key: cord-0858423-rbvxpyt9
authors: Pandey, Abhishek; Galvani, Alison P
title: The burden of childhood pneumonia in India and prospects for control
date: 2020-08-19
journal: Lancet Child Adolesc Health
DOI: 10.1016/s2352-4642(20)30238-8
sha: aad05ced5d7417fb57a6a64a14858663e5601fa8
doc_id: 858423
cord_uid: rbvxpyt9

nan

others might not. Additionally, individual genetic variation in the three major histocompatibility complex (MHC) class 1 genes have been reported to affect the severity of SARS-CoV-2 infection, 14 which could also explain the manifestation of Kawasaki disease in some infected children observed in Europe and the USA who might share a different MHC class 1 gene from that of Asian children. Genetic studies in SARS-CoV-2-infected children worldwide can provide more information regarding the association of certain MHC class 1 genes with Kawasaki disease, MIS-C, or PIMS-TS.

More questions than answers emerge from our collective experience in managing children with COVID-19. Why is there a lack of description of this inflammatory clinical phenotype in the Asia-Pacific region? What is the natural history of the cardiac lesions associated with this clinical phenotype? More work remains to be done, especially in long-term follow-up of paediatric COVID-19 survivors.

We declare no competing interests. The authors would like to pay tribute to Tomisaku Kawasaki, who passed away at age 95 on June 10, 2020. 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.

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 Nikada/iStock Globally, neonatal conditions are the leading cause of reductions in disability-adjusted life-years and affect outcomes that extend throughout life. 1 Providing neonatal care to optimise such long-term outcomes is challenging because short-term research outcomes might conflict, even within individual trials. 2 Evidencebased guidelines are a welcome tool to translate research into practice and reduce variation in care. Such standardisation of care can improve outcomes for patients. For example, adherence to a standardised guideline for enteral feeding is protective against necrotising enterocolitis, despite the heterogeneity in the content of the individual guidelines. 3 The latest guideline by the UK's National Institute for Health and Care Excellence (NICE) on neonatal parenteral nutrition is a welcome addition to neonatal practice, and is particularly important given the deficiencies frequently found in the provision of neonatal nutritional care in the UK. 4 The guideline makes recommendations for both preterm and term neonates. For preterm neonates, the guideline recommends commencing parenteral nutrition for all babies born before 31 gestational weeks, for those unlikely to establish sufficient enteral feeding because of comorbidities, or where insufficient progress is made establishing enteral feeding in the first 72 h after birth. For term babies, the guideline recommends that parenteral nutrition be administered to babies who are unlikely to establish enteral feeding and to all babies for whom feeding has been stopped for more than 72 h. The guideline recommends administering parenteral nutrition via a central venous catheter whenever possible, and that a standardised bag should be used initially. The guideline details how blood variables should be monitored, and when parenteral nutrition should be discontinued. The recommendations are clear, should be straightforward to implement, and represent an effort to standardise what is considered to be good practice.

The guideline will affect the care received by thousands of babies in the UK each year, which makes it imperative that recommendations are based on robust evidence. Unfortunately, however, the evidence upon which this guideline is based is scarce. Although there are areas with considerable research to draw on, such as the composition of certain macronutrients, there is a paucity of evidence to inform other fundamental aspects, such as indications and timings for commencing parenteral nutrition in neonates. Guidelines should clearly reflect and acknowledge the quality of evidence on which they are based. The NICE's guideline on early onset sepsis has been criticised for an over-reliance on measurements of C-reactive protein of

National, regional, and state-level pneumonia and severe pneumonia morbidity in children in India: modelled estimates for

The Health Workforce in India. Geneva: World Health Organization

Reducing the impact of pneumonia in India. London: Save The Children

Government of India. Introduction of pneumococcal conjugate vaccine (PCV): National Operational Guidelines

Malnutrition and infection: complex mechanisms and global impacts

Malnutrition in India: status and government initiatives

Ministry of Petroleum and Natural Gas