Kenya: Pneumonia Scourge - Poverty a Leading Cause of Deaths Among Children

13 January 2020

It's a disheartening picture of a mother and daughter at the children's hospital room.

The grandmother holds on to the hands of the unconscious grandson as if willing him to please rise up from the hospital bed, and be as naughty as he has never been - he won't be punished this time.

The boy's mother looks away, stares into space with a face clouded in misery. Not even her bright red dress can light up the moment. Pneumonia has made sure of that.

Her son, 11-year-old Daniel Esimit, lies helplessly at Lodwar County Referral Hospital (LCRH), where he is admitted.

Esimit has severe pneumonia that has posed a serious threat to his life. Dorcas Akedo's firstborn was referred to the hospital after medics at Kakuma Mission Hospital were unable to restore his health.

"I feel bad as a mother. It's so stressing when your child is sick; there is not a single day you live in peace," she says. "And yet there is so little you can do to help."

The young boy, the mother say, began discharging a thick mucous substance through his nose and his body started to feel hot.

"I knew something was seriously wrong with my child and decided to take him to hospital," says Akedo. On arrival at the hospital, the child was diagnosed with severe pneumonia.

BACTERIAL INFECTION

When we met Esimit, it had been three days since he got admitted to the hospital. He lay unconscious in bed receiving oxygen from a machine next to his bed.

The mother says he had not been able to eat in the previous three days.

Esimit's illness is among thousands of cases of pneumonia, which is a prevalent problem in Turkana County.

Across the country, many other children are suffering from the disease as a result of a bacterial or viral infection, which is largely preventable through vaccination.

Linda Misiko, Save the Children's child health technical adviser, defines pneumonia as an infection of the lungs, saying it is most often bacterial or viral, though it can also be caused by a fungus.

"The mucus created in the lungs provokes coughing, shortness of breath and fever, among other symptoms. As the lungs fill with fluid, their ability to intake oxygen decreases," says the doctor.

At Esimit's ward, for instance, two other children had been admitted, also suffering from severe pneumonia.

But it's in the adjacent ward where pneumonia had reared its ugly head. Here, a mother had lost a child to pneumonia a few minutes before we arrived, sending shock waves across the whole paediatric ward.

CHILD KILLER

In October alone, John Ngasike reveals that the paediatric ward admitted 157 children for various illnesses, top among them pneumonia.

"Pneumonia is one of the major reasons why we admit children here. This being the only referral hospital in the county, we also receive severe cases from other health facilities," he says.

According to Save the Children, a global child welfare organisation that has been battling the infection in the county since 2014, in the surrounding rural areas, about seven out of every 10 children contract severe pneumonia at some stage during their childhood.

For Ngasike, the clinical officer in charge at the Lodwar hospital, what worries him most are the deaths of children from pneumonia.

In October, for instance, he says that out of the 19 fatalities recorded in the paediatric ward, four of them were as a result of pneumonia, the highest a single disease caused.

"When you look at mortality, pneumonia features greatly as one of the causes. Most of these cases are brought to the hospital when the condition is very severe, to a point that they need oxygen support," says Ngasike.

And yet, he decries, this community harbours a negative attitude towards administering oxygen in the sense that it is seen as akin to sending the child to their death.

WEAK CONTROL MEASURES

In Kenya, as is the situation in the countries in sub-Saharan Africa, the burden of pneumonia is big and, experts say, the pace at which we are reducing its mortality is wanting.

Speaking to DN2 at the UN Complex in Gigiri, Peter Okoth, a health specialist at Unicef Kenya said: "In Kenya, there isn't a mechanism that focuses on pneumonia; it is not visible. It does not have that high profiling. We know there is intervention and government support for immunisation, which goes toward addressing pneumonia deaths. But the care and treatment for children who have suspected pneumonia is an area which requires additional investment."

To put it simply, an accident that kills 25 passengers hits the headlines instantly and remains in the news for days, yet an equal number of children die of pneumonia every day but do not receive as much attention, medical experts note.

Worse still, this happens when the healthcare system is working at an optimum level.

A new analysis by a coalition of international organisations, including Save the Children and Unicef, showed that in 2018 more than 9,000 children under the age of five died from the disease in Kenya -- equivalent to more than 24 every day or a child every one hour.

The report, "Fighting for breath in Kenya", was released during World Pneumonia Day, celebrated on the 12th day of November, with calls for more action towards eliminating the pneumonia scourge.

BELOW TARGET

Though Kenya has achieved massive reduction in pneumonia mortality among children under the age of five, the report says, this has been happening at a steady but slow pace of six per cent per annum since the year 2000.

"It's coming down, all right, but not at the rate that will lead us to achieving the target of three deaths per 1,000 lives by 2025," says Okoth, referring to Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) targets, which compel countries such as Kenya to ensure that not more than three deaths per a 1,000 live births are caused by pneumonia.

"Six per cent is the average annual rate of reduction in pneumonia mortality between 2000-2018, and at the same rate, Kenya is expected to reach the 2025 GAPPD target in 2029," reads the report.

According to Misiko, a range of effective strategies does exist to control the disease and considerably reduce its deadly impact. First off is vaccination.

"There are two types of bacteria that account for a large proportion of cases of pneumonia, and vaccines exist to protect from both: PCV (pneumococcal conjugate vaccine) and Hib vaccine for the haemophilus influenzae type b.

Both vaccines have been around for decades and repeatedly proven their ability to protect from pneumonia," says Misiko.

But even if a child were to contract the disease, the treatment exists and is cheaply and widely accessible.

According to Misiko, antibiotics are the most effective form of treatment for pneumonia. She adds that Amoxicillin DT represents the single greatest chance of survival for children sick with pneumonia.

POVERTY

She adds that a number of risk factors can be mitigated through improved family practices that can prevent children from getting ill in the first place.

These include exclusive breastfeeding to strengthen children's immune system, systematic hand washing with soap to limit the circulation of germs in families, improving family nutrition and HIV prevention.

But for a disease that experts concur is largely preventable and easily curable using antibiotics, how comes it is still killing so many children? We ask.

While hailing the government for improved vaccination, nutrition and a general rise in the living standards for Kenyans, Misiko, however, notes that despite the good national outlook, it is not until you go down to the counties that you start to see the discrepancies.

"It's the poor households that are worst hit," Misiko says. "Despite being largely preventable, poor families have less access to interventions that prevent pneumonia, such as immunisation. They also lack access to better hygiene and sanitation, education to enable them understand the disease and seek care, not to mention lack of access to health facilities."

Through the Unicef data, DN2 wanted to find out the top five counties that are greatly contributing to the burden of pneumonia in the country.

To begin with, the "Fighting for breath in Kenya" report revealed that the national average under five mortality rate due to pneumonia in 2018 was six per 1,000 live births.

MORTALITY RATE

A review of the data however reveals startling findings, reaffirming that pneumonia is largely a disease for the poor.

For instance, it is in 12 counties where children are more likely to die of pneumonia, with the counties having a mortality rate twice the national average.

Mandera County leads the pack at 18 per 1,000 live births, followed by Migori and West Pokot counties at 15 per 1,000 live births.

Kisii, Nyamira, Turkana, Kakamega, Siaya, Tana River, Wajir, Bungoma and Busia had an under five pneumonia mortality rate of between 12 and 14 per 1,000 live births.

"Most of these counties have other conditions that weaken the children such as HIV or malnutrition," says Okoth.

On the other end, 23 counties fell below the national average - including Kajiado and Nyeri - with two per 1,000 live births, under five mortality rate due to pneumonia in 2018.

According to the health experts, this means that a child born in Mandera - where pneumonia mortality rate is 18 per 1,000 live births - is nine times more likely to die of pneumonia as compared to one born in Nyeri.

Dr Okoth believes there is a strong relationship between the wealth and standards of living in these counties and the pneumonia outcomes.

"If you look at these counties, you find that there is better access to health services, so families seek care earlier. Also, health systems tend to be a bit stronger, and the immunisation coverage is better."

MALNUTRITION

As regards immunisation, the Kenya Demographic and Health Survey 2014 backs this up.

The survey pointed out that the country's vaccination coverage increased from 77 per cent in 2008/2009 to 79 per cent in 2014, with central Kenya leading at 90 per cent.

North Eastern, however, was found to be lagging behind at 51 per cent.

For regions plagued by perennial droughts such as the arid and semi-arid lands (Asals), one of the reasons pneumonia morbidity and mortality remain high is prevalence of malnutrition, experts say.

According to Misiko, there is a strong link between malnutrition and pneumonia. She says: "The presence of severe acute malnutrition can increase mortality from pneumonia 15-fold."

In an earlier interview, Regina Mbochi, a nutritionist who has monitored children's dietary needs in the northern counties for 10 years now, told DN2 that by weakening the body's immune system, malnutrition opens the floodgates for other diseases such as diarrhoea, pneumonia and malaria, which are likely to send a child to an early grave.

So for a county such as Turkana, where the "Kenya Food and Nutrition Situation Seasonal Assessment Report" (March, 2019) found that 54,264 children under the age of five years were suffering from acute malnutrition, solving malnutrition is akin to killing two birds with one stone.

HEALTH FINANCING

Oxygen availability across health facilities is yet another gap in combating pneumonia.

Children who suffer from the disease quite often require oxygen support because they develop a breathing problem.

Notably, in the last two years, the country has seen significant investment in oxygen generating machines, but experts say the country still has a long way to go.

"Oxygen availability is still very low despite the efforts in improving access in the last two years. That is an area where the country needs to scale up. No child should die because of lack of oxygen," says Okoth.

One of the biggest impediment to provision of health services has got to be its financing.

It is for this reason that the World Health Organisation (WHO) came up with global targets to help countries effectively finance health services.

The "Fighting for breath in Kenya" report shed some light on how Kenya is performing against the world targets.

For instance, WHO recommends that the government should spend at least $86 (Sh8,751) per person per year to provide essential health services, yet the Kenyan government spent $78 on health per person in 2018.

It also spent an equivalent of two per cent of the GDP on health in 2018 against a minimum recommendation of five per cent.

PARTNERSHIPS

Additionally, while the government surpassed the minimum expenditure on primary healthcare of 57 per cent by 10 per cent in 2016, the out-of-pocket expenditure on health remains high at 33 per cent, against a WHO ceiling of 25 per cent meant to avert catastrophic OOP expenditure.

Acknowledging that pneumonia morbidity and mortality is a public health concern in Turkana County, Gilchrist Lokoel, the county director of medical services says:

"As Turkana County, we have come up with a programme that brings together all partners who are doing any work related to child and adolescent health, with a clear focus on innovation and research to help reduce the under-five mortality,"

He also takes pride in the fact that the county is among the few counties that have formulated and operationalised Community Health Services Bill.

"This bill gives community health volunteers (CHVs) the impetus and confidence to operate in the community. And the county government has committed resources to pay them monthly," he says.

CAPACITY BUILDING

He told DN2 that the 1968 CHVs operating in the villages have undergone a mandatory six-week training and have to adhere to continuous refresher courses.

"We have trained them on how to detect pneumonia using the bead technology and the use of Amoxicillin to treat pneumonia. This has yet to be operationalised because the policy must come from Nairobi. So for us, we have already done the ground work and the CHVs are ready."

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