“FIGHT PNEUMONIA. SAVE A CHILD”
PNEUMONIA – NUMBER 1 KILLER OF CHILDREN
Dato’ Dr Musa Mohd Nordin
Consultant Paediatrician & Neonatologist
Exco Member, Malaysian Paediatric Association (MPA)
Founding Member, Asian Strategic Alliance for Pneumococcal Disease Prevention (ASAP)
In 2008, an estimated 8.8 million children died before their fifth birthday. 1 in 5 of the deaths was due to pneumonia. Pneumonia kills an estimated 1.4 million children under the age of 5 years every year – more than deaths from AIDS, Malaria and TB combined. One child dies from pneumonia every 20 seconds. Most of these pneumonia deaths occur in developing countries.
In Malaysia, the prevalence of pneumonia in children under 5 is between 28-39%. It is the fifth highest cause of death in Malaysian children, contributing 4% of under 5 deaths.
This global tragedy becomes even more depressing by the universal finding that only 1 in 5 caregiver could recognize the danger signs of pneumonia and only 1 in 5 children with pneumonia actually received the life saving antibiotics! Pneumonia often mimics the common cold, starting with a fever and cough and parents may not realize that the condition maybe much more serious than the flu.
The World Health Organisation (WHO) and UNICEF in their 2008 GAPP document outlined the Global Action Plan for Prevention and Control of Pneumonia. In summary, this child survival strategy embraced the following 3 key elements:
- Protection by handwashing, exclusive breastfeeding, improved nutrition, avoidance of indoor pollution (smoking, stove fires) and reducing risk factors (eg HIV).
- Treatment by improving access to health care and appropriate management at health facilities.
- Prevention of pneumonia by immunizing against germs that are responsible eg measles, pertussis, haemophilus influenza B (Hib) and pneumococcus.
The implementation of the GAPP interventions to Protect (breastfeeding), Prevent (vaccinations) and Treat (case management) in the 68 high child mortality countries would potentially avert up to 1.2 million post-neonatal pneumonia deaths annually by 2015, significantly contributing to MDG4 – reduce by two thirds, between 1990 and 2015, the under-five mortality rate.
The prevention strategy with “pneumonia vaccines” have been shown to substantially reduce pneumonia morbidity and mortality in children. Malaysia introduced the pertussis, measles and Hib vaccines in 1960, 1982 and 2002 respectively. However, the pneumococcal vaccine is still NOT in the Ministry of Health (MOH), National Immunisation Program (NIP).
And unfortunately the pneumococcus is the number 1 cause of pneumonia deaths. More than 50% of pneumonia deaths are due to the pneumococcus. Apart from pneumonia, the pneumococcus can cause other serious diseases namely meningitis (inflammation of the lining of the spine and brain), bacteraemia (germs in the blood) and other less invasive but nonetheless very burdensome in terms of volume of morbidity and complications – otitis media (inflammation of the middle ear) and sinusitis (infection of the sinuses). For every case of pneumococcal meningitis each year there are probably 1,000 cases of pneumococcal otitis media. The 2 cases below illustrate the spectrum of diseases caused by the penumococcus.
Case 1: A 3 yr. old girl presented with a 3 week history of coughing and 6 days of high grade fever. She did not respond to oral antibiotics and was referred to hospital. On admission she was febrile, breathing rapidly and was grunting. Her CXR (attached) showed pneumonia of the entire right lung, with fluid collection. The lung fluid was drained and it grew the pneumococcus. She required respiratory support in the Intensive Care Unit (ICU) for 5 days, oxygen for another 5 days. Her repeat CXR showed residual lung damage and she was in hospital for a total of 4 weeks.
Case 2: The second case a 5 months old girl was less fortunate. She had fever 36 hours prior to admission, was feeding poorly and vomited twice. She was noted to be more sleepy. Both her blood and cerebrospinal fluid grew pneumococcus. Despite ventilation in the ICU, intravenous antibiotics and close monitoring, she died within 10 hours.
Thus vaccination against invasive pneumococcal disease (IPD) is a pivotal life saving strategy and reduces morbidity because:
- it may prevent children from ever being infected
- it reduces the transmission of the bacteria in the community thus reducing IPD in the other age groups (herd immunity)
- it reduces the need for antibiotics resulting in lower rates of resistant bacteria
The pneumococcal vaccine first introduced in the USA in 2000, has since been shown to be highly efficacious in a wide variety of populations studied in the USA, American Indians, Gambia and South Africa. The pneumococcal conjugate vaccine (PCV) is the first vaccine in 20 years to show a significant reduction in all-cause child mortality in a major randomized, controlled clinical trial in the Gambia, where 7 deaths were prevented for every 1000 children vaccinated.
The WHO in a position statement in 2007 declared “Recognizing the heavy burden of pneumococcal disease in children and the safety and efficacy of PCV7 in this age group, WHO considers the inclusion of this vaccine in national immunization programs as a priority”
Looking at the annual world birth cohort in 2008, only 7% have been immunized with the PCV and most of these were in the developed countries. More than 50 countries have incorporated the PCV in their NIP. In Asia only Singapore, Macau and Hong Kong have included PCV in their NIP.
Since the arrival of the PCV to Malaysia in October 2005,only a meagre 10% of our birth cohort have been vaccinated against the pneumococcus and virtually all of these were in the private health sector. The vaccine is not available to the 70-80% of Malaysian children who attend the government health centres for their scheduled immunizations since the PCV is not in the nation’s NIP.
The Asian Strategic Alliance for Pneumococcal disease prevention (ASAP) has been at the fore front in the advocacy for the inclusion of PCV in the NIP of countries in the Asia Pacific. With her Malaysian partner, the Malaysian Paediatric Association, they were part of the Global Coalition against Child Pneumonia established in 2009, to advocate for global action to protect against, effectively treat and help prevent pneumonia.
Their annual event, World Pneumonia Day (WPD) which falls on 12 November 2011, was a call to address and to raise awareness about the increasing toll of pneumonia on children which the WHO & UNICEF appropriately labelled as the “Forgotten Killer of Children”. And timely too, this year’s event has focused on the theme “Fight Pneumonia. Save a Child”.