Gavi/2013/Adrian Brooks

Dr Kate O’Brien, Executive Director of the International Vaccine Access Center (IVAC), and Professor of International Health and Epidemiology at the Johns Hopkins Bloomberg School of Public Health.

When it comes to stopping childhood pneumonia, the odds are stacked against the poor and vulnerable; but vaccines can give them a fighting chance.

In 2009, approximately 3,400 children died of pneumonia every day. Now, with investments in pneumonia prevention and treatment – including the introduction and scale up of two vaccines to prevent the most common causes of pneumonia death, Haemophilus influenzae type b and pneumococcus – that number has fallen to 1,000.

Although we have made great progress, we can and have to do more: there remain hundreds of thousands of pneumonia deaths each year that shouldn’t happen.

Children with multiple risk factors for illness and those in hard-to-reach settings are not only at a higher risk of contracting pneumonia but also at higher risk of medical complications, and even death. Furthermore, children that are most vulnerable often experience multiple conditions that each independently increase their risk of the disease – a challenge referred to as “risk-stacking”.

 At-risk for pneumonia

The likelihood of a child fighting off pneumonia begins long before they come into contact with an infectious agent – and often even before they are born. Babies born prematurely come into the world with health, growth and development challenges right from the get-go. The consequences of prematurity linger on throughout the child’s first months of life, onward into later infancy, and for some well beyond infancy. Difficulty feeding, which can limit growth, as well as under-developed lungs and weakened immune systems, can leave premature infants much more susceptible to developing pneumonia when they encounter pathogens that might otherwise have been held in check. When a baby born prematurely develops pneumonia they are at increased risk of severity and even deadly outcomes. The reason why infants may be born prematurely is also important. Pregnant mothers living with HIV are more likely to have babies born prematurely and with low birthweight than mothers who are not HIV-positive. Exposure to HIV at birth, even if the baby is not infected, increases the risk of pneumonia, further stacking the risks for these children.

Nutritional status can also determine a child’s ability to fight infection. Pneumonia and death from an episode of pneumonia is much more likely in undernourished children, whatever the cause. In some low- and middle-income settings, over half of pneumonia deaths are among children with undernutrition. Further adding to the picture is the fact that other illnesses, like diarrhea, contribute to the risk of undernutrition and in turn enhance the risk for pneumonia. Children who experience frequent episodes of diarrhea are at greater risk for pneumonia, again connecting a child’s risk of pneumonia to their social and living situation. Poverty in this sense is the major driver of pneumonia risk.

Gavi/2014/Duncan Graham Rowe

Risks for inadequate care during an illness

We have highly effective and affordable tools to protect, prevent, and even treat pneumonia, but there are major inequities in deployment and delivery of these tools. Many families experience serious impediments to accessing care, and health systems in many districts are not yet able to provide the quality of care children need for recovery from their illness.

The ability to access life-saving treatments is disproportionately influenced by factors like poverty, living in rural areas and low education levels among parents. In five countries with some of the highest numbers of pneumonia deaths in children, treatment for pneumonia by an appropriate healthcare provider was nearly 15 to 30 percentage points lower among children in rural areas than children in urban areas. Similarly, treatment was between 10 and 38 percentage points lower in children of the poorest 20% of the population than in the wealthiest 20%.We also see that costs of care and treatment can be a major barrier to accessing care. For example, the cost of pneumonia treatment for families in the Gambia can be up to 10 times their daily budget, including direct medical costs and indirect costs like meals and transportation, further threatening the entire family.

On average, severe pneumonia kills one in 50 children who receive treatment at a hospital, yet it kills one in seven children who don’t access care at a hospital. It’s also estimated that nearly 40% of children with severe pneumonia don’t reach a hospital for treatment. Poor access to care and inadequate care-seeking behavior are seen in many countries, driven in part by rural location, cost and cultural factors which stop many families from access to life-saving hospital care.

Inadequate health systems have a direct impact on childhood mortality. District level facilities very often do not have oxygen or other treatment supplies for care of children with pneumonia. Referral hospitals are not intended to cope withthe burden of community-acquired pneumonia that they could be expected to take on if community facilities are not in a position to care for these children. A health facility visit for basic assessment, pulse oximetry monitoring to detect oxygen levels and antibiotics to treat a case of pneumonia is quickly impeded by one obstacle after another, making timely treatment an unreliable reality for many. Families and community health workers, where available, are therefore forced to handle severe – and difficult-to-treat – cases. In some cases, this means a preventable and treatable infection can escalate into a critical situation.

Even for those who can reach a hospital setting, the outcome is not always positive. One in four children who were taken to a large pediatric hospital in Bangladesh were refused admission to the hospital because all beds were full, resulting in a substantial proportion of those with symptoms of pneumonia being turned away. It is staggering to know that this situation is repeated in many low- and middle-income country facilities around the globe with health systems that are not adequate to provide the necessary care.

Although it is estimated that about 60% of children with severe pneumonia are treated in hospitals, 80% of pneumonia deaths happen outside hospitals. This shines a bright light on the imperative for pneumonia prevention as the foremost strategy – most children who die of pneumonia do not have medical care for their illness. We cannot ‘doctor’ our way out of this pneumonia burden problem. Vaccination is a proven tool to prevent many cases of pneumonia – and may further shield children from the many risks that are stacked against them.

Gavi/2013/Evelyn Hockstein

 With proper treatment, many children quickly recover from pneumonia. Yet, the event can have longer term consequences that confer risk to that child of future illness or death. A vicious cycle ensues with the child becoming increasingly vulnerable with every illness survived. For example, pneumonia is linked with poor growth and being underweight. Just as diarrhea is a risk factor for pneumonia, pneumonia is also a risk factor for diarrhea, with each pneumonia infection contributing to a seemingly inescapable cycle of undernutrition and infection.

Treatment costs can push families into poverty and derail financial stability. In Ethiopia, pneumonia is the second highest driver of medical impoverishment. It is estimated that in 2013, out-of-pocket direct medical costs for pneumonia led to an estimated 59,000 cases of poverty – 1 in every 6 cases of pneumonia. Similarly, a study in Bangladesh found that families are heavily borrowing or losing assets to bear the cost of their children’s pneumonia – a financial impact affecting the entire family.

Call to action

For cases of vaccine-preventable pneumonia, this entire cycle – a cycle influenced by larger social, economic, and heath factors, but exacerbated by a case of pneumonia – can be preempted by protecting children through vaccination and assuring ready access to adequate care, monitoring and treatment. We encourage policy-makers, donors, and the global health community to scale up support of vaccine programs, reaching especially those communities who are disproportionately affected by illness and by low vaccine access. Through vaccine programs can we address inequities and work to ‘unstack’ the risks in these most vulnerable children.