An eight-month-old boy with pneumonia is examined by a doctor at Amana Hospital in Dar es Salaam, Tanzania. Credit: Kristin Palitza/IPS

By Carey L. Biron
WASHINGTON, Apr 13 2013 (IPS)

The United Nations has unveiled a major framework aimed at, for the first time, coordinating worldwide efforts to work simultaneously to end childhood pneumonia- and diarrhoea-related deaths by 2025.

Together, these two diseases account for around 30 percent of all deaths of children under five years old, around two million every year. According to new data released by the World Health Organisation (WHO) and the U.N. Children’s Fund (UNICEF), most such deaths are taking place due to “piecemeal” services that are failing to reach the most at risk.

“Children who are poor, hungry and living in remote areas are most likely to be visited by these ‘forgotten killers’,” a new WHO/UNICEF report stated Friday, “and the burden placed by pneumonia and diarrhoea on families and health systems aggravates existing inequalities.”

The report comes as the agencies, backed by more than 100 global NGOs and civil society organisations, are announcing a new roadmap for national and international cooperation on the subject, called the Integrated Global Action Plan for the Prevention of Pneumonia and Diarrhoea (GAPPD). (A special issue of the medical journal The Lancet, also released Friday, covers the issue and the new action plan in depth.)

“With the release of the [GAPPD], we have a tool in place to combat these preventable illnesses once and for all,” Dr. Julio Frenk, dean of the Harvard School of Public Health, said Friday. “If we do this right, the ripple effects for equity, education and poverty reduction could be monumental.”

The new initiative goes to the heart of one of the Millennium Development Goals (MDGs), the internationally agreed development metrics. While MDG 4 requires that under-five child mortality be reduced by two-thirds by 2015 (compared to 1990 levels), progress has been deemed insufficient in several areas, including sub-Saharan Africa and South Asia.

Forgotten killers

While the action plan does not necessarily unveil any new techniques or funding mechanisms to battle pneumonia and diarrhoea, it does provide an approach that would integrate the use of already widespread interventions by multilateral, national and local actors.

“Although effective interventions have been well established, they are not always promoted together to achieve maximum benefit,” the report states.

“It is now clear that pneumonia and diarrhoea must be addressed in a coordinated manner. The determinants are often the same, hence preventive strategies and delivery platforms via health care facilities, families, communities and schools are similar.”

It is commonly known in the health field, for instance, that breastfeeding can cut down dramatically on rates of childhood diarrhoea. But new data suggests that just 39 percent of infants below six months of age are exclusively breastfed.

Likewise, slightly less than a third of children suspected to have pneumonia receive antibiotics, while only slightly more of those with diarrhoea receive cheap oral rehydration salts.

“The interventions are there already, but we now have to focus on reaching the poor and very vulnerable – those at highest risk who are often living in the hardest-to-reach areas,” George Armah, a University of Ghana researcher into causes of diarrhoea, told IPS by telephone.

“Importantly, these are things that can be done without much cost – for instance, improving vaccination coverage to these areas and improving sanitation.”

Yet while the new action plan aims at a minimum of 90 percent vaccine coverage by 2025, some are warning that high vaccine costs could make this integral part of the GAPPD approach untenable in the long term.

“Even at reduced prices, the [diarrhoea-causing] rotavirus and [pneumonia] vaccine together amount to 75 percent of the skyrocketing cost to fully vaccinate a child today. The price of the basic vaccines package has risen by an astronomical 2,700 percent over the last decade,” Dr. Jennifer Cohn, the medical director for the Access Campaign at Medecins Sans Frontieres (MSF), a humanitarian agency, said Friday.

“We are concerned that countries where we work will have the rug pulled out from under them when donor support to pay for vaccines tapers off and they are expected to foot the bill themselves. Because of the high price of new vaccines, countries may be forced to make difficult choices about which vaccines they can and can’t afford to use in order to protect children from killer diseases.”

Frontline focus

The WHO and UNICEF emphasise that the GAPPD framework puts particular focus on frontline health-care providers, particularly those operating in the smallest or remotest communities. The University of Ghana’s Armah likewise notes that much of the work necessary under the action plan will depend on those who staff community-level health posts.

“Here in Ghana, the medical programmes are now not only top-to-bottom but also bottom-to-top, and it will be important to recognise that those within the community are best placed to identify people in need of vaccinations,” he says.

“Further, while interventions are being done we absolutely have to work with people to change their habits – and recognise that we in developing countries have an important role in this. After all, if we increase vaccinations but don’t change people’s [habits], then we aren’t going to be able to bring down these problems. So we have to look at all of these things together.”

UNICEF and the WHO have set extremely ambitious goals, including reducing childhood pneumonia mortality to fewer than three per 1000 live births and diarrhoea mortality to just one per 1000 live births, both by 2025.

Yet the framework also offers a secondary set of broader goals that adhere closely to the holistic suggests Armah makes. If these were reached, their effects would go far beyond the immediate aims of ending childhood pneumonia- and diarrhoea-related deaths.

By 2030, for instance, the framework undertakes to offer universal access to basic drinking water in all homes and health care facilities. And by 2040, all homes are to have “adequate” sanitation.

In addition, the GAPPD pledges to provide universal access to clean energy technologies (smoky indoor cooking technologies being a major driver of pneumonia), as well as the “virtual elimination” of paediatric HIV, long considered one of the world’s neglected diseases.

“Implementation … will require focused interventions that make safe drinking water, sanitation, hygiene, nutrition, primary health care and health information and education available to everyone,” Harvard’s Frenk says. “The GAPPD is a key piece of the puzzle, and now is the time to make it matter.”

A child grimaces as he receives a measles vaccination at a school in Charsarda District in Pakistan's northwestern Khyber-Pakhtunkhwa Province in 2010. Credit: UN Photo/UNICEF/ZAK

By Lindsey Walker
UNITED NATIONS, Oct 9 2012 (IPS)

Pakistan, where some 126,000 children under five years old die from pneumonia every year, launched a new pneumococcal vaccine Tuesday, making it the first South Asian country to do so.

Pneumonia is the most common killer of children under five, and 99 percent of these deaths occur in developing countries, according to the World Health Organization (WHO).

Some 1.4 million children under the age of five die each year of pneumonia – more than child deaths by HIV/AIDS, tuburculosis, and malaria combined. And 550,000 of these deaths occur in South Asia alone, according to the United Nations children’s agency UNICEF.

The Global Alliance for Vaccines and Immunisation (GAVI), of which UNICEF and WHO are members, will bear 95 percent of the immunisation costs in order to bring the pneumococcal vaccine into Pakistan’s Expanded Progamme on Immunisation (EPI).

The EPI already includes several vaccinations, including those against polio, meningitis, and childhood tuberculosis, but has until now lacked the badly needed pneumococcal vaccine due to its considerable expense.

In an interview with IPS, Dr. Seth Berkley, CEO of the GAVI Alliance, said, “Historically, the delay between a vaccine being made available in the West and its availability in the east is 10, 15, (or possibly) 20 years.”

Pneumococcal, a vaccine that has been in existence for many years, is only recently conjugated into an inoculation safe for infants.

“When it came out of the West it was expensive,” Berkley said, “and the reason is that it is actually a collection of 10 or 13 vaccines (depending on which of the two products that are being used now) and it was a very complex, difficult to manufacture vaccine.”

The developing world was introduced to the vaccine only one and a half years after its introduction to the Western world, closing the usual gap by at least a decade. This is due to GAVI’s innovative Advance Market Commitment (AMC), an initiative that offered incentive to the vaccine manufacturers to produce large quantities of the pneumococcal at lower costs.

“AMC basically put out a programme to encourage manufacturers to make a vaccine that would contain the appropriate strains for the developing world,” said Berkley, “as well as having a better price point. That was the big innovation that occurred.”

AMC raised 1.5 billion dollars and offered a top up to the companies for the vaccines produced until the money ran dry. In this way, the price of each dose was reduced a staggering 90 percent from the price of each dose originally sold in the West.

In most countries, the poorest and most deprived children are likely to die before their fifth birthday.

“Coverage of key prevention should be higher among these children,” said UNICEF in a report published in early June of this year, “but too often the opposite occurs.”

In developing countries such as Pakistan, air and water pollution, overcrowding, and most importantly, lack of access to medical facilities all contribute to the enormous death toll by treatable and preventable illnesses.

The GAVI Alliance has called for “equity approach”. The concept is to treat children under the age of five in the lowest 20 percent of the economy in the same way as the top 20 percent of households are treated.

“Our long-term goal is to get it (the vaccination) to every child possible, especially because we know that the children who are stigmatised or who are in the poorer districts not only have higher incidence of disease because of living conditions, but also have less access to treatment,” Berkley told IPS.

He explained the strategy to accomplish this is to continue working with governments, NGOs and others to distribute the vaccine as widely as possible, despite the challenge of Pakistan’s wide gap between the rich and poor districts.

“It’s unlikely that the coverage in those places are as good as the places that have easy access,” said Berkley, “but on the other hand we don’t ignore them either. We try to do everything we can to get vaccines to them.”

GAVI’s financial support in the developing world comes in two parts: the financial backing to provide the vaccines themselves and the training needed to administer them, and the funding to improve the actual health system of the country in order to increase the functioning of the immunisation programmes.

Berkley explained that, in order for this these programmes to sustain themselves, there must be a visible price drop of vaccination costs, and the countries getting support from GAVI must begin to increase their payments as the economy improves.

Pakistan, for example, currently pays 20 cents per dose. Over time, as the economy begins to support itself, it will increase its payment to the full 3.50 dollars per dose, unless the price per dose has dropped by that time, as GAVI hopes and expects. AMC has already established that the price of each dose will not increase from 3.50 dollars.

“Above all, we must not lose sight of the heavy infant and child mortality burden facing Pakistan’s families,” said Dr. Guido Sabatinelli, WHO representative in Pakistan. “The introduction of the pneumococcal vaccine represents an important milestone in the fight to reduce this burden.”