Six days ago, the world marked World Pneumonia Day, with the aim of drawing global attention to the number one killer of children under the age of five years. We invited our colleague Francis Ohanyido who devotes most of his time to this disease to offer our community his perspective on this disease. He has delivered a tour de force of current priorities in the world and Nigeria.
By Francis Ohanyido
Last year alone, it was estimated that nearly a million children worldwide, died before their fifth birthday. One out of nine of these children (121,000) died in Nigeria. It is estimated that there are 6.7 million cases of childhood pneumonia annually. Nigeria thus has the second largest burden of the disease after India which has about ten times our population. In addition, pneumonia is estimated to constitute 15% of all causes of death in children below the age of 5.
One of the key highlights this year’s World Pneumonia Day was the release of a new report by the Institute for Health Metrics and Evaluation (IHME) titled “Pushing the Pace: Progress and Challenges in Fighting Childhood Pneumonia”. This report found that there had been a reduction in child pneumonia deaths over the last fifteen years of about 58%, but that this had not kept pace with reductions in deaths from other childhood killers such as measles and diarrhoea whose reduction stood at 83% and 68% respectively. In addition, funding remained an issue; illustrated by the fact that in 2011 only 2% ($US670 million) of the estimated $US30.6 billion of international development aid for health, was spent on fighting pneumonia, the leading cause of death among children under-five years! The IHME report has attracted a lot of comments from major actors in the pneumonia landscape worldwide. My good friend Ms. Leith Greenslade, Vice Chair at the MDG Health Alliance, clearly articulated my own take on the report:
“ …There is an opportunity to achieve a better alignment between the major causes of child death and the allocation of development assistance. The fact that many of the countries that have performed so poorly in reducing child pneumonia deaths have achieved remarkable reductions in reducing child deaths from other causes (e.g. diarrhoea and measles) suggests that disease prioritization and level of investment are critical factors. If we want to achieve MDG4 by 2015 and end preventable child deaths by 2030 we need to make sure that our spending tracks disease burden more closely than it has to date.”
It comes as no surprise that the report further confirmed the relative neglect of pneumonia disease among the top five causes of child mortality. This neglect has consequences on the institutional response to tackling the problem and even the health literacy of the population. A simple random chat with people in Nigeria clearly highlights that strong myths largely affect people’s understanding of the disease. Whenever I explain to people that Nigeria carries a significant chunk of the global burden of the disease, it has often been greeted by surprise…and even incredulity. Sadly, a significant number of people still think pneumonia is a disease of “cold environments”, rather than as a result of disease causing organisms. It is also not surprising that in the same report, Nigeria has showed only 4% reduction in pneumonia deaths among children under five years in the time reviewed.
During the course of a discussion on pneumonia with a senior legislator in the Nigerian National Assembly two months ago, she had asked me two questions : What can we do to change this state of affairs? What has been done so far in Nigeria?
I replied to her questions as follows: There is urgent need to mobilise resources to move against this disease if we want to achieve MDG 4, because it would enable the rollout of vaccines to prevent infection, strengthen programmes around health information, breastfeeding and access to clean cooking stoves. It would enhance the early recognition and treatment of children with pneumonia with the appropriate antibiotics such as the dispersible amoxicillin tablet and access to oxygen therapy where it is needed.
In response to her second question, I explained that despite many challenges, Nigeria was on the road to rolling out the pneumococcal conjugate vaccine at the end of the year, which would serve as the cornerstone of prevention (editors note: South Africa, Africa’s second largest economy after Nigeria has had the pneumococcal conjugate vaccine in its routine immunization schedule since 2009). The country’s partners at the last United Nations General Assembly week 2014 side meetings, had agreed to strengthen partnerships around breastfeeding including early initiation of breastfeeding due to the poor indices, as poorly breastfed babies are at a fifteen times greater risk of death from pneumonia when compared to babies who are exclusively breastfed for the first six months of life. (Children with malnutrition are also more likely to die of pneumonia). On the side of treatment, following compelling case profiles of several countries across Africa, Nigeria had started the process of rolling out the integrated community case management (ICCM) for malaria, pneumonia and diarrhoeal diseases. The country had also achieved local production of dispersible Amoxicillin tablets which is the first line drug for treatment of community-acquired pneumonia, a landmark achievement on the continent.
Because of the large human resource for health gap at the frontlines of Nigerian health system, the ICCM programme would use community assets by riding on the back of community-based health volunteers (CBHV) also called Community Oriented Resource Persons (CORPs) in underserved communities. Such structures are not new and have done well in Sokoto and Bauchi states in community-based distribution of misoprostol and chlorhexidine to reduce maternal mortality, with the support of USAID’s Targeted States High Impact Project (TSHIP). However, certain enabling policies need to be reviewed for pneumonia to be treated at the frontlines by such volunteers. Among the groups also being considered in this category to expand access to ICCM treatment for children are the ubiquitous patent and proprietary medicine vendors (PPMVs) found in every community in Nigeria.
Dr Ado Mohammed (centre), Executive Director NPHCDA (picture credit – http://thenationonlineng.net/)
One of the major challenges in ramping up pneumonia programmes has been around the diagnostic conundrum. Unlike its counterpart malaria, pneumonia diagnosis is mostly based on the clinical acumen of the provider for recognising signs in a child, because confirmation by X-ray is almost impossible at the lowest level of health care. New diagnostic technologies such as pulse-oximeters, mobile applications and other forms of tools to enhance quick, reliable and cost-effective diagnosis are being developed and tried. The inability to deliver compact and cost-effective oxygen therapy at primary care centers has also been a challenge at the frontlines that requires investment.
To end preventable child deaths by 2030 in Nigeria, we must move pneumonia to the centre stage of our child health programme strategies. The level of investment and disease prioritization we give to our strategies are critical factors, and require good integration at community level in managing the major childhood killers, namely, pneumonia, malaria and diarrhoea.
Editors note: We are excited that NPHCDA has announced the introduction of PCV into Nigeria’s immunisation programme in some pilot states by the end of 2014, however as Pridle et all noted, introducing PCV into a low-performing system may result in wastage, shortage, or other unintended consequences. We hope that NPHCDA has done the needful to ensure maximum benefit for Nigerian children.