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 Lucy Westcott
UNITED NATIONS, May 22 2013 (IPS)

PATH, a Seattle-based global health development organisation, is aiming to save two million lives by 2015 by jointly tackling diarrhea and pneumonia, the leading killers of children globally.

Steve Davis, president and CEO of PATH, delivered the message at the ninth annual PATH Breakfast for Global Health held in Seattle on Tuesday.

“Today we placed a bold stake in the ground, with partners around the world, to save two million lives by the end of 2015,” Davis told IPS.

PATH will begin its efforts in India, Cambodia and Ethiopia, where intervention is most urgently needed and PATH has resources. While all three countries have seen their child mortality rates from diarrhea drop, India’s pneumonia death rate remains stagnant, accounting for 24 percent of deaths of children under five, the same as in 2000, according to 2013 World Health Organisation statistics.

“No parent should have to bury a child because of something we can help prevent or treat,” Davis said.

Diarrhea and pneumonia are two diseases that overwhelmingly affect children in African and Asian countries, Davis said, with diarrhea claiming around 760,000 lives a year. And while the number of children dying in Africa before the age of five has decreased, it still vastly outnumbers all other parts of the world, according to the 2013 WHO statistics.

Melinda Gates, philanthropist and founder of the Bill and Melinda Gates Foundation, which helps fund health development and vaccines world wide, spoke at the breakfast of the importance of vaccinating children as well as “appropriate” science that meets the needs of communities in the developing countries.

“[The] developing world is littered with pilot programmes,” Gates said.

As he took to the stage, Davis pointed to a tool belt around his suit jacket. A visual aid, the belt allowed Davis to show and carry some of the tools that can prevent the deaths of so many children from diarrheal disease, tools that will be used to achieve PATH’s life-saving goal.

Clean water, soap, zinc tablets for oral rehydration therapy and the rotavirus vaccine, which stops some diarrheal diseases before they start, were all included.

But it’s not just science and vaccines that can improve the lives of communities ravaged by diarrhea. Deeply held cultural traditions and ideas about the disease have to be altered as well.

Dr. Alfred Ochola, PATH’s Technical Advisor for Child Survival and Development in Kenya, spoke about educating Kenyans on how to reduce the risk of diarrhea in their communities through hygiene practices like hand washing.

But Ochola, who lost a brother and sister to a diarrhea outbreak in Kenya as a child, has found that at first, people are reluctant to embrace change.

“A big [challenge] is combatting old beliefs that diarrhea is a curse and not an infection, and that the death of a child is an inevitable part of life. ‘God will give you another one’ is a common saying in Kenya,” Ochola said.

Many people believe a child who has diarrhea is cursed, Ochola said. Vomiting and diarrhea are welcomed because it rids the body of the evil inside it, while it should be taken as a sign that something is seriously wrong.

Poverty is another challenge in combatting the diseases. Although heart disease and diabetes are becoming the new illnesses of poverty, according to Davis, diarrhea and pneumonia still adversely affect children of developing countries in Africa and Asia.

In Africa and Southeast Asia, the percentage of child deaths are higher than the global average and have not significantly decreased in 10 years. Both regions have seen child mortality from diarrhea fall from 13 percent to 11 percent of deaths from 2000 to 2010, but in Africa, the rate of death from pneumonia has actually increased, from 16 percent to 17 percent.

“Too many people lack the financial means to seek care when it’s most needed, like paying for transportation to get to a health facility far from home… We often reach women and their children too late,” Ochola said.

Ochola told the story of Jane Wamalwa, a Kenyan woman who came to understand the reasons behind making a change in long-held practices in treating and preventing diarrhea. Wamalwa lost three children to the disease, and has now become a trusted source of information on good anti-diarrhea practice in her community, Ochola said.

“It has become her calling,” he added.

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 new vaccine will immunise five million Pakistani children annually against pneumonia. Credit: Adil Siddiqi

By Zofeen Ebrahim
KARACHI, Nov 22 2012 (IPS)

Medical practitioners at the National Institute of Child Health (NICH), a leading government-run children’s hospital in Karachi, hope that this will be the last winter they have to treat a stream of children suffering from pneumonia.

The disease is one of the leading killers of under-five children in the country, accounting for about 19 percent of child mortality.

Last month Pakistan became the first country in South Asia to introduce a free pneumonia vaccine, to immunise five million children against the deadly disease annually.

According to Dr. Mohsina Ibrahim at the NICH, the move will also help lower the incidence of other related diseases like meningitis, but only if “the vaccine is given the same importance as polio and taken door-to-door”, she told IPS.

The government was under considerable pressure to introduce the vaccine: with infant and under-five mortality rates of 78 and 94 per 1,000 children respectively, the country is unlikely to meet the target of reducing under-five mortality by two-thirds by 2015, as stipulated by the Millennium Development Goals (MDGs).

Considered to be the largest rollout of the vaccine after Africa and Central America, the new initiative will form part of the state’s routine child immunisation programme, a set of scheduled inoculations provided free of cost from birth to 15 months to protect against diseases like diphtheria, pertussis (whooping cough), measles, tetanus, meningitis, polio, tuberculosis, and hepatitis B.

The vaccine is being delivered through a partnership between the Pakistan government, the Global Alliance for Vaccines and Immunisation (GAVI), which supports and finances vaccines in the world’s poorest countries, the United Nations Children’s Fund (UNICEF) and the World Health Organisation (WHO).

GAVI plans to contribute 680 million dollars, and the government has donated 17 million rupees (175,000 dollars) to provide the vaccine until 2015.

“GAVI provides funds for countries to jump-start the introduction of newer vaccines, which they would otherwise never have the fiscal (capacity) to do,” Dr. Zulfiqar Bhutta, a leading paediatrician heading the women and child health unit at the Karachi-based Aga Khan University, told IPS.

This is done by procuring highly subsidised vaccines in bulk directly from manufacturers. “After a negotiated period, countries (are expected) to pick up the vaccine tab,” he said.

Efficacy not guaranteed 

According to Bhutta, the “critical task remains” of increasing routine vaccine coverage from 60 percent to 90 percent of all children, if the country hopes to stay on track for achieving the fourth MDG.

In addition, Bhutta said, there remains the challenge of “ensuring that these vaccines reach the poor and are not leaked or sold in the open market”.

Dr. Ifra Sameen, another paediatrician at the NICH, is also sceptical about the vaccine “reaching those in need”.

Acknowledging that it is a “step in the right direction”, she told IPS that she fears “good intentions may be marred by the low coverage of immunisation in the state’s health system.

“We have not been able to eliminate polio, which has received enormous political commitment and was (taken) door-to-door. In addition, we already have a vaccine for measles, yet the disease still persists. Given this scenario, what are the chances of eliminating pneumonia, which requires the child to be brought to the health centre and given three doses at three different times?”

Huma Khawar, coordinator of GAVI CSO Support, believes awareness is vital. Unless all caregivers, whether mother, father or grandparent, are fully convinced of the importance and benefits of the vaccine and ensure their children are immunised against all nine childhood diseases, efforts made by the government, GAVI and other U.N. partners to reduce under-five mortality will not go far.

In addition to being cut off from children in conflict-riddled areas and those controlled by militants, the programme must also overcome the hurdles of poverty, uneducated mothers and poor governance within the state-run health systems to ensure widespread inoculation, according to Ibrahim.

And while she is happy that an otherwise cost-prohibitive vaccine – costing a little over 13,000 rupees (roughly 133 dollars) for the entire course of three injections – will be available to everyone, she believes “it would have been better to have strengthened the coverage of existing vaccines, instead of introducing new ones”.

“The government should have focused on diphtheria, pertussis (whooping cough), measles and tetanus. The measles vaccine, which boasts an efficacy of 95 percent, would reduce the incidence of not just measles… but also pneumonia, meningitis and diarrhoea.”

The government should also tackle issues like “malnutrition, low birth weight, and non-exclusive breastfeeding, which put children at greater risk of pneumococcal disease,” said Ibrahim, adding that babies who live in overcrowded places, where indoor pollution levels are high and sanitation is poor, are particularly susceptible.

Malnutrition is perhaps the leading cause of pneumonia, said Sameen. According to the last Pakistan Demographic and Health Survey (PDHS) for 2006-7 38 percent of children under five years are underweight.

Sameen, who specialises in child nutrition, carried out a study on severely malnourished children admitted to NICH between January and June this year and found some 20 percent suffered from pneumonia.

The Global Action Plan for Prevention and Control of Pneumonia (GAPP), issued by the WHO and UNICEF, recommends a three-pronged approach to fighting child pneumonia that includes protection (exclusive breastfeeding and improved nutrition), prevention (including the routine use of measles, DTP3, Hib, and pneumococcal vaccines), and treatment (with appropriate antibiotics and oxygen).

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.”