The forgotten killer

PNEUMONIA needs to be put high on the national and global agenda if Papua New Guinea and other countries want to achieve the United Nations’ 4th Millennium Development Goal: to reduce childhood deaths by 2015.
According to the PNG Medical Research Institute (PNGIMR), pneumonia is a very serious preventable disease in PNG, more serious in fact than malaria, but receives very little attention. Therefore, the Government must seriously look at implementing ways to reduce the high burden of pneumonia in children. With the increasing rate of HIV/AIDS, pneumonia deaths in HIV positive people would only add to this burden.
PNG joined the rest of the world last Monday to observe the World Pneumonia Day. According to national health statistics (National Health Plan 2000-2010), pneumonia is the leading cause of death in PNG – 19.4 deaths per 100,000. It is the leading cause of death in children under 12 months of age and second only to malaria in children under five.
Globally, an estimated 156 million cases of pneumonia in children under five are reported each year, resulting in an estimated two million deaths.  Most of these deaths occur in developing countries, including PNG. A study in Goroka by PNGIMR scientists estimated that deaths from pneumonia in children less than six months of age to be 250 deaths per 100,000.
Malaria and pneumonia are the top two causes of deaths in PNG and the two diseases that bring most people to hospital. There are a number of germs that cause pneumonia, including viruses, bacteria and parasites. In PNG, the most common causes of pneumonia are two bacteria, the pneumococcus and haemophilus. Doctors and health workers diagnose pneumonia by watching the rate of breathing in a sick child. Children with cough and normal breathing are not treated. Children with cough and fast breathing must be treated with antibiotics at an outpatient department. This is considered mild pneumonia. Severe pneumonia is when a child has marked chest indrawing and goes blue because the lungs cannot get enough oxygen.
Pneumonia is thought to begin from bacteria growing in the nose and at the back of the throat, and studies by the PNGIMR have shown that PNG children carry these deadly bacteria from a very early age, which puts them at risk of getting this serious disease while they are still babies.
Poor hygiene, poor nutrition, overcrowding and environmental pollution are all risk factors for pneumonia by allowing the germs to be transmitted easily via airborne droplets and to weaken the host’s resistance against these infections. By improving these conditions, especially observing good hygiene practices, maintaining a nutritious diet, reducing overcrowding in houses and improving ventilation to reduce smoke from wood fires, can help reduce pneumonia deaths in children.
Vaccination is one strategy to prevent pneumonia deaths. For the bacteria that cause pneumonia in PNG, there are three vaccines available. The haemophilus vaccine, against Haemophilus influenza type b (Hib), the most dangerous of the haemophilus bacteria, was rolled out last year. This vaccine has already reduced deaths due to this infection in most countries that have introduced it into their schedules. There are two vaccines against pneunococcus, a 23-valent polysaccharide vaccine and a
7-valent conjugate vaccine. The 23-valent vaccine is recommended for children from two years onwards and the 7-valent is recommended for children under two years. The 23-valent vaccine has been successful in preventing deaths from pneumonia in PNG, even in children as young as nine months of age, but this study has not been repeated anywhere else in the world.
Both pneumococcal vaccines are expensive and the National Department of Health (NDoH) does not have the money to implement routine immunisation with these vaccines. However, moves have begun through the Global Alliance for Vaccines and Immunisation (GAVI) to assist developing countries and PNG has applied through the NDoH to introduce an expanded 10-valent version of this vaccine in 2010 or 2012.
“Before the vaccine can be introduced, we need to find the best schedule of this vaccine for PNG,” said William Pomat of the PNGIMR.
“In developed countries, three doses of 7-valent vaccine are given at two, four and six months. Because children in PNG are colonised by the bacteria earlier, an earlier schedule will be necessary to prevent pneumonia in young babies,” he explained.
He added that PNGIMR, in collaboration with the Telethon Institute for Child Health in Perth, Australia, is currently running a trial of the 7-valent vaccine looking at the effect of an earlier dose at birth, one and two months or at one, two and three months with a booster dose of 23-valent vaccine at nine months.
The preliminary results, Mr Pomat said, were promising and it was likely that an earlier schedule would be recommended to the NDoH for implementation. He said others such as measles and flu vaccines could further reduce deaths from pneumonia.
Securing supplies of drugs to hospitals and health facilities continues to be a big problem for the NDoH. Drug supplies to rural health facilities are further hampered by deterioration in infrastructure and the cost of transporting supplies to inaccessible areas. In most hospitals, there are problems with the supply of diagnostic reagents and the maintenance of equipment. X-ray machines which are important for diagnosis and confirmation of pneumonia by clinicians do not always function properly because of procurement issues. Oxygen is vital to treat severe pneumonia but its supply is limited.
Currently there are not enough statistics from around the country to provide accurate data on pneumonia deaths by region because many deaths in the villages are not properly recorded. Most of the data are from studies conducted in the Highlands region. From the National Health Plan, the Highlands and Momase regions have the highest recorded deaths from pneumonia at 21.6 deaths per 100,000 and 22.7 deaths per 100,000 respectively. In the remaining two regions, pneumonia is still in the top three causes of death. Accurate surveillance mechanisms would almost certainly increase the figures presented here.
In recognition of this, the PNGIMR will be hosting a Colloquium on Pneumonia in August next year to celebrate 40 years of research on pneumonia in PNG. Former staff and colleagues from here and abroad who have done research on the disease are expected to attend the celebrations which will be held in Goroka with the theme; “Action against pneumonia: A celebration of 40 years of pneumonia research in PNG and finding the best way forward.” As a celebration, the colloquium will highlight pneumonia to the mass media as the forgotten killer and bring the attention of the public to something that needs to be looked at seriously to achieve the Millennium Development Goals.