Pneumonia, killer of children

Pneumonia is killing children in their millions, but healthcare professionals say it’s a killer that is often "forgotten".

The Global Coalition Against Pneumonia comprises over 50 organisations, including international NGO’s, faith-based groups, academic and medical institutions, professional societies, charitable and advocacy groups. The non-profit organisation is creating awareness around pneumonia by encouraging participation in World Pneumonia Day on 2 November 2009.

Your contribution, says Prof Shabir Madhi, Professor of Vaccinology, University of the Witwatersrand, is easy: "We are appealing to all South Africans to wear blue jeans on the Monday 2 November to mark World Pneumonia Day as a call to action to reduce childhood mortality." The simple "donning of denim" can make an impact in highlighting the plight of vulnerable children.

In September 2009, the World Health Organization published new data in The Lancet [1] that highlighted two leading causes of pneumonia, which claims the highest number of lives of children under age five, globally and within developing countries.

Immunisation lags behind in developing countries

According to the studies, each year Streptococcus pneumoniae and Haemophilus influenzae type b [Hib] infections take the lives of an estimated 1.2 million children under age five. Even while safe and effective vaccines exist to provide protection against both diseases, the use of Hib vaccine has only recently reached low-income countries, and pneumococcal vaccine is not yet included in national immunisation programs in the developing world.

Data from the study show that in 2000, there were an estimated 14.5 million cases of pneumococcal disease worldwide and 826,000 children under the age of five died from the disease. Of the 14.5 million pneumococcal cases, 95% were attributable to pneumonia.

It is in developing countries that children bear the highest risk for pneumonia and prevention efforts are urgently required. The study's authors say that the need for vaccination and enhanced treatment is particularly urgent in Africa and Asia, which together account for 95% of all pneumococcal deaths.

World Pneumonia Day highlights need for action
As countries around the globe consider decisions to include life-saving pneumococcal vaccines in their national immunisation programs, World Pneumonia Day provides the perfect opportunity to demonstrate demand for this safe and effective prevention of one of the leading causes of pneumonia and move governments to act.

Professor Madhi says that the inclusion of vaccines into national immunisation programmes to prevent pneumonia is critical if developing countries are to achieve United Nations Millennium Development Goal 4 (MDG4) to reduce child mortality.

“The burden of pneumonia is considerable and almost entirely preventable through the use of vaccines. It is wholly possible to reduce the burden of childhood pneumonia and meningitis and, thereby, child mortality."

Professor Madhi has been involved in research on opportunistic infections in HIV-infected children and vaccine-preventable diseases for the past 13 years. "Pneumonia is a common opportunistic infection among HIV positive children globally," he says. "The pneumonia found in people with HIV is commonly known as Pneumocystis pneumonia (PCP). Pneumocystis is commonly found in the lungs of healthy people but, being a source of opportunistic infection, it can cause a lung infection in people with a weakened immune system."

What the numbers reveal
According to Professor Madhi, it is difficult to provide exact figures regarding morbidity and mortality in HIV+ children, but he says we do know the following:

  • The overall burden of pneumonia is nine-fold greater in HIV infected children
  • Although only comprising <5% of the general population, HIV infected children contribute to 35-45% of all hospitalisations for pneumonia in South Africa
  • HIV infected children are susceptible to a greater repertoire of pathogens compared to HIV uninfected children
  • Pneumococcus is the leading bacterial pathogen causing pneumonia in HIV infected and HIV uninfected children and HIV infected children have a 40-fold increased risk of developing severe invasive pneumococcal disease
  • Another major cause of pneumonia in children in Southern Africa is Mycobacterium tuberculosis, which is found in at least 8% of children hospitalised with severe pneumonia. The risk of developing pneumonia from MTB is 20-fold greater in HIV infected compared to HIV uninfected children
  • HIV infected children are more at risk of being hospitalised with pneumonia due to bacteria that are not susceptible to first line antibiotic
  • The case fatality arte from pneumonia is greater in HIV+ (approx 1-125) compared to HIV uninfected children (<25) in children hospitalised for pneumonia
  • One third of all deaths in HIV infected children result from pneumonia, even in the presence of anti-retroviral treatment
According to Pneumonia: the forgotten killer of children (UNICEF, WHO 2006 [2]) evidence from Malawi, South Africa, Thailand and Zambia show that PCP causes at least one of every four deaths among HIV-positive infants under the age of one.

Prevention is possible
WHO and UNICEF recommend cotrimoxazole prophylaxis for all HIV-positive children, as well as for infants born to HIV-infected mothers, in order to prevent them from developing pneumonia. Clinical trials in Zambia show a significant and sustained reduction in hospital admission and mortality rates among sick HIV-positive infants receiving cotrimoxazole compared to those in the placebo group.

The WHO says "despite the essential role of antibiotics in reducing child deaths from pneumonia, information about antibiotic use is limited. Results from limited data suggest that only 19 per cent of children with pneumonia received an antibiotic in the early 1990s.* In several countries, the proportion of children receiving treatment with antibiotics was less than 10 per cent, leaving 9 of every 10 children to fight the infection unassisted".

No child should die from this preventable disease, and the medical fraternity is urged to get involved and take action where possible. "In dealing with this 'forgotten killer', let us not forget that we are dealing with children who depend on us for their very lives," Professor Madhi concludes.

So . . . whether you're a CEO or a taxi driver, financial manager or florist – wear a pair of blue jeans on 2 November to show your support for World Pneumonia Day.

(SASPID – Southern African Society of Paediatric Infectious Diseases, October 2009)


[1] The Lancet, Volume 374, Issue 9693, Pages 893 - 902, 12 September 2009 doi:10.1016/S0140-6736(09)61204-6
Burden of disease caused by Streptococcus pneumoniae in children younger than 5 years: global estimates Original Text: Dr Katherine L O'Brien MD a , Lara J Wolfson PhD b, James P Watt MD c, Emily Henkle MPH a, Maria Deloria-Knoll PhD a, Natalie McCall MD a, Ellen Lee MD a, Prof Kim Mulholland MD d, Orin S Levine PhD a, Thomas Cherian MD b, for the Hib and Pneumococcal Global Burden of Disease Study Team

[2] 1. Pneumonia: The forgotten killer of children; The United Nations Children’s Fund (UNICEF)/World Health Organization (WHO), 2006. Download from

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