Childhood pneumonia in humanitarian emergencies in low- and middle-income countries: A systematic scoping review

Abstract

Background: Humanitarian emergencies increase many risk factors for pneumonia, including disruption to food, water and sanitation, and basic health services. This review describes pneumonia morbidity and mortality among children and adolescents affected by humanitarian emergencies.

Methods: We searched MEDLINE, EMBASE, and PubMed databases for publications reporting pneumonia morbidity or mortality among children aged 1 month to 17 years in humanitarian emergencies (eg, natural disaster, armed conflict, displacement) in low- and middle-income countries (LMICs).

Results: We included 22 papers published between January 2000 and July 2021 from 33 countries, involving refugee/displaced persons camps (n = 5), other conflict settings (n = 14), and natural disaster (n = 3). Population pneumonia incidence was high for children under 5 years of age (73 to 146 episodes per 100 patient-years); 6%-29% met World Health Organization (WHO) criteria for severe pneumonia requiring admission. Pneumonia accounted for 13%-34% of child and adolescent presentations to camp health facilities, 7%-48% of presentations and admissions to health facilities in other conflict settings, and 12%-22% of admissions to hospitals following natural disasters. Pneumonia related deaths accounted for 7%-30% of child and adolescent deaths in hospital, though case-fatality rates varied greatly (0.5%-17.2%). The risk for pneumonia was greater for children who are: recently displaced, living in crowded settings (particularly large camps), with deficient water and sanitation facilities, and those who are malnourished.

Conclusion: Pneumonia is a leading cause of morbidity and mortality in children and adolescents affected by humanitarian emergencies. Future research should address population-based pneumonia burden, particularly for older children and adolescents, and describe contextual factors to allow for more meaningful interpretation and guide interventions.

Figure 1

PRISMA 2009 flow diagram of literature search.

Figure 2

Pneumonia incidence (panel A) and proportional morbidity (panel B) among children in humanitarian emergencies in low- and middle-income countries. Panel A. IDP – internally displaced persons; U5 – children under 5 years of age.
*Pneumonia incidence rates have been converted to episodes per 1000 person-years to allow comparison between studies. †Pneumonia classified using pre-2014 WHO pneumonia definitions. Incidence rates for sub-classifications of pneumonia were as follows: 50 (non-severe), 15 (severe), 6 (very severe) and 22 (radiological end-point).
‡Pneumonia classified using WHO pneumonia and severe pneumonia categories.
Panel B. Pneumonia proportional morbidity among children in humanitarian emergencies in low- and middle-income countries. IDP - internally displaced persons, U5 – children under 5 years of age. *Proportional morbidity – pneumonia cases as a proportion of all paediatric cases in community, presenting to outpatient facilities, or admitted to hospital, unless otherwise specified.
†Van Berlaer reported for pneumonia as a primary diagnosis (9.0%), or as any diagnosis (13%). ‡Anwar also reported pneumonia morbidity estimates in three-year intervals: 12.2% (2005-2007), 9.9% (2008-2010), and 8.6% (2011-2013). §Severe pneumonia, % of all paediatric outpatients. ‖Sodemann also reported a pneumonia morbidity estimate of 10.8% in the pre-conflict period. ¶Birindwa also reported pneumonia morbidity rates of 12.2% pre-PCV13 and 7.1% post-PCV13. **Pneumonia, % of paediatric medical admissions during the period of impact of an earthquake. Pneumonia morbidity rates pre-impact and post-impact were reported as 22.0% and 19.4% respectively. ††Pneumonia, % of paediatric medical admissions.

Figure 3

Proportional mortality (panel A), case fatality rate (panel B), pneumonia incidence of death (panel C) among children in humanitarian emergencies in low- and middle-income countries. Panel A. IDP – internally displaced persons, U5 – children under 5 years of age. *Case fatality rate – pneumonia deaths as a proportion of pneumonia cases. †Under 15 years of age. ‡1-36 months of age. §Birindwa also reported pneumonia mortality rates of 4.8% pre-PCV13 and 4.9% post-PCV13. Panel B. IDP – internally displaced persons, U5 – children under 5 years of age. *Estimates for incidence of pneumonia-related death have been converted to deaths per 1000 person-years to allow comparison between studies. Panel C. IDP – internally displaced persons, U5 – children under 5 years of age. *Proportional mortality = pneumonia deaths as a proportion of all paediatric deaths in community, or hospital, unless otherwise specified. †Under 15 years of age.