Malaysia - A shield for our young

Pneumonia is, in fact, the number one killer of young children in many countries.

IN 2008, an estimated 8.8 million children died before their fifth birthday. One in five of the deaths was due to pneumonia. Pneumonia kills an estimated 1.4 million children under the age of five years annually – more than deaths from AIDS, malaria and tuberculosis combined.

In effect, 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 five is between 28% and 39%. It is the fifth highest cause of death in Malaysian children, contributing 4% of deaths under the age of five years.

This global tragedy becomes even more depressing if you look at the universal finding that only one in five caregivers could recognise the danger signs of pneumonia, and only one in five children with pneumonia actually received lifesaving antibiotics!

Pneumonia often mimics the common cold, starting with a fever and cough, and parents may not realise that the condition may be much more serious.

The World Health Organization (WHO) and UNICEF in their 2008 document outlined the Global Action Plan for Prevention and Control of Pneumonia (GAPP). 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 healthcare and appropriate management at health facilities.

·Prevention of pneumonia by immunising 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.

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 Health Ministry’s (MOH) National Immunisation Programme (NIP).

And unfortunately, the pneumococcus 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 medical conditions 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 three-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-ray 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 five days, and oxygen support for another five days. Her repeat chest x-ray 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.

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 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 US in 2000 has since been shown to be highly efficacious in a wide variety of populations studied in the US, 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 Gambia, where seven deaths were prevented for every 1,000 children vaccinated.

The WHO, in a position statement in 2007, declared: “Recognising 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 programmes as a priority.”

Looking at the annual world birth cohort in 2008, only 7% have been immunised with the PCV, and most of these were in 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 in Malaysia, 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 government health centres for their scheduled immunisations since the PCV is not in the nation’s NIP.

The Asian Strategic Alliance for Pneumococcal disease prevention (ASAP) has been at the forefront 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.

Datuk Dr MUSA MOHD NORDIN

The Star

Datuk Dr Musa Mohd Nordin is a consultant paediatrician & neonatologist and is a founding member of the Asian Strategic Alliance for Pneumococcal disease prevention (ASAP).

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