Although widely described as the forgotten killer of children by UNICEF, pneumococcal diseases, which include pneumonia, meningitis, and sepsis – all caused by the Streptococcus pneumoniae bacteria – is currently the world’s leading cause of vaccine-preventable deaths among children under age five.
Worse still, this triad of disorders continues to inflict a trail of unforgettable scars of ill health, premature death and a bleak survival expectation for millions of infants in Nigeria, which, currently, has the highest burden of infant and child deaths from pneumococcal disorders in Africa and is second only to India in the world.
Research shows that there are 91 serotypes of pneumococcus in existence, and even though many do not cause severe disease, but no less than 88 percent of global disease is caused by 23 of these 91 serotypes. But this hardly tells the story.
Surprisingly, just 11 serotypes account for over 80 percent of disease in children under 5 years of age and there are a few pneumococcal serotypes resistant to antibiotics, making treatment costly. Again, the different serotypes have different global distribution. For instance, serotypes 1 and 5 are responsible for a greater proportion of disease in developing countries such as in Africa and are serotypes that must be included in vaccines to maximise their effectiveness in developing countries.
Ironically, most cases of pneumococcal diseases are quite preventable with existing tools, such as vaccines and are treatable and for several decades, the challenge has been to ensure that the most vulnerable children have easy, affordable access to these life-saving interventions.
Alas, it has been a daunting task, particularly in Nigeria, where, according to the World Health Organisation (WHO) and UNICEF, only half of children with pneumonia have access to an appropriate healthcare provider, and fewer than one in five of them ultimately receive the correct antibiotics. This is the crux of the matter.
In 2009, the World Health Organization and UNICEF launched the Global Action Plan for the Prevention and control of Pneumonia (GAPP), an initiative which aims to accelerate pneumonia control in children with a combination of interventions to protect children from pneumonia by promoting breastfeeding and hand washing, and reducing indoor air pollution. The initiative is also to prevent pneumonia with vaccinations, treat pneumonia, ensuring every sick child has access to the right kind of care and can get the antibiotics and oxygen they need to get well. How much Nigerian children have benefited from this initiative is left to be desired.
But in line with efforts aimed at addressing the matter, experts gathered last week at the Lagos Sheraton Hotel, Ikeja, to discuss the topical issue and role of GSK’s pneumococcal vaccine towards achievement of the Millennium Development Goal 4 target. At the event which was primarily the official launch of GlaxoSmithKline’s pneumococcal vaccine, Synflorix, the experts fingered the lack of a reliableand sustainable immunisation strategy against pneumococcal diseases, and death of access to an appropriate treatment protocol to be the major stumbling block to the attainment of the goal of child and infant survival in the country.
Principal Investigator for Synflorix trial in Nigeria, Prof. Olumuyiwa Odusanya, described Streptococcus pneumoniae as a major cause of bacterial invasive disease (e.g. meningitis) and respiratory tract infections (e.g. acute otitis media) in young children. Odusanya, who is also Ag. Dean , Faculty of Clinical Sciences, Lagos State University College of Medicine (LASUCOM), Ikeja, remarked that as the leading cause of vaccine-preventable death in children under five years of age, Streptococcus pneumoniae is responsible for an estimated 61 percent of all pneumococcal deaths worldwide occur within 10 countries in Africa and Asia.
In his review of the trial study the vaccine Synflorix developed by GSK as a10-valent pneumococcal non-typeable H. influenzae protein D conjugate vaccine (PHiD-CV), he said: “This study represents the first trial assessing PHiD-CV in sub-—Saharan African children. Primarily, the purpose was to evaluate the immunogenicity of PHiD-CV in infants in Sub-Saharan Africa.”
Also speaking, Consultant Paediatrician, College of Medicine University of Ibadan, and the University College Hospital, Ibadan, Nigeria Prof. Adegoke Falade, observed that pneumonia kills more children than AIDS, malaria, measles and meningitis combined. “No less than 8.795 million under-5 children died in 2008 with 1.575 million (18 percent) due to pneumonia. The picture is clearer if it is realised that 4.294 million (49 percent) of child deaths occurred in India, Democratic Republic of the Congo, Pakistan, China and Nigeria.”
According to Mr.Lekan Asuni, Managing Director, GSK Pharmaceutical Anglophone West Africa, one out of every five Nigerian children dies before their fifth birthday with childhood pneumonia the leading cause of the deaths. He said in recent times, the Paediatric Association of Nigeria has advocated for the availability and inclusion of pneumococcal vaccine in the nation’s national programme on immunisation.
In a presentation entitled “Prevention, Treatment and Management Strategies of Pneumococcal Disease”, Consultant Paediatrician and President, Paediatric Association of Nigeria, Dr.Dorothy Esangbedo observed that as much as prevention of pneumonia is critical, effective treatment is no less essential.
“Preventing pneumococcal disease is critical in improving child survival and health, however, appropriate treatment also saves lives and minimises suffering. Antibiotics are the mainstay of treatment and there is need for supportive management makes hospitalisation necessary in severe cases.”
Esangbedo, an experienced endocrinologist further observed that factors affecting choice of antibiotics include clinical syndrome, pneumonia, meningitis, sepsis, otitis media, severity of disease and the age of the child. Others include local patterns of antimicrobial resistance, presence of high-risk groups, undernourished children and HIV-positive children.
Truthfully, attaining appropriate treatment for pneumococcal disease is no picnic. It can be a difficult exercise for health-care providers to distinguish between infections caused by bacteria, compared to other organisms such as viruses or parasites.
“That is why in Nigeria and Africa in general, pneumonia is sometimes misdiagnosed as malaria. In such cases, children may never receive potentially life-saving antibiotics. Their treatment may be delayed until the disease becomes more severe,” Esangbedo lamented.
“Parents and caregivers may not recognise symptoms in a child and/or know to take the child to a health-care provider. They may face barriers to accessing appropriate care such as high cost of treatment, distance to health-care centre and the families may mistrust the health system. They may also seek advice from unqualified individuals and health-care providers may misdiagnose a child with pneumococcal disease and fail to administer appropriate treatment.”
On the cause of antibiotic resistance, she identified clinical overlap between bacterial and viral respiratory infections often means antibiotics are given unnecessarily. “Just 20 percent of respiratory infections require antibiotic treatment. The remaining 80 percent of cases do not improve with antibiotic use and contribute to the emergence of antibiotic resistance.
One of the consequences of delayed treatment of pneumococcal disease, according to the expert, includes the possibility of further treatment being inadequate to prevent devastating consequences of disease. She argued that complications such as deafness from pneumococcal meningitis could occur, that is why time is of the essence. Delays in treatment may actually increase the chance of disability and death.
“Pneumococcal disease exerts heavy emotional toll and can cause serious financial difficulties for both families and communities. This contributes to the poverty cycle.”
Costs of illness include direct medical costs, e.g. hospital costs, medical personnel time, diagnostics and medications; non-medical direct costs, e.g. transportation to health-care facilities, food while hospitalised and productivity costs, e.g. lost work time for family members caring for ill children
Pneumococcal disease is preventable. Fact. But prevention is much more important because it saves lives, saves children, their families and communities from unnecessary suffering and reduces health care expense. The primary prevention strategy against pneumococcal disease is vaccination,” notes Esangbedo. “Pneumococcal vaccination is well-tolerated, effective and dramatically reduces mortality and morbidity.”
Essentially, there are three main types of pneumococcal vaccines. They are pneumococcal polysaccharide vaccines (PPV), pneumococcal conjugate vaccine (PCV) and protein vaccines. “The PPV class of vaccines are used to vaccinate adults and immuno-compromised children over two years of age. It contains inactivated polysaccharides from 23 serotypes of pneumococcal bacteria and is not recommended for infants under the age of two years. The reason is that their immature immune system does not allow recognition of the vaccine in this age group.
“As for the PCV, it is currently used to vaccinate children under the age of two, years. Its advantages include fact that it is well-tolerated in young infants and adults and HIV-positive patients. Co-administration with other vaccines is not affected and it can be used on the same schedule as the diphtheria–tetanus–pertussis (DTP) vaccine. The proven safety and effectiveness of PCV in children is undeniable as it can control increasing problem of antibiotic resistance.”
She explained that new formulas for pneumococcal vaccines are currently under investigation and most research is centred on identifying proteins common to the majority of pneumococcal strains. “Such ‘common proteins’ could protect against many pneumococcal strains in a single, protein-based vaccine.”
The medic avowed that the important benefit of vaccines is a critical factor to consider in immunisation. “Herd immunity is key. No vaccine offers 100 percent protection, but the spread of disease is higher in children who have not been vaccinated. When a critical percentage of population is vaccinated, spread of disease is effectively stopped (herd immunity threshold). This threshold depends on infectivity of disease, vulnerability of population and environmental factors. Herd immunity protects those who have no access to vaccines or refuse vaccines.”
Summing up, Esangbedo pointed out that vaccination of children is the best method of prevention against pneumococcal disease. The need for effective, early treatment is primal and essential to prevent severe morbidity and mortality, however, treatment is costly and risk of resistance to antibiotics is high. However, implementation of community-based management strategies will help prevent morbidity and mortality from pneumococcal disease.
Another good prevention strategy is adequate nutrition. It ensures a well-functioning immune system to protect children from pneumococcal diseases and other illnesses. Undernourished children are at greater risk of suffering death or disability. Underweight children are four times more likely to die of pneumonia than children of normal weight.
The role of breastfeeding cannot be underestimated, more so as breastfeeding in the first six months of life is a key component of adequate nutrition.Infants exclusively breastfed have a lower risk of infection and severe disease than those who are not. Children not breastfed are twice as likely to die of pneumonia before age 18 months compared to breastfed children
Pneumococcal disease: Know the facts
What is it?
It is the leading cause of serious illness in children and adults throughout the world. It is caused by a common bacterium, the pneumococcus, which can attack different parts of the body. In the lungs, they cause the most common form of community-acquired bacterial pneumonia; in the bloodstream, they cause bacteremia; when they invade the covering of the brain, they cause meningitis. Pneumococci may also cause otitis media (middle ear infection) and sinusitis.
Who is at risk?
Anyone can get pneumococcal disease. Most at risk are persons aged 65 and older; individuals with weak immune systems due to cancer, leukemia, Hodgkin’s disease or HIV; sickle cell disease or without a functioning spleen;chronic illness such as lung, heart, and kidney disease, diabetes and alcoholism; residents of chronic or long-term care facilities.
What is the significance?
Each year in Nigeria, there are hundreds of thousands hospitalised cases of pneumococcal pneumonia as a common bacterial complication of influenza and measles. In addition, in terms of invasive disease, there are so many untreated cases of bacteremia and meningitis annually. Invasive disease bacteremia and meningitis is responsible for the highest rates of death among the elderly and patients who have underlying medical conditions. Invasive pneumococcal disease is causing more deaths annually. More than half of these cases involve adults for whom vaccination against pneumococcal disease is recommended.
Is there appropriate treatment?
Pneumococcal disease is treated primarily with penicillin, but in recent years, strains resistant to one or more of these commonly used antibiotics have emerged. This resistance makes treatment difficult and may result in longer hospitalisations and more expensive alternative therapy. Emergence of resistant strains places further emphasis on the need for prevention through vaccination.
What is the best prevention?
The best way to protect against pneumococcal disease is through vaccination. Currentlt available in Nigeria are the polysaccharide vaccine and a conjugate vaccine. The polysaccharide vaccine is used in adults and the conjugate vaccine is used in children. But the scope of coverage of vaccination is extremely inadequate.
Who should be vaccinated?
Vaccination with pneumococcal polysaccharide vaccine is recommended for:
Everyone two years of age and older with chronic medical conditions such as diabetes, chronic lung (except asthma), heart, kidney or liver disease.
Those whose immune systems have been weakened by conditions such as cancer or HIV infection.
People without a functioning spleen and those with sickle cell disease.
Residents of chronic care or long-term care facilities.
Experts say the polysaccharide vaccine is not recommended for infants and young children under two years of age, as this age group does not respond to polysaccharide vaccines. However, Nigerian children under age two fall into the highest general risk group for invasive pneumococcal infections. The pneumococcal conjugate vaccine is recommended for all children 2-23 months of age. Other children at increased risk include those with sickle cell disease, HIV infection, and other immunocompromising or chronic medical conditions; these children should receive pneumococcal conjugate vaccine and pneumococcal polysaccharide vaccine..
When is the best time to get vaccinated?
In adults, pneumococcal vaccination with PCV is appropriate at any time of the year. In infants aged 2-23 months, the conjugate vaccine is advocated for incorporation into the childhood immunisation schedule.
Source: Vanguardngr.com
Date: 4 September 2011