Commentary: A Failure To Innovate
by Leith Greenslade
This article was originally posted on the World Pneumonia Day blog.
Revolution, transformation, breakthrough, modernization, ingenuity, inspiration, invention, a.k.a. innovation.
This is what is so desperately needed to fight the leading killer of children under five and what we have been lacking for more than a decade. The last great innovation in childhood pneumonia was the introduction of the pneumococcal conjugate vaccine in the United States in 2000. Since then, nothing much has changed in the way we prevent, diagnose and treat childhood pneumonia and this is one of the major reasons more than one million children are dying from pneumonia each year and the world is so off-track to achieve Millennium Development Goal 4. Without a revolution in the way we respond to childhood pneumonia and particularly in those parts of the world where deaths are concentrated, we cannot fundamentally advance the health of the world’s children.
Here’s what we know. According to UNICEF, pneumonia kills more children under five than any other single cause – an estimated 1.1 million children in 2012 and 17 percent of all child deaths (6.5 million). 80 percent of deaths are among children under two years of age and 330,000 are among newborns. 60 percent of deaths occur in just six countries – India, Nigeria, Democratic Republic of Congo, China and Ethiopia – because in these high population countries most children with suspected pneumonia are not taken to an appropriate health care provider and even fewer receive antibiotic treatment, and the pneumonia-fighting vaccines – especially the pneumococcal vaccine –– are often not routinely available. Further the behaviors that protect against pneumonia infection like exclusive breastfeeding, good infant feeding practices, hand washing with soap and reducing indoor air pollution are not widespread practices in countries with high child mortality.
Here’s what we don’t know. Why do most families fail to seek care for a child with suspected pneumonia and why is treatment with antibiotics so low? Is it because families don’t recognize the danger signs – rapid breathing, cough, fever and chest indrawing – and don’t understand the seriousness of the infection, which can lead to death very quickly? Or is it because they mistake these signs for something else – malaria, a common cold, a spiritual malady – and use the wrong medicine or no medicine at all but a local remedy? And for those children who do make it to a health care professional, how are they diagnosed and treated? Is a respiratory rate counter used to count their breathing; are they referred to another facility for treatment or given antibiotics on the spot? If antibiotics are given, is a full course taken when the child returns home? And if the child is referred to a facility, does the child go and once there what is the quality of treatment provided? Is pulse oximetry used to test for oxygen deprivation and does the facility have a supply of oxygen? And if a child arrives severely ill, can the facility intervene to prevent death?
We don’t really know how to answer these questions, but a 2008 study by Karin Källender and colleagues sheds some light onto the path to death for children with pneumonia. This study analyzed all of the deaths of children aged one month to five years from 2005 to 2007 in the Iganga/Mayuge Demographic Surveillance Site in Uganda. During this period 164 children died, 44 (27 percent) of pneumonia. Importantly, pneumonia was the primary cause of only 12 of the 44 deaths because most children who died were also suffering from other conditions including AIDS and malnutrition, malaria, anemia and diarrhea. At the time of death the majority of children were in hospital (21) with the remainder either at home (14), in a clinic or health center (5) or en route to a health facility (4). A clear pattern of care seeking behavior emerged in this study with most parents opting to treat a sick child at home first using malaria medicines, antibiotics or both either bought from local drug shops or obtained from neighbors or leftover from previous illnesses. Even though most families lived less than an hour from the nearest health facility, children typically had to wait for two days until professional care was sought outside the home, with most being taken to a government hospital or center and a minority to private or NGO clinics. Even after arriving at a facility, one third of children were referred on again. The high proportion of children who died in facilities suggests that children were very sick once they arrived and that the facilities struggled to treat such severely ill children.
What we learn from this study is that we need the kind of innovations that can disrupt every stage of the path to death for children with pneumonia. We need behavior change innovations that simultaneously increase both the proportion of children who are taken to qualified health professionals and innovations that decrease the time between onset of symptoms and care seeking. Communications campaigns that educate families about pneumonia – its causes and symptoms, how to prevent it and the high risk of death for small children if you don’t act fast – are urgently needed, particularly in the regions where child pneumonia deaths are concentrated. In malaria endemic countries families and health care providers need to know how pneumonia differs from malaria and that home-based management of pneumonia can be deadly. To reduce the time between onset of symptoms and care seeking outside the home, families may need incentives such as vouchers to reduce the cost of seeking care at qualified facilities in both the public and private health sectors (e.g. transport vouchers, free service vouchers, food vouchers) and help with the costs of treatment.
We need diagnostic innovations that make it easy for all health workers – from the local drug shop owner to the community health worker to the facility doctor – to diagnose a child with pneumonia accurately, quickly and affordably. The Holy Grail is a point-of-care rapid diagnostic test that can tell you whether a child has viral pneumonia, bacterial pneumonia or malaria, or a combination, in the space of minutes. Such a test does not yet exist but would entirely disrupt the current approach which tries to identify children with pneumonia by counting their rate of breathing using counting beads, handheld timers, mobile applications, or sensors that fit to the child – each with its own limitations in terms of accuracy, affordability and usability. New devices to identify children who need oxygen are also a priority with innovations in pulse oximetry showing great promise but much more investment needed to bring these innovations to market and to wide use in health facilities. It is critically important that all diagnostic innovations are designed to meet the needs of the children most at risk of death from pneumonia – newborns and children under the age of two years.
A variety of treatment innovations are needed to give children with pneumonia access to treatment close to home and to lower the burden of treatment compliance on caregivers. In places where most treatment is sought first from local drug shops we need programs to train and equip these providers to treat childhood pneumonia with the recommended antibiotics in child-friendly formulations (i.e. amoxicillin dispersible tablets) and government and NGO-funded community health workers should also be trained and equipped in the same way, with all of the usual caveats on rational use of antibiotics and the need to refer very sick children to the nearest facility. Simplified antibiotic regimens that make it easier for families to comply with treatment will make a difference and new antibiotic formulations such as one-dose formulations that can be given on the spot by health providers have the potential to revolutionize compliance and treatment coverage. For children who are referred to facilities, supply of oxygen is a major gap (only one of the children in the Källender study received oxygen) and innovations in oxygen concentrators and generators specifically designed for children and for settings without electricity or access to spare parts and technicians are an urgent priority.
And finally we need integrated delivery innovations that offer families one-stop shop services where they can have their children immunized against the leading causes of pneumonia, receive guidance and support to practice pneumonia prevention (e.g. exclusive breastfeeding, proper infant feeding, hand washing with soap, reducing indoor air pollution) and return to have their child diagnosed and treated should they suspect pneumonia. Integration of pneumonia and malaria diagnosis and treatment in countries where both are leading killers of children is particularly important as the evidence suggests many children with pneumonia are paying a heavy price for the current lack of coordination and malaria medicines are being wasted on children who do not have malaria. Further, when we know that the children who die from pneumonia are also malnourished and can be suffering from other illnesses including diarrhea and AIDS, we need services that can treat the entire child and not one or two diseases. This is exactly what the new Integrated Global Action Plan for Pneumonia and Diarrhoea recommends and donors need to step up and start investing in integrated solutions and partnering with agencies who can effectively work across the leading disease areas of child survival – particularly pneumonia, diarrhea, malaria and nutrition.
On World Pneumonia Day 2013 and with 780 days left to prevent the deaths of an estimated 3.5 million children under five and achieve Millennium Development Goal 4 the call needs to go out to all innovators to step up to fight the leading killer of children under five. We need the best and brightest talent – healthcare professionals, inventors, scientists, academics, entrepreneurs, designers, entertainers, journalists, engineers, students and more – working in partnership on the biggest challenge in child survival. To provide a platform for engagement a Pneumonia Innovations Team has come together with membership from UN agencies, governments, non-profits, corporations, universities and investors from all over the world with a mission to accelerate the development and adoption of the new technologies and practices with the greatest potential to reduce child deaths from pneumonia. We invite all who have something innovative to contribute to join with us. Make World Pneumonia Day 2013 the day when you decided to step up to the pneumonia innovation challenge. The next great innovation can be just around the corner…