Trends and spatial distribution of pneumonia admissions and deaths among children <5 years, Uganda, 2013–2021

Background Pneumonia is the second leading cause of hospital admissions and deaths among children <5 years old in Uganda. In 2013, Uganda adopted various interventions to protect, prevent, and improve the treatment of pneumonia under the Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD), including the introduction of the pneumococcal conjugate vaccine (PCV) into routine immunization schedule. However, little is known about the impact of these interventions on pneumonia admissions and deaths. We described the trends and spatial distribution of pneumonia hospital admissions and mortality among children <5 years in Uganda, 2013–2021. Methods We analysed secondary data on pneumonia admissions and deaths from the District Health Information System version 2 during 2013–2021. Reporting rates were calculated as the percentage of expected complete monthly health facility reports submitted to the national surveillance database. The proportion of pneumonia cases admitted and case-fatality rates (CFRs) for children <5 years were calculated for children <5 years presenting at the outpatient department. At national, regional, and district levels, pneumonia mortality rates were calculated per 100,000 children <5 years. The Mann-Kendall Test was used to assess trend significance. Results There were 753,978 pneumonia admissions and 13,632 (2%) deaths during 2013–2021. Reporting rates ranged from 78–92%. The overall proportion of pneumonia cases admitted among children <5 years was 23%. The overall CFR was 0.41%, and the overall pneumonia mortality rate among children <5 years was 21 deaths per 100,000. From 2013 to 2021, there were declines in the proportion of pneumonia cases admitted (33% to 15%; p=0.051), mortality rates (26/100,000 to 13 per 100,000; p=0.01), and CFR (0.61% to 0.24%; p=0.01), concomitant with increasing PCV coverage. Kotido District had a persistently high proportion of pneumonia cases that were admitted (>30%) every year while Kasese District had persistently high mortality rates (68-150 deaths per 100,000 children <5 years). Conclusion Pneumonia admissions, mortality, and case fatality among children <5 years declined during 2013–2021 in Uganda after the introduction of PCV. However, with these trends it is unlikely that Uganda will meet the 2025 GAPPD targets. There is therefore a need to review implementation of existing interventions, identify gaps in order to highlight priority actions to further accelerate declines. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The funders had no role in the study design, data collection, data analysis and decision to prepare or publish this manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Our study utilized routinely generated aggregated surveillance data with no personal identifiers in health facility in-patient monthly reports through the DHIS2. The Ministry of Health (MoH) of Uganda through the office of the Director General Health Services gave approval to access data from the DHIS2. We stored the abstracted data set in a password-protected computer and only shared it with the investigation team. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§ §See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56 42 U.S.C. §241(d) 5 U.S.C. §552a 44 U.S.C. §3501 et seq. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The datasets upon which our findings are based belong to the Uganda Public Health Fellowship Program and can be availed upon reasonable request from the corresponding author with permission from the Uganda Public Health Fellowship Program. * DHIS2 : District Health Information System version 2 GAPPD : Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea HC : Health Centre HMIS : Health Management Information System PCV : Pneumococcal Conjugate Vaccine UBOS : Uganda Bureau of Statistics