THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 4, NO.4 157

Pneumonia and Child Mortality in India

•As public health improves in the developing countries and other infections arebetter controlled, it can be expected that the respiratory infections will emergefrom their present obscurity." This prophecy by Monto and Johnson came true in1978 with the publication of a relatively minor study conducted in Narangwal-arural area in Punjab." The study showed that mortality from pneumonia in ruralchildren was high (and could be reduced).

Worldwide, pneumonia accounts for more than 25% of deaths in children below5 years (about 4 million deaths per year); two-thirds of these occur in infancy andmore than 90% in developing countries.' Although the incidence of upper respira-tory tract infections in children is similar in both the developed and developingworld, the mortality from lower respiratory tract infections is about 30 timesgreater in developing countries. Hence, attention needs to be focused on the mainkiller, i.e. pneumonia.

What is the magnitude of the problem in India? Any guess is hazardous in theabsence of complete reporting and an agreed definition. However, data from somemeticulously conducted cohort studies in rural areas'" reveal that each year about10% to 13% of children contract pneumonia, around 13% being the case-fatalityrate. Similarly, pneumonia is the primary or an associated cause in 20% to 40% ofchildhood deaths. The pneumonia-specific mortality rate is 16 per 1000 children."?Assuming the proportion of children below five years to be 12% of the nationalpopulation, we reach a staggering estimate of 10 to 13 million attacks of childhoodpneumonia each year, and 1 to 1.6 million pneumonia deaths in children below 5years of age.

Prematurity, low birth weight, failure to breast feed, malnutrition, an attack ofmeasles, domestic smoke and overcrowding have been implicated as the mainpredisposing factors." Lung puncture studies from India? and other developingcountries'? have consistently implicated Streptococcus pneumoniae, Haemophilusinfluenzae and Staphylococcus aureus as the causative organisms in childhoodpneumonia providing a rational basis for treating all cases of childhood pneumoniawith antibiotics.

Based on clinical studies":" the World Health Organization has recommendedsimplified criteria for the diagnosis of pneumonia in children. These include thepresence of cough with tachypnoea (defined as respiratory rates of more than 60, 50or 40 per minute in neonates, post-neonates and toddlers respectively)." Treatmentwith procaine penicillin, oral ampicillin or co-trimoxazole has been recommended.The criteria for referral have been specified. Such case management of pneumoniaby paramedical or village health workers has been visualized to be the mainstay ofthe national acute respiratory infections control programmes.

Will this strategy work? A field trial in Gadchiroli district, Maharashtra-an areawith a population of 80 OOO--has recently provided strong evidence in its support."Extensive health education of parents to suspect pneumonia in their children andseek care, training of multipurpose health workers of primary health centres,village health workers and traditional birth attendants to diagnose and treatpneumonia with co-trimoxazole syrup were the main community-based interven-tions. In one year 612 cases of pneumonia were treated by these trained workerswith a case-fatality rate of less than 1%. Without active case detection efforts, 76%of the cases of pneumonia in the area were covered by the programme with a resul-tant 30% decline in infant and under-five mortality and a 54% decline in thepneumonia mortality. The service became so popular that even rural medicalpractitioners started referring cases of childhood pneumonia to the village healthworkers and traditional birth attendants. The cost of the medicines was approxi-mately Rs 4.5 per case treated or Rs 45 per death averted.

The gains of such a programme are four-fold-increased child survival, reducedmorbidity, decrease in the use of irrational medicines for ordinary coughs or colds,

158 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 4, NO.4

and enhanced credibility of the health workers. This programme has the potentialfor saving the lives of more than one million children each year in India alone, andis therefore a major step towards the child survival revolution.

Many issues are still unresolved. Neonatal pneumonia remains difficult totackle. Overuse of antibiotics, emergence of antibiotic resistance and the phenome-non of so-called replacement mortality" need close monitoring. A major organiza-tional reorientation will be required to scale up this approach from a pilot project tothe national level and to integrate it into the current activities of the primary healthcentres.

Other approaches to reduce the incidence or severity of pneumonia will have tobe simultaneously pursued. Important among these are immunization especiallyagainst measles, safe delivery and neonatal care including promotion of breastfeeding, improving child nutrition and, finally, reducing overcrowding and domes-tic smoke.

There is little doubt that the control of childhood pneumonia with community-based case management will be a major component of the primary health carestrategy of this decade.

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diarrhoea and pneumonia. Trap Doct 1978;8:220-5.3 Leowski J. Mortality from acute respiratory infections in children under 5 years of age: Global

estimates. World Health Stat Q 1986;39: 138-44.4 Kielmann AA. Child and Maternal Health Services in Rural India: The Narangwal Experiment. Vol

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nutrition and infections: II. Morbidity and mortality and effects. Indian J Med Res 1978;68(suppl):2 1-4 I.

6 Bang AT. Bang RA. Tale O. et al. Reduction in pneumonia mortality and total childhood mortality bymeans of community-based intervention trial in Gadchiroli, India. Lancet 1990;336:201-6.

7 Kumar V. Dutta N. Community based studies on infant mortality in Haryana: Methodological issuesrelating to reporting and causation. In: Jain AK. Visaria P (eds.) Infant mortality in India:Differentials and determinants. New Delhi:Sage Publications. 1988: 185-99.

8 Anonymous. Causes of ARI:Many unanswered questions. ARI News April 1986;4: 1-3.9 Kalra SK. Sasidharan T. Vatwani V. Sarkar P. Lung puncture: A diagnostic aid in childhood

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14 The Kasongo Project Team. Influence of measles vaccination on survival pattern of 7 to 35-month-old children in Kasongo, Zaire. Lancet 1981;1:764-7.

ABHA Y T. BANGSEARCH

Gadchiroli 442605Maharashtra

India