Addressing Pneumonia Burden in India Dr. Rakesh Kumar, JS (RCH) MoHFW – GoI
India’s Contribution to Global Burden
Extreme Poor : People living on < 1.25 USD / Day ( World Bank report 2010)
India's Contribution to Global Burden
Mortality Global India
Neonatal Deaths 2.85 Million 758,000
Infant Deaths 4.8 Million 1.1 Million
Under 5 Deaths 6.6 Million 1. 36 million
Pneumonia Deaths
( Children )
1.1 Million 388,000
Source : SRS 2012, Lancet Pneumonia series 2013 & UN Interagency estimates 2013
Current Indicators and 12th Plan Target
Indicator Current
Global
Current
India
12th Plan
Target
MMR(Per 100,000)
210 178 100
NMR(Per 1000 Live Births)
21 29 -
IMR(Per 1000 live Births)
35 42 25
U 5 Deaths(Per 1000 Live Births)
48 52 33
Data Source :Global - UN Interagency estimates 2013
India : MMR ( SRS 2010-12), NMR, IMR & U5MR ( SRS 2012)
Year India (millions) World* (millions) India’s share (%)
1990 2.85 12.4 23.0
2011 1.36 6.6 20.6
*Source: World Health statistics & United Nations
Under Five Mortality Rate
58.8% decline
46.7 % decline
India’s progress on MDG4
Recent Progress has been Good
India’s contribution to global burden is reducing :
Maternal deaths reduced from 19% to 16%
Neonatal deaths reduced from 30% to 28%
Under 5 deaths reduced from 24 to 22%
21% decline in Early neonatal mortality between 2007-12
NRHM brought focus as well as resources for health
RMNCH+A is the strategic framework for Call to Action
Knowledge and money is there but need to translate it
into results on ground
Data Source: UN IGME 2013,& SRS 2007-11
Policy Environment is Also Supportive …
Increased allocations for health sector under 12th plan (1.87 % of GDP
against expenditure of 1.04% at end of 11th plan)
National Health Mission-NRHM & NUHM
Harmonization of Partner’s support in HPDs
RKSK has brought focus and resources for Adolescents
Recent Policy decisions for high impact interventions for newborn survival
Antenatal Steroids for premature labor
Vitamin K for New born
Kangaroo mother care
Injection Gentamycin by ANM
Phased roll-out of HIB containing Pentavalent Vaccine
Currently 8 states,
11 more by October 2014
Nation wide by April 2015
Percentage Decline in Under Five
Mortality Rate : 2009 to 2012
27.226 26
5
Data Source: SRS 2009 & 2012
7.1
Under Five Deaths by States in Absolute Numbers : 2012
37
1,8
60
1,6
3,8
97
INDIA (1,359,289)
14
,97
7
Data based on SRS 2012
Four States – UP, Bihar, MP & Rajasthan
Account for more than Half of Under 5 Deaths
India’s Roadmap For Accelerating the
progress…
Investments need to match the Disease Burden
Prioritizing Geographies
Reaching those who are often Left out
Continuum of Care ensuring Quality :
Across Life stages
Service delivery platforms with equal focus on community & Hospitals
Need to Expand the Depth and Breadth of Effective Coverage
Causes of Under 5 Deaths : India
Data Source : 2012 CHERG Estimates for Causes of Under 5 Deaths for Year 2010
• Neonatal causes
account for 52% of
under 5 deaths.
• Pneumonia (15%) and
Diarrhea (12%) major
killers after 1st month
• Malnutrition underlying
factor in 35% of deaths
• Infections continue to
be a major killer
80% of Under 5 Deaths are caused by Neonatal causes, Pneumonia & Diarrhea
Pneumonia and Diarrhea : Forgotten Killers
Globally Pneumonia and Diarrhea accounted for 1.7 million
child deaths in 2012
Many of the Risk factors are common :
Absence of Exclusive Breast Feeding in 0 – 6 months :
(15 times higher risk of Pneumonia mortality in non exclusive BF)
Under nutrition (8.7 times more risk of pneumonia in wasted children)
Zinc deficiency
Failure to immunize ( Measles, HIB and Pneumococcal vaccine)
Lack of Hand washing with soap
Overcrowding and poor hygiene
Addressing These Will Have Dual Benefit
Pneumonia Burden : Global (0- 4 years Age)
1.1 Million child deaths each year.
81% of pneumonia deaths occur in first two years of life
120 Million episodes of Pneumonia each year
Incidence reduced from 0.29 to 0.19 episodes per child-
year between 1990 to 2011
Case Fatality in severe pneumonia – 8.9%
Pneumococcus is responsible for 18% of severe
pneumonia and 33% of childhood pneumonia deaths
Five countries with the largest burden of
Pneumonia deaths
In 2010, Five Countries Accounted for More Than 45% of Global Pneumonia Deaths
• India
• Pakistan
• Afghanistan
• Nigeria
• Democratic
Republic of Congo
Liu, et al. 2012 Lancet 379:2151-61
Pneumonia Burden : India ( 0- 4 years Age)
388,000 deaths each year, highest in the world.
Pneumonia contributes 23% of total under five deaths in
India (In First month - 8%, One month to 5 Years - 15%)
35 Million episodes of Pneumonia each year of which 4
million are severe pneumonia.
0.28 episodes of Pneumonia per child- year
18.8% children in 0-2 years of age had Acute Respiratory
Infection in previous two weeks. (CES 2009)
Reducing Pneumonia Deaths : Key Interventions
Exclusive Breast Feeding in 0 - 6 months age group
Immunization ( Measles, HIB and Pneumococcal vaccine)
Adequate nutrition and complementary feeding
Improved quality of fuel for cooking to reduce air pollution
Solid fuel increases pneumonia incidence by 80%
Improved Care Seeking
Appropriate Case management at all levels
Community case m/m can reduce pneumonia deaths by 32%
Oxygen (35% reduction in pneumonia mortality)
Antibiotics ( Oral and Injectable)
Integrated Approach for Pneumonia & Diarrhea
Protect
Exclusive Breast
feeding for 6 mths
Adequate
complementary
feeding
Vitamin A
supplementation
Prevent Vaccines (Measles,
Pertussis, HIB,
Pneumococcal, Rota virus)
Hand Washing with
soap
Safe drinking water &
Sanitation
Reduce household air
pollution
HIV prevention &
Cotrimoxazole
prophylaxis
Treat Improved care
seeking & referral
Case m/m at
community &
Facility level
Supplies(ORS, Zinc,
Antibiotics, Oxygen)
Continued feeding
including Breast
Feeding
GAPPD : Integrated Global Action Plan for Pneumonia and Diarrhea
Ending All Preventable Deaths from Pneumonia & Diarrhea by 2025
Source: The Lancet 2010; 376:1853-1860 (DOI:10.1016/S0140-6736(10)61461-4)
Wide Regional Variations in Causes of under 5 Deaths
Pneumonia : 4. 7% in South India to 18 % in Central India
Lancet 2010, Million Death Study
DISTRICTS WITH
MINIMUM U5MR
DISTRICTS WITH
MAXIMUM U5MRRANGE
State Averages Mask Wide Intra State Disparities( Annual Health Survey 2011-12 )
ASSAM (75) DHEMAJI (48) KOKRAHJAR
(100)52
BIHAR (57)51
PATNA (50) SITAMARHI (101)
RAJASTHAN (59)52
KOTA (44) BANSWARA (96)
JHARKHAND (50)51
PURBI SINGHBHUM(35) PASCHIMI SINGHBHUM (86)
UTTARAKHAND (68)61
PITHORAGARH (23) HARIDWAR (84)
ODISHA (68)89
BALESHWAR (53) KANDHAMAL
(142)
M.P ( 73)85
INDORE (48) PANNA (133)
U.P (68)85
KANPUR NAGAR
(50)SHRAWASTI
(135)
CHATTISGARH (55) 47
DURG (49) SURGUJA (96)
184 High
Priority
Districts
across 28
StatesRajasthan
Tripura
Mizoram
Manipur
Nagaland
Arunachal Pradesh
Sikkim
Jammu & Kashmir
Uttar Pradesh
West Bengal
DelhiHaryana
Uttarakhand
ChandigarhPunjab
Himachal Pradesh
Bihar
Dadra and Nagar Haveli
Puducherry
Tamil Nadu
KeralaLakshadweep
Goa
Karnataka
Meghalaya
Maharashtra
Assam
Daman and Diu
Gujarat Madhya Pradesh
Chhattisgarh
Orissa
Jharkhand
Andaman & Nicobar Islands
Andhra Pradesh
UNICEF High priority districts
Other partners HPD
• Rural and Urban Poor
• Tribal & Minority groups
• Hard to Reach Areas
• Harmonised technical
assistance by DPs
• 5x5 high impact interventions
Critical Gaps in Addressing Pneumonia Deaths
Capacity of Health Workers
Early Diagnosis
Appropriate case management
Timely Referral
Access barriers to treatment and care
Cost (HIB & Pneumococcal vaccine) & need for more effective vaccine
Irregular supply of essential commodities (Antibiotics and Oxygen)
Less focus of Policy makers and planners on forgotten killers
Failure to convert policy into action plan and coverage on ground
Interventions Often Fail to Reach Those Who Need Them the Most
Initiatives In India for Reducing Pneumonia Burden
Improving capacity of Health Workers
Home visits by ASHA ( HBNC)
IMNCI for community case management & referrals by ANM
FIMNCI for improved management at Facility (Medical officers / Staff Nurse)
Improving Access to Care :
Free transport and Free treatment under JSSK till one year of age
Injection Gentamycin by ANM in community for those who refuse referral
Improving Immunization coverage and covering more diseases
Measles SIA and Measles second dose in RI schedule
Phased roll-out of Pentavalent vaccine
Improved Availability of Essential Commodities
Oxygen & Antibiotics part of essential commodities being monitored under RMNCH+A
Technical Guidelines For Pneumonia Management are under Finalization