Pneumonia is the single leading cause of mortality in children under five and is a major cause of child mortality in every region of the world, with most deaths occurring in sub-Saharan Africa and South Asia. Pneumonia kills more children under five than AIDS, malaria, and measles combined, yet increased attention in recent years have been on the latter diseases.
Pneumonia is an illness, usually caused by infection, in which the lungs become inflamed and congested, reducing oxygen exchange and leading to cough and breathlessness. It affects individuals of all ages but occurs most frequently in children and the elderly. Among children, pneumonia is the most common cause of death worldwide. Historically, in developed countries, deaths from pneumonia have been reduced by improvements in living conditions, air quality, and nutrition. In the developing world today, many deaths from pneumonia are also preventable by immunization or access to simple, effective treatments that could accelerate the control of pneumonia and reduce early childhood mortality.
Pneumonia is a form of acute respiratory tract infection (ARTI) that affects the lungs. When an individual has pneumonia, the alveoli in the lungs are filled with pus and fluid, which makes breathing painful and limits oxygen intake. Pneumonia has many possible causes, but the most common are bacteria and viruses. The most common pathogens are Streptococcus pneumonia, Haemophilus influenza type b (Hib), and respiratory syncytial virus (RSV). S. pneumonia is the most common cause of bacterial pneumonia in children under five years in the developing world.
The second most common cause of bacterial pneumonia in children is Hib, followed by RSV – the most common cause of viral pneumonia in children under two years. The populations most at risk for pneumonia are children under five years, people aged 65 or over, and people with pre-existing health problems. Streptococcus pneumoniafrequently colonizes the upper respiratory tract. The human nasopharynx is the only natural reservoir for S.pneumonia and these bacteria along with viruses are commonly found in a child’s nose or throat; these pathogens are then aspirated into the lungs, causing disease.
Pneumonia can be spread in a number of ways. The pathogen is transmitted through direct contact with respiratory secretions, colonizes the nasopharynx and may then cause blood-borne diseases. S. pneumonia can cause both non -invasive and invasive disease in all age groups, particularly in children younger than five years and adults 65 years or older. In addition, people with certain medical conditions, such as chronic heart, lung, or liver diseases, or sickle cell anemia are also at increased risk for pneumococcal diseases. People living with HIV/AIDS or people who have had organ transplants and are taking medications that decrease their immunity to infection are also at high risk of getting this disease.
A healthy child has many natural defenses that protect its lungs from pneumonia. Undernourished children, especially those who are not exclusively breastfed or with inadequate zinc intake, are at a higher risk of developing pneumonia. Immunosuppression due to other co-infections is important risk factors in pneumonia -related mortality; infants, children, or the elderly suffering from illnesses, such as AIDS, measles, or malaria are also more likely to develop pneumonia. Additionally, environmental factors, such as crowded living conditions and exposure to indoor air pollution may contribute to increasing children’s susceptibility to pneumonia.
The Lancet Global Burden of Disease (GBD) Study 2010 has a category for lower respiratory tract infections (LRTI), which includes influenza, Streptococcus pneumonia (pneumococcal pneumonia), Haemophilus influenza type b (Hib), respiratory syncytial virus (RSV), and “other lower respiratory infections”. For the purposes of this report, pneumococcal pneumonia, Hib, and RSV were chosen as the focus to assess the disease burden in further details.
Curative and Preventive Strategies
Pneumonia is caused by a combination of a variety of factors, including pathogens, the environment, health systems, and health-seeking behaviours. Therefore, no single intervention can effectively prevent, treat, or control pneumonia. As such, a confluence of key interventions to control pneumonia would include immunization against specific pathogens, early diagnosis and treatment of the disease, and improvements in nutrition and environment all living conditions (e.g. safe drinking water, sanitation, hygiene, low household air pollution). Children under five, especially infants aged 0-5 months, not exclusively breastfed are 15 times more likely to die due to pneumonia than children who are exclusively breastfed, interventions for increased breastfeeding practices will help decrease childhood mortality due to pneumonia as well as diarrhea. The potential for saving lives by scaling up the proper interventions is large. Modeled estimates suggest that by 2015 child mortality, due to pneumonia, could fall 30% across the 75 countries with the highest mortality burden if national coverage of key pneumonia interventions were raised to the level in the richest 20% of households in each country.
The medical experts led by PAN said for Nigeria to achieve universal access to pneumonia prevention and care, governments at all levels should make medical care free for all ages, develop a policy to ensure sustainable funding for immunization activities and invest in the training and retraining of health workers including doctors.
To protect, prevent and care for Nigerian children against pneumonia the medical experts recommend among others: strengthening of routine immunization especially against measles, diarrhea and haemophilus influenza; exclusive breastfeeding for the first six months of life; good nutrition and supplementation with micronutrients; avoidance of unnecessary exposure to cold, improvement of socio-economic status of Nigerian families; improve health-seeking behaviour by parents; reduction of household air pollution and overcrowding; and provision of safe drinking water and improve hygiene/sanitation.
The Multiple Indicator Cluster Surveys (MICS) and Demographic Household Survey (DHS) provide information on caregivers’ knowledge of symptom of pneumonia and on the extent to which caregivers seek appropriate provider for their children with suspected pneumonia. According to these two surveys from 1998 to 2004, the majority of caregivers did not recognize the common symptoms of pneumonia and only 54% of children under five in the developing world were taken to an appropriate provider. However, recent data from MICS and DHS between 2000 to 2010 showed that care -seeking for children with symptoms of pneumonia has increased slightly in developing countries, from 54% in 2000 to 60% in 2010.
In addition, feeding infants only breast milk in the first six months of life is a key protective intervention highlighted in the Global Action Plan for Prevention and Control of Pneumonia (GAPP) report. Exclusive breastfeeding has multiple positive effects such as nutritional benefits and allows the mother to pass on key components of her immune system to her child to strengthen the infant’s immunity, thereby protecting infants from pneumonia, diarrhoea, and other infections.
Pneumonia can be diagnosed in a number of different ways. Healthcare providers can diagnose pneumonia by the symptoms, a physical examination, or by ordering diagnostic tests. Laboratory tests could include chest X-rays and cell cultures (followed by PCR antigen testing of blood or antigen testing of urine.) to look for bacteria in the infected part of the body. Usually there should be a combination of clinical, radiological, and laboratory findings to increase the likelihood of correct diagnosis. Chest X-rays and laboratory tests can help confirm the diagnosis of pneumonia by presence of specific findings.
Respiratory syncytial virus (RSV) is an important cause of viral pneumonia in children under five. However, differentiating between viral and bacterial pneumonia is difficult because X -ray detected lesions can look similar for various viruses and co-infections can occur between various pathogens. Studies looking at RSV incidence and mortality in developing countries identified RSV by enzyme -linked immunosorbent assay (ELISA) or immunoflu orescence assays, which have 12% to 50% lower sensitivity than does polymerase chain reaction (PCR). The need for low-cost, key interventions like accurate and point-of-care diagnostic tools for pneumonia would significantly contribute to the prevention of childhood mortality related to pneumonia.
Around 85% to 90% of antibiotic consumption occurs in the community, with 80% of this consumption going towards treating respiratory tract infections. Once a child develops pneumonia, death is avoidable through cost-effective and life-saving treatment from antibiotics for bacterial pneumonia. When children suffering from pneumonia are treated promptly and effectively with antibiotics their chances of survival increase significantly.
Vaccination is a safe, effective, and cost-effective tool for preventing pneumonia. There are vaccines against major infectious diseases that can cause pneumonia – the flu (influenza virus), measles, pertussis, Hib, and pneumococcus. “Nigeria government through vaccination is saving at least 230,000 children yearly. The WHO recommends that all routine childhood immunization programs include vaccines that protect against these diseases. New vaccines against Hib and pneumococcus are available; many low-income countries have already introduced the Hib vaccine, and pneumococcal conjugate vaccines (PCVs) are increasingly becoming available in developing countries as well. The 7-and 13-valent conjugate vaccines (PCV7, PCV13) have demonstrated effectiveness in reducing incidence and severity of pneumonia and other lower respiratory infections in children. Immunizations help reduce childhood pneumonia in two ways. First, vaccinations help prevent children from developing infections that directly cause pneumonia, such as Hib and S. pneumonia. Second, immunizations may prevent infections that can lead to pneumonia as a complication, such as influenza, measles and pertussis. Pneumococcal conjugate vaccines are highly effective in preventing pneumococcal disease. Currently, there are three vaccines on the children’s routine immunization schedule that have the potential to significantly reduce childhood mortality from and related to pneumonia: measles, Hib, and pneumococcal conjugate vaccines. In 2007, the WHO recommended introducing pneumococcal conjugate vaccine (PCV) into all national immunization programs, particularly in countries with high mortality. Since that time, progress has been made in introducing PCV globally with increasing usage in low-income countries.
Haemophilus influenza type b (Hib) is the second leading cause of bacterial pneumonia in children, but it is preventable with the highly effective Hib vaccine. The Hib vaccine has been shown to have protective efficacy greater than 90% against both laboratory-confirmed invasive meningitis and bactaeremic and non-invasive pneumonia. By the end of the 1990s, two-thirds of high-income countries had added Hib vaccine to their immunization schedule, but lower-income countries were slower to implement routine vaccination into their national programmes. In 2006, the WHO recommended the introduction of the Hib vaccine into all national routine immunization programmes.
By 2010, 169 countries (88% of all WHO Member States) have adopted this plan. Since then the gap in vaccination introduction between low-and high-income countries has significantly decreased. Hib conjugate vaccines are some of the safest and efficacious (over 90% efficacious against invasive Hib disease) vaccines available. High coverage of Hib vaccine immunization in children under five could reduce childhood pneumonia and decrease incidence of severe pneumonia.
The two vaccines that protect against pneumococcal disease are the 23-valent polysaccharide vaccine (PPV 23) and the 13-valent protein-conjugated polysaccharide vaccine (PCV 13), which replaced the 7-valent conjugate vaccine (PCV7) in 2010 in the United States.
The polysaccharide vaccine (PPV) is T cell-independent and does not produce an anamnestic reaction; this means it does not enhance the reaction of the body’s immunologic memory and immunity may not be long-lasting. Therefore, PPV is not effective in children younger than two years old, but it is approved for individuals aged Two and older at risk for developing pneumonia and the vaccine is deemed more appropriate for adults (mostly those aged 50 years and older). On the other hand, conjugate vaccines (PCV) elicit a T cell-dependent response and produce an anamnestic reaction that makes the vaccine more effective in infants and children younger than two years of age.
There are three PCVs available globally:
- PCV7 (the 7-valent CRM197 conjugated vaccine)
- PCV10 (has the same serotypes as PCV7 plus serotypes 1, 5, and 7F, but different carrier proteins: protein D, diphtheria toxoid and tetanus toxoid)
- PCV13 (has the same serotypes as PCV7 plus serotypes 1, 3, 5, 6A, 7F, and 19A each conjugated to CRM197).
Newer pneumococcal vaccines with more serotypes (PCV10, PCV13) are currently on the market and have been prequalified by the WHO for use in developing countries with emphasis on Nigeria, which will provide increased coverage of the serotypes most commonly found in those areas.
The WHO recommends that use of PCV in routine childhood immunization programs in all countries and particularly in countries where all-cause mortality among children under five is greater than 50 per 1000 live births, or where there are more than 50,000 children dying annually in countries with a high prevalence of HIV infection.
President PAN said: “The global target is providing universal access to pneumonia prevention and care. We are looking at a world where every child has equitable chance of survival and thriving. Treatment and care should be equitable. We want our government to do everything within their power to make sure that every child to access the care for pneumonia. “We are saying that healthcare should be made free at all levels from the federal to states and local governments. We are aware of what some states are doing for example Lagos state. But we want all states of the nation not just Lagos even at various levels for health care to be made free. So that will empower every household to access health and improve their socio-economic status because they will now channel the saved funds to improve their livelihood.” Oluwu continued: “The new vaccines that will go a long way to prevent this disease especially the incidence of pneumonia should be quickly brought on board in our immunization schedule. Agberien said: More than 99 percent of deaths from pneumonia occur in the developing world, where access to health care facilities and treatment is out of reach for many children. Investments in preventing, treating, and protecting children against the two leading killers of young children – pneumonia and diarrhea – have contributed significant declines in child mortality over the last decade, but there is more to be done. Tackling these two diseases will make the greatest strides toward reducing child deaths and achieving Millennium Development Goal 4.
In December 2014, the Federal Government of Nigeria introduced Pneumonia Vaccine into the routine National Immunization Programme. Children are to receive three vaccinations at 2 months of Age, 4 months and 12 months.
Adults over the age of 65 years are to receive one pneumonia vaccination.
On a final note, to advance progress, we must continue to scale up interventions that we know will save children’s lives, including continued access to vaccines, proper antibiotics treatment, improving sanitation, as well as promotion of practices such as exclusive breastfeeding, frequent hand washing, , care seeking, and use of clean cooking stove to reduce indoor air pollution.