Global Action Plan for Prevention & Control of Pneumonia (GAPP)

AMC Pre-Tender Meeting Copenhagen, 26 August 2009

Dr Osman David Mansoor Senior Adviser EPI (New Vaccines) Programme Division UNICEF New York

Pneumonia: The Forgotten Killer of Children

http://www.unicef.org/publications/index_35626.html

15 countries account for ¾ of childhood pneumonia cases worldwide

Country millions

India 44 China Nigeria Pakistan Bangladesh Indonesia 18 7 7 6 6 Brazil Ethiopia 6 4 DRC 3 Philippines 3 Afghanistan 2 Egypt 2 Mexico 2 Sudan 2 Vietnam 2 TOTAL 113 million

NOTE: Country level estimates do not add up to the total due to rounding

Lancet Child Survival Series: Key Findings

Pneumonia

A few causes kill most children in all countries and regions

Disease Burden

About 156 million cases of pneumonia and close to 1.8 million deaths occur in under five children every year Other infectious 14%

Under 5 deaths (non neonatal) ~6.5 m

Non communicabl e 6% Injuries 6% Pneumonia 28% HIV/AIDS 3% 35% associated with malnutrition Measles 6% Malaria 11% Diarrhoea 26%

Sources: Rudan et al. Bull WHO 2008; 86:408-16 WHO Global Burden of Disease 2004

Global distribution of under-five deaths by cause (2000-2003)

Source – State of the world’s children 2008, UNICEF

Total Number of Under 5 Deaths: 10.4m

Source: WHO: The Global Burden of Disease : 2004 Update

Neonatal pneumonia/sepsis is estimated to cause 26% of all neonatal death

Diseases preventable with current vaccines account for 25% of annual mortality in children under five (data from 2002).

Leading causes of vaccine preventable child deaths

800,000 600,000 400,000 200,000 P ne um o.

R ot av iru s H ib P er tu ss is M ea sl es NT

Status of Global PCV Introduction, 2008

Source: WHO/ IVB Database as of 10 February 2009 – Provisional data

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2009. All rights reserved In routine immunization schedule in 2008 ( 29 countries 15 %) In routine immunization schedule in 2008 for risk groups ( 13 countries 7 %) In Routine Immunization Schedule in 2008 Part of the Country – 1 countries (1%) Planning to introduce from 2009 ( 9 countries or 5%) Worldwide progress in introducing pneumococcal conjugate vaccine – Worldwide, 2000-2008. MMWR Morb Mortal Wkly Rep. 2008 Oct 24;57(42):1148-51 & Wkly Epidemiol Rec 2008;83(43):388-92.

GAVI support approvals

Global Immunisation Meeting New York, February 2009

10

Management of Pneumonia

http://www.unicef.org/publications/index_21431.html

http://www.who.int/child-adolescent-health/publications/CHILD_HEALTH/JS_Pneumonia.htm

• Advocates for community-level treatment by well-trained and supervised health-care workers.

• Describes the barriers preventing access and provides examples of effective large-scale and sustainable community-level treatment.

Need to establish multi pronged approach

No single approach will fully address the problem of pneumonia; it requires: • Prevention: vaccination (Pertussis, Measles, Hib and PCV) • Case management (community and facility) • Risk factor modification: environmental pollution, breastfeeding & nutrition etc.

Implementation at scale of a package of interventions including Hib and PCV, case management and nutritional interventions could reduce overall child mortality by up to 20% and be highly cost-effective (Niessen L et al - unpublished)

GAPP Vision & Goals

“That every child is protected against pneumonia through a healthy environment, and has access to preventive and treatment measures.” • Reduce mortality from pneumonia in children less than 5 years of age by 50% by 2015 compared to 2000 levels; • Reduce the incidence of severe pneumonia by 25% in children less than 5 years of age by 2015 compared to 2000 levels.

GAPP strategies

Case-management • antibiotics, oxygen, supportive care Improved nutrition • breastfeeding, micronutrients, improved feeding Risk factor reduction • indoor air pollution, hand washing, HIV prevention Immunizations • Hib, PCV , Measles, Pertussis

GAPP Targets

Case-management • • 90% access to appropriate case management 80% of children with difficult or fast breathing are taken to an appropriate health provider [C4D] Improved nutrition • 90% coverage of exclusive breastfeeding Risk factor reduction • No target Immunizations (GIVS targets) • 90% coverage of each vaccine 80% coverage in every district

PROTECT FRAMEWORK FOR PNEUMONIA CONTROL

Exclusive breastfeeding Adequate nutrition Reduce low birth weight Reduce Indoor air pollution Hand washing

PREVENT

Vaccination PMTCT Cotrimoxazole prophylaxis Zinc supplementation

REDUCE PNEUMONIA MORTALITY TREAT

Case management in community, health centres and hospitals

Proportion of Children <5 with Suspected Pneumonia Taken to Appropriate Health Provider

Only 1 in 5 caregivers know the ‘danger signs’ of pneumonia – cough and fast or difficult breathing

Source:

DHS, MICS & other national surveys

Patterns of pneumonia risk

Patterns of pneumonia mortality risk may vary in different settings: •Economic poverty - wealth quintiles •Distance from a health facility geography •Other factors •Ethnicity •Gender (in some settings) Ability to deliver immunization through outreach & community case management near the home is the central argument for their primary role in pneumonia control 35 30 25 20 15 10 5 0 urban periurban rural rural

Pneumonia mortality in highland PNG by distance from a health facility

30 20 10 0 70 60 50 40 100 90 80 distance IMR pneumonia mortality

Source: Mulholland et al. Bull WHO 2008

And poorest have least access

Bangladesh: Equity in Pneumonia Interventions

Between poorest and wealthiest quintiles

Excl BF 0-5 mos Measles vaccine Full vaccine coverage Vit A supp (within last 6 mos) Handwashing Careseeking behavior Amoxicillin for pneumonia 0 Source: MICS 3, 2006 10 20 30 40 50 60 Coverage (%) of interventions 70 80 90 100

Global Action Plan for the Prevention and control of Pneumonia (GAPP)

OBJECTIVES: To accelerate pneumonia control through scaling up the delivery of interventions of proven benefit in the context of newborn and child survival strategies in countries To identify and implement a set of priority activities within each area of work in reducing pneumonia mortality To develop an approach towards monitoring , documenting and evaluating the impact of the action plan

The process

Consultative meeting held in March 2007 • Technical consensus on the key interventions for prevention & control of pneumonia Publication of reviews on epidemiology and on potential interventions for control • Documentation of the evidence base Stakeholder's meeting in 2008 • Broader consensus on priority interventions and strategies Country implementation needed

Joint implementation of the interventions: win-win situation

Scale up delivery of selected interventions through existing programmes • EPI, IMCI, Safe Motherhood, Child Nutrition, HIV prevention, Environmental Health Create synergies between the different programmes to maximize the benefit and create efficiencies: • Joint planning, review and revisions of policies and strategies • • Joint advocacy and social mobilization Harmonize processes for procurement & stock management of supplies and for logistics • Develop synergies in processes for monitoring & evaluation

Communication (C4D): Key behaviours

EPI has protected our country’s children against serious diseases for many years. Now, when you fully immunize your child they will also be protected against the main causes of pneumonia; but you still need to know and respond to the danger signs of pneumonia in your child as nt all cases caneb prevented.

• Parent takes child to health facility/vaccination site for all scheduled immunization episodes, on time.

• Mothers breastfeed early and exclusively until the age of six months • Caregivers wash their own hands as well as their child’s at the four critical times • Caregivers seek immediate medical attention if a child exhibits the danger signs • Caregivers keep children away from smoke as far as possible • For HIV exposed children, caregivers give their child cotrimoxazole prophylaxis • Vaccinators explain that the vaccines will only prevent a proportion of cases and therefore there is also a need for other key behaviours and knowledge for care seeking.

Vaccine as part of package

Rotavirus vaccines Zinc treatment Enhanced Diarrheal Disease Control

Challenge to use new vaccine introduction to enhance other aspect

Sanitation/ hygiene Oral rehydration therapy/ breastfeeding http://www.eddcontrol.org/

Trends in Global Under 5 Mortality,

20

1960-2007

10 8 6 4 2 0 18 16 14 12 1960 1970 1980 1990 2000 2007 2015