Nearly one in ten children born in India will not live to see their fifth birthday, the under-5 mortality, on an average, for India, being 85 per 1000. Nearly half these deaths occur in the first month of life. If one survives that period, the two main causes of death are diarrhoeal disease and pneumonia.
However, the deaths due to pneumonia have only recently been acknowledged, pneumonia being identified as the “forgotten killer of children” by the UNICEF
Simple strategies
A vast majority of children can be saved by the implementation of prevention and treatment strategies universally. Simple measures like exclusive breastfeeding for six months can prevent child deaths by a good 16 per cent. Provision of adequate nutrition which would correct deficiencies of micronutrients such as zinc, have also been proven to be effective. Thousands of deaths can be prevented by prompt recognition of the severity of the illness, appropriate diagnosis and adequate use of antibiotics, by trained health personnel.
Pneumonia is an easily treatable condition, and the organisms that cause these illnesses respond well to available antibiotics. The danger to life arises because of late presentation to health care facilities. Is health care access a problem in India? Does India have inadequate healthcare resources? On the contrary, there has been a tremendous growth in healthcare resources and health related manpower, with an adequate doctor patient ratio. There is however, a misdistribution with concentration of resources in urban settings, and a distancing of health care access from the population, geographically, socio-economically and even by gender.
With inequity in health care access, what are the alternatives? Universally, immunisation has been known to protect children against life threatening illnesses. The use of vaccines to reduce the burden of pneumonia is not a new concept, targeting diseases which result in pneumonia. The pertussis (whooping cough) vaccine has been in use for the last five decades, worldwide, and has been available in India as part of the triple antigen. Measles vaccine, in wide use since the 1980s is estimated to have saved 2.5 million lives, and is part of the Government of India immunisation programme. Both diseases however, continue to be prevalent in parts of India, in states where the immunisation coverage is low, bringing home the point that vaccines work only if given, and access to health systems is critical for the well-being of a society.
New vaccines
The two newer vaccines targeting pneumonia (and meningitis), available in India in the private sector, are the Hib conjugate vaccine and the Pneumococcal Conjugate Vaccine (PCV). These vaccines are relatively expensive, costing approximately Rs. 200-300 per dose for the HiB vaccine and over Rs. 3000 per dose for the Pneumococcal vaccine. Introduction of these vaccines into the national immunisation schedule would imply a huge ongoing financial commitment for the Government, and the Government would need to be sure that such a measure is cost-effective.
Do these vaccines work against pneumonia? How do we demonstrate that they work against pneumonia? There is no confirmatory diagnostic test for pneumonia, the closest approximation being an x-ray. Protection against pneumonia by vaccines is therefore difficult to measure, and is often reported as protection against radiologically confirmed pneumonia. Demonstration of efficacy is a difficult task.
The protection given by Hib vaccine varies from 22 to 44 per cent in various studies across the world. The Government of India, based on available evidence, has made a decision to introduce the Hib vaccine into the national immunisation schedule, in a phased manner. This would be done as a pentavalent injection, combining diphtheria, tetanus, whooping cough, hepatitis B and Hib conjugate vaccine.
As for the pneumococcal vaccine, the pneumococcal organism has many different types (serotypes) and a vaccine is denoted by its valency, i.e. the number of serotypes it covers. The serotypes that cause disease vary in different countries and the same vaccine may not work with equal measure in all countries. The version of this expensive vaccine currently available in the private sector in India is seven valent, and there is some concern that this vaccine does not cover all of the locally prevalent serotypes.
Pros and cons
There are justifiable arguments against the successive introduction of newer and more expensive vaccines into a country. The existing immunisation programme is not optimally utilised, immunisation rates being as low as 50 per cent in some areas. Even with financial support from agencies outside the country, vaccine programmes involve a great commitment in terms of finance, organisation, manpower and other resources. There are already pressing issues like water and sanitation that need to be addressed. Should the money be spent instead in making health care access more equitable?
More than one million lives around the world can be saved per year with simple and effective interventions such as promotion of breast feeding, attention to nutrition, scaling up of treatment strategies, and ensuring immunisation for the vulnerable. All carers for children should become partners in this fight against pneumonia, so that this easily treatable condition does not continue to claim such a large quantum of young lives.
The writer is on the faculty of Christian Medical College, Vellore, T.N
