A new imperative for global pneumonia control: a commentary.

Some 25 years ago an important advance enabled substantial progress in reducing childhood pneumonia deaths. The WHO case management approach, based largely on the work of Frank Shann and others and nicely reviewed by Ayieko and English in this issue, used minimum criteria for diagnosing pneumonia and emphasized early antibiotic treatment by first line health workers. In 2006 this approach remains as valuable as ever, but recent global advances in pneumonia control have not kept up the pace of the early 1980s; pneumonia remains the leading killer of young children worldwide; and valuable tools for reducing the global burden of pneumonia continue to sit idle. New interventions and funding sources are available and it is time to seize the opportunity provided by these resources to move global pneumonia control firmly into the new century. The case management approach was based on a simple count of respirations by peripheral health workers, with oral trimethoprim-sulfamethoxazole given if respirations are above 40 breaths per minute (50 in infants 1 year), and hospital referral if there are danger signs (chest indrawing, stridor, inability to drink, others). In a series of intervention trials in the early 1980s, this approach was shown to significantly reduce overall mortality in those less than 5 years in at least 6 countries despite differences in design and methodology. An important caveat is that the intervention was most effective in areas where baseline mortality was very high, and diminishingly effective as baseline mortality declined, with no evidence for an effect where infant mortality rates were below 90 per 1000 live births per year. The case management approach for pneumonia was modified only slightly in the ensuing years, and then incorporated essentially unchanged into the Integrated Management for Childhood Illness in 1997. In 2002 the Global Fund was established as one of several significant efforts to raise public awareness, inject new resources, and reinvigorate the fight against leading infectious killers—namely AIDS, TB and malaria. Meanwhile pneumonia authorities divided their focus as they diverged on their language; Acute Respiratory Infection, Acute Lower Respiratory Tract Infection, Severe Acute Lower Respiratory Infection, and several other acronyms subcategorized the infections of various segments and subsegments of the respiratory tree. Lost in this confusion of acronyms was the fact that pneumonia (a simpler term that effectively captures most of the important disease) remained the leading infectious cause of mortality, killing more children than AIDS, malaria and measles combined. Reviews such as the one by Ayieko and English, and new publications such as the one by WHO and UNICEF entitled Pneumonia, The Forgotten Killer of Children, have begun to refocus attention on the importance of pneumonia. The case management approach of the early 1980s needs to be reinvigorated, especially in areas where infant mortality remains above 90/1000. But beyond a renewal of the approaches of 25 years ago, pneumonia treatment and prevention efforts in the 21st century also need to be updated. In the years since 1980, the landscape for children in developing countries has changed, in many ways for the better. The number of countries with national infant mortality rate above 90 per 1000 live births per year has declined steadily. In 1980 there were 56 such countries with the potential to benefit from nationwide application of the WHO case management approach. By 2005 that number had dropped to 19 (18 of them in Africa). According to a recent WHO/UNICEF summary, only 54% of children in the developing world with suspected pneumonia are taken to an appropriate provider, and only 19% (data from the early 1990s) received antibiotics. In those countries and in areas of other countries where infant mortality is above 90, aggressive efforts to implement the case management approach can be reliably predicted to result in substantial reductions in childhood mortality. In many other developing and middle-income countries with infant mortality rates lower than 90, where pneumonia remains the leading infectious cause of morbidity and mortality, other approaches are indicated. At the WHO, Shamim Qazi and his colleagues have taken the lead on a series of efforts to update the case management approach by incorporating new information, and have called for a coordinated new effort to address the pneumonia problem worldwide. New antimicrobial agents are available, and resistance may threaten the effectiveness of drugs recommended in the 1980s for outpatient treatment of pneumonia. In response, new guidelines for second line drugs are now in development. Similarly, new options for treatment of severe pneumonia in hospitalized children and the role of Accepted for publication February 7, 2007. From the Centers for Disease Control and Prevention, Atlanta, Georgia. Address for correspondence: Scott F. Dowell, MD, MPH, Centers for Disease Control and Prevention, Mailstop D-69, 1600 Clifton Rd. NE, Atlanta, GA 30333. E-mail: sdowell@cdc.gov. Copyright © 2007 by Lippincott Williams & Wilkins ISSN: 0891-3668/07/2605-0441 DOI: 10.1097/01.inf.0000261197.70855.1e