Dr Kehinde Fasina, a consultant paediatrician at the Paediatric Pulmonology Unit of the University College Hospital (UCH), Ibadan, in this interview by SADE OGUNTOLA, speaks on what Nigerians need to know about pneumonia and its prevention, including the advantages of vaccination and nutrition for healthy children.
It is said that pneumonia is the leading infectious cause of deaths in children worldwide. Why is this so?
Pneumonia is a lower respiratory tract infection, even though it may at times be preceded by an upper respiratory tract infection. The infection is deep-seated in the lung tissue, unlike an upper respiratory tract infection that starts from the nose and spreads to other parts of the respiratory tract. It is a leading cause of death due to infection in children below the age of five years. Haemophilus influenzae type B and Streptococcus pneumoniae are the most notorious organisms known to cause pneumonia. Of course, some other germs like Klebsiella pneumoniae, Staphylococcus aureus, Group A beta hemolytic streptococcus, Esherichia coli and some viruses and fungal organisms have also been implicated as the cause of pneumonia and the progression of the disease.
Now, pneumonia is the leading infectious cause of death in children because the two major organisms that cause the condition are virulent encapsulated organisms. The capsule tends to protect these organisms against antibiotics and some other agents used to conquer this infection. The shedding of these capsules helps these organisms resist killing by the immune defences of the lungs. These organisms also release some chemical substances that make antibiotics ineffective. Also, it is deadly because it is a deep-seated infection inside the lungs, and this infection can easily spread to surrounding airway channels and blood vessels, ultimately spreading through the blood stream to other organs in the severe form of the disease.
Children are generally more vulnerable to pneumonia and other infections because their immune systems are naive and also due to their continuous exposure to infective organisms from adults at daycare centres and schools. It is important to know that some children are even more vulnerable to pneumonia because their immune systems are compromised by malnutrition, undernourishment and a lack of exclusive breastfeeding.
Nutrition plays a significant role in immune modulation. When children are malnourished or undernourished, their immunity will not be optimal to combat illnesses, as children suffering from malnutrition are more at risk of acquiring pneumonia.
Also, poverty is a factor that predisposes children to pneumonia. When a family is financially handicapped to provide basic nutritional needs, good housing, good water system and access to basic social services, including transportation to the nearest healthcare facility when a child is sick or to be vaccinated, it renders these children, who are totally dependent on adults, very vulnerable to severe illnesses and they may eventually succumb to these illnesses.
Our health system is dysfunctional and does not favour the survival of children with infectious diseases like pneumonia. Many mothers in pregnancy do not access antenatal care; they deliver their babies at home, and some of these babies are not vaccinated. Hence, we have many children who are not fully immunised because they did not complete their immunisation schedule.
Studies have shown that the poor educational status of mothers can also predispose a child to many childhood illnesses, including pneumonia. Mothers who have a higher educational status know the value of vaccination and ensure that their children are fully vaccinated; they also know the value of good hygienic practices to avoid diseases.
What are other factors that predispose children to pneumonia?
Other factors include living in an overcrowded environment, exposure to household and outdoor pollution, parental smoking, daycare attendance, concomitant illnesses like heart diseases, a lack of exclusive breastfeeding, poor immunisation status (lack of measles immunisation) and low birth weight. All these activate the process of contracting the germs that cause the disease.
What are the symptoms of pneumonia?
Pneumonia is a disease of the respiratory system, the system that is involved in exchanging gases (carbon dioxide and oxygen). If there is no proper gas exchange, there could be respiratory difficulty, respiratory failure and, eventually, death. Of course, pneumonia can lead to two major things: the further spread of infection from the lung to other parts of the body and the disease of the airway, which involves swelling of the airways and plugging of the airways with mucus, thereby leading to narrowing and blockade of the airways. Breathing subsequently becomes difficult, leading to fast and difficult breathing.
So the infection can kill the child by affecting the lung tissue when proper gas exchange is altered. The ineffective process may become widespread — what we call septicaemia — a case of an infection spreading into the blood. The mothers will say the breathing is fast, and by the time the clothes are removed, the chest wall will be seen moving in and out, what is called lower chest wall in-drawing.
Majority of those infected also have a high fever and fast breathing. Some are brought into the hospital coughing, unconscious, or discoloured because gas exchange is completely impaired. Unfortunately, many children with pneumonia are brought late for treatment because mothers are unable to recognise fast breathing in the children. When interviewed in the emergency room, they usually say they are unable to recognise abnormal breathing (fast breathing) in their children and do not know it is dangerous.
Some will say they became only concerned because the child was not breathing like other children. Some mothers also assumed that “catarrh, cough, and fast breathing” in children are synonymous only with the common cold. So they focused more on the nose; they didn’t check the chest movements; probably that is one of the reasons why we are losing these children in Nigeria.
Mothers fail to recognise the basic signs of pneumonia, which are high-grade fever, cough and intercostal in-drawings with or without a lower chest wall in-drawing. If you look at the chest wall of such a child, there is movement in and out of the lower chest wall — what is called lower chest wall in-drawing. This is suggestive of serious respiratory distress. That is how deadly pneumonia is.
What is the incidence of pneumonia in Nigeria?
Pneumonia has been rated as the number one cause of infectious disease that leads to death in children in Nigeria. Nigeria has the highest case fatality rate of pneumonia globally. It is also reported that 140,000 children die annually from pneumonia in Nigeria, which is quite bad. The burden of pneumonia in Nigeria is frightening. Also, Nigeria and four other countries account for half of childhood pneumonia deaths worldwide.
Are there proven strategies to help protect children from this condition?
Basically, there are causative, predisposing, or contributing factors for the development of pneumonia. Avoiding all these factors will reduce the likelihood of pneumonia, which is remarkable. Causative organisms have been highlighted earlier. Predisposing factors for pneumonia in children include lack of exclusive breastfeeding, low birth weight, prematurity, malnutrition, poverty, air pollution, poor hygiene, overcrowding, poor ventilation and congenital problems like congenital heart disease and congenital immune deficiencies. Of course, not vaccinating or receiving inadequate vaccination against the germs that can cause pneumonia can also predispose a child to developing pneumonia.
What is the place of the pneumococcal vaccine in all of these?
Since the introduction of this vaccine, the incidence of pneumonia has dropped drastically. The population of children that we admit for pneumonia in our emergency rooms has reduced. The ones that we now see are more of mild pneumonia, though we still attend to a good number of severe cases. For mild pneumonia, it is oral drug administration, so we ask them to go home and come back to see us on a follow-up basis.
The theme for 2023 World Pneumonia Day is ‘Defeat pneumonia, every breath counts, every action matters’. How possible is this?
For pneumonia, gaining a single breath is very difficult because of the spread of this infection to the lung tissue. By the time we see many of these children, they come in with fast breathing — a breathing rate that is higher than what is expected for the child’s age. When the breathing rate is higher than expected, it is ominous. So, every breath counts.
Certainly, we can defeat pneumonia if people observe and avoid established predisposing factors. However, while the incidence of pneumonia had declined globally by 51 percent, it only declined by eight percent in Nigeria. It shows that we are still not doing enough to stem cases of pneumonia in our country.
Vaccination is important against the organisms that cause this infection; equally important is avoiding the predisposing factors. Both work hand in hand to provide protection from pneumonia for children. Misconceptions about vaccination are rife in some population and they jeopardise the lives of children. But when mothers are educated about vaccination and practices that safeguard children’s health, they accept and put such knowledge to use.
The vaccines that are protective against pneumonia, with the efforts of the Paediatric Association of Nigeria and the Federal Government, are now available in health facilities across the country. But more still needs to be done to ensure that our health system does not fail our children. Something needs to be done to reach out more to this vulnerable age group. Access to healthcare facilities and care for children under five years old needs to be simplified and prioritised to ensure a further drop in pneumonia cases in children.
A situation where mothers cannot recognise the signs of pneumonia or do not have the money to access healthcare, which makes them resort to patronising medicine vendors or pharmacies for the care of their children, can be detrimental to defeating pneumonia in Nigeria. So, appropriate care is delayed and then there is the issue of resistance to drugs. That is another problem because of the abuse of antibiotics by drug vendors.
There are also other illnesses that go hand-in-hand with pneumonia, like malnutrition, malaria and diarrhoea. Part of the global action to curb pneumonia is to make available interventions to handle these other co-morbidities. When a child has pneumonia, an infectious disease, the germs can spread from the lungs to other organs in the body, making the child susceptible to diarrhoea and other illnesses.
As such, aside from the government making available vaccines to prevent pneumonia, the government should also ensure that the health system can handle all these diseases and conditions that go hand in hand with pneumonia. Affordability and accessibility for these interventions are critical in eradicating pneumonia, considering the current economic status of Nigerians, too.
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