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

Progress has been Good…

But

Not Uniform

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

Where Do We Invest ??

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

Prioritizing Geographies

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

b The question is

not , if India can

afford to do it…

The question is

can India afford

not to do it…

Thanks