The disgraceful neglect of childhood pneumonia

Lancet Global Health
Dec 2018 Volume 6 Number 12 e1253-e1404

The disgraceful neglect of childhood pneumonia
The Lancet Global Health

This week WHO held its first ever Global Conference on Air Pollution and Health and published an associated report, Prescribing clean air, which summarised the “uniquely damaging” effects of breathing polluted air on the health of children. The evidence in this age group is compelling: some of the stark headline figures include the fact that 93% of children younger than 5 years globally live in environments where levels of fine particulate matter (PM2.5) exceed the WHO guidelines and that air pollution, both ambient and household, contributed to more than half a million deaths from lower respiratory tract infections in children under 5 years in 2016.

Lower respiratory tract infections, by which we usually mean pneumonia, are the second leading cause of death in under-5s worldwide, and the leading cause in Africa. Air pollution is just one of many poverty-linked risk factors, others being undernutrition, poor hygiene, limited or no breastfeeding, and lack of access to vaccines. In turn, death rates in those who succumb to infection are much higher in impoverished regions than in higher-income ones owing to slow care seeking (stemming from poor health education or geographical or financial barriers to care), diagnostic failure, and inappropriate treatment.

The WHO report recognises that the issue of air pollution, particularly ambient air pollution, is largely a high-level issue for governments and regions, and its recommendations for health professionals centre around awareness-raising, research, advocacy, and prescribing of household-level solutions (such as switching to cleaner fuels, where possible). But what about the other, potentially more tractable, risk factors and system failures that contribute to pneumonia’s standing as a barely surpassed killer of children?

A simple search of this journal’s website reveals a healthy number of research and opinion pieces that combine the topic of pneumonia with those of breastfeeding (28 articles in 5 years), nutrition (11 articles), and WASH (water, sanitation, and hygiene; 5 articles). Similarly, in this journal alone, pneumonia vaccination, diagnosis, and treatment have all received recent attention. In this month’s issue, for example, Eileen Dunne and colleagues report positive effects of the roll-out of 10-valent pneumococcal conjugate vaccine (PCV) on direct and indirect carriage of Streptococcus pneumoniae in Fiji, and Keith Klugman and colleagues highlight the potential for PCV to reduce the burden of mortality from S pneumoniae–influenza co-infection. January also saw the publication of Ambrose Agweyu and colleagues’ important paper on the appropriateness (or not) of WHO’s updated guidance on management of childhood pneumonia.

Why, then, is there so little cross-disciplinary global solidarity around childhood pneumonia? Or, as Kevin Watkins and Devi Sridhar put it in The Lancet recently, why is it “a global cause without champions”? They point out that pneumonia does not feature in WHO’s latest Global Programme of Work and that no major donor has made the cause their own. In fact, according to the report Sizing up pneumonia research, pneumonia research received just US$84 in funding per death in 2015, compared with $336 for tuberculosis, $2120 for HIV, and $3585 for influenza. Further, pneumonia barely registers as a top child killer in the minds of the general public. A straw poll of non-medical acquaintances pointed to malaria or diarrhoea as the most likely candidates. Yes, we have the upcoming World Pneumonia Day on November 12 (the website of which remained sadly unpopulated as we went to press), and WHO released a Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) in 2013. Yet there has otherwise been relative quiet on the global and national fronts.

In trying to explain the neglect, Watkins and Sridhar point to the poverty-linked nature of pneumonia, in children particularly, and the fact that—unlike cholera, measles, or HIV—it is not easily transmitted across social boundaries into the constituencies with the most political influence. They call for all high-burden countries to adopt integrated pneumonia action plans framed around the GAPPD and for a global summit on pneumonia. We concur. A child dying of pneumonia may be more difficult to imagine than one dying from inhaling visibly polluted air, but the solutions, in large part, are much closer at hand.