The Missing Piece: why the global pandemic is an inflection point for pneumonia control

“Why have health systems everywhere been so ineffective in the face of a respiratory pandemic?”

The world has experienced another global pandemic of respiratory infection more devastating than the 1918 viral influenza pandemic for many countries. To date, COVID-19 has officially killed 4.8 million people and unofficially five to 10 times more.

Despite the existence of effective vaccines emerging with impressive speed early in the pandemic, governments everywhere are still scrambling to reduce the death toll. Most were ill-equipped to deal with waves of COVID-19 patients needing respiratory care, especially oxygen.

Lack of access to treatment continues to cause many COVID-19 deaths, especially in low- and middle-income countries (LMICs).

Why have health systems everywhere been so ineffective in the face of a respiratory pandemic?

After all, pneumonia has been the leading infectious cause of death in the world for a long time. Prior to the pandemic, an estimated 2.5 million adults and children died from it each year, according to the Global Burden of Disease (GBD) – far more than HIV/AIDS, tuberculosis and malaria. All countries were affected.

In 2019, pneumonia deaths clustered among children under five in low-income countries and among adults aged over 69 in high-income countries. And there were many middle-income countries carrying “double-burdens” of pneumonia among both populations.

So, if pneumonia was truly a “global health” issue, why weren’t we better prepared for COVID-19?

Pneumonia has been the single biggest “missing piece” on the global health agenda for decades. There is no global goal for reducing pneumonia deaths and no global health agency responsible for supporting countries to prevent, diagnose and treat pneumonia. Even with Gavi’s mandate to vaccinate the world’s most vulnerable children, half did not receive all the pneumonia-fighting vaccines in 2019. 

With little support from global health agencies, governments struggled to protect their populations from pneumonia in the decade leading to the pandemic. With air pollution, child malnutrition, and tobacco smoking exposing vast populations to respiratory infections – and with hospitals lacking the tools (e.g., pulse oximetry and oxygen) and the staff trained to respond – pneumonia deaths barely declined over the period.

Enter the pandemic and the full scale of the tragedy emerged. Beginning with reports of oxygen shortages and deaths in Latin America in the summer of 2020, the crisis quickly spread to Asia, the Middle East, Eastern and Central Europe, and Africa, peaking in India in May 2021. Between March and August alone, COVID-19 officially killed 270,000 people in India driving global COVID-19 oxygen needs to a record peak.*

*In May 2021 all LMICs needed 28 million cubic meters of oxygen per day just to treat COVID-19 patients according to the COVID-19 Oxygen Needs Tracker.

“Nations must never again be blindsided by another respiratory pandemic and suffer mass fatalities as a result.”

How many of these deaths could have been prevented if health systems were equipped to effectively treat respiratory infections we don’t know.  But the numbers may be in the millions.

What is clear is that the COVID-19 pandemic must be an inflection point for pneumonia control in every country. Nations must never again be blindsided by another respiratory pandemic and suffer mass fatalities as a result. They must begin to address their massive burdens of pneumonia from other causes among both children and adults. If they don’t, they will remain dangerously exposed to another respiratory pandemic and at risk of failing to achieve many of the Sustainable Development Goals (SDGs) for health, especially reducing maternal, newborn and child deaths (SDGs 3.1, 3.2) and communicable and non-communicable disease burdens (SDGs 3.3, 3.4).

Why? Because the tools that reduce pneumonia deaths will also reduce deaths from these other causes and conditions.

The Missing Piece makes the case for a total reboot of the way governments and global health agencies invest in pneumonia. Many have already begun to do so in response to the pandemic and shouldn’t stop once the pandemic is over. 

National governments should turn their pandemic response plans into Pneumonia Control Strategies to drive declines in deaths from all-cause respiratory infections over the next decade and reduce the risk of another respiratory pandemic. They should set ambitious pneumonia mortality reduction targets for both children and adults and ensure that interventions are targeted to the populations at greatest risk of death. The costs of pneumonia vaccinations, diagnostic tests, and treatments should be covered as part of Universal Health Coverage (UHC) so that patients don’t incur massive bills.

For the countries which cannot cover these costs from national budgets, global health agencies should continue to provide the financial support they initiated during the pandemic. Gavi should keep subsidizing COVID-19 vaccinations among adults, and add pneumococcal, influenza, and RSV (when available) to the list. UN agencies (e.g., Unitaid, WHO, UNICEF, UNDP, UNOPS, etc) should continue to finance diagnostic tools and treatments for respiratory infections, especially pulse oximetry and oxygen.

And private philanthropies (e.g., Wellcome Trust, Bill & Melinda Gates Foundation, ELMA Philanthropies, Skoll Foundation, etc.) should continue to support local non-government organizations to strengthen respiratory care services that serve the most vulnerable.

Although COVID-19 exposed the tragic flaw in the global health architecture, it has also revealed just how much global health agencies and their donors can do when pressed to invest in pneumonia control. When the leading infectious killer is also prone to devastating pandemics, the cost of not prioritizing it will be measured in millions of lives lost every year and millions more every time a respiratory infection pandemic strikes.

This is the only way that a world in which pneumonia deaths and pandemics are rare in every country is achievable. 

Read the full report here and support by sharing on twitter via @Stop_Pneumonia and @JustActions.

The Missing Piece report was launched on 11 October 2021.