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. It accounts for 18% of all deaths of children under five years old worldwide. 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 years is between 28-39%. It is the fifth highest cause of death in Malaysian children, contributing 3.8% of under-5 deaths in 2006, and increasing to 5.1% in 2016.
For under-5 deaths due to pneumonia in 2016, Orang Asli children had the highest risk of deaths. Non-citizens, Bumiputra Sabah and “other Malaysian” children also had significantly higher risk of death due to pneumonia.
This global tragedy becomes even more depressing by the universal finding that only one in five caregivers could recognize the danger signs of pneumonia. Pneumonia often mimics the common cold, starting with a fever and cough and parents may not realise that the condition maybe much more serious than the flu. And only one in five children with pneumonia actually received life-saving antibiotics.
The World Health Organization (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 three 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 immunising against germs that are responsible, eg measles, pertussis, influenza, 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.
The prevention strategy with “pneumonia vaccines” have been shown to substantially reduce pneumonia morbidity and mortality in children. Malaysia introduced the pertussis, measles, Hib and pneumococcal conjugate vaccines (PCV) in the Ministry of Health (MOH), National Immunisation Program (NIP) in 1960, 1982, 2002 and 2020 respectively. The influenza vaccine is not in the NIP.
The Malaysian Paediatric Association (MPA) and its partners championed for the inclusion of the PCV, the latest “pneumonia vaccine” in the NIP since 2005. It was included in 2020 Budget, by the Pakatan Harapan government with a kick-start budget of RM60 million. The PCV prevents against the pneumococcus which is the number one 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 two cases below illustrate the spectrum of diseases caused by the penumococcus:
Case 1: A 3-year-old girl presented with a three-week history of coughing and six 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 Chest X-rays (CXR) 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 five days. Her repeat CXR showed residual lung damage and she was in hospital for a total of four weeks.
Case 2: The second case a five-month-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 from pneumococcal septicaemia and meningitis
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 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 randomised, controlled clinical trial in the Gambia, where seven 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 immunisation programs as a priority.”
Since the arrival of the PCV to Malaysia in October 2005, only about 15% of our birth cohort have been vaccinated against the pneumococcus, and virtually all of these were in the private health sector.
The Malaysian Paediatric Association (MPA), namely Dato’ Dr Musa Mohd Nordin and Datuk Dr Zulkifli Ismail, are both co-founders of the Asian Strategic Alliance for Pneumococcal disease prevention (ASAP) that has been at the forefront in the advocacy for the inclusion of PCV in the NIP of countries in the Asia Pacific.
The MPA and ASAP, were part of the Global Coalition against Child Pneumonia (GCCP) established in 2009, to advocate for global action to protect against, effectively treat and help prevent pneumonia.
The Global Coalition against Child Pneumonia annual event, the World Pneumonia Day (WPD), which falls every year on 12 November, was a call to address and to raise awareness about the increasing toll of pneumonia on children which the WHO and UNICEF appropriately labeled as the “Forgotten Killer of Children”. Let us together “Fight Pneumonia. And Save a Child”.
Dr Musa Mohd Nordin is treasurer of MPA and co-founder of ASAP. Dr Husna Musa is a paediatrician at University Putra Malaysia.
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