17 Nov Pneumonia: Closing the Treatment Gap
Article posted on November 17, 2016.
Interview with Keith Klugman on Addressing Access to Appropriate Antibiotics, from the 2016 Progress Report
- Infant mortality has been reduced by 50% over the last 15 years and there has been an even greater reduction in pneumonia mortality.
- In many of the poorest parts of the world, the key hurdle in child pneumonia treatment may be access to antibiotics by the poorest of the poor women.
- The resistance observed to amoxicillin so far in low-resource settings is a low or intermediate resistance, which can be overcome by the existing recommended treatment guidelines for amoxicillin dosage.
Beginning in November, Stop Pneumonia is featuring a series of excerpts from the 2016 Pneumonia and Diarrhea Progress Report: Reaching Goals Through Action and Innovation. The annual report identifies the 15 countries with the greatest number of deaths from pneumonia and diarrhea among children under the age of five. In addition, the country profiles, Q&As, and essays focus on how to save children’s lives through action and innovation. The report is produced by the International Vaccine Access Center, at the Johns Hopkins Bloomberg School of Public Health.
2016 Pneumonia and Diarrhea Progress Report
Pneumonia: Closing the Treatment Gap
Interview with Dr. Keith Klugman, Gates Foundation
Addressing Access to Appropriate Antibiotics and Correcting Underlying Malnutrition
As Director for Pneumonia at the Bill & Melinda Gates Foundation, Keith Klugman, MD, PhD, leads efforts to improve the development and delivery of pneumonia vaccines and expand the use of diagnostic tools and antibiotic treatments. In addition, Klugman is a leading expert on antimicrobial resistance (AMR) in pneumonia pathogens. His work has contributed to the development of pneumococcal conjugate vaccines that are now part of the routine immunization schedule for children in countries around the world.
Q: How are we doing in the fight against pneumonia?
A: Pneumonia is a major contributor to mortality in children, particularly in parts of the world with high infant mortality rates. The fraction of infant mortality that is attributable to pneumonia increases with increasing child mortality. For instance, in parts of the world like the United States where infant mortality is low, pneumonia is a very small part of that low mortality. Whereas in parts of rural Africa and Asia where infant mortality is high, pneumonia is still a very large cause of infant mortality.
The good news: infant mortality has been reduced by 50% over the last 15 years and there has been an even greater reduction in pneumonia mortality. Certain countries, for example China, Bangladesh, and Ethiopia, have seen dramatic reductions in both infant mortality and pneumonia mortality. However, we have to be cautious. There are some countries, such as Nigeria and Angola, where there has been little change in these areas. The scorecard is mixed.
Q: What are the major hurdles in treating child pneumonia? How have these changed over the last decade?
A: There are at least two aspects to immediately highlight: the drug that is chosen, and access to the drug, which is largely an economic issue. The drug of choice for treating pneumonia was changed by WHO over a decade ago, from cotrimoxazole, to which there is broad resistance, to amoxicillin. In some countries, this switch has not been made yet. There has been progress over the last decade, but one of the challenges is ensuring that amoxicillin dispersible tablets (amoxicillin DT), which dissolve in water, is widely available in all countries.
Access to antibiotics is a key issue; it has been a strong predictor of reduction in pneumonia mortality and may have influenced the reduction in pneumonia mortality in places including China and India.
But in many of the poorest parts of the world, the key hurdle may be access to antibiotics by the poorest of the poor women. I believe this is where countries like Nigeria are failing. Even if antibiotics are available at remote sites, there remains an economic barrier for the very poor to travel there and pay for them.
If we believe that getting mothers access to cash is a critical determinant of infant mortality, then an approach focused on financial services for the poor may be an important lever to reducing pneumonia mortality. We have a group at the Gates Foundation that focuses on this; their innovation is direct transfer of funds from governments to the poorest women in the community, with the idea that mothers may be able to protect their infants from pneumonia mortality if they received small amounts of money to pay for care.
Q: Antimicrobial Resistance (AMR) is a high-profile public health issue, which intersects with child pneumonia treatment. Are you observing an increase in resistance in low-income settings?
A: Here we have good news. The resistance that we have observed to amoxicillin so far in low-resource settings is a low or intermediate resistance, which can be overcome by the existing recommended treatment guidelines for amoxicillin dosage. High dose oral amoxicillin DT therapy remains the drug of choice to treat outpatient community-acquired pneumonia.
So far, our observations are that the high-level amoxicillin-resistant strains, against which amoxicillin would not be expected to work, are rare. It is possible that the organism plays a biologic price for high-level resistance; they seem to be less virulent. Although there is increasing concern about AMR in Gram negative pathogens, which are a major cause of neonatal sepsis, they are not—we believe at the moment—a major cause of pneumonia in older infants.
Q: What role does innovation play in fighting pneumonia?
A: There is always scope for innovation in the fight against this major killer of children. Here we have significant resource problems. The resources which are available for innovation in the pneumonia space are far less than for other major infectious killers such as HIV, TB, and malaria.
On the treatment side, we need to examine the major risk factor of pneumonia mortality: under-nutrition. The outcome of malnourished children treated for pneumonia is much worse than for well-nourished children. We need more insight into how to improve the outcomes of malnourished kids with pneumonia.
A further area that needs innovation is the provision of oxygen. Oxygen can be lifesaving, but there are major barriers to provision of oxygen, largely around a constant source of electricity. Without a reliable electricity source, you cannot get a reliable supply of oxygen. There are innovations in batteries or ideas for oxygen storage that could transform the availability of oxygen for kids with pneumonia.
Q: How will efforts to combat pneumonia evolve over the next decade?
A: One thing which I find quite exciting on the horizon for pneumonia advocacy is the recent statement by the World Bank about the importance of child health to development. There is a great opportunity for advocacy to frame reducing the burden of disease in children as a strategy for development.
In pneumonia treatment, we see an evolution to concentrate on mortality at the extremes of the access to care. In remote rural areas we are looking forward to innovative ideas being implemented around antibiotic access, including financial services for the poorest.
While we anticipate many more children getting access to care, hospital care remains very poor in many countries. So at the other extreme of the provision of care, we hope to see (1) greatly improved treatment of at-risk malnourished children in health facilities, (2) strategies to measure the need for oxygen in at-risk children, and (3) innovative ways to provide that oxygen.
We still have a long way to go, but I think there is ground for optimism in the fight against pneumonia.
Keith Klugman, MD, PhD has chaired or served on numerous expert committees for WHO and the CDC, among other U.S. and international organizations, and has published more than 550 scientific papers on the subjects of pneumonia, meningitis, antimicrobial resistance, and vaccines for bacterial pathogens, which have been cited more than 25,000 times to date.