WEEKLY EPIDEMIOLOGICAL REPORT

A publication of the Epidemiology Unit

Ministry of Health, Nutrition & Indigenous Medicine
231, de Saram Place, Colombo 01000, Sri Lanka
Tele: + 94 11 2695112, Fax: +94 11 2696583, E mail: epidunit@sltnet.lk
Epidemiologist: +94 11 2681548, E mail: chepid@sltnet.lk
Web: http://www.epid.gov.lk

Vol. 43 No. 50 03th 09th December 2016

Pneumonia - the child killer
Pneumonia is a form of acute respiratory infection that one of the commonest causes of pneumonia, responsi-
affects the lungs. Pneumonia accounts for 16% of all ble for at least one quarter of all pneumonia deaths in
deaths of children under 5 years old, killing 920 136 chil- HIV-infected infants.
dren in 2015. Pneumonia can be caused by viruses, bac- However, more specific information for the aetiology of
teria, or fungi. Pneumonia can be prevented by immuniza- childhood pneumonia is not available. Research is ur-
tion, adequate nutrition, and by addressing environmental gently needed to better describe the distribution of pneu-
factors. Pneumonia caused by bacteria can be treated monia by its causes. Knowing which pathogens lead to
with antibiotics, but only one third of children with pneumo- pneumonia is critical for guiding treatment and policies.
nia receive the antibiotics they need. Pneumonia is the
Symptoms
single largest infectious cause of death in children world-
wide. Children with pneumonia may have a range of symptoms
depending on their age and the cause of infection. Bacte-
Pneumonia affects children and families everywhere, but
rial pneumonia usually causes children to become se-
is most prevalent in South Asia and sub-Saharan Africa.
verely ill with high fever and rapid breathing. Viral infec-
Children can be protected from pneumonia; it can be pre-
tions, however, often come on gradually and may worsen
vented with simple interventions, and treated with low-
over time. Some common symptoms of pneumonia in
cost, low-tech medication and care.
children and infants include rapid or difficult breathing,
According to the latest WHO data published in 2014, Influ- cough, fever, chills, headaches, loss of appetite and
enza and Pneumonia deaths in Sri Lanka reached 7 292 wheezing. Children under five with severe cases of pneu-
(5.7%) of total deaths. The age adjusted death rate was monia may struggle to breathe, with their chests moving in
35.08 per 100 000 of population. or retracting during inhalation (known as lower chest wall
In Sri Lanka, 21,111 and 21,811 cases of pneumonia and indrawing). Young infants may suffer convulsions, uncon-
1417 and 1448 deaths due to this disease had been re- sciousness, hypothermia, lethargy and feeding problems.
ported for years 2005 and 2006 respectively. Forty per- How is pneumonia diagnosed?
cent of these pneumonia cases were among children
Chest X-rays and laboratory tests are used to confirm the
under 4 years of age.
presence of pneumonia, including the extent and location
Causes of pneumonia of the infection and its cause. But in resource-poor set-
Data on the pathogen-specific causes of pneumonia are tings without access to these technologies, suspected
limited, and available information is often difficult to inter- cases of pneumonia are diagnosed by their clinical symp-
pret. It is known that the bacterial pathogen Streptococcus toms. Children and infants are presumed to have pneumo-
pneumoniae is the leading cause of severe pneumonia nia if they exhibit a cough and fast or difficult breathing.
among children across the developing world. Bacteria also Caregivers, therefore, have an important role to play in
contribute to non-severe pneumonia cases, but to a lesser recognizing the symptoms of pneumonia in children and
extent, and more cases are probably of viral origin. An- seeking appropriate medical care as necessary.
other major cause is the bacterial pathogen Haemophilus Transmission
influenzae type b (Hib). Other pathogens include important
Pathogens causing pneumonia may reach the childs
viruses, less common bacteria and fungi.
lungs through different routes. Although information on the
Causes of pneumonia can be summarized as follows. pathogenesis of childhood pneumonia is limited, it is
Streptococcus pneumoniae the most common cause widely believed that common bacterial pathogens causing
of bacterial pneumonia in children; pneumonia are often already present in a childs nose or
throat and are then inhaled into the lungs, causing infec-
Haemophilus influenzae type b (Hib) the second tion. Pathogens may also be spread through contaminated
most common cause of bacterial pneumonia; air droplets or may result from blood-borne infections.

respiratory syncytial virus is the most common viral

During or shortly after birth, babies are at higher risk of
developing pneumonia from coming into contact with or-
cause of pneumonia;
ganisms in the birth canal or from contaminated sub-
in infants infected with HIV, Pneumocystis jiroveci is stances contacted during delivery.
Contents Page
1. Leading Article Pneumoniathe child killer 1
2. Summary of selected notifiable diseases reported -(26th 02nd December 2016) 3
3. Surveillance of vaccine preventable diseases & AFP -(26th 02nd December 2016) 4
WER Sri Lanka - Vol. 43 No. 50 03rd09th December 2016
Why are children vulnerable? referred to a hospital or clinic for treatment. Treatment regimens will
A healthy child has many natural defences that protect its lungs from need to be chosen based on their efficacy in local settings.
the invading pathogens that cause pneumonia. However, children and Once a child develops pneumonia, a caregiver must recognize the
infants with compromised immune systems have weakened defences. symptoms and seek appropriate care immediately. Since a large pro-
Undernourished children, particularly those not exclusively breastfed or portion of severe pneumonia cases in children of the developing world
with inadequate zinc intake, are at higher risk of developing pneumo- is caused by bacterial pathogens, prompt treatment with a full course
nia. Similarly, children and infants suffering from other illnesses, such of effective antibiotics is the key to reducing pneumonia deaths.
as AIDS or measles, are more likely to develop pneumonia. Environ- Three essential steps are needed to reduce deaths among chil-
mental factors, such as living in crowded homes and exposure to pa- dren under five with pneumonia:
rental smoking or indoor air pollution, may also have a role to play in
1. Recognize a child is sick
increasing childrens susceptibility to pneumonia and its severe conse-
quences. 2. Seek appropriate care

Prevention 3. Treat appropriately with antibiotics

RECOGNITION OF PNEUMONIAS DANGER SIGNS
Preventing children from developing pneumonia in the first place is
essential for reducing child deaths. Recognizing the symptoms of pneumonia is the first step in reducing
deaths among children under five. Caregivers play a critical role in
Immunization against Hib, pneumococcus, measles and whooping
recognizing pneumonias symptoms and immediately seeking appro-
cough (pertussis) is the most effective way to prevent pneumonia.
priate care for their sick children. Indeed, it is critical that caregivers
Adequate nutrition is key the to improving children's natural de- understand the importance of this disease and the risk it poses to their
fences, starting with exclusive breastfeeding for the first six months childrens health. Yet, even though pneumonia is the leading killer of
of life. This is also effective in preventing pneumonia and reducing children in the developing world, only 1 of every 5 caregivers knows
the length of the illness. the two tell-tale symptoms of pneumonia: fast breathing and difficult
Addressing environmental factors such as indoor air pollution (by breathing.
providing affordable clean indoor stoves, for example) and encour- The following graph shows the % caregivers who know that difficult or
aging good hygiene in crowded homes also reduces the number of fast breathing is a sign to seek care immediately
children who fall ill with pneumonia.
In children infected with HIV, antibiotics can be given daily to de-
crease the risk of contracting pneumonia.
Recent research also suggests that hand washing may play a role
in reducing the incidence of pneumonia.
To protect children from pneumonia globally, WHO and UNICEF
have developed the Global Action Plan for the prevention and con-
trol of Pneumonia (GAPP). The aim of the GAPP is to increase Data from UNICEF-supported Multiple Indicator Cluster Surveys
awareness of pneumonia as a major cause of child death and spur (MICS) 1999-2001
action to deal more effectively with the problem.
Home treatment of pneumonia
The Global action plan for the prevention and control of pneumonia
(GAPP) includes recommendations on what needs to be done, specific Treating children with severe pneumonia at home is just as effective as
goals and targets, and estimates of what it will cost and how many treating them in hospitals, a new study has found. The study results
lives will be saved. Its aim is to increase awareness of pneumonia as a could significantly change the way the illness is managed in develop-
major cause of child deaths, and it calls on global and national policy- ing countries, saving a significant number of lives every year and tak-
makers, donor agencies and civil society to take immediate action to ing pressure off health systems.
implement the plan. In a research, conducted in Pakistan by researchers from the Boston
The GAPP has a three-pronged vision: University School of Public Health and supported by WHO and the
U.S. Agency for International Development (USAID), which was pub-
Protecting every child by providing an environment where they are lished in The Lancet medical journal, 2037 children with severe pneu-
at low risk of pneumonia (with exclusive breastfeeding for six monia were randomly assigned to get either injectable antibiotics in a
months, adequate nutrition, preventing low-birth-weight, reducing hospital or antibiotic pills at home. The trial was the first to compare
indoor air pollution, and increasing hand washing); the outcomes of hospital treatment of severe pneumonia with home-
Preventing children from becoming ill with pneumonia (with vaccina- based treatment, and the results demonstrate the safety and efficacy
tion against its causes: measles, pertussis, Streptococcus pneumo- of treating it with oral antibiotics outside a hospital setting.
niae and Haemophilus influenzae b, as well as preventing and treat- In the study, there were 87 (8.6%) treatment failures in the hospitalized
ing HIV in children, and providing zinc for children with diarrhoea); group, and 77 (7.5%) in the group treated at home. Of the five children
Treating children who become ill with pneumonia with the right care (0.2%) who died during the study, four were in the hospitalized group
and antibiotics (in communities, health centres and hospitals). and one was at home.
Treatment This study confirmed the findings of three other trials in Africa, Asia,
Prompt treatment of pneumonia with a full course of appropriate antibi- Europe and Latin America, which showed that oral antibiotics were just
otics is lifesaving. Cotrimoxazole and amoxicillin are effective drugs as effective as injectable antibiotics in treating hospitalized children
against bacterial pathogens and are often used to treat children with with severe pneumonia.
pneumonia in developing countries. Infants under two months with Source:
signs of pneumonia/sepsis are at risk of suffering severe illness and Pneumonia the forgotten killer of children WHO/ UNICEF
death more quickly than older children, and should be immediately
Annual health bulletin 2005-2006

Page 2
 RDHS Dengue Fever Dysentery Encephaliti Enteric Fever Food Leptospirosis Typhus Viral Human Chickenpox Meningitis Leishmani- WRCD
Division s Poisoning Fever Hepatitis Rabies asis

A B A B A B A B A B A B A B A B A B A B A B A B T* C**
Colombo 158 14547 2 169 0 13 1 56 0 65 3 280 1 9 2 48 0 0 5 437 1 58 0 0 81 100
Gampaha 23 6051 0 149 0 14 0 27 0 93 0 318 0 18 0 52 0 1 0 378 0 48 0 7 33 87

Kalutara 28 3136 1 111 0 10 0 33 5 41 1 412 0 8 0 31 1 3 2 286 1 98 0 0 79 93

Kandy 32 3794 2 151 0 18 0 22 0 40 1 113 2 96 0 49 0 0 4 238 2 47 0 11 91 100

Matale 19 1043 0 64 0 1 0 16 0 4 1 87 0 20 0 25 0 1 0 37 1 62 0 23 69 92

NuwaraEliya 0 390 1 106 0 3 0 57 0 36 1 66 2 84 0 38 0 0 1 151 3 50 0 0 62 85

Galle 33 2436 1 140 0 8 0 9 0 10 6 333 1 111 0 9 0 0 7 284 0 38 0 3 65 90

Hambantota 21 767 1 82 0 1 0 5 0 61 3 103 1 65 2 104 0 0 1 219 0 15 16 376 83 100

WER Sri Lanka - Vol. 43 No. 50

Matara 12 1205 1 114 0 16 0 8 0 39 5 191 0 56 0 41 0 0 2 180 2 29 0 189 94 94

Jaffna 67 2094 15 367 2 12 1 85 4 123 0 21 5 615 1 10 0 1 0 169 1 65 0 1 92 92

Kilinochchi 0 76 1 49 0 2 0 36 0 76 0 16 0 26 0 2 0 0 0 10 0 11 0 0 75 75

Mannar 6 160 0 46 0 4 0 23 1 12 0 11 0 42 0 0 0 0 0 7 0 4 0 0 80 80

Vavuniya 9 244 1 16 0 5 1 98 1 45 3 18 0 11 0 6 0 0 0 33 0 10 0 7 100 100

Mullaitivu 0 170 0 29 0 5 0 19 0 41 0 24 0 6 0 2 0 1 0 25 0 11 0 6 60 80
Batticaloa 10 496 5 314 0 5 1 52 1 99 0 49 0 6 0 13 0 1 6 110 1 20 0 1 79 93

Ampara 3 232 0 50 1 3 0 1 0 21 0 26 0 0 0 11 0 0 1 169 0 5 1 9 71 86

Trincomalee 1 372 1 57 0 2 0 13 0 25 0 35 1 26 0 34 0 2 4 162 0 15 1 17 67 75

Kurunegala 24 2320 10 318 0 12 0 4 0 19 5 160 0 45 0 34 0 4 11 393 6 70 2 103 79 93
Table 1: Selected notifiable diseases reported by Medical Officers of Health

Puttalam 16 980 2 98 0 5 0 7 1 3 0 52 0 61 0 3 0 3 3 95 5 80 0 4 71 79

Anuradhapura 3 671 5 127 1 4 1 12 0 34 3 265 1 26 1 40 0 1 2 262 0 48 4 256 63 89

Polonnaruwa 0 433 0 45 0 4 0 12 0 15 0 89 0 4 0 5 0 0 2 149 0 21 4 129 57 100

Badulla 17 1052 9 138 0 13 0 13 0 32 2 133 1 114 2 123 0 1 8 251 1 201 0 3 76 88

Monaragala 6 413 1 127 0 1 0 5 0 11 1 64 2 124 1 147 0 2 2 87 1 26 0 39 82 100

Ratnapura 29 2838 5 353 0 33 1 29 0 25 13 591 0 40 5 208 0 0 7 250 1 160 0 1 67 83

Kegalle 11 1375 1 80 1 20 0 33 0 58 2 177 4 39 0 33 0 0 3 324 1 57 1 3 73 100

Kalmune 6 638 5 106 1 7 0 5 0 64 0 21 0 0 0 7 0 4 3 114 0 29 0 0 62 77

SRILANKA 534 47933 70 3406 6 221 6 680 13 1092 50 3755 21 1652 15 1075 1 25 74 4820 27 1278 29 1188 74 90
Source: Weekly Returns of Communicable Diseases (WRCD).
*T=Timeliness refers to returns received on or before 02nd December, 2016 Total number of reporting units 339 Number of reporting units data provided for the current week: 312 C**-Completeness
03rd09th December 2016
26th 02nd Dec2016 (49th Week)

Page 3
A = Cases reported during the current week. B = Cumulative cases for the year.
WER Sri Lanka - Vol. 43 No. 50 03rd09th December 2016
Table 2: Vaccine-Preventable Diseases & AFP 26th 02nd Dec2016 (49th Week)
Number of Number of
Total Difference
No. of Cases by Province cases cases Total num-
number of between the
during during ber of cases
Disease current same
cases to
to date in
number of
date in cases to date
week in week in 2015
W C S N E NW NC U Sab 2016 in 2016 & 2015
2016 2015

AFP* 00 00 00 00 00 00 00 00 00 00 00 62 65 -4.6%

Diphtheria 00 00 00 00 00 00 00 00 00 00 00 00 00 0%

Mumps 02 00 00 01 01 03 00 01 00 08 08 379 366 +3.5%

Measles 01 00 00 00 01 00 01 00 00 02 13 370 2549 -85.4%

Rubella 00 00 00 00 00 00 00 00 00 00 00 11 08 +37.5%

CRS** 00 00 00 00 00 00 00 00 00 00 00 00 00 0%

Tetanus 00 00 00 00 00 00 00 00 00 00 00 10 16 -37.5%

Neonatal Teta-
nus
00 00 00 00 00 00 00 00 00 00 00 00 00 0%

Japanese En-
cephalitis
03 00 00 00 00 00 00 00 00 03 01 21 13 +61.5%

Whooping
Cough
00 00 01 00 00 00 00 00 00 01 03 67 101 -33.6%

Tuberculosis 96 13 15 02 09 12 11 01 01 160 185 8668 9191 -5.6%

Key to Table 1 & 2

Provinces: W: Western, C: Central, S: Southern, N: North, E: East, NC: North Central, NW: North Western, U: Uva, Sab: Sabaragamuwa.
RDHS Divisions: CB: Colombo, GM: Gampaha, KL: Kalutara, KD: Kandy, ML: Matale, NE: Nuwara Eliya, GL: Galle, HB: Hambantota, MT: Matara, JF: Jaffna,
KN: Killinochchi, MN: Mannar, VA: Vavuniya, MU: Mullaitivu, BT: Batticaloa, AM: Ampara, TR: Trincomalee, KM: Kalmunai, KR: Kurunegala, PU: Puttalam,
AP: Anuradhapura, PO: Polonnaruwa, BD: Badulla, MO: Moneragala, RP: Ratnapura, KG: Kegalle.
Data Sources:
Weekly Return of Communicable Diseases: Diphtheria, Measles, Tetanus, Neonatal Tetanus, Whooping Cough, Chickenpox, Meningitis, Mumps., Rubella, CRS,
Special Surveillance: AFP* (Acute Flaccid Paralysis ), Japanese Encephalitis
CRS** =Congenital Rubella Syndrome
AFP and all clinically confirmed Vaccine Preventable Diseases except Tuberculosis and Mumps should be investigated by the MOH

Number of Malaria Cases Up to End of November 2016,

35
All are Imported!!!

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this publication
ON STATE SERVICE

Dr. P. PALIHAWADANA
CHIEF EPIDEMIOLOGIST
EPIDEMIOLOGY UNIT
231, DE SARAM PLACE
COLOMBO 10