The young child was rushed to the Emergency Room with fast breathing, nostrils flaring, and chest indrawing; he was pale and febrile. His condition has been going on for several days and he had a poor appetite, hence little intake of food and water. The diagnosis was pneumonia, a lung infection that may be acquired from the air with fatal complications.
Pneumonia or pneumococcal disease is still one of the leading causes of death among children under five years of age. The death toll approximately amounts to 2,400 children per day. In fact, it accounted for almost a million deaths in 2016, with most victims below 2 years of age. Around 60% of childhood pneumonia deaths are concentrated in 10 countries that are considered as developing. These developing countries, including the Philippines, are beset with poverty-related factors such as lack of safe water and sanitation, poor nutrition, prevalent air pollution, and inadequate access to health care that aggravate the pneumococcal disease. According to Dr. Salvacion Gatchalian, Pediatric Infectious Disease Society of the Philippines (PIDSP) Immediate Past President, the increase in pneumonia mortality is also due to poor health-seeking behavior. She says “children are only brought to the hospital when it’s already too late. It is because some people do not know, they do not realize the gravity of the situation”. In adults, pneumonia may also have fatal outcomes, especially in patients with poor immune responses (e.g. diabetic, HIV, or cancer patients).
Pneumonia is an acute respiratory infection that may be due to viruses, bacteria or fungi. The infection is spread via droplets in the air; those with poor immunity are more vulnerable to developing the disease after getting infected.
In the country, the Acute Respiratory Infection Research group of the Research Institute of Tropical Medicine (RITM-ARI), through its Science and Technology Research Partnership for Sustainable Development (SATREPS), conducted studies to evaluate effective measures in mortality reduction and prevention of pneumonia. They identified the Respiratory Syncytial Virus (RSV) as the most common cause of this condition. As for the bacteriologic agent, the most common remains to be Streptococcus pneumoniae.
Controlling the situation
According to the RITM-ARI SATREPS, pneumonia may be prevented via improvement of health care practices, reinforcement of appropriate health-seeking behaviors, and roll-out of efficient immunization programs.
Increasing the level of awareness of Filipinos about the condition is very important in facing pneumonia. The condition, although with similar signs and symptoms, should be differentiated from acute cases of cough and colds or asthma. According to Dr. Gatchalian, fast breathing is one key feature that may be noted for pneumonia. RITM-ARI SARTEPS also identified maternal reasons and lower socioeconomic status as major risk factors in the Philippines. Mothers may be encouraged to seek free early consults in barangay health stations, health centers, and public hospitals for their children with respiratory symptoms.
Health professionals also play a significant role in the control of pneumonia in the country. Early detection and appropriate management are crucial. Dr. Gatchalian stresses the importance of rational drug use and correct antibiotic utilizations in preventing the development of antibiotic resistance. This is true not only in the pediatric population but also in the management of adult pneumonia cases.
Simple interventions to protect people against pneumococcal disease are to have access to safe drinking water, practice good sanitation, and frequent hand washing. Improvement of indoor air quality may also go a long way. As for the pediatric population, exclusive breastfeeding for the first 6 months of life and consequent good nutrition with extended breastfeeding up to the 2nd year of life confer protection against the deadly respiratory infection.
Effective Prevention via Vaccination
The United Nations devised an integrated global action plan for the control of pneumonia. An important aspect of the integrated framework is prevention and one of the best strategies is via vaccination. High vaccine coverage is considered as the key to increasing the immunity of the population.
The Pneumococcal Conjugate Vaccine (PCV) is very effective in preventing one of the most common bacterial etiologic agents of pneumonia across different strains. In 2013, the Department of Health added the PCV to the Expanded Program of Immunization for children, given for free in the health centers across the country. Currently, there are two kinds of PCV in the Philippines – PCV 10 and PCV 13. The two are considered comparable in efficacy, but the latter covers more serotypes of S. pneumoniae (including 3, 6A and 19A) and decreases the incidence of acute otitis media as well. Both PCV types have extensive post-introduction safety surveillance data and excellent safety profiles.
Assessment of the efficacy of PCV in the Philippines by the RITM-ARI research group showed that the areas within the country with poor access to health care obtained the highest levels of vaccine efficacy. Thus, the latest recommendation in the implementation of the national immunization program is to focus on the areas where children are most likely to benefit.
Children, as recommended by the Philippine Pediatric Society and PIDSP, require 3 doses of PCV at around 6, 10, and 14 weeks of age; or the doses being given at least 4 weeks apart. A booster may be optional but increases immunity when given, especially to children with poor immune status. On the other hand, the adult recommendation is formulated by the Philippine Society of Microbiology and Infectious Diseases and the Philippine Vaccine Foundation, requiring 2 doses for people aged 59 years and above. PCV 13 is recommended to be given before a dose of pneumonia polysaccharide vaccine a year after to have a better immune system response. In younger adults, pneumonia vaccine may still be administered to those with poor immunity.
Given that the estimated cost of hospitalization due to pneumonia may amount to 23,000 pesos, the PCV vaccine is a cost-effective alternative apart from avoiding sick days, absences or even preventable deaths.