The burden of childhood pneumonia in India and prospects for control

Pneumonia continues to be the leading cause of mortality in children worldwide, with India accounting for 20% of those deaths and a higher burden of childhood pneumonia than any other country.¹ In The Lancet Child & Adolescent Health, Brian Wahl and colleagues² report the first comprehensive evaluation of state-specific pneumonia incidence in children in India using a risk factor-based modelling approach. By calculating the effect of temporal changes in prevalence of well-known pneumonia risk factors such as malnutrition, incomplete immunisation, and exposure to indoor air pollution on incidence, the authors estimated the change in pneumonia morbidity over time. Wahl and colleagues obtained individual-level data from the National Family Health Survey in India to model the number of children with each combination of risk factors, thereby accounting for interactions between risk factors, which is a novel aspect of the study when compared with previous models that have considered that the prevalence of risk factors were independent.² Vital insights obtained from this study regarding national and subnational estimates of pneumonia burden could inform data-driven interventions to address pneumonia morbidity.² At the national level, the estimated number of pneumonia cases in Indian HIV-uninfected children markedly reduced from 83·8 million cases (95% uncertainty interval [UI] 14·0–300·8) in 2000 to 49·8 million cases (9·1–174·2) in 2015. State-level estimates highlight the considerable heterogeneity in incidence and progress towards mitigation that exists between states. In Uttar Pradesh and Madhya Pradesh, more than half of all children aged younger than 5 years were estimated to have pneumonia in 2015 (565 cases per 1000 children [95% UI 94–2047] in Uttar Pradesh; 563 cases per 1000 children [88–2084] in Madhya Pradesh). By contrast the states of Kerala and Tamil Nadu had the lowest incidence of pneumonia (137 cases per 1000 children in Kerala and 169 per 1000 children in Tamil Nadu).² Although a considerable need for progress remains throughout India, the reductions in pneumonia incidence observed in Kerala and Tamil Nadu between 2000 and 2015, can inform strategies to achieve comparable reductions in other states and other countries.

Since the health-care system in India is primarily administered by the 36 states and union territories, subnational policies and investments are fundamental to health outcomes. Kerala and Tamil Nadu have among the highest per-capita health expenditure in India, although these states are not the most affluent. The number of health-care workers per 100 000 population in 2001, was substantially higher in Kerala (394) and Tamil Nadu (223) than Bihar (110) and Uttar Pradesh (135).³ Additionally, disparities in public health services between rural and urban areas are the lowest in Kerala and Tamil Nadu. By contrast, childhood mortality varies markedly between rural and urban areas in Uttar Pradesh and Bihar. The availability of health care also affects the likelihood that people will seek care for pneumonia. Specifically, 90% of people in rural Kerala seek care for pneumonia compared with 60% of people in rural Bihar.⁴ A pentavalent vaccine for Haemophilus influenzae type b, a leading bacterial cause of pneumonia and meningitis, was introduced in Kerala and Tamil Nadu before expansion to the rest of the country by the end of 2015.

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In 2010, pneumococcal pneumonia was estimated to account for 30% of all pneumonia deaths in India.⁵ In 2017, the Ministry of Health and Family Welfare of India allocated national funding to offer the pneumococcal conjugate vaccine, with prioritised roll-out to the states with the highest pneumonia burden. Application of the methodology developed by Wahl and colleagues to district-level data on risk factors for pneumonia will also facilitate prioritisation within states.

At present, India has the largest population of children (<14 years) worldwide. To enable these children to have a healthy and productive life, it is imperative to mitigate the challenge of pneumonia through the implementation of multifaceted preventive measures. Several policies, including improving nutrition and reducing pollution, which could reduce pneumonia incidence, are also aligned with the UN Sustainable Development Goals and have effects on other diseases. For example, malnutrition in children is recognised as a risk factor for many diseases such as HIV, tuberculosis, and malaria.⁶ Therefore, Indian Government initiatives such as the Integrated Child Development Service programme, the National Health Mission, and the Village Health Sanitation and Nutrition Committee will also be instrumental in reducing the burden of pneumonia.⁷ Another national programme, Pradhan Mantri Ujjwala Yojana,⁸ which aims to replace unclean cooking fuel in rural Indian households with liquid petroleum gas for cooking, will also minimise indoor pollution, a key risk factor for pneumonia.

The nationwide lockdown implemented in India from March 24 to July 3, 2020, to combat COVID-19 has interrupted provision of these services. Moreover, economic repercussions of the COVID-19 pandemic might delay the expansion of the pneumococcal conjugate vaccine, which could potentially stall progress towards decreasing the burden of pneumonia. Future studies investigating the cost-effectiveness of preventive measures for pneumonia across other diseases could supplement the findings of Wahl and colleagues, and lead to the galvanisation of resources required to strengthen and expand these vital interventions.