To compare the cost-effectiveness of interventions to reduce pneumonia mortality through risk reduction, immunization and case management.

Country-specific pneumonia burden estimates and intervention costs from WHO were used to review estimates of pneumonia risk in children under 5 years of age and the efficacy of interventions (case management, pneumonia-related vaccines, improved nutrition and reduced indoor air pollution from household solid fuels). We calculated health benefits (disability-adjusted life years, DALYs, averted) and intervention costs over a period of 10 years for 40 countries, accounting for 90% of pneumonia child deaths.

Solid fuel use contributes 30%(90% confidence interval: 18-44) to the burden of childhood pneumonia. Efficacious community-based treatment, promotion of exclusive breastfeeding, zinc supplementation and Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae immunization through existing programmes showed cost-effectiveness ratios of 10-60 International dollars (I )perDALYinlow-incomecountriesandlessthanI 120 per DALY in middle-income countries. Low-emission biomass stoves and cleaner fuels may be cost-effective in low-income regions. Facility-based treatment is potentially cost-effective, with ratios of I 60-120perDALY.Thecost-effectivenessofcommunitycasemanagementdependsonhomevisitcost.

VaccinesagainstHibandS.pneumoniae,efficaciouscasemanagement,breastfeedingpromotionandzincsupplementationarecost-effectiveinreducingpneumoniamortality.Environmentalandnutritionalinterventionsreducepneumoniaandprovideotherbenefits.Thesestrategiescombinedmayreducetotalchildmortalityby17%.