21 May What do the new Global Burden of Disease estimates tell us about childhood pneumonia deaths?
For the first time since global child mortality statistics have been collected, the end of child pneumonia deaths is in sight. New estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) show that the number of children dying from pneumonia dropped sharply from 693,000 in 2019 to 502,000 in 2021, the lowest number ever recorded. This 28% reduction over three years is due to the impact of COVID-19 restrictions and underscores the lifesaving power of preventing the spread of infection.
Sustaining this momentum will require a razor focus on increasing coverage of existing pneumonia-fighting vaccines (i.e., pneumococcal conjugate vaccine/PCV, Hib, measles, and pertussis), accelerating development of new vaccines (i.e., Respiratory syncytial virus, Group B streptococcus, and Klebsiella pneumoniae), and improving diagnosis and treatment for the major, non-vaccine preventable causes of childhood pneumonia death (i.e., Staphylococcus aureus). If this rate of pneumonia mortality reduction continues, the achievement of global child pneumonia target of three pneumonia deaths for every 1,000 births is within reach for all countries.
Childhood pneumonia episodes have declined significantly
In 2021, there were seven million fewer episodes of childhood pneumonia compared to 2019. This 16% drop from 45 to 38 million episodes was the result of pandemic infection control measures, including stay-at-home orders, school and community closures, and face mask requirements. Although all regions experienced significant declines in the spread of pneumonia infections, children in higher income countries benefited more, with pneumonia episodes dropping by one-third (Table 1). In contrast, Sub-Saharan Africa and South Asia experienced much lower declines – 12% and 9% respectively. As these are the regions where child pneumonia deaths concentrate, achieving higher rates of reduction would have caused child pneumonia deaths to fall even further.
Lowest recorded pneumonia deaths among children
In 2021, there were almost 200,000 fewer childhood pneumonia deaths compared to 2019. This 28% drop from 693,000 to 502,000 deaths is the largest reduction recorded by the GBD since 1990. Although all regions experienced significant declines in deaths, children in high income countries benefited much more, with pneumonia deaths almost halving (Table 2). In contrast, Sub-Saharan Africa experienced much lower decline (22%), along with South-east Asia, East Asia, and Oceania (28%). It is worth noting that South Asia performed much better at ensuring that declines in child pneumonia episodes flowed through into mortality declines.
Five pathogens cause 60% of child pneumonia deaths
Five pathogens were responsible for 60% of child pneumonia deaths in 2021 – Streptococcus pneumoniae (28%), Staphylococcus aureus (10%), Klebsiella pneumoniae (9%), Respiratory syncytial virus (6%), and Influenza (5%). Three of these are currently vaccine-preventable with pneumococcal conjugate vaccines, RSV, and influenza vaccines, while a vaccine for Klebsiella pneumoniae is in development (Table 3).
While PCV coverage remains relatively low at 60%, influenza vaccine coverage is not routinely measured, and RSV vaccines and a new long-acting monoclonal antibodies (mAb) injection for pregnant women to protect their infants have only just been approved in Europe and the USA. The authors note that mAbs are currently too costly for use in most LMICs and cost-effectiveness will depend on multiple factors, especially pricing.
Critically, Staphylococcus aureus is not vaccine-preventable and has higher rates of poor clinical outcomes, including sepsis and death, compared to Streptococcus pneumoniae, and the ability to develop resistance to multiple antibiotics.
It is now possible to end child pneumonia deaths
What does the new GBD tell us about how to achieve the end goal – the near elimination of child pneumonia deaths in every country by 2030? First it gives cause for optimism. Prevention works. If the spread of the major pathogens causing pneumonia can be reduced by infection control measures like vaccination, major reductions in child deaths are possible. A key priority for pneumonia control in the next seven years must be to achieve full coverage (>90%) of the PCV vaccine, especially in every country in Sub-Saharan Africa and South Asia.
A second priority is to accelerate introduction of affordable RSV vaccines and MAbs in the same regions. Countries should be able to make real choices about the best way to reduce RSV infections – maternal vaccination or infant injection with MAbs. A third priority on seasonal childhood influenza vaccine coverage is also warranted, elevating it to the status of other routine vaccines including measles and Diphtheria, Tetanus, and Pertussis (DTP) ands regularly reporting national, regional, and global coverage rates. And fourth, rapid research to develop a Klebsiella pneumoniae vaccine.
Vaccines alone cannot end childhood pneumonia, so improvements in diagnosis and treatment with antibiotics, medical oxygen, and respiratory therapies have a strong role to play. This is especially so for leading bacterial killers like Staphylococcus aureus, which is not vaccine-preventable and increasingly resistant to antibiotics. A fifth priority is to develop new, low-cost, less-resistant antibiotics.
And finally, as the authors note, of all underlying conditions childhood wasting is a factor in the most child pneumonia deaths – more than half. There needs to be integration of wasting prevention, diagnosis, and treatment interventions in all aspects of pneumonia control – in the home, at the point of vaccination, and when sick children are brought to health facilities and admitted to, and discharged from, hospitals. In reality, this won’t happen unless Ministries of Health institutionalize it and global health donors demand it of Gavi, the Vaccine Alliance.
Implementing the agenda just outlined in the 30 countries* that are home to 90% of child pneumonia deaths is our best collective bet of ending child pneumonia deaths by 2030. This is in line with the call for a new Child Survival Action agenda that brings the most cost-effective interventions to fight the leading causes of death among children at greatest risk of death.
We call on Ministries of Health in the 30 highest burden child pneumonia countries to join forces with global health agencies, including the World Health Organization, UNICEF, USAID, The Global Fund, Gavi, The Global Financing Facility, and their donors to achieve a child survival milestone that has always eluded humanity – the end of childhood pneumonia deaths.
*Nigeria, India, Pakistan, Chad, Ethiopia, Niger, Somalia, Burkina Faso, Democratic Republic of Congo, Indonesia, Tanzania, Madagascar, Bangladesh, South Sudan, China, Cameroon, Côte d’Ivoire, Myanmar, Mali, Egypt, Philippines, Afghanistan, Guinea, Uganda, Angola, Mozambique, Zimbabwe, Kenya, South Africa, and Malawi.
May 2024