In 2013, the World Health Organization and UNICEF set the gold standard for integrated approaches with the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD). The plan marked a new chapter in efforts to curb pneumonia and diarrhea, the top infectious disease killers of children under age five worldwide. Bold and comprehensive, the GAPPD recognized that effectively addressing these scourges would require multiple approaches and leveraging overlapping tools in an integrated way.
Today, we’re up against another global challenge—the COVID-19 pandemic. The coronavirus responsible causes respiratory disease, and some of those infected go on to develop pneumonia. As the world grapples with how to bring COVID-19 under control, guidelines like GAPPD have long-standing wisdom to impart about integrated approaches to respiratory disease and why they’re so important. For nations with limited resources, large disease burdens, and weak health care systems, the stakes couldn’t be higher.
Why integration?
Severe respiratory disease has many causes, and people don’t live their day-to-day lives in programmatic siloes. Therefore, one solution simply isn’t enough. Thankfully, it’s possible to address multiple challenges at once—and conserve public health resources in the process—by deploying a suite of measures and tapping their overlapping potential. This principle forms the backbone of strategies long in play against pneumonia. Similarly, multi-pronged COVID-19 response approaches (vaccine development/deployment, drug development, testing, mask mandates, handwashing, physical distancing, etc.) are being implemented around the world.
So, what is the full suite of time-tested pneumonia tools and strategies to lean on in the COVID-19 era?
Pneumonia tools (orange) and diarrhea control tools (dark blue) share a suite of complementary and overlapping interventions (light blue), including respiratory care (not pictured), that could also help with COVID-19. Image courtesy of DefeatDD.org.
Preventing disease in the first place
The key to saving lives? Stopping infections before they start.
Respiratory diseases like COVID-19 are commonly spread by exposure to droplets from an infected person’s sneeze or cough, or from contact with contaminated surfaces. That means poor hygiene, poor sanitation, and overcrowding are important drivers of transmission. Underlying health conditions resulting from malnutrition, poor air quality, and other diseases can compound things, making infections easier to get and more likely to become severe.
For these reasons, PATH and partners are supporting a combination of interventions that can prevent infection or reduce the chance of developing severe disease like handwashing with soap, basic sanitation, clean water, good nutrition, clean cookstoves to reduce indoor and outdoor air pollution, and exclusive breastfeeding.
Vaccines are another key in prevention. They are a global health best buy and a first line of defense against respiratory diseases, including many that PATH works on such as pneumococcus, respiratory syncytial virus, influenza, pertussis, group B Streptococcus, Nipah virus—and COVID-19. In immunization, PATH leverages decades of hands-on experience developing, introducing, and improving vaccines and immunization technologies in multisector partnerships with manufacturers and resource-limited countries to advance and sustain country goals for immunization equity and vaccination coverage.
As the race to rollout COVID-19 vaccines remains an urgent global priority, we must also ensure that other important vaccines can be within reach for everyone who needs them. These efforts are especially critical now for epidemic response and preparedness because they protect people with underlying health problems, relieve overburdened health systems, and prevent co-infections where COVID-19 infection increases susceptibility. Furthermore, more affordable and accessible vaccines for pneumonia (like the newest pneumococcal vaccine becoming available in Indiaand other countries) are crucial for freeing up healthcare resources and enabling herd immunity (a community-level cocoon of immunity that interrupts transmission and protects the most vulnerable).
“Gaining the upper hand on any severe respiratory disease requires addressing it from multiple angles and leveraging tools in an integrated way.”
Access to diagnostics and treatment
When respiratory infections do take hold, early access to diagnostics and treatment saves lives. To meet these needs, PATH and partners have been working to break down barriers and improve access to these critical tools, including reliable oxygen delivery systems, improved access to pulse oximeters and clinical decision support algorithms, and research to optimize amoxicillin for low-resource settings.
By afflicting the lungs, pneumonia (COVID-19-related or otherwise) can result in fatal oxygen deficiency in the blood, or hypoxemia. Many such deaths could be prevented with reliable access to oxygen paired with pulse oximetry, but many health facilities are not equipped to treat hypoxemia, especially beyond surgical wards.
The COVID-19 pandemic has put unprecedented emphasis on the role of medical oxygen as a lifesaving therapy for patients struggling to breathe but has also pushed to the surface a long-existing oxygen access gap. It showcased an overwhelming demand for oxygen technologies and supplies across health facilities in many countries, especially where that balance is already threatened. Closing this gap will require an integrated set of solutions and investment in strengthening the oxygen delivery systems—for COVID-19 and beyond.
A graphic developed for the Markets Matter: Closing the Oxygen Gap campaign, an international effort to increase access to lifesaving medical oxygen during COVID-19 and beyond.
As the pandemic continues to highlight the need for readily available diagnostics like COVID-19 testing, we must also prioritize additional tools to help healthcare workers identify pneumonia and other leading causes of illness and death in children. Devices like pulse oximeters that measure the amount of oxygen in the blood, or clinical decision support algorithms that help process patient information and symptoms through digital applications, are key for alerting health workers to signs of severe disease. While these tools are routinely used in some countries, barriers related to demand, supply, and adoption prevent access in some low-resource settings.
Additionally, the recommended first-line treatment for bacterial childhood pneumonia is the antibiotic amoxicillin. In its traditional forms, however, it can be difficult to use in some settings because of factors like heat and light sensitivity and the need for precise measurement. Solutions to resolve these barriers are critical to ensuring equity of access.
Overall, success will require commitment from health program leaders to pass policies; finance training, procurement, and maintenance; and increase awareness of the burden of pneumonia and the importance of proper detection and treatment at all levels of care and politics.
From integration to impact
PATH has a long history of working alongside countries, NGOs, and other partners to apply multi-pronged strategies in communities bearing the greatest disease burdens. Together, we’ve made remarkable progress by evolving global and national policies, strengthening primary health care systems, and improving the reach of lifesaving tools.
For instance, since 2012, annual childhood pneumonia deaths have fallen by nearly 30 percent—from roughly 1.1 million to 800,000. Diarrhea deaths have also seen dramatic reductions, offering another set of complementary insights. Households and communities, more broadly, have also benefited from many of these interventions, enabling healthier lives for all.
Despite these gains, however, pneumonia remains the world’s deadliest infectious disease. In fact, many countries have fallen short of the GAPPD targets, which has meant pneumonia death reductions have not kept pace with other infectious diseases efforts. It also means that many countries may fail to reach the 2030 health targets laid out in the UN Sustainable Development Goals. COVID-19 will further derail what progress has been made—unless concerted investment is made to push progress forward.
As COVID-19 takes us into the unknown, it’s important (and perhaps comforting) to remember that well-established lessons from pneumonia control can make a huge difference, especially in countries and communities where health inequities make the challenge even greater. We know that the odds of success are better when the full suite of tools can meet its full, equitable potential.
