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
210
178
100
21
29
-
35
42
25
48
52
33
(Per 100,000)
NMR
(Per 1000 Live Births)
IMR
(Per 1000 live Births)
U 5 Deaths
(Per 1000 Live Births)
Data Source :Global - UN Interagency estimates 2013
India : MMR ( SRS 2010-12), NMR, IMR & U5MR ( SRS 2012)
India’s progress on MDG4
Under Five Mortality Rate
58.8% decline
46.7 % decline
Year
India (millions)
World* (millions)
India’s share (%)
1990
2011
2.85
1.36
12.4
6.6
23.0
20.6
*Source: World Health statistics & United Nations
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
Progress has been Good…
But
Not Uniform
Percentage Decline in Under Five
Mortality Rate : 2009 to 2012
27.2
26
26
7.1
5
Data Source: SRS 2009 & 2012
371,860
Under Five Deaths by States in Absolute Numbers : 2012
14,977
1,63,897
Four States – UP, Bihar, MP & Rajasthan
Account for more than Half of Under 5 Deaths
INDIA (1,359,289)
Data based on SRS 2012
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
Where Do We Invest ??
Causes of Under 5 Deaths : India
• 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
Data Source : 2012 CHERG Estimates for Causes of Under 5 Deaths for Year 2010
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 childyear 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
•
•
•
•
•
India
Pakistan
Afghanistan
Nigeria
Democratic
Republic of Congo
In 2010, Five Countries Accounted for More Than 45% of Global Pneumonia Deaths
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
Prevent
Protect




Exclusive Breast
feeding for 6 mths
Adequate
complementary
feeding
Vitamin A
supplementation
Vaccines (Measles,
Treat

Improved care
seeking & referral

Case m/m at
community &
Facility level

Supplies(ORS, Zinc,
Pertussis, HIB,
Pneumococcal, Rota virus)

Hand Washing with
soap

Safe drinking water &
Sanitation


Reduce household air
pollution
HIV prevention &
Cotrimoxazole
prophylaxis
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
Prioritizing Geographies
Wide Regional Variations in Causes of under 5 Deaths
Pneumonia : 4. 7% in South India to 18 % in Central India
Lancet 2010, Million Death
Source: The Lancet 2010; 376:1853-1860 (DOI:10.1016/S0140-6736(10)61461-4)
Study
State Averages Mask Wide Intra State Disparities
( Annual Health Survey 2011-12 )
DISTRICTS WITH
MINIMUM U5MR
DURG (49)
CHATTISGARH (55)
PURBI SINGHBHUM(35)
JHARKHAND (50)
BIHAR (57)
PATNA (50)
ASSAM (75)
RANGE
47
51
KOTA (44)
52
PITHORAGARH (23)
M.P ( 73)
INDORE (48)
PASCHIMI SINGHBHUM
(86)
SITAMARHI (101)
52
UTTARAKHAND (68)
SURGUJA (96)
51
DHEMAJI (48)
RAJASTHAN (59)
DISTRICTS WITH
MAXIMUM U5MR
61
KOKRAHJAR
(100)
BANSWARA (96)
HARIDWAR (84)
PANNA (133)
85
U.P (68)
ODISHA (68)
KANPUR NAGAR
(50)
85
BALESHWAR (53)
89
SHRAWASTI
(135)
KANDHAMAL
(142)
184 High
Priority
Districts
across 28
States
Jammu & Kashmir
Himachal Pradesh
Punjab
Chandigarh
Uttarakhand
Haryana
Delhi
Arunachal Pradesh
Sikkim
Assam
Rajasthan
Uttar Pradesh
Bihar
Nagaland
Meghalaya
Manipur
Tripura
Jharkhand
Gujarat
West Bengal
Madhya Pradesh
Mizoram
Chhattisgarh
Daman and Diu
Dadra and Nagar Haveli
Orissa
Maharashtra
Andhra Pradesh
Goa
Karnataka
Puducherry
Tamil Nadu
Lakshadweep
Kerala
UNICEF High priority
districts
Other partners HPD
•
•
•
•
•
Rural and Urban Poor
Tribal & Minority groups
Hard to Reach Areas
Harmonised technical
assistance
by DPs
Andaman & Nicobar Islands
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
b
The
question is
not , if India can
afford to do it…
The question is
can India afford
not to do it…
Thanks