Pneumococcal disease has been the subject of some high profile awareness campaigns recently. But what’s in the name?
Pneumococcal disease is caused by the bacterium, Streptococcus pneumoniae, or simply pneumococcus. Pneumococcal infections can range from relatively minor ear and sinus infections to genuinely life-threatening complications such as pneumonia and blood infect-ions.
Children under the age of two and the elderly are among those most at risk, but it is treatable if detected early.
There are vaccines available to prevent pneumococcal disease.
Pneumococcus in focus
Pneumococcal disease can be divided into two distinct forms – invasive and non-invasive.
Invasive pneumococcal disease is made up of meningitis (infection of the membranes surrounding the brain and spinal cord), septicaemia (infection of the blood) and severe bacteraemic pneumonia (infection of a greater part of the lungs, sometimes with accompanying fluid in the chest cavity).
Non-invasive disease causes middle ear infection, sinusitis and throat infection.
In some rare instances, pneumococcus can also be the causative organism in skin or bone infect-ions.
The complications from pneumococcal disease are dependent on the origin of the infection. If the infection happens in the brain, the patient may suffer long-term brain damage, with a mortality rate of up to 20%.
Lung infections can lead to decreased lung function and frequent infections, with a mortality rate of up to 10%.
Other complications can include deafness, mental and physical disabilities, fluid in the chest cavity and death.
For younger children, the dangers of meningitis and severe bacteraemic pneumonia are even more severe. They can end up with permanent hearing loss and brain damage.
The level of awareness for this disease remains low among the public, said Hospital Kuala Lumpur’s Institute of Respiratory Medicine senior consultant chest physician Prof Datuk Dr Abdul Razak Muttalif.
The incidence of pneumonia and meningitis caused by pneumococcus occurs at the extremes of age – the very young, below the age of two years, and the elderly, above the age of 65.
Pneumococcus is a commonly observed bacterium in the community. As such, any case of pneumonia that is contracted within the community must be treated as caused by pneumococcus.
Pneumococcus has been observed to heavily affect those who are malnourished, have underlying medical conditions, smokers, alcoholics and those with chronic lung diseases, noted Prof Abdul Razak.
The reasons for this susceptibility are unclear. It has been theorised that certain gene defects may affect the immune response to the bacterium, rendering a person more susceptible to pneumococcal infection.
Counting the cost
The Malaysian healthcare sector can effectively manage the disease, but the cost can be very high, particularly when the patient develops complications that require more medical care and a longer hospital stay.
If the case of pneumonia is severe, the patient will have to be kept in hospital for a month or more, given antibiotics and fluids intravenously through a drip, and may require oxygen to help breathing.
In very serious cases, breathing assistance through a ventilator in an intensive care unit (ICU) may be required.
In some cases, the patient may have to undergo a procedure called a bronchoscopy to look into the airways and lungs, and clear any blockages found.
These are very costly and time-consuming procedures.
This is why prevention is a much better and more cost-effective solution, Prof Abdul Razak said.
The family of a patient with pneumococcal disease bears the full impact of the disease. Financial purse strings are stretched and relationships are tested.
This is a story that is often left untold, said consultant paediatrician and paediatric cardiologist Datuk Dr Zulkifli Ismail.
Every time a child is admitted to the hospital, the parents will have to take leave from work to look after the child.
Many parents may have to leave their other children at home in the care of grandparents or hired caregivers.
“We have had parents getting divorced while their child is admitted, presumably from the stress,” Dr Zulkifli said.
The family may have to pay for the hospital stay, and admission to the ICU may cost as much as RM1,000 a day in a private hospital.
Even if admitted to a government hospital, the expenses incurred by travelling to hospital, food, accommodation and so on, have a significant impact on the family.
Coverage and cost-effectiveness
Pneumococcal vaccine uptake rates in Malaysia have been increasing, but the vaccines are currently being taken up exclusively via private health institutions.
As the vaccine is being dispensed by private doctors, the uptake rate of the 7-valent pneumococcal conjugate vaccine (PCV7) a year after its introduction in 2005 was only 3% of the birth cohort of about 450,000 babies.
At this time, it is estimated that the current uptake rate is about 18% of the birth cohort.
The demographics for people who have taken the vaccine are mostly the urban and affluent socio-economic group.
Unfortunately, the groups at highest risk of pneumococcal disease are not getting the benefits of pneumococcal conjugate vaccine (PCV), namely the indigenous Orang Asli and the children who live in rural areas, plantation estates and the interiors of Sabah and Sarawak, said consultant paediatrician and neonatologist Datuk Dr Musa Mohamad Nordin.
For the vaccine to be effective in protecting the community against pneumococcal disease, there is a critical mass necessary to confer herd immunity against pneumococcal disease.
This critical mass is an uptake of at least 70%-80% of the community.
Understandably, cost has been a major factor hindering the government from adding the pneumococcal vaccine to the national immunisation programme (NIP).
Costs are an acute concern, particularly now at a time of economic uncertainty.
Dr Musa said that “there was initial scepticism when we at the Malaysian Paediatric Association first began the ‘Fight Pneumococcal Disease’ campaign in 2006”.
But over a decade since its introduction in Malaysia and the observed benefits of vaccinating against pneumococcus, the paediatric fraternity and the Health Ministry are convinced of the benefits of PCV.
There have been at least two published studies that explore the cost-effectiveness of implementing PCV in Malaysia, Dr Musa said.
One Malaysian study by Al Junid et al estimated that PCV7 vaccination of infants of a hypothetical 550,000 birth cohort would incur costs of RM439.6 million.
Though initial costs are expected to be large, spread over 10 years, vaccination would reduce hospitalisations due to pneumococcal disease by 9,585 cases.
This will lead to a cost savings of RM37.5 million to the health system, with 11,422.5 life-years saved at a cost effectiveness ratio of RM35,196 per life-year gained.
This is approximately 50% lower than the World Health Organiza-tion’s recommendations for cost-effectiveness.
Another study by Wu et al also found that implementation of PCV would be both cost-effective and improve health outcomes for Malaysians.
It estimated that a PCV programme would reduce the disease burden by over 4,000 fewer invasive pneumococcal disease cases, 768,000 fewer pneumonia cases, and over 570,000 fewer otitis media cases.
PCV would save over 7,700 lives over a period of 10 years.
Conservative estimates from the study also found a long-term savings of US$77 million (RM342.42 million) yearly to the healthcare system if PCV was implemented.
The implications of these studies are clear – initial investment may be a burden to the nation’s coffers, but over time, this investment would translate to less suffering due to pneumococcal disease, long-term improvements in life ex-pectancy and quality of life, and most importantly, save lives.
It would be unwise to pinch pennies when it comes to the health of the country’s future generations.
Victim of its own success
The Malaysian NIP has been successful in preventing many infectious diseases in this country.
Dr Zulkifli said the successful implementation of the NIP has made it a victim of its own success.
Vaccination has been so successful at preventing, and even eradicating diseases like smallpox and poliomyelitis, that people have become complacent and even started to reject vaccination.
Generally most people, not just Malaysians, have never seen cases of severe diphtheria or tetanus before, and therefore, think these diseases never existed.
A small number of Malaysians have become complacent and are also influenced by a small number of very vocal anti-vaccine lobbyists.
If any of the vaccines pose a danger to recipients as the lobbyists claim, doctors and other medical personnel will not give the vaccines to themselves and their family members.
The pneumococcal vaccine has been available to the public for many years now.
The private health sector has been dispensing PCV7 in Malaysia since late 2005.
In 2013, PCV7 was replaced with PCV13 (13-valent PCV).
Both PCV7 and PCV13 have resulted in great reductions in cases and admissions due to pneumococcal pneumonia and meningitis.
PCV13 extended the spectrum of coverage and was even better at preventing these diseases in many countries where PCV13 is included in the NIP.
PCV13 in the United States was been shown to reduce 70%-80% of pneumococcal pneumonia.
A 10-valent pneumococcal conjugate vaccine is also currently available and is also effective and equally safe.
Prof Abdul Razak, Dr Zulkifli and Dr Musa said that PCV implementation is a cost-effective solution to prevent unnecessary suffering and death from a vaccine-preventable disease.
It would be extremely unfortunate if the Government were to deny its most vulnerable citizens access to PCV.
Initial costs are expected to be high, but spread over time, the numbers would be insignificant, taking into account the cost-savings to the healthcare system, the reduction in cases of pneumococcal disease, and the significant improvement in quality of life of its citizens.
The government should consider vaccination as a prudent investment in its people.
The PCV has been available in Malaysia for 11 years, why are we still sitting on it?