Gasping for breath: Why pneumonia is still hard to beat

In 1901, Dr William Osler, one of the founders of modern medicine in described pneumonia as “the captain of the men of death.” He was writing about the USA, where the disease was a major killer of children and a source of fear for their parents.

To date, pneumonia remains a "captain of the men of death” as no other infectious disease claims the lives of more children than it does in the world and in Kenya. The vast majority of these children are from poor families.

In 2016 in Kenya, 11,203 children under the age of five died of pneumonia according to data from the Global Burden of Diseases, a slight reduction from the 14,972 who died in 2010.

Most pneumonia deaths occurred Kakamega (818), Meru (674), Nakuru (593), Mandera (566) and Homa Bay (534 deaths).

In 2017, pneumonia was responsible for 21,584 deaths according to the Economic Survey 2018, accounting for 22 per cent of deaths, and standing as the leading cause of the death for the third year in a row.

With a vaccine which was introduced in 2011, protecting children against 10 strains of bacteria that cause severe pneumonia, one would wonder why despite a reduction, a preventable and curable disease still kills so many.

“Most of the affected children come from poor families which live far from health facilities and are not able to access timely care. Majority die because of delays in seeking appropriate treatment,” explains Dr Peter Okoth, a specialist in child health at Unicef.

“The disease leaves desperately vulnerable children fighting for breathe, as their parents wrestle with anxiety, and all too often, the distress, grief and trauma that comes with loss,” added Dr Okoth.
Pneumonia is the inflammation of air sacs in the lungs, caused by viruses, bacteria, or fungi.

RESPIRATORY INFECTION

In Kenya, about 700,000 cases of pneumonia in children under the age of five are treated every year. About one in three children are not taken to a healthcare facility when they suffer acute respiratory infection, and for the two in three that are, many are seen by a health workers when it is too late to save the sick child.

“The main cause of pneumonia in children is that they are exposed to risks factors including indoor population, shortage of drugs and lack of information necessary to promote interventions that prevent children from getting pneumonia especially vaccination and hygiene,” says Dr Okoth.

Dr Osman Warfa, the head of the Neonatal Child and Adolescent Health Unit (NCAHU) at the Ministry of Health says that over time, government-led preventive measures including the introduction of pneumococcal vaccine in 2011 and increased coverage of exclusive breastfeeding have been instrumental in reducing pneumonia-related deaths.

However, the pneumonia burden in children under the age of five remains high, with one in five child deaths attributed to the disease.

According to a report published by Save the Children last November, the reasons for these deaths are inaccurate diagnosis, shortages of frontline antibiotics and weak referral systems.

When diagnosed accurately and early, pneumonia can be treated with a three- to five-day course of antibiotics that costs less than Sh200.

LACK OF PREVENTION

“Children die from pneumonia because they are denied the benefits of prevention, accurate diagnosis and treatment. Most hospitals do not have the necessary drugs for prevention,” noted the study.
The study titled Fighting for Breath revealed that millions of children under the age of two in low- and middle-income countries, who are the most vulnerable, are not immunised against the world’s deadliest disease.

The pneumococcal vaccine was introduced in Kenya in 2011 as part of the national immunisation schedule, with children supposed to receive all the three doses of the vaccine at six, 10 and 14 weeks.

However, data shared by Save the Children shows that 418,517 children aged 12-23 months were not immunised with the pneumococcal vaccine in 2017.

If such children are also not adequately breastfed and suffer malnutrition, then their risk of suffering from or dying of pneumonia.

Breastfeeding as recommended – exclusively for the first six months of life, then with complimentary feeds up to at least age two – confers protection against pneumococcal bacteria and strengthen a child’s natural defences.

“Children who are appropriately breastfed are less likely to experience severe or fatal pneumonia, because colostrum produced in the first hours and days of a baby’s life is rich in antibodies and is the most potent immune system support known to science,” notes the Save the Children report.

Research published in The Lancet last month, estimates that sub-optimal breastfeeding contributes to an estimated 823,000 avoidable deaths in children under the age of five.

The paper estimates that optimal breastfeeding could prevent a third of respiratory infections and more than half of hospital admissions associated with those infections.

Breastfeeding is also associated with a reduced risk of under-nutrition and diarrhoea, both of which are risk factors for pneumonia.

According to Save the Children going to hospital is not a guarantee that a child’s life will be saved from the crutches of the preventable and curable respiratory infection.

Surveys of the availability of essential medicine, show that fewer than 50 per cent of healthcare facilities in the country have the child-friendly Amoxicillin dispersible tablets, the most effective frontline treatment.

HIGH PREVALENCE

Speaking to the Healthy Nation, Dr Okoth revealed that the uptake of the drug is very low more so in the rural areas where pneumonia attacks are prevalent, since most hospitals in the country are not stocking the drug.

“We know that reaching children in remote rural areas and urban slums is the biggest challenge we face as we move forward in closing the immunisation gap and giving all children the opportunity to be fully immunised.

“We should work towards equipping health centres,” notes Dr Custodia Mandlhate.

Dr Okoth said in order to reach every child, community and parents have to be sensitized on the importance of immunisation and how risky it is not to be immunised.

Dr Walter Otieno, a paediatrician based in western Kenya, says that pneumonia could easily be controlled, but the worst consequence is hypoxaemia, which is what kills most of the children.

Hypoxaemia is a condition that leaves children with insufficient oxygen in the blood.

“This is the time that we lose most of the children because they are literally gasping for air. It calls for immediate admission yet most facilities lack oxygen that could save their lives. This is the most dangerous part of the condition.”

DIAGNOSTIC TOOLS

Dr Otieno adds that lack of diagnostic tools such as pulse oximeters; a non-invasive mechanism for measuring oxygen levels in the blood, in most hospitals, leads to misdiagnosis of pneumonia, putting many children at risk of dying.

According to Dr Warfa, high pneumonia deaths are also caused by the inability of health workers to master the updated guidelines for children under the age of five years.

Parents and guardians have also been blamed for feeding children below six months, instead of exclusive breastfeeding, and not observing immunisation schedule.

The government is now calling upon the health workers to understand that cough syrups should not be prescribed to manage pneumonia in children under the age of five years and to exclusively breastfeed babies up to six months.

“Amoxicillin dispersible tablets are the best treatment for pneumonia because this is a broad spectrum antibiotic that is stable, cheaper, easy to administer, store and transport and compliance is high,” says Dr Warfa.

He adds that another challenge in reducing the pneumonia deaths is that health workers do not use pulse oximeters to assess a sick child with a cough or difficulty in breathing.

“The updated guidelines on the management of sick children, including those suffering from pneumonia, have not reached health workers. They are still prescribing other antibiotics or cough syrups which are not recommended for treating pneumonia in children under the age of five years,” says Dr Warfa.

The Ministry of Health developed an implementation plan outlining key interventions to accelerate the reduction of pneumonia and diarrhoea-related deaths, key among them the updated pneumonia management guidelines that recommend the use of Amoxicillin dispersible tablets for the management of pneumonia in children.

ACTION PLAN

Dr Warfa adds that parents should also be involved in preventing pneumonia attacks.

“Mothers should ensure that children’s lungs are not subjected to household air pollution or potentially dangerous microbes from unsafe water. This can be powerful sources of protection,” he says.

The Save the Children report notes that winning the battle against pneumonia will require wider changes that make healthcare accessible and affordable for all.

The report advises that it is vital for families and caregivers to be equipped with the information they need to recognise symptoms of pneumonia, and that mothers are empowered to make decisions and access care in a timely manner to prevent child deaths.

The report also calls on governments in every high-burden country to adopt integrated Pneumonia Action Plans geared towards eradication targets.

The training of community health workers to correctly diagnose and treat pneumonia is also critical. However, anti-pneumonia strategies will only succeed if health system coverage extends to the hardest-to-reach children.