Zero-dose PCV children

dangerously exposed to pneumonia

Children living in countries that do not offer the pneumococcal conjugate vaccine (PCV) are dangerously exposed to pneumonia, the biggest infectious killer in the world.

Prior to the COVID-19 pandemic, pneumonia killed an estimated 2.5 million people each year including 672,000 children under five – more than any other infectious disease, according to the Global Burden of Disease (GBD). COVID-19 will increase the total burden of respiratory infection deaths by 2 million in 2020.

In this context it is vital that all countries are protecting their populations, and especially their most vulnerable populations, with every tool available to prevent pneumonia from any cause.

The pneumococcal vaccine is one of the most powerful tools we have to prevent pneumonia because it targets the leading bacterial cause – Streptococcus pneumoniae (pneumococcus). It is a highly effective vaccine. For example, after Kenya introduced the vaccine in 2011, the average annual incidence of severe pneumococcal disease dropped by 92% among children under five and hospital admissions fell sharply.

Accordingly, the World Health Organization (WHO) recommends that all children under five receive the pneumococcal conjugate vaccine and some national governments also recommend that the elderly receive it, as pneumonia is also a major cause of death among adults aged over 70 in most countries.

But not every country has followed these recommendations and there are currently hundreds of millions of vulnerable children and adults who do not receive the pneumococcal vaccine.

They are dangerously exposed to pneumonia and at risk of spreading infection to others.

All vulnerable populations deserve to be protected with the pneumococcal vaccine, but this is even more critical during a pandemic of viral pneumonia. This is because high coverage of the pneumococcal vaccine not only reduces bacterial pneumonia among children and the elderly but protects COVID-19 patients from bacterial co-infection that can increase their risk of death. Both reduce demands on already stretched health systems.

This is why every country in the world needs to protect children and the elderly with the pneumococcal vaccine.

While Gavi, the Vaccine Alliance has a strong track record of supporting low-income countries to introduce the pneumococcal vaccine among children, middle- and high-income countries should immediately take the initiative and introduce the vaccine to fully protect their child and elderly populations.

How many zero-dose PCV children are there in the world?

There are approximately 430 million children under the age of fifteen living in countries with no coverage of the PCV vaccine, including 145 million children under five and 285 million children ahed five to 14. This means that more than one out of every five children under 15 is not protected from the leading cause of bacterial pneumonia.

Where do zero-dose PCV children live?

There are 52 zero-dose PCV countries spread across every region of the world. The Western Pacific region is home to 291 million (67%) zero-dose PCV children, followed by the Eastern Mediterranean with 67 million (16%), and Africa with 27 million (6%). In contrast, Europe is home to 17 million (4%), Southeast Asia to 17 million (4%), and the Americas to 11 million (2%) no-dose PCV children.

What price are zero-dose PCV countries paying?

The cost of this exposure is ultimately measured in children’s lives lost due to pneumonia – an estimated 76,300 every year in the zero-dose PCV countries, or 11% of all pneumonia deaths among children under 15.

The zero-dose PCV countries with the heaviest burdens of child pneumonia deaths include China, Somalia, Chad, Guinea, Egypt, South Sudan, Viet Nam, Tajikistan, Turkmenistan, and  Iran. Together, these ten countries account for 95% of the 76,300 child pneumonia deaths occurring in zero- dose PCV countries.

As most of the 52 zero-dose PCV countries are also experiencing heavy burdens of pneumonia deaths among their elderly populations, protecting children with the PCV should have a significant impact on reducing infections and deaths from pneumonia among the elderly.

Although there are no routine estimates of pneumonia deaths prevented among the elderly with PCV vaccination among children, studies suggest that childhood PCV vaccination leads to substantial protection across the whole population within a decade.

What about COVID-19?

With the exception of seven countries* all of the zero-dose PCV countries have confirmed COVID-19 cases. The ten countries with the largest numbers of confirmed COVID-19 cases included Iran, Ukraine, Czechia, Austria, Jordan, Belarus, Malaysia, Tunisia, Egypt, and Venezuela according to the WHO.

Although there is no evidence that PCV vaccination offers protection against COVID-19 infection, ensuring that all children are protected with PCV and the other pneumonia-fighting vaccines (Hib, pertussis, and measles) will reduce the likelihood of co-infections with bacterial pneumonia and COVID-19 among both children and adults.

*Cook Islands, Nauru, North Korea, Samoa, Tonga, Turkmenistan, Tuvelu, and Vanuatu.

What must be done?

The eight Gavi-eligible countries on the list of 52 zero-dose PCV countries — Chad, Comoros, Guinea, Somalia, South Sudan, Syria, Tajikistan, and Viet Nam — must commit to introducing the PCV and apply to Gavi for support.

The remaining 44 non-Gavi-eligible countries should also announce the introduction of the PCV and a commitment to achieving at least 90% coverage by 2025, in line with the target outlined in the Global Action Plan for Pneumonia and Diarrhea.

Wide coverage of the PCV by 2025 will help countries reduce child pneumonia deaths and accelerate the achievement of the Sustainable Development Goal (SDG) for child survival, which requires that every country reduce child deaths to at least 25 for every 1,000 babies born by 2030.

Introduction of the PCV in both Gavi-eligible and non-Gavi-eligible countries should form part of national pneumonia control strategies that aim to reduce pneumonia prevalence, incidence, and deaths among all vulnerable populations by reducing child wasting, exposure to air pollution and smoking, as well as by improving diagnosis and treatment with pulse oximetry, oxygen therapies, and the WHO-recommended antibiotics, where necessary.

Fully protecting children with the PCV will also mitigate the effects of COVID-19 on all vulnerable populations by reducing the risk of bacterial pneumonia and co-morbidities that can significantly increase the risk of death.

COVID-19 has shown the world that all countries need national strategies to prevent and control pneumonia, especially among their most vulnerable populations.

Note this analysis only looks at countries that have not yet introduced the PCV. It does not address the urgent need to increase coverage of the vaccine from the current global average of 48% to above 90% in the low-dose countries that have already introduced the vaccine but which have coverage below 60%, including Angola (53%), Bhutan (26%), Central African Republic (47%), Haiti (42%), India (15%), Indonesia (3%), Iraq (37%), LaoPDR (56%), Mongolia (49%), Namibia (57%), Nigeria (57%), Papua New Guinea (35%), and Philippines (43%).

Updated 17 February 2021

To find out more about the COVID-19 response and the global agenda to reduce all-cause pneumonia deaths, visit