THE PIECE Why the global pandemic is an inflection point for pneumonia control
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THE PIECE Why the global pandemic is an inflection point for pneumonia control Revised and updated for COVID-19 and the Global Burden of Disease 2019
The Missing Piece
Why the global pandemic is an
inflection point for pneumonia control
Revised and updated for COVID-19 and the Global Burden of Disease 2019
2 The Missing Piece 3
Acknowledgments
6 Overview
Contents
Chapters
10 22
T
his report was written by Leith Greenslade at JustActions. It
1. Who 2. Where do most
relies extensively on Global Burden of Disease (GBD) 2019 data
dies from pneumonia deaths
provided by the Institute for Health Metrics and Evaluation (IHME)
pneumonia? occur?
and on an updated 2020 analysis of OECD Official Development
Assistance (ODA) and private contributions to pneumonia-related
activities conducted by Development Initiatives. The report also
30 44
summarizes the results of a 2020 study of global investments in
pneumonia research by the Research Investments in Global Health
(ResIn) project based at the University of Southampton.
3. Are pneumonia 4. How effectively are
deaths declining pneumonia deaths
Special thanks to Chris Troeger from IHME, Duncan Knox from
fast enough? being prevented?
Development Initiatives, and Michael Head from ResIn and to the
many members of the Every Breath Counts Coalition whose work
has contributed to this report.
Funding for the report was provided by the New Venture Fund. 54 64
5. How adequate 6. Where
are investments to will future
reduce pneumonia breakthroughs
Copyright 2021 © JustActions. deaths? come from?
Suggested citation: JustActions, 2021. The Missing Piece. Why
74
the global pandemic is an inflection point for pneumonia control.
Revised and updated for COVID-19 and the Global Burden of
Disease 2019. New York, USA.
70
7. What does
success look like
Call to Action
in the context of COVID-19 and the quest
COVID-19? for pneumonia control
78 Appendices
A B C
Global Burden World Bank Development
of Disease regions Initiatives
methodology methodology
4 The Missing Piece World Pneumonia Day 5
P
neumonia is a leading cause of death and disability
and the leading infectious cause of death in the
world. In 2019, pneumonia caused an estimated
2.5 million deaths across all ages according to the
Global Burden of Disease (GBD).
Three-quarters of pneumonia deaths are concentrated
among two vulnerable populations—the very young and the
very old. An estimated 672,000 pneumonia deaths are among
children under five years and 1.2 million deaths are among
adults over 69 years. Unlike most other leading infectious
disease killers, pneumonia deaths follow a “U-shaped curve”
across the life course, peaking in the early and later years of
life. 1
Pneumonia is truly a “global health” issue that affects every
country. Two-thirds of pneumonia deaths cluster in a diverse
group of 20 low-, middle-, and high-income countries drawn
mostly from Sub-Saharan Africa, South Asia, East Asia and
the Pacific, and the Americas. In low-income countries, the
burden of pneumonia deaths falls disproportionately on
children under five years, while in high-income countries
it is adults aged over 69 years who shoulder the burden.
Importantly, many middle-income countries carry “double-
burdens” of pneumonia deaths, losing both large numbers of
Overview
children and the elderly each year.
Despite recent gains in reducing child pneumonia mortality,
progress in reducing all-age pneumonia deaths has not kept
pace with other leading infectious diseases in most countries.
And pneumonia deaths among adults are rising, including
from COVID-19, so that the overall pneumonia burden is
increasing in many countries. In fact, deaths from COVID-19
could add up to two million deaths to the global respiratory
infection death toll for 2020. Even after the pandemic ends,
increases in risk-related pneumonia deaths from air pollution,
tobacco smoking, and temperature extremes among elderly
1 eaths from HIV/AIDS and tuberculosis follow an “N” shaped curve as deaths concentrate
D
among adults of working age, and malaria deaths follow an “L” shaped curve as deaths
concentrate among children under five years.
6 The Missing Piece World Pneumonia
Overview
Day 7
75 % Share of two vulnerable
populations—children under
five years and adults over 70
years—in pneumonia deaths
Leadership for developing, financing, and Powerful champions are still needed at local,
implementing pneumonia control strategies national, and international levels to put pneumonia
rests with the government leaders and agencies control high on the agendas of governments and the
responsible for health in the countries where international health and development community.
pneumonia deaths are concentrated. The current These champions should advocate for investments
movement to introduce Universal Health Coverage in pneumonia control strategies targeting the most
populations will continue to make it difficult for mortality reduction targets for both children and (UHC) can contribute significantly to pneumonia vulnerable populations as part of UHC, and for the
many countries to reduce pneumonia deaths. adults and ensure that interventions are targeted reduction by fully covering the costs of vaccination, types of research and development efforts that
to the populations at greatest risk of death. This diagnosis, and treatment, especially for the most will uncover breakthrough technologies with the
Continued lack of action on pneumonia, from “precision public health”2 focus on pneumonia vulnerable populations of children and the elderly. power to deliver the next generation of improved
COVID-19 and other causes, will prevent many control has the potential to both significantly A health system that is effective at reducing both pneumonia prevention, diagnostic, and treatment
countries from achieving the Sustainable accelerate achievement of national health goals and the incidence of pneumonia and pneumonia tools and reduce the risk of another global
Development Goals (SDGs) for health by 2030. For strengthen pandemic preparedness and response. deaths is not only a quality health system, but a respiratory pandemic.
these countries, pneumonia is the “missing piece” health system that delivers equity by serving the
and a major barrier to reducing child deaths to at For countries struggling with child pneumonia most vulnerable. A world in which child pneumonia deaths have
least 25 per 1,000 births (SDG 3.2), to combatting deaths, reductions in child wasting, household been driven close to zero and where pneumonia
the overall communicable and non-communicable air pollution, and low birth weight, combined Some countries will continue to require external deaths among adults are rare in every country
disease burdens (SDGs 3.3, 3.4), and to increasing with full coverage of the pneumonia-fighting support to achieve pneumonia control. Increases is achievable. It will be a world in which children
access to quality healthcare services, essential vaccines, improved access to diagnostic tools in the historically low levels of international everywhere have enough good food to eat, where
medicines, and vaccines for all (SDG 3.8). such as pulse oximetry, and treatment with development assistance for health allocated to the vast majority of babies are born with a healthy
recommended antibiotics, oxygen, and therapeutic pneumonia will continue to be essential in the weight, and where the air is cleaner for everyone. It
Specific pneumonia control strategies are needed foods will save the most children’s lives. Where the countries that are struggling with large numbers will be a world where every child and adult is fully
to reduce the major risk factors and rapidly increase pneumonia burden falls among the elderly, and/or very high rates of pneumonia deaths and protected with the “pneumonia-fighting” vaccines
coverage of the interventions that are most cost- reductions in air pollution and tobacco smoking, slow progress. External actors can best support and where every family takes a child who exhibits
effective at preventing, diagnosing, and treating together with increases in vaccination coverage, these countries by working in direct partnership pneumonia symptoms for healthcare confident
pneumonia, especially among children under five including with COVID-19 vaccines, will be critical. with governments and with organizations that that they will receive an accurate diagnosis and
years and adults over 69 years. The pandemic Access to quality, affordable pneumonia diagnosis align their work with government health plans, fast treatment with antibiotics, oxygen, and/or
response plans that many countries have introduced and care for elderly populations will increasingly be including the 12 United Nations and multilateral therapeutic foods if needed, without paying user
already include many of the actions required for a priority in many low- and middle-income countries health, development, and humanitarian agencies fees. It will be a world where every country is
effective pneumonia control and could provide the (LMICs). When new tools like a respiratory syncytial that signed the Global Action Plan for Healthy Lives operating at full speed to prevent the emergence
foundation for continued declines in deaths from all- virus (RSV) vaccine become available, both very and Well-being For All, and as part of initiatives and of another respiratory pandemic and prepared
cause respiratory infections over the next decade. young and very old populations will benefit. coalitions such as Every Breath Counts. to respond quickly if it does. Only then, will death
Governments need to set ambitious pneumonia from pneumonia be rare everywhere.
2 Precision public health can be defined as “the application and combination of new and existing technologies, which more precisely describe and analyse individuals
and their environment over the life course, to tailor preventive inter-ventions for at-risk groups and improve the overall health of the population.” See Weeramanthri,
T.S. et al., 2018. Editorial: Precision Public Health. Frontiers in Public Health, 6. Available at: http://dx.doi.org/10.3389/fpubh.2018.00121.
8 The Missing Piece Overview 9
P
neumonia is a major cause of death stroke, and chronic obstructive pulmonary disease
and disability in the world. In 2019, (COPD) and the fourth leading cause of DALYs
pneumonia caused an estimated 2.5 after neonatal disorders, ischemic heart disease,
million deaths and 97 million Disability- and stroke.4 If COVID-19 deaths are classified
Adjusted Life Years (DALYs) across as “lower respiratory infections” in the Global
all age groups according to the Global Burden of Burden of Disease 2020, they will add 2 million
Disease (GBD).3 Pneumonia is the fourth leading to pneumonia deaths bringing the global total
cause of death after ischemic heart disease, to almost 4.5 million deaths (Charts 1 and 2).
Chart 1: Pneumonia is the fourth leading cause of death
across all ages
Number of deaths, all ages (million) COVID-19 (2020)
10.0
1 8.0
6.0
4.0
2
WHO
2.0
2.5
0.0
Ischemic Stroke COPD Pneumonia* Lung Neonatal Alzheimer's Diabetes Diarrhea Cirrhosis
Heart Disease Cancer Disorders
*Pneumonia refers to the category “lower respiratory infections”
Source: Global Burden of Disease 2019, Level 3
DIES FROM Chart 2: Pneumonia is the fourth leading cause of
Disability-Adjusted Life Years (DALYs) across all ages
PNEUMONIA?
Number of Disability Adjusted Life Years (DALYs), all ages (million)
200
160
120
97
80
40
0
Neonatal Ischemic Stroke Pneumonia Diarrhea COPD Road Diabetes Low Back Congenital
Disorders Heart Injuries Pain Defects
Disease
Source: Global Burden of Disease 2019, Level 3
3 See Note (a) for an explanation of the GBD methodology.
4 A measure of years of life lost due to sickness, disability, and early death.
Who dies from pneumonia? 11
Chart 4: Pneumonia deaths
No other infection causes anywhere near
cluster among children
this burden of mortality.
under five years and adults
Pneumonia is the leading infectious cause
over 69 years
of death in the world. More people die from
Number of pneumonia deaths, various age groups
pneumonia than from diarrhea, tuberculosis,
HIV/AIDS, and malaria (Chart 3). Meningitis, 42K
neonatal sepsis, typhoid, whooping cough, 5-14 years
and encephalitis are minor infectious disease
killers compared to pneumonia, according to
the GBD. If all COVID-19 deaths are added to 170K 672K
the total for all-cause pneumonia, its impact 15-49 0-4 years
years
on mortality will dwarf all other infectious
killers.
Pneumonia deaths are concentrated among
the very young and the very old. Three-
quarters (1.9 million) of the estimated 2.5
million pneumonia deaths that occurred in 382K 1.2M
2019 were among children under five years 50-69 years 70+ years
and adults over 69 years. In that year, the
GBD estimates that 672,000 children under
five years and 1.2 million adults over 69 lost
their lives to pneumonia (Chart 4).
Source: Global Burden of Disease 2019
Unlike most other leading infectious
diseases, pneumonia deaths follow a
“U-shaped” curve across the life course,
with deaths spiking among children and the Chart 5: Pneumonia death
elderly (Chart 5). In contrast, deaths from rates follow a “U-shaped
curve” across the life course
Number of pneumonia deaths per 100,000 population
Chart 3: Pneumonia is the leading infectious cause of
372.0
death across all ages
Number of deaths, all ages
Neonatal Whooping 264.7
Diarrhea HIV/AIDS Malaria Sepsis Cough
1.53M 0.86M 0.64M 0.23M 0.12M
2.49M 2M
Pneumonia COVID-19
(2020)
1.18M 0.24M 0.13M 31.7 3.3 4.3 27.7
Tuberculosis Meningitis Typhoid
0-1 yrs 1-4 yrs 5-14 yrs 15-49 yrs 50-69 yrs 70+ yrs
Source: Global Burden of Disease 2019, Level 3 Encephalitis
Source: Global Burden of Disease 2019
0.09M
12 The Missing Piece Who dies from pneumonia? 13
Chart 6: Pneumonia is the leading cause of death among
children under five years
Number of deaths, 0-4 years
700,000 672K
600,000
500,000
Chart 7: Three-quarters
400,000 of all child pneumonia
deaths occur in the first
300,000 year of life
200,000 Number of pneumonia deaths, various age groups
100,000
79K margin. Diarrhea, the second leading
7-27 days 168K
0 infectious cause of death among the
Pneumonia Preterm Encepha- Diarrhea Other Malaria Neonatal Congenital Other Meningitis 1-4 years
Birth lopathy Neonatal Sepsis Heart Congenital elderly, caused an estimated 612,000
deaths in 2019 by comparison
Source: Global Burden of Disease 2019, Level 3
(Chart 8).
HIV/AIDS and tuberculosis follow an “n” shaped Pneumonia kills more males than
curve with deaths concentrating among adults females, largely due to the higher
29
of working age, while malaria deaths follow an number of pneumonia deaths among
307K
“L” shaped curve with deaths concentrating baby boys in the first six days of
%
29-364 days
among children under five years. 117K life and among men aged 15 to 69
0-6 days years. These 98,000 additional
Pneumonia is the leading cause of death among male deaths more than offset the
children under five years and is responsible additional 28,000 pneumonia deaths
for many more deaths than other infections
like diarrhea, malaria, neonatal sepsis, and
Source: Global Burden of Disease 2019
meningitis (Chart 6). Pneumonia deaths
Childhood are concentrated among infants, with 75%
pneumonia (504,000) occurring among children under
12 months of age. Almost 30% (196,000) of Chart 8: Pneumonia is the fifth leading cause of death
deaths that infant pneumonia deaths happen in the first among adults aged over 69 years
month of life, and almost 20% (117,000) in the
happen in the first week after birth, according to the GBD
(Chart 7).
Number of deaths, 70+ years (million)
0.84M
first month of life Hypertensive
Heart
0.61M
Colorectal
Cancer
Pneumonia is the fifth leading cause of Disease
death among adults aged over 69 years after 5.90M 4.35M
ischemic heart disease, stroke, COPD, and 2.49M 1.51M 1.23M 1.04M
Alzheimer’s, according to the GBD. Pneumonia
is the only infectious cause of death in the top
Ischemic Stroke COPD Alzheimer's Pneumonia Lung 0.84M 0.80M
Heart Cancer Diabetes Kidney
ten killers of elderly adults and the leading Disease
Disease
infectious disease killer of the elderly by a wide Source: Global Burden of Disease 2019, Level 3
14 The Missing Piece Who dies from pneumonia? 15
among women aged over 69 years (Chart 9). Rates behavioral risks which were a factor in 1,010,000
of pneumonia death per 100,000 population are pneumonia deaths. Major environmental risks
also higher for males across all age groups, except include exposure to air pollution, lack of access
among children aged one month to 14 years. to handwashing and low temperature. Major
behavioral risks include child wasting, smoking,
The majority of pneumonia deaths can be attributed exposure to secondhand smoke, and low birth
to specific risks, especially to environmental and weight (Chart 10).
behavioral factors, as defined by the GBD.5 In 2019,
environmental risks contributed to an estimated The leading risk factors for pneumonia death vary
1,077,000 pneumonia deaths, followed by by age and by gender. Among children under five
Chart 9: Pneumonia kills more males than females in
most age groups
Number of pneumonia deaths, various age groups Males Females
0 100,000 200,000 300,000 400,000 500,000 600,000 700,000
0-6 days
7-28 days
29-364 days
1-4 years
5-14 years
15-49 years
50-69 years
70+ years
Source: Global Burden of Disease 2019
672,000
Chart 10: Air pollution, child wasting, and smoking are the
leading risk factors for pneumonia death across all ages
Number of pneumonia deaths, all ages
No Handwashing Low Temperature Short Gestation
270K 159K 105K Number of children
under five years who
lost their lives to
pneumonia in 2019
423K 368K 326K 275K 172K 144K 88K
Household Air Child Outdoor Air Smoking Secondhand Low Birth High
Pollution Wasting Pollution Smoke Weight Temperature
Source: Global Burden of Disease 2019, Level 4
5 Note the category of “behavioral” risks in the GBD includes low birth weight and short gestation or preterm birth.
16 The Missing Piece Who dies from pneumonia? 17
Chart 12: Air pollution, smoking, and secondhand
smoke are the leading risk factors for pneumonia death
among adults over 69
Number of pneumonia deaths, 70+ years
180,000
135,000
90,000
45,000
0
Smoking Outdoor Air Household Air Low No Secondhand Alcohol High
Pollution Pollution Temperature Handwashing Smoke Use Temperature
years, child wasting, air pollution, and low birth contributes to a much higher number of male Source: Global Burden of Disease 2019, Level 4
weight are the major risk factors (Chart 11). For pneumonia deaths. While household air pollution,
adults aged over 69 years, smoking, air pollution, exposure to secondhand smoke, and wasting
and exposure to low temperatures are major risk contribute to more pneumonia deaths among
factors (Chart 12). There are 150,000 more risk- females, this is not enough to offset the impact of Chart 13: Risk-related pneumonia deaths are higher for
related pneumonia deaths among males than smoking on male pneumonia deaths (Chart 13). males than females due to smoking
females, across all ages. This is because smoking
Number of pneumonia deaths, all ages Males Females
0 50,000 100,000 150,000 200,000 250,000
Chart 11: Wasting, household air pollution, and low birth Smoking
weight are the leading risk factors for pneumonia deaths Household Air Pollution
among children under five
Child Wasting
Number of pneumonia deaths, 0-4 years
400,000 Outdoor Air Pollution
350,000 No Handwashing
300,000 Low Temperature
250,000
Secondhand Smoke
200,000
Low Birth Weight
150,000
Short Gestation
100,000
High Temperature
50,000
0
Child Household Low Birth No Short Outdoor Air Child Child Non- Secondhand Source: Global Burden of Disease 2019, Level 4
Wasting Air Pollution Weight Handwashing Gestation Pollution Stunting Underweight exclusive Smoke
Breast-
feeding
Source: Global Burden of Disease 2019, Level 4
18 The Missing Piece Who dies from pneumonia? 19NEW DEVELOPMENTS
Pneumonia Definitions
Lower respiratory infection (LRI), acute respiratory cause of death (12%). The pathogens Klebsiella
infection (ARI), severe acute respiratory infection Pneumonaie, Pneumococcus, Cytomegalovirus,
(SARI), community-acquired pneumonia, and Staphylococcus Aureus/Staph, Haemophilus
hospital-acquired pneumonia are all names Influenzae type B, RSV, and Pneumocystis
used to describe pneumonia. When SARS-CoV-2 Jirovecii were responsible for most child deaths.
(severe acute respiratory syndrome coronavirus Pneumonia was also a major immediate cause
THE
2) first appeared in Wuhan it was described as a of neonatal mortality (19%) with the pathogens
“pneumonia of unknown cause.” The proliferation Acinetobacter Baumannii and Klebsiella
of terms creates confusion, undermines the Pneumonaiea responsible for most deaths.
STORY collection of data, and ultimately contributes to
fragmentation of effort across clinical settings, COVID-19 adds a major new viral cause of
SO FAR…
institutions, and countries. pneumonia to deaths from lower respiratory
infections, primarily affecting adults to date. With
There are even more causes of pneumonia two million COVID-19 deaths in 2020 according
than terms to describe the condition, including to IHME COVID 19 projections, all-cause
Pneumonia is the leading infectious viral, bacterial, and fungal pathogens.Pre- pneumonia mortality could increase by a massive
disease killer in the world, responsible COVID-19 studies have shed light onto the major 80%, bringing the total to 4.5 million, assuming
for an estimated 2.5 million deaths and causes of pneumonia in low-resource settings, COVID-19 deaths are counted as lower respiratory
97 million DALYs in 2019, according to especially among children. The Pneumonia infections in the GBD. As we deepen our
Etiology Research for Child Health (PERCH) understanding of the exact causes of pneumonia
the GBD. Deaths cluster among the most
study analysed the main causes of pneumonia sickness and death across all age-groups, it is
vulnerable—young children under five
in children hospitalized across seven countries critical that efforts are made to standardize the
and adults over 69 years. Pneumonia kills including Bangladesh, Kenya, The Gambia, Mali, terminology used to describe this massive burden
an estimated 672,000 children under South Africa, Zambia, and Thailand and found of mortality by health experts, governments and
five, three-quarters of whom are under that viruses caused 61% of cases, followed by global health agencies (e.g., WHO and IHME), in
12 months of age and 1.2 million adults bacteria (27%), tuberculosis (6%), and fungi data sets (e.g., GBD, United Nations), and across
over 69 years. More males than females (5%). The respiratory syncytial virus (RSV) low-, middle-, and high-income clinical settings.
die from pneumonia and the rate of was the leading pathogen responsible for 31%
pneumonia death is also higher for males. of all hospitalizations followed by rhinovirus LEARN MORE:
(7.5%), human metapneumovirus/HMPV O’brien, K.L. Et Al., 2019. Causes of Severe
The populations most at risk of death
(7.5%), parainfluenza (7.4%), pneumococcus Pneumonia Requiring Hospital Admission in
from pneumonia include children who
(6.7%), haemophilus influenzae type B (5.9%), Children Without HIV Infection from Africa and
are wasted, exposed to air pollution, and/ tuberculosis/TB (5.9%), staphylococcus aureus/ Asia: The PERCH Multi-Country Case-Control
or born with low birth weight and elderly staph (2.7%), influenza (2%), and pneumocystis Study. The Lancet, 31;394(10200):757-779.
populations exposed to smoking, air jirovecii (2%). Available at: https://doi.org/10.1016/S0140-
pollution, and low temperatures. Smoking 6736(19)30721-4.
contributes to many more pneumonia Due to the challenges of sampling the area of
deaths among males, while exposure to infection following death in low-resource settings, Taylor, A.W. Et Al., 2020. Initial Findings from a Novel
household air pollution and secondhand it is difficult to know the exact causes of pneumonia Population-Based Child Mortality Surveillance Ap-
deaths. The Child Health and Mortality proach: A Descriptive Study. The Lancet Global
smoke contribute to more pneumonia
Prevention Surveil-lance (CHAMPS) network is Health, 8(7):E909-E919. Available at: https://doi.
deaths among females. COVID-19 could
using minimally-invasive tissue sampling (MITS) org/10.1016/S2214-109x(20)30205-9.
add an additional 2 million deaths to the to determine specific causes of pneumonia death
2020 total for lower respiratory infections. among neonates and children in seven countries Zhu, Z. Et Al., 2020. From SARS and MERS to
No other infection causes anywhere near including Ethiopia, Bangladesh, Kenya, Mali, COVID-19: A Brief Summary and Comparison of
this burden of death. Mozambique, Sierra Leone, and South Africa. Severe Acute Respiratory Infections Caused by
They found that among children, lower respiratory Three Highly Pathogenic Human Coronaviruses.
infections were the leading immediate cause of Respiratory Research, 21(1). Available at: http://
death (47%) and the second leading underlying dx.doi.org/10.1186/S12931-020-01479-W.T
he 2.5 million deaths from pneumonia adults and are dealing with “double burdens” of
are concentrated in Sub-Saharan pneumonia mortality among both children and the
Africa, South Asia, and East Asia and elderly (Chart 14).
the Pacific. Sub-Saharan Africa is home
to the largest number of pneumonia Two-thirds (1.6 million) of pneumonia deaths are
deaths followed by South Asia and East Asia and further concentrated in a group of 20 low, middle-,
the Pacific.6 In contrast, pneumonia causes far and high-income countries. Among these countries
fewer deaths in Europe and Central Asia, Latin India is the stark outlier with an estimated 434,000
America and the Caribbean, North America, and pneumonia deaths—17% of all global pneumonia
the Middle East and North Africa. deaths—followed by China, Nigeria, Japan, and
Brazil. There are six countries from Sub-Saharan
2
In most regions the vast majority of pneumonia Africa in the top 20—Nigeria, the Democratic
deaths occur among adults. In contrast, 56% of Republic of Congo, Ethiopia, Tanzania, South
pneumonia deaths in Sub-Saharan Africa and 38% Africa, and Burkina Faso—and six high-income
of pneumonia deaths in South Asia are among countries—Japan, the United States of America
children under 15 years. These two regions also (USA), the United Kingdom (UK), Russia, Germany,
have significant pneumonia mortality among older and Argentina. Of the remaining LMICs on the list,
WHERE
Chart 14: Pneumonia deaths concentrate in specific
regions among specific age groups
Number of pneumonia deaths, various age groups
DO MOST
0-4 years 5-14 years 15-49 years 50-69 years 70+ years
700,000
PNEUMONIA 600,000
DEATHS
500,000
400,000
OCCUR? 300,000
200,000
100,000
0
Sub-Saharan South East Asia/ Europe/ Latin America/ North Middle East/
Africa Asia Pacific Central Asia Caribbean America North Africa
Source: Global Burden of Disease 2019
6 See Note (b) for a list of countries in each World Bank region.
22 The Missing Piece Where do most pneumonia deaths occur? 23Chart 15: Two-thirds of pneumonia deaths
are concentrated in a diverse group of 20
high-burden countries
20
Number of pneumonia deaths, various age groups
0-4 years 5-14 years 15-49 years 50-69 years 70+ years
0 75,000 150,000 225,000 300,000 375,000 450,000
India
Number of
China
countries
accounting for Nigeria
two-thirds of all Japan
pneumonia deaths Brazil
USA
Pakistan
Philippines
East Asia and the Pacific is home to four (China, the However in India, Bangladesh, the USA, the UK, and
Ethiopia
Philippines, Indonesia, and Thailand), South Asia to Argentina more females die from pneumonia. The
three (India, Pakistan, and Bangladesh), and Latin largest gap is in India, where pneumonia kills an
DRCongo
America and the Caribbean to one (Brazil). estimated 30,000 more females than males. These
additional female deaths cluster among girls aged Indonesia
The vast majority of pneumonia deaths in high- one month to 14 years and among women over 49
income countries occur among adults aged over 69 years (Chart 16). In Bangladesh, the USA, the UK, UK
years, as do more than 50% of pneumonia deaths and Argentina additional female deaths are due
in China, Brazil, and Thailand. In contrast, over to larger populations of elderly females. However, Bangladesh
50% of pneumonia deaths in Nigeria, Pakistan, in India this is not the case as rates of pneumonia
Tanzania, and Burkina Faso are among children death are higher for females across all age groups Russia
under five years. Critically, six of the countries are except women 15 to 49 years.
dealing with significant burdens of pneumonia Tanzania
death among both the very young and the very Pneumonia deaths are often further concentrated
old, including India, the Philippines, Ethiopia, in specific populations within countries, but Thailand
the Democratic Republic of Congo, Indonesia, estimates of sub-national pneumonia mortality for
and Bangladesh. Only Russia and South Africa all age groups do not yet exist. They are available South Africa
are experiencing high proportions of pneumonia for children under five years as part of the Local
deaths among their working-age populations. More Burden of Disease analysis provided by the Argentina
than one-quarter (26%) of pneumonia deaths in Institute for Health Metrics and Evaluation (IHME).
Russia and 20% in South Africa are among 15 to These maps reveal several sub-national clusters Germany
49 year olds (Chart 15). of high-risk child pneumonia “hotspots” running
across northern Africa with mortality risk peaking Burkina Faso
In three-quarters of the 20 high-burden countries, in eastern Burkina Faso, north-eastern Nigeria (e.g.,
pneumonia kills more males than females. Jigawa, Yobe, Borno, and Adamawa states), the
Source: Global Burden of Disease 2019
24 The Missing Piece Where do most pneumonia deaths occur? 25Chart 16: Gaps between female and male pneumonia
deaths are widest in India
Number of pneumonia deaths, various age groups Males, India Females, India
0 20,000 40,000 60,000 80,000 100,000 120,000
0-6 days
7-28 days
29-364 days
1-4 years
5-14 years
15-49 years
50-69 years
70+ years
Source: Global Burden of Disease 2019
eastern Central African Republic, southern South Sudan,
and southern Somalia. In Asia, there are sub-national
clusters of child pneumonia mortality risk in northern
Uzbekistan, southern Afghanistan, the Sindh and Khyber
Pakhtunkhwa provinces of Pakistan, and the northern
states of India (e.g., Uttar Pradesh, Bihar, Madhya Pradesh,
and Rajasthan). Governments and global health donors
and agencies should use this data to identify exactly
where the populations of children at greatest risk of death
from pneumonia are located within national borders and
prioritize pneumonia control efforts to them. Because the
geographic areas with the greatest risk of child pneumonia
death may not be the same as the populations with the
greatest numbers of child pneumonia deaths, decision-
makers will need to take into account broader indicators
to identify the largest numbers of children at greatest risk
of death from pneumonia. In the absence of sub-national
maps of adult pneumonia deaths, decision-makers can
identify the populations of elderly at greatest risk by using
sub-national maps of exposure to air pollution and tobacco
smoking as proxies.
26 The Missing Piece Where do most pneumonia
World Pneumonia
deaths occur?
Day 27NEW DEVELOPMENTS
Pneumonia Maps
The development of online, interactive maps that populations at greatest risk of death and dramatically
pinpoint where pneumonia deaths cluster within accelerate national achievement of child survival
nations has the potential to transform the impact of goals. This is not only important for children. Precision
interventions, rapidly accelerate mortality declines, public health maps that reveal the adult populations
and close health inequities. The Institute for Health most at risk of pneumonia death would also help
THE
Metrics and Evaluation (IHME) is advancing the many countries reduce large and growing pneumonia
development of Local Burden of Disease maps and burdens. Maps that include pneumonia prevalence,
has applied advanced bayesian geostatistical tools to incidence, and mortality for all age-groups have the
STORY map pneumonia prevalence, incidence, and mortality
rates per 1,000 children under five years across the
world.
potential to dramatically improve the cost-effectiveness
of national pneumonia control efforts and international
development assistance.
SO FAR… This analysis reveals clusters of child pneumonia
deaths in two global “hotspots”. The first runs in a band
COVID-19 has underscored the importance of maps
that can capture prevalence, incidence, and mortality
Two-thirds of pneumonia deaths are from West to East Africa, beginning in Guinea and Sierra rates during a pandemic in real-time and at the global,
Leone and continuing through Southern Mali, Burkina national, state, and local levels. The WHO Coronavirus
concentrated in a diverse group of 20
Faso, Niger, Chad, Northern Nigeria, the Central African Disease (COVID-19) Dashboard provides national
low-, middle-, and high-income countries Republic, South Sudan, Ethiopia, Kenya, and Southern estimates of confirmed COVID-19 cases and deaths
representing most regions of the world. Somalia. Rates of child pneumonia mortality in these while the COVID-19 Dashboard by the Center for
While pneumonia mortality in some of populations range from three deaths per 1,000 children Systems Science and Engineering (CSSE) at Johns
these countries concentrates among in Southern Mali to seven deaths per 1,000 children in Hopkins University (JHU) also provides sub-national
children or the elderly, many carry “double north eastern Nigeria. For comparison, the lowest rate estimates in some countries. Many other tools and
in Sub-Saharan Africa is 0.2 in South Africa. apps have emerged with local COVID-19 data at the
burden” of pneumonia deaths in both age
district level. Wide access to these maps and apps
groups. In most of these countries, males
A second pneumonia “hotspot” is in Asia and runs is not only a critical tool for government pandemic
are more likely to die from pneumonia north to south-east from Uzbekistan to Cambodia and surveillance and response, but for populations to
than females with the exception of India includes Tajikistan, Afghanistan, Pakistan, Northern understand their local risk and change their behaviors
where both pneumonia death numbers India, Myanmar, and Laos. Rates of child pneumonia accordingly. Governments, companies, and the global
and rates among girls and elderly women mortality in these populations range from 1.5 deaths health community should significantly increase their
are higher. In many countries, pneumonia per 1,000 children in parts of Myanmar to 2.9 deaths investments to further develop disease mapping tools
per 1,000 children in Southern Pakistan. The lowest and their uptake as part of disease control efforts both
deaths are further concentrated within
rate in Asia is 0.1 in Thailand. during the pandemic and beyond.
specific geographic areas and there is
an urgent need for governments and By comparing pneumonia prevalence with mortality LEARN MORE:
global health donors and agencies to use in these sub-national populations, local burden of India State-Level Disease Burden Initiative Child
these maps to more effectively target disease maps can also offer some assessment of the Mortality Collaborators. Subnational Mapping of
prevention, diagnosis, and treatment effectiveness of both population behaviors and the Under-5 and Neonatal Mortality Trends in India: The
health system in reducing child pneumonia mortality. Global Burden of Disease Study 2000–17. The Lancet.
services to accelerate the achievement
For example, the health system in sub-national 11 May 2020. Available at: https://doi.org/10.1016/
of health goals. Ideally, decision-makers
populations experiencing high pneumonia prevalence S0140-6736(20)30471-2.
would have easy access to sub-national but lower mortality may be functioning more effectively
estimates of pneumonia prevalence, and/or the population may be practicing more “pro- Institute for Health Metrics And Evaluation (IHME).
incidence, and mortality for all age groups health” behaviors (e.g., good nutrition, low exposure Local Burden of Disease – Lower Respiratory Infections.
so that pneumonia control efforts could to air pollution, etc.). Populations where mortality is Seattle, WA: IHME, University of Washington, 2019.
be targeted for maximum impact on lives particularly high relative to prevalence may have limited Available at: https://vizhub.healthdata.org/lbd/lri.
access to quality health services and/or high exposure
saved across the life course.
to the major pneumonia risk factors. Reiner, R.C. Et Al., 2019. Identifying Residual Hotspots
and Mapping Lower Respiratory Infection Morbidity
Using “precision public health” mapping has the and Mortality in African Children from 2000 to 2017.
potential to improve the targeting of pneumonia Nature Microbiology, 4(12), PP.2310–2318. Available at:
prevention, diagnosis, and treatment efforts to the http://dx.doi.org/10.1038/s41564-019-0562-y.
28 The Missing Piece World Pneumonia Day 29P
neumonia deaths declined by 14%
between 2000 and 2019 from an
estimated 2.9 million to 2.5 million
according to the GBD. This decline
was driven by children under five years
where pneumonia deaths fell by 57%. In contrast,
pneumonia deaths among adults aged 15 to 49
years remained largely flat and deaths among
adults over 49 years increased, most sharply
among adults aged over 69 years where pneumonia
deaths rose by 55% (Chart 17). While much of this
increase was driven by aging populations, little
progress was made in reducing the actual rate of
pneumonia deaths among adults over the period
3
(Chart 18).
While the gender gap in pneumonia deaths (more
males than females die from pneumonia) has
narrowed since 2000 as deaths have fallen more
quickly for males (-15%) than females (-13%), it has
not been eliminated. Between 2000 and 2019 the
ARE
gender gap narrowed as child pneumonia deaths
PNEUMONIA Chart 17: Pneumonia deaths have fallen among children
under 15 years but risen among adults over 49 years
DEATHS Number of pneumonia deaths, various age groups
2000 2019
DECLINING Change -57% -41%
-2%
33% 55%
FAST ENOUGH?
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
0-4 years 5-14 years 15-49 years 50-69 years 70+ years
Source: Global Burden of Disease 2019
30 The Missing Piece Are pneumonia deaths declining fast enough? 31Chart 18: Rates of pneumonia death have fallen sharply among
children under five years in contrast to other age groups
Number of pneumonia deaths per 100,000 population
2000 2019
Change
-60% -50% -20% -20% -10%
300
250
200
150
100
among boys under five years declined faster and
50 the number of pneumonia deaths among women
50 to 69 years increased. However over the same
0 period pneumonia deaths increased more rapidly
0-4 years 5-14 years 15-49 years 50-69 years 70+ years for men aged 15 to 49 and men aged above 69 years
Source: Global Burden of Disease 2019 than for women, offsetting the other trends. The
rate of pneumonia deaths among males continues
to be higher than for females—34 and 31 deaths
Chart 19: Numbers of pneumonia deaths have fallen per 100,000 respectively.
in all regions except Latin America and the Caribbean
Pneumonia deaths have fallen in all regions, except
and North America in Latin America and the Caribbean and in North
Number of pneumonia deaths, all ages America. The sharpest decline of 29% occurred in
South Asia, followed by Sub-Saharan Africa (-19%),
2000 2019
57
and the Middle East and North Africa (-17%), all
%
-3% driven by sharp declines in child pneumonia deaths.
Change -19% -29% -9% 37% 9% -17% In contrast, the East Asia and the Pacific region
recorded smaller declines (-9%), as did Europe and
900,000 Central Asia (-3%), due to rising pneumonia deaths
800,000 among elderly populations. Pneumonia deaths
700,000 actually rose over the period across Latin America
600,000
Decline in child and the Caribbean (37%) and North America (9%)
due to the growing number of pneumonia deaths
500,000 pneumonia deaths among adults aged over 69 years (Chart 19).
400,000 between 2000
Pneumonia deaths have risen in eight of the 20
300,000
and 2019, from high-burden countries, with increases ranging
200,000
100,000
an estimated 1.6 from 6% in the USA to 181% in Thailand, according
to the GBD. Steep increases occurred in middle-
0 million to 672,000 income countries with aging populations including
Sub-Saharan South Asia East Asia and Europe and Latin North Middle East
Africa Pacific Central Asia America and America and North in Thailand, Brazil, and the Philippines, while high-
Caribbean Africa income countries also experienced this effect
Source: Global Burden of Disease 2019
32 The Missing Piece Are pneumonia deaths declining fast enough? 33Chart 20: Numbers of pneumonia deaths have risen in
eight of the 20 high-burden countries
Number of pneumonia deaths, all ages 2000 2019
0 20,000 40,000 60,000 80,000 100,000 120,000 Change
Japan 52%
Brazil 66%
USA 6%
Chart 21: Numbers of pneumonia deaths have fallen
in 12 of the 20 high-burden countries
Number of pneumonia deaths, all ages 2000 2019
Philippines 50%
0 100,000 200,000 300,000 400,000 500,000 600,000 Change
-25%
Thailand 181% India
China
-39%
Argentina 103%
Nigeria -20%
Germany 41%
Pakistan -21%
Burkina Faso 22% Ethiopia -50%
Source: Global Burden of Disease 2019 DRCongo -29%
Indonesia -32%
including Argentina, Japan, the USA, and Germany. burden country with the exception of Burkina
However, pneumonia deaths also rose in Burkina Faso, with declines ranging from 29% in Nigeria
UK -14%
Faso driven by increases in child pneumonia to 89% in China (Chart 22). In stark contrast,
deaths (Chart 20). In the remaining 12 high-burden numbers of pneumonia deaths among those aged
countries, pneumonia deaths fell with reductions over 69 years rose sharply in all of the high-burden Bangladesh
-55%
ranging from 14% in the UK to 55% in Bangladesh. countries except in the UK, ranging from 2% in
The reductions in pneumonia deaths achieved the USA to 357% in Thailand (Chart 23). In fact,
Tanzania
by Bangladesh, Ethiopia, China, and Indonesia the number of pneumonia deaths among those -23%
between 2000 and 2019 are remarkable (Chart 21). aged over 69 years more than doubled in Brazil,
the Philippines, Argentina, and Thailand over the Russia
-17%
Declines in pneumonia deaths in the high-burden period. These sharp increases reflect the aging of
countries between 2000 and 2019 were driven by the populations in these countries and offset the South Africa
reductions in deaths among children under five impressive declines in child pneumonia deaths, -16%
years. Child pneumonia deaths fell in every high- especially in the Philippines and Thailand.
Source: Global Burden of Disease 2019
34 The Missing Piece Are pneumonia deaths declining fast enough? 35Chart 22: Pneumonia deaths among children under five Chart 23: Pneumonia deaths among adults aged over 69
years have fallen in 19 of the 20 high-burden countries years have risen in 19 of the 20 high-burden countries
Number of pneumonia deaths, 0-4 years 2000 2019 Number of pneumonia deaths, 70+ years 2000 2019
0 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 Change 0 40,000 80,000 120,000 160,000 200,000 Change
-29% India 95%
Nigeria
-66% China 21%
India
-33% Japan 63%
Pakistan
-70% USA 2%
Ethiopia
-43% Brazil 179%
Tanzania
15% UK -13%
Burkina Faso
-89% Philippines 195%
China
DRCongo
-65% Argentina 113%
Bangladesh
-81% Germany 51%
Philippines -49% Indonesia 58%
Indonesia -75% Nigeria 40%
Brazil -71% Thailand 357%
South Africa -56% Bangladesh 89%
Russia -69% Ethiopia 42%
USA -38% DRCongo 41%
Argentina -52% South Africa 19%
Thailand -81% Russia 43%
Japan -62% Pakistan 20%
United Kingdom -46% Tanzania 30%
Germany -48% Burkina Faso 26%
Source: Global Burden of Disease 2019
Source: Global Burden of Disease 2019
36 The Missing Piece Are pneumonia deaths declining fast enough? 37Progress in reducing pneumonia deaths has not Chart 24: Pneumonia deaths have fallen more slowly
kept pace with many other leading infectious than other leading infectious killers
disease killers. The 14% decline in pneumonia
deaths since 2000 is lower than the declines for all Number of deaths, all ages 2000 2019
other leading infectious killers including measles
(-86%), HIV/AIDS (-45%), whooping cough (-41%), 0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 Change (%)
meningitis (-39%), diarrhea and malaria (-37%),
tuberculosis (-31%), typhoid (-29%), and neonatal
Pneumonia -14%
sepsis (-17%) (Chart 24).
As a result of this slower decline, many countries
will struggle to reduce child pneumonia deaths to
the levels required for achievement of the SDG for Diarrhea -37%
child survival—25 child deaths per 1,000 live births
by 2030. To achieve this goal, countries will need
to reduce child pneumonia deaths to at least three
per 1,000 live births by 2025, the target established Tuberculosis -31%
in 2013 by the World Health Organization (WHO)
and UNICEF in the Integrated Global Action
Plan for Pneumonia and Diarrhoea (GAPPD).7 At
current rates of progress, seven of the high-burden HIV/AIDS -45%
countries will not achieve this target including
Nigeria, India, Pakistan, Ethiopia, Tanzania, Burkina
Faso, and the Philippines (Chart 25).
Malaria -27%
7 Chan, M. & Lake, A., 2013. Integrated global action plan for the prevention
and control of pneumonia and diarrhoea (GAPPD). The Lancet, 381(9876),
pp.1436–1437. See also the Integrated Global Action Plan for Prevention and
Con-trol of Pneumonia and Diarrhoea (GAPPD), 2013. Geneva: World Health Meningitis -39
Organization (WHO) and UNICEF, available at: https://www.who.int/maternal_
child_adolescent/news_events/news/2013/gappd_launch/en/.
Neonatal Sepsis -17%
14
Decline in pneumonia
% Typhoid
Whooping Cough
-29%
-41%
deaths between 2000
and 2019, from an
estimated 2.9 million to Measles
-86%
to 2.5 million Source: Global Burden of Disease 2019
38 The Missing Piece Are pneumonia deaths declining fast enough? 39Chart 25: Seven high-burden countries will struggle to Chart 26: Many other countries with more than
achieve the child pneumonia mortality target by 2025 5,000 child pneumonia deaths will also struggle to achieve
the child pneumonia mortality target by 2025
Number of child pneumonia deaths per 1,000 births
35
Number of child pneumonia deaths per 1,000 births
Nigeria Trendline
40
30
Trendline
Niger
Burkina Faso 35
25
Ethiopia
Tanzania Somalia
20
30 Guinea
South Sudan
Chad
Myanmar
India
15 Afghanistan
Pakistan
25
10
Cote d'Ivoire
Philippines
20 Benin
Mali
5 Mozambique
Madagascar
Target: 3 deaths per 1,000 births 15
0
2000 2005 2010 2015 2019 2025 2030 Cameroon
Sources: Global Burden of Disease 2019 and United Nations World Population Prospects 2019
10
It is important to note that many other countries deaths among adults, and especially among
not on the list 20 high-burden countries, most adults, will also struggle to achieve the SDGs
of them in Sub-Saharan Africa, will also fail to relating to communicable and non-communicable
5
achieve the GAPPD target. Of special concern are disease reduction, and access to healthcare
the countries where more than 5,000 children for all. Achieving these goals will be extremely
are dying from pneumonia each year and where challenging for those countries where pneumonia Target: 3 deaths per 1,000 births
there has been little or no progress in reducing deaths among adults over 69 years have risen by
0
deaths. For example, at current rates of progress, more than 60% since 1990, including India, the 2000 2005 2010 2015 2019 2025 2030
more than 100,000 children will still be dying from Philippines, Brazil, Thailand, Argentina, and South
pneumonia across Niger, Somalia, Afghanistan, Africa. As many of the these countries have also Sources: Global Burden of Disease 2019 and United Nations World Population Prospects 2019
Chad, Mali, Cameroon, Mozambique, Guinea, been disproportionately affected by COVID-19
Myanmar, Madagascar, South Sudan, and Benin in deaths among older adults, they will need to adopt
2025 (Chart 26). special measures to reduce death from all-cause
respiratory infections to achieve the health vision
Countries with rising burdens of pneumonia of the SDGs.
40 The Missing Piece Are pneumonia deaths declining fast enough? 41NEW DEVELOPMENTS
Pneumonia Targets
At current rates of progress and in the context of the and surveys.
THE
COVID-19 pandemic, it will be very difficult for many high-
burden pneumonia countries to achieve the Sustainable WHO, UNICEF, and partners should revise and relaunch the
Development Goals (SDGs) for health that they adopted GAPPD, which sunsets in 2025, and update and extend the
STORY
in 2015. Countries where child pneumonia deaths remain child pneumonia mortality target to two deaths per 1,000
stubbornly high, and where progress is slow, will struggle lives births by 2030. International health agencies should
to achieve SDG 3.2 (reducing child mortality to at least 25 introduce a new pneumonia mortality target for vulnerable
SO FAR…
deaths per 1,000 live births), and countries with high and adult populations that is consistent with the broader SDG
rising burdens of pneumonia deaths among adults, including health targets. Targets and measurement indicators for all of
from COVID-19, will be hampered in their efforts to curb both the major risk factors for pneumonia death and for the most
communicable and non-communicable disease deaths (SDGs effective health interventions should be widely adopted and
Despite substantial progress in reducing 3.3, 3.4). Countries that cannot provide access to “quality routinely measured, including for pulse oximetry, oxygen, and
child pneumonia deaths in most healthcare services, essential medicines, and vaccines for the recommended antibiotics.
countries, increases in adult pneumonia all,” including for pneumonia prevention, diagnosis, and
deaths, especially among the elderly, treatment, will fail to achieve Goal 3.8. And countries where If this approach was endorsed by the World Health Assembly
are contributing to a rising burden of more than 90% of children with pneumonia symptoms are in 2022, national governments would have two 2030
not taken to see a healthcare provider will struggle to achieve pneumonia mortality targets—for children and for adults—
pneumonia in many countries, which is
Universal Health Coverage (UHC), as pneumonia careseeking and a suite of intervention targets and indicators to use as
now being exacerbated by COVID-19. Prior the basis for national pneumonia control strategies. COVID-19
is one of 16 indicators in the UHC Service Coverage Index that
to the pandemic, among the 20 countries measures national progress to UHC. has demonstrated the threat of respiratory infection and if all
with the largest numbers of pneumonia countries were actively working to protect their vulnerable
deaths, deaths were rising in eight. But if all governments adopted targets for pneumonia populations from all causes of pneumonia and measuring
Progress in reducing pneumonia deaths mortality and for coverage of the most critical interventions their progress each year, this would strengthen pandemic
(e.g., vaccines, nutrition, clean air, pulse oximetry, oxygen, preparedness and reduce the risk that future respiratory
has not kept pace with declines in other
and antibiotics) and regularly measured progress as part pandemics will kill millions more.
leading infectious disease killers. There is
of national child survival agendas, communicable and
also a persistent gender gap in pneumonia non-communicable disease strategies and pandemic LEARN MORE:
deaths, with more males than females preparedness plans, great progress towards the SDGs, UHC, Chan, M. & Lake, A., 2013. Integrated action for the
dying from pneumonia each year. The slow and future pandemic preparedness is possible. Despite this, prevention and control of pneumonia and diarrhoea. The
pace of progress in reducing pneumonia few high-burden countries have embraced the 2025 target for Lancet, 381(9876), pp.1436–1437. See also the Integrated
deaths poses a significant challenge for child pneumonia mortality—less than three child pneumonia Global Action Plan for Prevention and Control of Pneumonia
deaths per 1,000 lives births—established by the WHO and and Diarrhoea (GAPPD), 2013. Geneva: World Health
the achievement of the health-related
UNICEF in the Global Action Plan for the Prevention and Organization (WHO) and UNICEF, available at: https://
SDGs in many LMICs, especially the child Control of Pneumonia (GAPPD) and this is one of the reasons www.who.int/maternal_child_adolescent/news_events/
survival (3.2), communicable and non- so many are off-track to achieve this goal according to recent news/2013/gappd_launch/en/ , and the WHO GAPPD
communicable disease reduction (3.3, progress reports from the International Vaccine Access Monitoring Visualization Tool, available at: https://www.
3.4), and access to healthcare (3.8) goals. Center (IVAC) and the WHO GAPPD Monitoring Visualization who.int/maternal_child_adolescent/epidemiology/gappd-
These challenges will be most acute in the Tool. And in the absence of accepted pneumonia mortality monitoring/en/.
targets for adults, national infectious and non-communicable
countries with large burdens and/or very
disease plans do not set national pneumonia mortality targets. International Vaccine Access Centre (IVAC), 2020. Johns
high rates of child pneumonia deaths—
Pneumonia is the only major infectious disease killer without Hopkins Bloomberg School of Public Health. (2020).
almost all of them in Sub-Saharan Africa— specific mortality reduction targets across the life course. Pneumonia and Diarrhea Progress Report.Available at: https://
and in the countries with sharp increases www.jhsph.edu/ivac/wp-content/uploads/2020/11/IVAC_
in the number of pneumonia deaths among Although national targets exist for vaccine coverage, wasting PDPR_2020.pdf
the elderly, almost all of them middle- and reduction, air quality, and low birth weight they are not part of
high-income countries with heavy burdens pneumonia control strategies at the national level. And there Lam, F. et al., Good data is critical to equitably improve
are no coverage targets at all for pulse oximetry, oxygen, or oxygen access. A call to action to fill data gaps & ensure every
of COVID-19 deaths among older adults.
the recommended antibiotics for pneumonia treatment. The breath counts, on behalf of the Every Breath Counts Coalition
Every Breath Counts Coalition Indicators Working Group Indicators Working Group, 2020. Available at: https://
has recommended new pulse oximetry and oxygen service stoppneumonia.org/good-data-is-critical-to-equitably-
coverage indicators and called for their adoption by the major improve-oxygen-access-a-call-to-action-to-fill-data-gaps-
LMIC health facility data collection and management tools ensure-every-breath-counts/.
42 The Missing Piece World Pneumonia Day 43T
o reduce pneumonia deaths to the levels pneumonia countries. India alone is home to 20
required for the achievement of the million wasted children and has a wasting rate of
SDGs, countries will need to minimize 17.3%. 2.4 million (10.2%) of children in Indonesia
risk factors and improve coverage of the are wasted, 2.3 million (6.8%) in Nigeria, 2 million
most effective prevention, diagnostic, (7.1%) in Pakistan, 1.6 million (1.9%) in China, and 1.2
and treatment interventions, especially among the million each in Ethiopia (7.2%), Bangladesh (8.4%),
most vulnerable populations. Although there has and the Democratic Republic of Congo (8.1%).
been significant progress in reducing risk-related There are also large populations of wasted children
child pneumonia deaths in most countries, large in the Philippines (603,000), Tanzania (333,000),
populations of children remain exposed to wasting, Burkina Faso (286,000), and Brazil (262,000).8
air pollution, low birth weight, and other risks and Wasted children are further concentrated within
subsequently die from pneumonia (Chart 27). countries. For example, wasting rates across India
range from less than 1% to 19%, from less than 1%
The most urgent priority in pneumonia risk to 17% in Ethiopia, and from less than 1% to 15%
4
reduction is to further reduce child wasting. More in Nigeria and Pakistan.9 These very high sub-
than 70% of the estimated 47 million wasted national wasting rates far exceed the new global
children in the world live in the high-burden target of 3% by 2030.10
Chart 27: Risk-related child pneumonia deaths are
HOW
declining
Number of pneumonia deaths, 0-4 years 2000 2019
EFFECTIVELY All risk-related pneumonia deaths
0 400,000 800,000 1,200,000 1,600,000 Change
-58%
ARE PNEUMONIA Child Wasting
Household Air Pollution
-58%
-67%
DEATHS BEING Low Birth Weight
No Handwashing
-54%
-56%
PREVENTED?
Short Gestation -51%
Outdoor Air Pollution -37%
Child Stunting -67%
Child Underweight -68%
Non-exclusive Breastfeeding -59%
Secondhand Smoke -67%
High Temperature -47%
Low Temperature -74%
Source: Global Burden of Disease 2019
8 UNICEF, WHO, World Bank, 2020. Levels and Trends in Child Malnutrition. Key Findings of the 2020 Edition of the Joint Child Malnutrition Estimates. Geneva. Available at:
https://www.unicef.org/reports/joint-child-malnutrition-estimates-levels-and-trends-child-malnutrition-2020.
9 Institute for Health Metrics and Evaluation (IHME), 2020. Local Burden of Disease – Child Growth Failure. Seattle, WA: IHME, University of Washington. Available at: http://
vizhub.healthdata.org/lbd/cgf.
10 This extends the World Health Assembly target of 5% child wasting by 2025 to 3% by 2030.
44 The Missing Piece How effectively are pneumonia deaths being prevented? 45You can also read
