Tackling pneumonia, a ‘forgotten killer’

LUSAKA, Zambia — Inside the pediatric ward of a hospital here, Jess Chihumba tended to her 6-month-old daughter, Holly, alternately nursing her, cuddling her, and watching over her through the crib’s iron bars.

For the last four days, Jess had remained vigilant, foraging for moments of fitful sleep in a hard plastic chair pulled up next to the crib. Handwritten on a clipboard chart hanging above Holly’s head was her diagnosis: pneumonia and dehydration.

Holly's pediatric pneumonia case is just one of the estimated 120 million that occur each year globally, concentrated largely in Southeast Asia and Africa. Pneumonia is the greatest single cause of child death, killing an estimated 1.3 million children under 5 yearly, more than HIV/AIDS, malaria, and tuberculosis combined. Pneumonia is treatable, but formidable compared with other leading causes of child death, especially for those under the age of 2. Unlike malaria, pneumonia is caused by many different pathogens, and unlike diarrhea, its presence is tricky to detect without invasive or highly advanced techniques. Pneumonia also progresses quickly and is therefore difficult to treat in a place like Zambia, where getting to a hospital – or even a nurse at a barebones health clinic — is a challenge.

So pneumonia has been a “forgotten killer” to which funding and advocacy simply has not gone. It is a disease, as UNICEF has called it, of poverty, exacerbated by poor nutrition, poor sanitation, and poor air quality.

Holly was admitted to University Teaching Hospital, Zambia’s largest hospital, on a Tuesday in mid-July. Jess, 28, knew something was wrong with her youngest daughter days earlier. Holly had a fever, along with fits of cries and coughing, so Jess had carried her by foot to the closest clinic, one hour away. There she was given an oral rehydration solution, generic Tylenol, and an injected drug that hospital nurses later believed was an antibiotic.

But Holly’s condition only worsened. Over the next few days her fever climbed, and she started to vomit and have diarrhea. Jess carried Holly to the clinic two more times. On the third visit, Holly was so ill that she was transported to the hospital by ambulance — a relative luxury in a country where the health system is woefully under-resourced. None of Jess’s other three children had ever been so sick, and Jess feared for Holly’s life. 

Each year, thousands of children like Holly are referred by clinics around the country to University Teaching Hospital, with its labyrinth of concrete buildings and passageways. Sick children may be forced to share cribs, and one nurse may be responsible for up to 100 patients, but the care here is among the best in Zambia for those who cannot afford private hospitals.

That is, if the children can get referred here on time, which sometimes is not the case. In the nursery room next door to Holly’s, a two-month-old boy had recently passed away, just two hours after having been admitted with severe pneumonia.

This summer Zambia became the latest country to introduce a new vaccine to protect against pneumonia. Proponents believe it can prevent 500,000 children from dying and millions more from getting sick around the world each year. The vaccine launch in Zambia comes months after a United Nations Development Programme report found that at its current pace, the country will not meet the Millennium Development Goal for reducing child mortality. 

In a country with long distances between health care facilities, pervasive drug shortages, and just half the health care professionals needed, the vaccine will help bring down child mortality rates. It immunizes against pneumococcal disease, a bacterial infection that causes roughly one-third of all pneumonia child deaths. Called the pneumococcal conjugate vaccine — “PCV10” for short, after the 10 pneumococcal serotypes against which it protects — it immunizes against pneumococcal disease, a bacterial infection that causes roughly one-third of all pneumonia child deaths. In July, it was kicked off in the capital with great fanfare: a marching band, theatrical performances, and celebratory speeches by high-level health officials. 

Already, the vaccine has been distributed to every district in the country. That impressive feat was made possible by Zambia’s partnerships with multilateral organizations such as the GAVI Alliance and UNICEF, as well as donor governments. But it also followed Zambia’s own efforts to improve vaccine storage and prioritize child health. The Zambian government aims to vaccinate more than 360,000 children in the next 12 months with PCV10, and nearly all of the 650,000 children born each year by 2015. PCV10 is one of three new vaccines Zambia has announced plans to roll out this year. The expanded immunization program tells of “an improving story” for Zambia, said Charlie Whetham, GAVI’s officer for the country.

The PCV10 vaccine will likely have a significant impact on further driving down child illness and death, said Dr. Rodgers Mwale, a health specialist in maternal, newborn, and child health at UNICEF Zambia. That would build on the near 30 percent reduction in childhood mortality the country has seen since 1992.

“Coming at a point that we are seeing very good progress on, say the malaria front, one hopes this also brings a proven intervention,” said Mwale. “We think two, three, four years down the line we should see appreciable reduction in mortality and morbidity.” 

The vaccine will not prevent all cases of pneumonia, which also can be caused by other bacteria and viruses. But it could prevent many young children like Holly from contracting the disease.

THE ROAD TO LUFWANYAMA

As the road cuts across the dry winter landscape to Lufwanyama, a rural district in the northern Copperbelt region, it turns from paved blacktop to potholed dirt and back again. The change reflects the contours of the mining industry’s reach here. Lufwanyama is surrounded by copper and emerald mines that have generated significant wealth and development, but the district seems left behind, marked by expansive maize fields, tall elephant grass, and small thatched houses.

With a population of 92,000 spread out across nearly 4,000 square miles, Lufwanyama has only two doctors, one ambulance and no hospital, although a new hospital is slated to open later this year. Nurses form the backbone of Zambia’s health system, but in Lufwanyama, these are few and far between. The needs for the district are too great for the government’s local health office even to quantify.

A white Land Cruiser with the red logo of “Save the Children” stamped on the doors kicked up red dirt along the route, carrying a half-dozen of the organization’s employees and a GlobalPost reporter. It headed to Mibenge health post, one of 17 health facilities in Lufwanyama, a single slab of a building that had only recently gotten electricity.

Affixed with masking tape above a plastic barrel of water for hand washing was a poster advertising the pneumococcal vaccine. Mothers sat on benches with their children, waiting to see a nurse named Precious Mutale, who had been administering the vaccine since June. (Some districts received PCV10 well before the national launch.) The mothers held their children’s pink-and-blue paper immunization cards, some gritty with wear.

Mutale said she already had distributed first doses to 10 six-week-old infants. To be fully immunized, each child requires two additional doses at 10 and 14 weeks. Here, as is true at clinics across the country, patients get the doses for free. The $3.50 cost of each dose was negotiated by GAVI, and while this year it is financed entirely by GAVI, there are future plans for cost sharing with the Zambian government. The government health office in Lufwanyama estimates that the district received more than 2,000 does of the pneumococcal vaccine, more than enough to cover every infant in the district. With the vaccine, Mutale said with excitement, “we have something we can prevent.”

The process of getting the vaccine to remote clinics like this one required a complex global coordination. Each thimble-size vaccine vial was manufactured by GlaxoSmithKline, whose headquarters are in Brentford, England. It was procured by UNICEF and flown to Zambia from its global warehouse in Copenhagen. And it was stored in Lusaka, in special vaccine refrigerators, before being transported to the district health office in Lufwanyama, and finally to Mibenge. At each point in its journey, PCV10 had to be stored and refrigerated properly, between 2 and 8 degrees Celsius. 

It is too early to tell what impact the vaccine is having on the health of children here in Lufwanyama or elsewhere in Zambia. In the United States, a similar vaccine cut hospital admission rates for pneumonia by 39 percent among children under 2, according to a study by the Vanderbilt University School of Medicine. The first assessment of Zambia’s rollout will take place nationally six months out by the World Health Organization, GAVI’s Whetham said. 

Even a promising vaccine, however, cannot replace the need for treatment. And so, in Lufwanyama, Save the Children has been working with the local government health office to implement a holistic plan at the community level for handling and treating the three major causes of child illness: pneumonia, malaria, and diarrhea. The approach, called integrated community case management, was recommended for scale-up by WHO and UNICEF in a joint statement last year. 

At the Kamupundu Primary Health Care Unit, a smaller clinic near Mibenge, Elizabeth Kafumo sat before a weathered wood table that functioned as her examination room, drug supply storage, and personal desk. Wearing a white doctor’s coat, she ushered women and their children into the room one by one. Elina Makopo, 25, came carrying her 12-month-old twins, one strapped to her front, the other to her back. The children, she said, had been coughing for days.

Kafumo saw Makopo and her children, Jane and Give, as any pediatrician might. She took the children’s temperatures and measured the girth of their arms to see that they were nourished. She counted their breaths and, after confirming that both were above 50 breaths per minute, came to her conclusion: The children had pneumonia. (Fast breathing is a symptom of pneumonia for children under 5, along with chest indrawing, according to WHO.) Kafumo prescribed a full course of the antibiotic amoxicillin for the suspected infection. She counted out the chalky white pills from a large bottle on her desk, placed them in a clear sleeve, and handed them to Makopo. Then, after mixing the first dose with water and ensuring each child tolerated it, Kafumo was on to the next mother in line.

But Kafumo is not a doctor or nurse. With a ninth-grade education, Kafumo is a maize farmer and one of the estimated 5,000 volunteers in the country’s Community Health Worker (CHW) program. With too few health care providers spread too far across the country, CHWs like Kafumo help fill the treatment gap in rural areas like Lufwanyama. CHWs, trained only for six weeks, are responsible for counseling their communities on nutrition, basic sanitation, and HIV/AIDS, among other things.

Since 2009, Kafumo and more than 80 CHWs like her in the district have been additionally supported by a Save the Children’s project called LINCHPIN (Lufwanyama Integrated Newborn and Child Health Project), funded by USAID and private funders. As part of its overall aim to increase the use of newborn and child health care services in Lufwanyama, LINCHPIN has trained these CHWs in the integrated community case management framework so that sick children can be quickly and appropriately cared for. The project supports an expansion of the CHW government program.

It is not the only work Save the Children does through LINCHPIN or in the district, but it is a critical part of it. In developing countries, integrated community case management is believed to have the potential to reduce child deaths from pneumonia by 70 percent.

Still, even with capable CHWs like Kafumo, LINCHPIN faces challenges. A midterm evaluation conducted by Save the Children last year found that CHWs were properly trained, but also concluded that there were more basic needs such as “stock-outs of essential medicines” that were common and that limited the overall success of their work.

Karen Waltensperger, senior adviser for health in Africa at Save the Children, conceded that a fundamental component of LINCHPIN – the CHWs themselves – seemed unsustainable. Many worked five to eight hours a day for free. About one-quarter of the 86 CHWs Save the Children originally trained in integrated community case management dropped out. (Save the Children recently trained an additional 15.)

“Would you be a volunteer forever?” Waltensperger asked.

Recently, the government has piloted a new, paid community health worker program, but it is unclear how that will relate with the existing CHWs. Meanwhile, some enterprising CHWs have managed to get on the government payroll by becoming cleaners for the health center, Waltensperger said. 

The reality, observers here say, is that the government cannot yet fully support the integrated community case management effort – or the health system writ large. Some of the Lufwanyama health centers, which are responsible for ordering drugs for the community health workers, get half of the medicines they ask for from the district government, according to Save the Children. On top of these shortages, the district pharmacist orders 300 100-ml bottles of liquid amoxicillin for children every month, and nearly just as often, the bottles do not come.

For medicine, supplies, training, and more, Lufwanyama relies on nongovernmental partners to make up the difference. (Save the Children does not, however, buy drugs.)

But the sustainability of donor support is uncertain. Officials from the Zambian government, UNICEF, and WHO all commended Save the Children’s work in Lufwanyama and stressed the importance of case management at the community level. But LINCHPIN is scheduled to end in 2014. No new funding has come in and no transition plan has been outlined, although Save the Children wants to continue related work in the district. 

“Five years isn’t a very long time for a project,” Waltensperger said. “There’s a lot of things that have changed and gotten much better under LINCHPIN, so we would want to make a plan to build on that.”

It is a hope, but not a guarantee. Nearly 250 miles south, at a clinic in Lusaka, a CHW said she was trained by one international nonprofit from 2004 through 2008 on how to identify, prevent, and treat child diseases. The woman, Christine Ndapisha, said she had not received training since, and it was evident. She saw that “PCV10” was printed on the new national immunization cards, but she had no idea what that stood for. She had heard little about the new vaccine for pneumonia.

'I DON'T LIKE BABIES DYING'

In a new national storage facility for vaccines in Lusaka, Vichael Salavwe recalled a formative experience that led him here in the first place. He was at a hospital, seeing patients, he said, when a mother came over, moaning, and grabbed his legs.

“Can you please bring back my child?” she begged of him.

Salavwenot had not yet been able to see the child on his rounds, but already the child had died.

“I don’t like babies dying,” he said.

Salavwe is the chief officer of integrated management of childhood illness in the Ministry of Community Development and Maternal and Child Health, a government arm focused on community public health that spun off, rather abruptly, from Zambia’s Ministry of Health this past March.

Salavwe said the bulk of his ministry’s budget goes to immunization. He proudly showed off five large vaccine refrigerators that the Zambian government recently acquired with donor support.

A 2011 country assessment found that Zambia fell short of WHO targets in nearly every indicator for effective vaccine management, including proper temperature and vaccine distribution.

But in the last few years, Zambia has made a concerted effort to improve that. Since 2010, according to UNICEF’s Rodgers Mwale, Zambia has invested $1.35 million and achieved about 70 to 80 percent of the expansion. Following Zambia’s summer rollout of the pneumococcal vaccine, the Japanese government announced that it would grant the country another $2.34 million to close the gap, so that it could reach greater cold-chain capacity, particularly at the district level.

The increase in coverage parallels Zambia’s rising investment in health. It is one of six African countries to have met a pledge to spend at least 15 percent of its annual budget on health.

“We have fully owned the program,” Salavwe said of prioritizing child health. The government is helping to pay for vaccines, he said. It is working to provide better health services to rural areas. It has developed new plans to address maternal and child health.

“All we are getting from partners … is support to augment what is already existing,” he said.

THE ULTIMATE PREVENTION

At the University Teaching Hospital pediatric ward, Jess glanced at Holly. The child was swaddled in blankets, one a secondhand University of Michigan fleece that Jess had bought at a local shop. Jess blamed the cold weather for causing Holly’s illness. It’s a common belief, although studies show that the relationship is more correlative than causative.

Jess said she was grateful that Holly was feeling better. The little girl was even sitting up.

Under the watch of nurses and doctors who visit daily, Holly had received an abundant mixture of medicines, including intravenous penicillin. Her fever had come down, and while she still had the IV tube taped atop her hand, her mother was hopeful that they would both leave soon, nearly a week after they first arrived.

“It’s gratifying when people come early, and when cases are referred to this place,” said Mary-Cheer Sinyinda, a nurse who has seen the ebb and flow of patients at the hospital for years. She now spends her days at the hospital monitoring the sickest children, those with severe pneumonia, who are part of a multisite study funded by the Bill & Melinda Gates Foundation.

Outside, a well-regarded pediatrician who has worked at the hospital for 40 years contemplated the state of his country’s child health.

“Immunization has done a good deal” in reducing child deaths, said the doctor, Chifumbe Chintu. “We’re not seeing polio now. This was a big problem. We’re not seeing tetanus. It was rampant during my days.”

The pneumococcal vaccine follows in this same vein. But it is not a panacea.

“You know what he tells me?” said his colleague, James Chipeta, the assistant dean of research at the hospital and a collaborator on the Gates-funded pneumonia study.

Chipeta nodded to Chintu, who, in turn, broadly smiled with recognition.

“He says,” Chipeta continued, if only there was “a vaccination against poverty.”

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