South-East Asia Regional Conference on Epidemiology

<strong>South</strong>-<strong>East</strong> <strong>Asia</strong> <strong>Regional</strong> <strong>Conference</strong> on Epidemiology | 181
The aetiology of pneumonia is quite varied. Available data suggest that pneumococcus is a
significant cause of pneumonia in children (30% to 50%), followed by Haemophilus influenzae type
b (Hib) (10% to 30%) and Staphylococcus aureus. Among viruses, respiratory syncytial virus (RSV)
has been associated with 15% to 40% of childhood pneumonia or bronchitis, with recent evidence
indicating that influenza viruses are emerging as major contributors. Recent data from urban Dhaka
show that about 28% of influenza-positive cases in children eventually develop into pneumonia.
The risk factors for childhood pneumonia fall into three categories. These are (a) definite risk factors:
malnutrition and low birth weight, non-exclusive breastfeeding, lack of measles immunization, indoor
air pollution and crowding; (b) likely risk factors: parental smoking, nutritional zinc deficiencies,
mother’s inexperience as a caregiver and other concomitant diseases such as diarrhoea; and (c)
possible risk factors, which commonly underlie many of the cases: mother’s education or lack of it,
daycare, rainfall (humidity), high altitude (cold air), vitamin A deficiency, birth disorder and outdoor
air pollution.
Some of the pneumonia risk factors are generally high in the countries in the Region, e.g. low birth
weight and stunting. The incidence of low birth weight is very high in Bangladesh, India, Maldives,
Nepal and Sri Lanka. Only Indonesia and Thailand report low levels of low birth weight. Stunting is
also very common in Bangladesh, India and Nepal. Sanitation facilities are not adequate except in Sri
Lanka and Thailand. Immunization coverage is high in most countries with the exception of India.
The rates of exclusive breastfeeding in children aged less than six months are not high in any of the
countries in the Region, except DPR Korea.
In general, there is a scarcity of pneumonia treatment coverage data in the Region. The proportion
of children with pneumonia taken to an appropriate health-care provider ranges from as low as 22%
in Maldives to as high as 93% in DPR Korea. The coverage is 30% in Bangladesh, 60% in India and
84% in Thailand. There is much less data available on the key treatment intervention, i.e. whether
or not a child with pneumonia received antibiotics. There is no national monitoring of this indicator,
in contrast to the routine data collection and reporting on children with diarrhoea receiving oral
rehydration solution (ORS).
Bangladesh provides an interesting case-study on interventions that are important in preventing
and treating pneumonia and diarrhoea. It is one of the few countries with a fairly high rate of ORS use.
The data from the last five Demographic and Health Surveys (DHS) show an increased use of ORS.
In the last survey in 2007, about 81% cases reported using ORS for diarrhoea in the previous two
weeks, and the rate was similar in both urban and rural areas. This possibly partly explains the large
decline seen in the deaths due to diarrhoea in the country. There is anecdotal evidence from ongoing
research to suggest that the incidence of diarrhoea may also be going down in the country. In contrast,
the pneumonia treatment rate and mortality (as proportion) has remained static over these years.
An explanation for this is that the risk factors, behaviours and practices associated with pneumonia
have not changed much over the years. There has been no change in exclusive breastfeeding rates
in Bangladesh. The last DHS survey showed a slight improvement in the early ages but no overall
improvement in exclusive breastfeeding rates. Improvement in the nutritional status has been quite
small; stunting has declined 16% between 2004 and 2007. However, there are large differentials in
stunting by economic conditions, with the poorest having more than twice the burden of stunting than
the least poor.
In Bangladesh, appropriate care-seeking for childhood pneumonia has remained more or less static
over the years. Care-seeking from health facilities or health workers remained between 40%-50% in
urban areas and 20%-30% in rural areas (Fig. 1). In the last DHS of 2007, there were huge disparities
in care-seeking from health facilities or health workers with 17% among the poorest and 60% among
the least poor - a more than threefold differential (Fig. 2). Care-seeking is affected by distance from