination, every child can have protection from debilitating and fatal illnesses, no matter where they live or how much money their families have. Vaccines not only keep children from getting sick but protect the community by reducing the circulation of disease. Hib vaccine, preventing the second-most leading cause of bacterial pneumonia, has been approved for use in the UIP and rolled-out in 11 states in India.Pneumococcal vaccination (PCV) is licensed, available in the private market in India, and recommended by the Indian Academy of Pediatrics (IAP). Pneumococcal vaccine is highly recommended by the World Health Organization (WHO) and its global use has demonstrated its impact on reducing pneumonia, not only in vaccinated children but in the community, including unvaccinated individuals such as the elderly. Unfortunately, because of cost and access, this vaccine is not available to the majority of children in India. India has also proven its ability to reach every child through the polio eradication effort. With catch-up campaigns and creative tactics, vaccinators were able to reach even the hardest-to-reach children with multiple doses of the vaccine and eradicate the disease. Now it is time to increase the political and societal will, motivation and action to reduce pneumonia and diarrhea. National access to Hib and PCV vaccines is a crucial component in the battle to prevent illness and death from childhood pneumonia.

The immunization programme in India is designed and can be amplified for scale and reach. The IVAC report notes India’s challenges with increasing immunization coverage, as measured by coverage of three doses of diphtheria-tetanus-pertussis vaccine and of measles vaccine; however, when compared to some of the other interventions like exclusive breastfeeding for six months or use of oral rehydration solution (ORS) for diarrhea, one can see that immunization actually is reaching more children.

Prevention is essential to interrupt the vicious cycle of ill health and poverty. Behind every child sick with pneumonia are parents and care givers who take off work. Lost wages, not to mention hefty healthcare bills, can push families further into poverty. And every illness sets the child back, making their immune system weaker, slowing their development, and keeping them from attending school and achieving their potential. An investment to protect every child from pneumonia is an investment in India’s future and social justice.

With the momentum of polio eradication, new commitment from the government to introduce three new childhood vaccines into the UIP, and renewed efforts around increased use of ORS and improved access to sanitation, India is well placed to significantly reduce deaths from pneumonia, diarrhea, and other childhood diseases. We encourage India not to let this momentum slip by, but to move quickly now to scale up these interventions to protect its children. Hopefully, as the Mars Orbiter Mission continues exploring the planet next door, next year’s progress report will see India improving its pneumonia and diarrhea prevention scores, reflecting that more children will have a chance at a healthy and productive life here on earth.

Andrea Sutherland MD, MSc, MPH works at the International Vaccine Access Center and is on faculty at the Johns Hopkins Bloomberg School of Public Health.  The team at IVAC contributed to the authorship of this article.