World Pneumonia Day highlights the urgent need to protect vulnerable lives from pneumonia's devastating toll
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The persistent Streptococcus pneumoniae bacteria, which was first identified by more than a century ago by microbiologists Louis Pasteur and George Sternberg, has become one of humankind's greatest foes. Each year, pneumonia remains among the leading causes of death worldwide, particularly in low- and middle-income countries where healthcare access is limited. The death toll for India is staggering, with more than 127,000 children under five dying from pneumonia each year. This accounts for 14 percent of the deaths within this age group. Observed on 12 November, World Pneumonia Day serves as a reminder of these fatalities and the urgent need for focused prevention measures.
The burden of pneumonia falls hardest on India's most vulnerable citizens: children, the elderly, the malnourished, and those with chronic diseases. Poor air quality in crowded cities and using solid fuels for cooking add to this burden. However, its burdens affect families beyond just illness: treatment costs an average of US$ 25.6 per episode for elderly patients, and indirect costs (which comprise three-fourths of the total costs) through lost productivity may drive the lowest-income households to their knees.
Each year, pneumonia remains among the leading causes of death worldwide, particularly in low- and middle-income countries where healthcare access is limited.
The imperative to act is clear given the risks. Expansion of pneumococcal vaccinations nationwide could prevent millions of cases and eventually save more than US $1 billion in healthcare costs within five years. This highlights both the dual medical and economic benefits of investing in prevention.
Pneumonia is a major cause for concern, especially for children under the age of five. Incidence rates exceeding 500 cases per 1,000 children were reported in 2015 for states such as Madhya Pradesh and Uttar Pradesh, indicating that the burden may be acute in some regions. Among adults aged 65 and older, information on pneumonia rates is limited, but studies indicate a concerning burden. Streptococcus pneumoniae has been identified as the leading cause of community-acquired pneumonia (CAP), responsible for nearly two-thirds of global bacterial pneumonia cases. Other pathogens responsible include Klebsiella pneumoniae, Staphylococcus aureus, Haemophilus influenzae type b (Hib), and the Respiratory Syncytial Virus (RSV) which particularly targets children below the age of five. These infection rates are driven by a plethora of socioeconomic and environmental factors that may increase one’s susceptibility to the infection and limit access to adequate and timely care.
Socioeconomic conditions profoundly shape the pneumonia burden in India. Poverty limits access to healthcare, nutritious food, and proper housing—all essential for a good immune system that prevents infections. Overcrowding in homes and unhygienic conditions prevail in most households of a lower socioeconomic status. People in such families often live in poorly ventilated housing units, where the chance of respiratory infections spreading is high. As many poorer families still rely on solid fuels such as wood or dung for cooking and heating, the risk is compounded, doubling the rate of childhood respiratory infections and contributing to the figure of 44 percent pneumonia deaths in children under five globally. Education level, especially of the mother or primary caregiver, has an impact on health awareness and healthcare-seeking behaviours. A less educated caregiver may not notice early signs or know about the availability of vaccines, thus delaying the time taken to report to healthcare facilities, which increases mortality. This can be observed more in rural locations where health services are limited, and health education projects are harder to access.
Overcrowding in homes and unhygienic conditions prevail in most households of a lower socioeconomic status.
Critical gaps in health infrastructure further compound the problem of dealing with pneumonia in India. Vaccine coverage remains patchy due to logistical problems and unawareness. There is a shortage of skilled health workers and major medical consumables, including oxygen therapy units, which are needed for the treatment of pneumonia in rural and other deprived parts of the country. Antimicrobial Resistance (AMR) makes the problem even worse, as a resistant pathogen can cause longer stays in hospitals and result in the use of costly broad-spectrum antibiotics, with increased mortality and costs to healthcare. Pneumonia will need targeted investments in health access, public education, nutritional programmes, cleaner cooking technologies, and AMR control efforts to build resilience against this persistent threat.
In India, for the majority, vaccination is almost synonymous with the vaccination of children. However, among the older population, mortality due to pneumonia is so common that it is often called “The Captain of Death,” and it is proven that pneumococcal vaccination prevents or lessens the severity of a major subset of pneumonia cases. However, a systematic review that surveyed research articles from 2010 to 2020 regarding vaccination in the Indo-Pacific, found that the adult pneumococcal vaccination rate in India is one of the lowest in the region.
This is not specific to pneumococcal vaccines and is reflective of a broader trend in India of very low adult vaccination rates. A literature survey published in 2020 found that adult vaccination coverage in India is “negligible,” with a primary barrier being the lack of national adult vaccination guidelines.
A systematic review that surveyed research articles from 2010 to 2020 regarding vaccination in the Indo-Pacific, found that the adult pneumococcal vaccination rate in India is one of the lowest in the region.
For the first time in history, the Longitudinal Ageing Study in India (LASI) 2017-18 collected systematic data on the vaccination coverage of older adults (aged above 45) across India. Across the four categories covered under the survey, namely influenza, pneumococcal, typhoid and hepatitis B vaccines, the estimated proportion of respondents above 45 years of age who reported ever being vaccinated was 1.5 percent. As Figure 1 demonstrates, pneumococcal vaccination has the lowest coverage across age groups, both for older men and women. An analysis published in the World Health Organization (WHO) Bulletin in 2022 shows that being male, an urban resident, a wealthier household, more years of schooling, existing medical conditions and sedentary behaviours were all significant predictors of vaccine uptake. Given the high social and economic cost of vaccine-preventable conditions like pneumonia among the older population, such low vaccination coverage requires immediate policy attention.
Figure 1: Data compiled by the authors from Rizvi and Singh (2022)
Beyond pneumonia’s impact on health, it poses a significant economic burden on both households and the healthcare system. The direct costs of treatment are substantial. They encompass hospitalisation, medication, diagnostics, and other healthcare services. A 2014 study estimated it to be INR 249,199 for ventilator-associated pneumonia (VAP) after adjusting for demographic characteristics. The cost for community-acquired pneumonia (CAP), according to another 2024 study, varied across facilities, averaging INR 210,862 in private hospitals and INR 5,575 in government hospitals for inpatient treatment and INR 4,121 in private and INR200 in government facilities for outpatient treatment.
The immense economic strain on rural and low-income families with children who have pneumonia, causes many of them to rely on external financial support to meet the expenses.
Indirect costs such as the loss of productivity, the burden on caregivers and financial strain, particularly on low-income families, further exacerbate the economic toll. CAP patients experienced prolonged cough and fatigue, with hospitalised patients missing, on average, 16 work days, and non-hospitalised patients missing nine. 97 percent of the patients required support from family, friends and caregivers during their recovery. For caregivers of children receiving treatment at public facilities, 77 percent reported missing work, as opposed to 26 percent for private facilities. The immense economic strain on rural and low-income families with children who have pneumonia, causes many of them to rely on external financial support to meet the expenses.
Research conducted in 2023 suggested variations in the total economic burden and also in the direct and indirect costs across regions. For instance, in Pune, the economic burden of pneumonia is driven by high direct costs, while in Chennai, indirect costs are the predominant factor. The disparities are further exacerbated by limited health insurance coverage. Preventative measures could significantly reduce this strain.
Policies aimed at improving air quality can further alleviate the economic burden of the disease. Direct costs can be reduced by providing subsidised services, insurance coverage, and more affordable private care options, whereas indirect costs can be reduced by strengthening caregiver support and social safety nets to alleviate the strain.
India has made significant progress in tackling pneumonia, especially through its implementation of the pneumococcal conjugate vaccine (PCV) under the Universal Immunization Programme (UIP) in 2017 and Mission Indradhanush. By 2022, 83 percent of infants were vaccinated with PCV, demonstrating the nation’s commitment. This effort has contributed to a reduction in under-five mortality rates, which fell from 45 per 1,000 live births in 2014 to 32 per 1,000 in 2020.
The National Health Mission and domestic budget allocations, as well as funding from international donors like Gavi and the Bill & Melinda Gates Foundation have increased overall funding.
In December 2020, the Serum Institute of India also rolled out Pneumosil, the first PCV developed indigenously, enhancing access and affordability. Leading organisations like the Indian Academy of Pediatrics (IAP) and the Indian Council of Medical Research have sound guidelines for diagnosing and managing pneumonia so that front-line healthcare providers are well-equipped to handle this public health challenge. Despite these welcome changes, challenges remain as discussed earlier. Low vaccination coverage persists in rural areas, and public awareness of pneumonia prevention needs improvement. Therefore, funding for these initiatives is very essential. The National Health Mission and domestic budget allocations, as well as funding from international donors like Gavi and the Bill & Melinda Gates Foundation have increased overall funding. Ongoing monitoring through systems, such as the Integrated Disease Surveillance Programme (IDSP), is critical in ensuring that India can adapt and step up to the situation.
A resilient future against pneumonia demands mass vaccination for both children and senior citizens, cleaner air, and better healthcare access. Investing in adult immunisation, social safety nets, and affordable care is the need of the hour to reduce pneumonia’s toll on India’s most vulnerable—one breath at a time.
S. Uplabdh Gopal is an Associate Fellow within the Health Initiative at the Observer Research Foundation.
Oommen C. Kurian is Senior Fellow and Head of Health Initiative at the Observer Research Foundation
Nimisha Chadha is a Research Assistant at the Observer Research Foundation
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Dr. K. S. Uplabdh Gopal is an Associate Fellow within the Health Initiative at ORF. His focus lies in researching and advocating for policies that ...
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Oommen C. Kurian is Senior Fellow and Head of Health Initiative at ORF. He studies Indias health sector reforms within the broad context of the ...
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Nimisha Chadha is a Research Assistant with ORF’s Centre for New Economic Diplomacy. She was previously an Associate at PATH (2023) and has a MSc ...
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