In India: Preventing childhood pneumonia: the case for vaccines

V.K. Paul   Each year, millions of Indian children get immunized. In the last few months, new vaccines including the injectable polio vaccines and the rotavirus diarrhoea vaccines were added to the portfolio of the Universal Immunization Programme (UIP) under the National Health Mission. These new vaccines, previously out of reach for a majority of children, will soon be available free of cost for those that are most vulnerable to these deadly diseases.   Although substantial improvements have been made in the delivery of essential health services such as immunization, as seen through the success of polio eradication and more recently of Mission Indradhanush, child morbidity and mortality still remain one of the gravest health loss burdens faced by our nation. In India, more than 1.2 million children die before their fifth birthdays.   Moreover, it is estimated that, among Indian children aged 1-59 months, more than 140,000 deaths were attributed to pneumonia and 24,000 to meningitis in 2015. Streptococcus pneumoniae (pneumococcus) is the most common cause of bacterial pneumonia, causing approximately one-third of all child pneumonia deaths. Pneumococcal disease is vaccine preventable.   Both the World Health Organization (WHO) and the Indian Academy of Pediatrics (IAP) have recommended pneumococcal conjugate vaccine (PCV) for use in national immunization programmes. More than 130 countries, including over 50 GAVI-eligible countries, have introduced PCV since 2010[i]. Among these, Pakistan was the first in South Asia to introduce PCV in 2012, and Afghanistan, Nepal and Bangladesh followed the suit. India, however, is one of the only South Asian countries which has yet not introduced PCV.   The case for the vaccine is strong. Studies in countries such as the United States have shown a 77% decrease in invasive pneumococcal disease among children under age five and a 39% decrease in hospital admissions for all-cause pneumonia among children under age two in the years following PCV introduction.   What’s more, treating just one episode of pneumonia is expensive for families. A 2009 study estimated that the average direct cost to a household for a single episode of pneumonia in a child aged 2-36 months is about 6,000 rupees (90 dollars) for a tertiary care hospital and about 2,000 rupees for a secondary care facility in India. Because it has not yet been introduced into the UIP, PCV costs about 1,600-3,200 rupees per dose, making it prohibitively expensive for a majority of the population. This situation will change dramatically with the marketing of the affordable pneumococcal vaccine manufactured by Indian companies in the next few years.

  Needless to say, these high out of pocket expenses substantially burden the poorest of Indian households. As a result, only a negligible number of children with suspected pneumonia receive potentially life-saving antibiotic treatment. Even when treatment works, each illness weakens a child’s immune system and negatively impacts their physical and cognitive development. Thus, the best approach is certainly to prevent pneumonia from occurring in the first place. Already, the measles and Hemophilus influenzae vaccines, a part of UIP, have succeeded in averting hundreds of thousands of pneumonia deaths due to these pathogens.   The return on investment for immunization is also significant. A recent study covering 94 low- and middle-income countries found that, for every US dollar invested in childhood immunization, we can expect to save about $16 in healthcare costs, lost wages and productivity due to illness and death; when we account for the full value of people living longer, healthier lives, that return rises to $44 per dollar invested.   By preventing the onset of disease, vaccines help avert the direct and indirect medical, and lost productivity costs. Immunization enables children to have better physical, cognitive and educational development thereby promoting a healthy and productive population. Immunization is a cost-effective public health intervention and PCV the most viable public health tool capable of reducing the burden of pneumonia and consequent child mortality.   Controlling pneumonia poses the next significant challenge for child health and survival in India. Recognizing this, the NTAGI, India’s highest advisory body on immunization, cleared PCV for introduction in the UIP. The infrastructure afforded by the polio experience and the zeal and reach of the on-going Mission Indradhanush will enable the vaccine reaching the remotest parts of the country and benefiting those who need it the most. This strategy coupled with early detection and treatment of pneumonia due to other causes would go a long way in reducing under-5 child deaths.   Child health is the cornerstone for an efficient healthcare system and today’s robust commitment towards strengthening the immunization programme is remarkable and speaks volumes about our nation’s vision and priorities. We need to continue to build on the current momentum to achieve the pivotal milestone of controlling pneumonia related deaths to ensure all our children have the opportunity to reach their full potential.  

Dr. V.K. Paul is a renowned pediatrician and neonatologist, leads the pediatrics department at the All India Institute of Medical Sciences (AIIMS) in New Delhi, He also heads the WHO Collaborating Centre for Training and Research in Newborn Care and the India Council of Medial Research's Centre for Advanced Research in Newborn Health at AIIMS.