India will start providing free vaccination against pneumococcal diseases this year as part of its universal immunisation programme. Beginning in phases with five states -- Himachal Pradesh, Bihar, Uttar Pradesh, Rajasthan and Madhya Pradesh -- pneumococcal vaccination will be scaled up to cover all states over the next two years.
There’s need for the live-saving vaccine. Pneumococcal infections kill one child every three minutes in India, with more than 180,000 children dying of the infection each year. The symptoms include high fever, chills, a productive cough with breathing difficulty, and pain in the lungs, which can lead to septicaemia (blood poisoning) and death. Pneumococcal infections spread from person to person through close contact and take more lives each year than HIV, malaria, tuberculosis, Zika and Ebola, combined.
It’s not just children who get sick. Lower respiratory tract infections, including pneumonia, are the fourth common cause of all deaths in India, after heart disease, chronic obstructive pulmonary disease and stroke, reports The Global Burden of Disease 2015.
Anyone can get pneumococcal disease, but children under two years, adults 65-years-old and above, smokers and people with compromised immunity because of disorders such as chronic lung conditions, liver disease, kidney disease or heart disease are at higher risk.
Shot of life
The magic wand against infection is the Pneumococcal Conjugate Vaccine (PCV-13), which protects children and adults against common ear infections and life-threatening infections in the lungs (pneumonia), blood (bacteremia) and the membrane covering the brain and spinal cord (meningitis). PCV-13 protects against 13 of the 90 strains of bacteria that cause the most severe infections in children and about half of infections in high-risk adults.
It’s a deactivated vaccine that contains no live bacteria and cannot cause disease. “It is a highly effective vaccine, and many studies in the European Union, US, Africa and Australia showing it is 85-100% effective in preventing disease,” says Dr Keith P. Klugman, director, pneumonia, Bill & Melinda Gates Foundation, on a visit to India.
The vaccine does more than protect those who are vaccinated. Studies show that PCV-13 lowers antimicrobial resistance (AMR) by bringing down infection in the community and reducing the need for antibiotics. “It greatly reduces antibiotic use in children, as bacterial ear infection is the biggest reason for antibiotic prescription in children,” says Klugman. These effects are amplified by the vaccine extending protection to unvaccinated persons in the community to create “herd immunity”.
Apart from eliminating antibiotic use, vaccination lowers the risk of complications by opportunistic infections, and the need for broad-spectrum treatment of a clinical syndrome, such as pneumonia.
Vaccines, including PCV, even work against those bacterial strains that have developed resistance. “Resistance was already becoming a problem in Haemophilus influenzae, Streptococcus pneumoniae (pneumococcus), and Neisseria meningitidis (meningococcus) by the time vaccines against these organisms were introduced, but the vaccines have reduced or nearly eliminated the problem,” write researchers from Harvard in the journal mBio, the journal of the American Society of Microbiology.
A systematic review of the indirect effects of PCV vaccination on the general population published in Lancet Global Health 2017 showed that childhood PCV programmes lead to substantial protection across the whole population within a decade.
The US is a case in point. Before the vaccine, pneumococcal disease caused more than 700 cases of meningitis, about 13,000 blood infections, about 5 million ear infections, and 200 deaths in children under-5 each year. Within four years of the vaccine becoming available, severe pneumococcal disease in children fell by 88%. “With the introduction of PCV vaccines (PCV7 in 2000 and PCV13 in 2010) in children in the US, it reached the lowest level of disease within three years and herd protection in five years,” said Dr Klugman. “Vaccinating children is the most cost-effective way to prevent infection in the general population.”
“Cotrimoxazole was the WHO drug of choice to treat pneumonia a decade ago, but since then, overuse and misuse has led to some bacterial strains becoming resistant to it. This makes prevention through vaccination even more imperative,” says Dr Klugman.
The PCV-13 vaccine can safely be given with other vaccines in the immunisation schedule. Along with the rotavirus vaccine, which was introduced last year in the four states -- Andhra Pradesh, Haryana, Himachal Pradesh and Odisha – it will help demonstrate how the two vaccines bring down hospitalisations and deaths in children. If both vaccines reach all the children they are meant to reach, they can swiftly halve under-5 deaths.
Close to 30% children miss out on life-saving vaccines in India each year. The challenge is making sure no child is missed.
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