Pneumonia mortality among children in Brazil: a success story

EDITORIAL

Pneumonia mortality among children in Brazil: a success story

Inge Axelsson^I; Sven Arne Silfverdal^II

^IMD, PhD. Department of Pediatrics, Research and Development Unit, Östersund County Hospital, Department of Health Sciences, Mid Sweden University, Östersund, Sweden

^IIMD, PhD, MPH. Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden

The global number of deaths among children under 5 years of age was 8.8 million in 2008,¹ corresponding to 24,000 deaths per day. This figure is horrific, but fortunately decreasing. During the period 1990-2008, the under-5 mortality rate decreased 28% globally and 61% in Brazil.¹ In this issue of Jornal de Pediatria, Rodrigues et al. report that deaths from pneumonia during 1991-2007 decreased 74% for infants and 56% for children 1-4 years old in Brazil.² Thus, the total mortality and the mortality due to pneumonia have had roughly the same development in Brazil, pneumonia making up about 5% of the under-5 deaths.

Globally, pneumonia is the number 1 killer of children causing about 20% of under-5 deaths. It is the "forgotten killer of children" with more childhood deaths than HIV, malaria, and measles combined.³ In Brazil, there are 4 million cases of childhood pneumonia each year.³ However, Brazil is an upper middle income country⁴ and infectious diseases are not so dominant causes of mortality compared to low income countries.

Table 1 shows that among the five most populated countries in the world, Brazil has improved the under-5 mortality faster than any of the other countries. Systematic improvement of prevention and treatment of pneumonia has been essential for this success. Gapminder World5 is an interactive web-service displaying time series of development statistics for all countries, for some countries back to the early 1800s. By moving the time arrow, one can see that Brazil now has about the same life expectancy and under-5 mortality as the United States had in 1975 and 1972, respectively.

The decline of the mortality rate of pneumonia among children in Brazil has been slower in northern Brazil where the mortality rate of pneumonia is now double that in the south. The authors suggest that Integrated Management of Childhood Illness (IMCI),⁶ national clinical practice guidelines and vaccination against Haemophilus influenzae group b (Hib) and Streptococcus pneumoniae (pneumococci) have been important for the success and that different implementations of these tools may explain the differences between North and South.

What next? The member states of the United Nations are committed to achieve the Millennium Development Goal 4 (MDG4): to reduce the under-5 mortality rate by 2/3 by 2015, compared to 1990. The mortality rate has decreased (Table 1) but not fast enough to fulfill MDG4. Therefore, the Global Action Plan for Prevention and Control of Pneumonia (GAPP)⁷ recommends urgent implementation of key strategies for treating, preventing and protecting children from pneumonia:

- case management at all levels: hospital, health facility and community levels;

- vaccination against measles, whooping-cough, Hib and pneumococci (conjugated vaccine);

- prevention and management of HIV infection;

- improvement of nutrition and reduction of low birth weight, including promotion of exclusive breastfeeding during the first 6 months of life, and zinc supplementation;

- control of indoor air pollution;

- encouragement of hand washing.

GAPP claims that these interventions, if implemented, have the potential to reduce pneumonia mortality and morbidity by more than half. Primary health staff should use IMCI or related national guidelines for assessment and management of sick children. There are several good reports that could be used as scientific bases for national or regional clinical practice guidelines for doctors. Important findings in these papers may be summarized as follows:

- Most children with tachypnea do not have chest x-ray signs of pneumonia. Only 14% had it in a huge study in Pakistan (n = 1,932), and only 1.3% (26/1,932) had lobar consolidation.⁸ Adding fever to WHO's criteria for pneumonia (which is based solely on tachypnea) greatly improves the specificity of the criteria with only marginally lowered sensitivity, according to a recent study from São Paulo⁹.

- Most cases of mild pneumonia in high-income countries do not need antibiotics.¹⁰ This rule should probably not be used in middle or low income countries. Children with mild pneumonia have no serious symptoms or signs, are not septic (do not look "toxic") and do not have oxygen saturation below 95%.

- Streptococcus pneumonia is the most common cause of pneumonia but other bacteria or virus or a combination of bacteria and virus are also common. There is no reliable method to differentiate between bacterial and viral pneumonia. Moderate or severe pneumonia should therefore be treated with antibiotics¹⁰.

- Oral antibiotics (amoxicillin or cotrimoxazole) for 3 days are as good as intravenous antibiotics or a longer duration of medication for non-severe cases (except children who vomit).¹¹ This observation is based on trials in low income countries. Because of globally increased resistance, macrolides are not safe for pneumococcal pneumonia.¹²

Brazil has already fulfilled MDG4 but should continue the successful work, especially in the northern parts of the country where the pneumonia mortality rate among children is lagging about 8 years behind the South.²

References

• ¹
  UNICEF. The State of the World’s Children. Table 1: Basic Indicators. 2009. http://www.unicef.org/rightsite/sowc/statistics.php Acesso: 9 Jan 2011.
• 2. Rodrigues FE, Tatto RB, Vauchinski L, Leães LM, Rodrigues MM, Rodrigues VB, et al. Pneumonia mortality in Brazilian children aged 4 years and younger. J Pediatr (Rio J). 2011;87:111-114.
• 3. UNICEF. Pneumonia: the forgotten killer of children. New York: UNICEF / WHO Press; 2006. http://www.unicef.org/publications/index_35626.html Acesso: 9 Jan 2011.
• 4. The World Bank. Data: Brazil. http://data.worldbank.org/country/brazil Acesso: 9 Jan 2011.
• ⁵
  Gapminder World. http://www.gapminder.org/ Acesso: 9 Jan 2011.
  » link
• 6. World Health Organization (WHO), UNICEF. Integrated management of childhood illness. Geneva: WHO Press; 2008. http://whqlibdoc.who.int/publications/2008/9789241597289_eng.pdf Acesso: 9 Jan 2011.
• 7. World Health Organization (WHO), UNICEF. Global Action Plan for Prevention and control of Pneumonia (GAPP). Geneva: WHO Press; 2009.
• 8. Hazir T, Nisar YB, A Qazi SA, Khan SF, Raza M, Zameer S, et al. Chest radiography in children aged 2-59 months diagnosed with non-severe pneumonia as defined by World Health Organization: descriptive multicentre study in Pakistan. BMJ. 2006;333:629.
• 9. Cardoso MR, Nascimento-Carvalho CM, Ferrero F, Alves FM, Cousens SN. Adding fever to WHO criteria for diagnosing pneumonia enhances the ability to identify pneumonia cases among wheezing children. Arch Dis Child. 2011;96:58-61.
• 10. British Thoracic Society Standards of Care Committee. British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002;57 Suppl 1:i1-24.
• 11. Russell K, Robinson J, Yorke D, Axelsson I. The Cochrane Library and Treatment for Community Acquired Pneumonia in Children: An Overview of Reviews. Evid-Based Child Health. 2009;4:1149-64.
• 12. Don M, Canciani M, Korppi M. Community-acquired pneumonia in children: whats old? Whats new? Acta Pediatrica. 2010;99:1602-8.

Correspondence

Publication Dates

• Publication in this collection
  03 May 2011
• Date of issue
  Apr 2011