Effective “case management” strategies can help to ensure that children receive the right treatment for pneumonia quickly, even in the poorest communities. “Pneumonia project in Malawi was based on our TB model which was delivering standard case management to children most at risk. The ‘know how’ is there but getting the ‘know how’ to the children is the problem. We know that the standard case management works but in most countries the problem is the weak health systems. One of the International Union Against Tuberculosis and Lung Disease (The Union)’s strengths is technical assistance in trying to build up and give capacity building to the health systems. And we showed this that if we do this for children with lung disease then we can have a huge impact. And it doesn’t cost a fortune. Another challenge is delivering oxygen to children with very severe pneumonia. So this needs to be addressed as well” said Dr Penny Enarson, Head, Child Lung Health Division, The Union.
DRUG STOCK-OUTS ARE MAJOR STUMBLING BLOCKS
Antibiotics used for treating pneumonia are still the first line antibiotics (and not the expensive ones) such as Benzopenicillin, gentamycin, amoxicillin among others. “These are quite inexpensive, easily managed but again usually it is the problem of logistics. Very often the governments either don’t get the supply or don’t maintain the supply of these antibiotics. So it is a major stumbling block for any strategy that is based on the standard case management because it relies on uninterrupted supply of antibiotics. These antibiotics are not expensive especially in India, because India is manufacturing a lot of these drugs. Countries in South Asia, South East Asia and Africa import these drugs from India. So it is a matter of commitment and ministries of health being logistically capable of keeping a stock of drugs always at the district and health centre levels for they are not expensive. There are two new vaccines for pneumonia, the HiB vaccine and pneumococcal vaccine. But both of them are expensive and not many countries have added them to their vaccine regiment because of the cost perhaps. These are major vaccines that really help in reducing deaths from pneumonia”, said Dr Penny Enarson.
IRRATIONAL USE OF DRUGS IS ANOTHER CHALLENGE
A problem when we can buy drugs over the counter is the over use or irrational use of drugs. “We follow rational use of drugs in standard case management and lot of it is about educating the mother on rational use of drugs. For example, children with common cold don’t need antibiotics, although it is so much easier for the physician to give it and mother is happy indeed. Children with common cold need some extra food and care etc, else this is where probably drug resistance can occur” said Dr Penny Enarson.
"To do a drug-resistance study is quite expensive, and that is why lot of countries don’t know their drug-resistance history. But by actually doing the treatment we do get to know that it works. In lot of countries there is no resistance to first line antibiotics but recently there has been some shift away from benzopenicillin and gentamycin for very severe pneumonia. Usually for less severe pneumonia we were earlier using cotrimoxazole but nearly every other country is resistant to that. More countries are now switching to amoxicillin which is a little more expensive. These are based upon the recommendations of the WHO and lot of these studies were done in Pakistan", said Dr Penny Enarson.
"It has shown in many studies that if we exclusively breastfeed an infant for the first six month,s then the child is less likely to get infections and it also helps the immune system, which is extremely important. However, in countries where there is no family planning, it is likely that there are more infants than one the mother has to nourish. So it can be quite difficult. The other issue is that should mothers who are living with HIV continue breastfeeding? But with antiretrovirals this issue has been addressed and studies show that exclusive breastfeeding cuts down on infections in the infant."
Dr Enarson thinks that, "Most of the deaths of pneumonia occur in under one year of age, so that is why there is real push for mothers to exclusively breastfeed and reduce the risk of the child dying. It has been shown that the children who are exclusively breastfed don’t die of pneumonia as often as the ones who aren’t.”
Dr Enarson agrees that, "Malnutrition is a huge problem and more so in Asia than anywhere else. 50% deaths in children are precipitated by malnutrition. Simple handwashing can cut down a huge amount of early infections especially during mother and child interaction. Malnutrition has to be addressed in conjunction with other disease programmes such as diarrhoea, pneumonia, measles, malaria, etc as they all are compounded by malnutrition. Indoor air pollution is also known to increase the risk of pneumonia. Especially for mothers who have infants on their backs or are holding the child while cooking and smoke from cook stoves can up the risk. Secondhand smoke is a risk for developing pneumonia."
RARELY A CHILD COMES TO CLINIC WITH ONE ILLNESS
“I can speak from my experience in Malawi that rarely will we see a child with one illness. So if the child has pneumonia, she/he may have diarrhoea, measles, malaria, malnutrition, or co-infection with HIV in areas or populations where HIV incidence is high. It is difficult to tell the child who presents with pneumonia and malaria. Very often one or the other is missed. Meningitis is also another co-morbidity. People need to be aware that children don’t come with just one problem” said Dr Penny Enarson.
Pneumonia is still the number one killer of children. It is dreadful that these children should not be dying because it is quite easy to diagnose and fairly cheap to treat. The governments and others working on health systems strengthening need to understand that if they really want to reach the Millennium Development Goal No. 4 then they have to address pneumonia in children, else they will not reach it.
We can win the fight against pneumonia. More than one million young lives can be saved annually with vaccines and antibiotics, by reducing indoor air pollution and through breastfeeding for the first six months of life.
Bobby Ramakant – CNS
Citizen News Service(CNS), India/Thailand
Wikio News, Africa
Elites TV News, California, USA