Pneumonia is leading infection among children afflicted with HIV

Recently, Uganda launched the new 10-valent pneumococcal vaccine (PCV 10) that is expected to protect 1.5m children below one year against pneumonia infections by end of the year. I interviewed Seth Berkley, the Global Alliance for Vaccine Initiative (GAVI) CEO about the new vaccine. GAVI is channelling over 5m doses of the new vaccine to Uganda. 

Below are the excerpts of the interview.

What are pneumococcal diseases and what is their impact?

Pneumococcal disease (PD) is caused by the bacterium Streptococcus pneumoniae, also known as pneumococcus, and is the number one vaccine preventable cause of death in children under 5 years of age globally. Pneumococcus is the most common cause of fatal pneumonia in children. In Uganda, it is estimated that pneumonia is responsible of 17% of the deaths in children under 5.

What are the symptoms of pneumococcal disease?

Pneumococcus is the most common cause of fatal pneumonia in children. Other life-threatening pneumococcal infections include meningitis and sepsis.

What complications arise from pneumococcal disease?

The pneumococcus is the most common cause of invasive (serious) bacterial infections in children, including meningitis, bacteremia (infection of the blood), and pneumonia (infection of the lungs). The pneumococcus is also the most common bacterial cause of acute middle ear infections in children

How is pneumococcal disease transmitted?

The bacterium spreads from person-to-person via respiratory droplets - if the infected person coughs or sneezes in close proximity to other people, the other people may become infected.

Why is pneumococcal disease a health problem in Uganda and the world?

It is one of the major causes of under-5 children’s deaths. Of children under five with suspected pneumonia in Uganda, only 73% are taken to an appropriate health care provider, and 47% receive antibiotics. About 60% of infants less than 6 months are exclusively breastfed.

Who is at risk of acquiring pneumococcal disease?

While persons of any age can acquire pneumococcal disease, young children, particularly infants, are most vulnerable. Immunity-weakening conditions such as malnutrition, HIV/ AIDS, low birth weight, and non-exclusive breastfeeding put children at greater risk for pneumococcal disease.

How can pneumococcal disease be prevented?

The Global Action Plan for Prevention and Control of Pneumonia (GAPP), issued by WHO and UNICEF, recommends a three-pronged approach to address child pneumonia that includes protection (exclusive breastfeeding and improved nutrition), prevention efforts (including routine use of measles, Hepatitis B and pneumococcal vaccines), and treatment (appropriate antibiotics). GAPP estimates that scaling up coverage of these key interventions to 90% could help prevent more than two-thirds of childhood pneumonia deaths worldwide.

What pneumococcal vaccines has GAVI made available to Uganda and other countries?

Pneumococcus comes in 90 varieties or “serotypes.” Three existing pneumococcal conjugate vaccines (PCVs) protect against 7, 10, and 13 of the most common serotypes. The 10- and 13-valent pneumococcal vaccines cover more than 70% of the invasive pneumococcal disease (IPD) causing serotypes afflicting African children. Uganda introduced the 10-valent pneumococcal vaccine (PCV 10).

Which new vaccines are currently in development and why are new vaccines needed?

New vaccines are needed to protect against additional serotypes of pneumococcus to better protect children. Also, efforts are been made to find less expensive vaccines.

Are there people who should not be vaccinated? If yes, why?

PCV are considered safe in all target groups for vaccination, including immuno-compromised individuals.

How and when should the PCV be administered?

The PCV-10 should be given in three doses. The minimum age at first dose is 6 weeks, with a minimum interval of four weeks between the subsequent doses - e.g., 6, 10 and 14 weeks. Ideally, PCV-10 should be given simultaneously with other childhood vaccinations: DTP (for Diphtheria), Hib (Hepatitis B) and Oral Polio Vaccine administration.

Should HIV positive individuals receive the PCV?

Yes, pneumococcal vaccination is recommended in HIV infection to help reduce invasive pneumococcal disease. Studies have shown that children with HIV/AIDS are 9-40 times more likely to contract pneumococcal disease than HIV-negative children, and may also be more likely to contract antibiotic-resistant strains of the disease. In fact, pneumonia is the most common infection leading to hospitalization among HIV-infected children. In Uganda, there are an estimated 1.4 million people currently living with HIV/AIDS, about 190,000 of whom are children under age of 15.

 Do adults need the PCV?  How often, if at all?

The GAVI supports immunization in children, because most complications arise in young children. PCVs for immunization of older populations and the potential use of such vaccines for immunization in pregnancy to protect new born babies are currently not considered sufficient by the World Health Organization (WHO) to make policy recommendations.

Does the PCV have any side effects, mild or otherwise?  Which ones?

The safety of pneumococcal conjugate vaccines for children has been well demonstrated in clinical trials and confirmed after the distribution of more than 198 million doses worldwide. Post-licensure surveillance has found that the use of childhood pneumococcal vaccine also protects unvaccinated children and adults by reducing transmission.

What impact has the PCV had in countries where it has been introduced?

Immunization with PCV7 in the United States, the first country that introduced broadly the vaccination, has led to profound reductions in the disease burden among adults in the first 7 years of the program. The impact of PCV in GAVI eligible countries is being carefully monitored as part of routine sentinel surveillance.

Coping with kidney failure at nine

Although kidney disease has been around for decades, I can bet majority of us know little about how adults or children suffering the disease’s tribulation view their own lives and deal with their complicated medical regimens. This is the very reason nine year old Renah Kaitesi sits long hours a week at the entrance of Capital Shoppers Supermarket in Ntinda lobbying good Samaritans for money to enable her get a kidney transplant.

She is suffering stage five of kidney disease commonly known as the established chronic kidney disease. It is also associated with names like end-stage renal disease (ESRD) or terminal renal failure. Here, haemodialysis (a process where a person’s blood is routed across an artificial membrane that cleanses it thus removing substances that would normally be excreted in urine) and kidney transplant are the only treatment options.

Kaitesi is in dismal need of the latter. On the day I met her, her weak diminutive body was slumped on a white plastic chair and in front of her was a box pasted with pictures of her in a swollen state. This is where money is dropped. 

She is trying to raise shs. 75m for a kidney transplant.

“HELP, HELP, HELP. I am nine years old and suffering from lupus-related stage five kidney failure. Please help me go for a transplant in Apollo Hospital in India. THANK YOU. GOD BLESS YOU,” read the words on the side of the box facing the entrance of the supermarket.

Her father, Julius Busingye Mujuni, a resident of Kanungu District cannot help but keep a thank you praise and a smiley face to whoever donates some money. He has paid a heavy price to keep her daughter alive. Not only did he sale his car, house and cows to raise see her alive, he also obtained a shs 4m loan from one of the district SACCOs which he has not been able to pay.

In Kaitesi’s eyes, her life is imperfect without good health and education. Before her eyes could succumb to sleep, she muttered a few words and this is what she said,

‘I am in Primary five this year and I want to study and stay alive. Please help me so that I can live and in the future help others in need like me.’

The genesis of her woes;

Kaitesi was born a normal child and up until kidney disease waned her dream of living a normal life, she studied at Kambuga Modern Primary School. In fact, at the time of her sickness, she had been promoted to primary five.

Her father, Busingye recalls the time, in May last year, when he went to visit her at school on the school’s visitation day and found that she had been plagued by a fungal infection.

She was taken to Kambugu Hospital in Kanungu district for treatment but her school life took a turn- from being the boarding section to being a day scholar.

“After two months, her body started getting swollen and she was even limping and feeling pain in her right leg and the following day, her eyes, face and legs were all swollen,” Busingye recounts.

She was again taken to Kambuga Hospital and the doctor in charge then, Dr Daniel Kasuda hinted on the fact that Kaitesi might be suffering from kidney disease.

In an earlier interview with Dr Robert Kalyesubula a nephrologist at Mulago Hospital, he explained that swelling happens when one’s kidneys lose their ability to remove different types of waste from the blood. Consequently, this leads to swelling in the legs, ankles, feet, face and hands.

Dr Kasuda prescribed drugs such as Prednisolone and Lazix for a week but before the week could elapse, Kaitesi worsened. She was then given a new drug regimen and later scanned. The scan results turned out positive- she was suffering from kidney failure.  

By this time, she could not walk, talk or see as the swelling had blinded her. She was even feeding intravenously.

In short, her condition was heart breaking.

“Because the machines and personnel could not handle her condition, we were told to go elsewhere and thus we went to Nyakibaale Hospital in Rukungiri district,” her father recalls. 

This was August, 2012. They spent a month at Nyakibaale and when all treatment options proved vain, they were referred to Mbarara Regional Hospital. The daunting history of failed treatment repeated itself and after spending September bed ridden, she was referred to Mulago hospital, the country’s national referral hospital in October.

Busingye, a driver by profession says by this time, he had spent about Shs 6m.

Mulago becomes new home;

Kaitesi was first admitted to Ward 11 at Old Mulago where blood samples were collected by the MBN Clinical laboratories and taken to South Africa. They confirmed the disturbing truth that Kaitesi had chronic renal failure. This cost Shs 160,000.

Meanwhile, her health continued deteriorating and later, the hospital’s managing director; Dr Byarugaba Baterana referred them to Ward 6A, the hospital’s renal unit. This is when she was put on dialysis. The dialysis machine is commonly referred to as an artificial kidney and a patient is recommended to use the machine at least three times a week for several hours each time.

For the first month of being on dialysis, Busingye spent Shs 4, 688, 000. This father of three including a seven months old baby had sold his cows, house and car and obtained a loan to meet the hospital’s costs.  The sacrifice is not yet worth saving Kaitesi’s life.

Contrary to her promising improvement when I met her at Mulago Hospital on World Kidney day, Kaitesi has since worsened.

“It’s devastating!” the soft spoken Busingye said, ‘Dialysis has been keeping Renah alive, but will do so only for so long. She needs a transplant and that is why I brave the cold to solicit for money needed for her transplant.”

On a good day, he collects Shs 100,000 but still this comes at a cost-that of exposing his beloved first born child to infections through the catheter (a tube that conveys blood from the body to the dialysis machine) fixed on her left upper arm.  Once contaminated, it costs Shs 300,000 to replace it and Kaitesi has had hers replaced four times already.

When not soliciting for money, Busingye spends his days and nights at Mulago Hospital or sometimes a friend’s home.

We need help!

The only cry you’ll hear from Busingye’s heart when you meet him is ‘Please help us, Renah needs a transplant.’

During the interview, he intermittently raises his head to look at his daughter and in her, he no longer sees the bright and cheerful girl she once was but one hanging on donor mercies.

Her aunt, Ruth Nuwagaba has offered to donate own of her kidneys and what is left is Shs 75m.

To help Kaitesi, please call +256 772830319/ +256 751830319 or channel in your donations to AC-5120011923-Centenary Bank, Kanungu Branch.

Vocational training-an investment for the future

Every year on 1^st May, Uganda commemorates International Labour day; a day where working classes call for action for improved employment conditions and social justice issues. Uganda has adopted the theme: ‘Skilling Ugandans for increased labour productivity: A shared responsibility for this year’s celebrations that are being hosted at St Peter's College in Tororo district.

H. E. President Yoweri Museveni is expected to be the chief guest. In honour of the celebrations, more than 60 MPs are to be awarded and these include; Hon Sarah Opendi, Tororo district woman MP, Hon Adbu Katuntu MP Bugweri County, Hon Vicent Bagiire MP Bunya County, Hon Badda Fred MP Bujumba County and Hon John Bosco Mubito MP of Budiope West County.

The 2008 Business, Technical, Vocational Education and Training (BTVET) Act last year adopted the Skilling Uganda strategic plan in a bid to address major challenges identified regarding relevance, quality, access and equity, management and financial sustainability of BTVET.

The plan denotes an emphasis on skills development where students are trained in vocational skills such as wood and metal work, building and pottery among others.

In his recently published book, ‘Vocational Training, an investment for the future’, Eng Dr Nathan Muyobo, the chairperson of Lugogo Vocational Institute writes that the answer to Uganda’s quest for a knowledgeable and skilled work force is dynamic and relevant vocational training.

He notes that good vocational training is expected to be in a practical working environment which results in the promotion of personal development, particularly in making the individual develop the capacity for working independently.

Therefore the crux of good vocational training should aim at providing trainees with capacity to transfer from one job to another in the same trade, provide them with basic entrepreneurial skills for possible self employment and the capacity to cope with new challenges.

He also says that for this training to be more effective, knowledge about starting a business, accounting and management have to be taught.

Challenges;                                                                                                 

Eng Muyobo notes that there is a growing preference among the youth to strive to continue studying up to higher institutions like universities which they envisage as being a better way of preparing themselves for professional life.

“Vocational training therefore faces the challenge of proving its worth as an equally positive and strong route to future professional prosperity and this is not realised early enough as many of those who have passed through universities fail to find employment after graduating,” he writes.

Another challenge is inadequate trainers to assist trainees with appropriate skills. Consequently, training often focuses on low-cost skills training which mismatches the current and emerging labour needs.

During the recently released 2012 BTVET results, Prof Eriabu Lugujjo, chairman, Industrial Training Council said the system is chocking with limited Master trainers in major training institutes. Consequently, training often focuses on low-cost skills training which mismatches the current and emerging labour needs. Constrained by lack of marketable skills and formal sector jobs, most youths therefore engage in the informal sector or agriculture-related work.

“The government should improve and retain trainers in order to upgrade their competencies and encourage students to partake vocational education,” Prof Lugujjo said.

On a positive note however, Jinja Training Vocational College has been rehabilitated and in August the first batch of in-service trainers will be admitted.

BTVET is currently provided by 133 public institutions, about 600 private training service providers and 17 apprenticeship programmes. With USE giving primary school leavers the option to attend vocational training for free at eligible institutions, BTVET enrolment has soared in recent years with female enrolment currently at 40%.

Immunization: Parents to face arrest

A deliberate failure by parents to immunize their children will be treated as a crime, President Museveni has warned. Speaking at the launch of the new 10-valent pneumococcal vaccine (PCV 10) at Bugabwe Primary School in Iganga last week, Museveni said such parents deserve to be punishment severely.

“I’m going to consult with my people on what penalty should be given to parents who do not bring their children for immunization because some are just reluctant to do so,” he said.

He also urged parents to ensure that they adopt healthy practices like boiling drinking water, using clean latrines, adopt proper eating habits to avoid obesity and behavioural change to avoid contracting HIV. 

The vaccine is administered to children below the age of five years, to protect them against pneumococcus, the commonest cause of fatal pneumonia in children, and other life-threatening pneumococcal infections such as meningitis and sepsis.

While anyone can acquire pneumonia, young children, particularly infants (below one year old) are most vulnerable. The children are more vulnerable if they are poorly fed and have HIV/Aids, low birth weight, and non-exclusive breastfeeding.

Dr Irene Mwenyango of the Uganda National Expanded Program on Immunization (Unepi) says of the children under-five, who are susceptible to pneumonia in Uganda, only 73% are taken to an appropriate health care provider, where 47% of these receive antibiotics.

“About 60% of all infants [in the country] are breastfed for less than six months, and it is estimated that pneumonia is responsible for 17% of the deaths in children under five,” she said.

The Global Action Plan for Prevention and Control of Pneumonia (GAPP), issued by WHO and UNICEF, recommends a three-pronged approach to address child pneumonia that includes protection (exclusive breastfeeding and improved nutrition), prevention efforts (including routine use of measles, DTP3, Hepatitis B and pneumococcal vaccines), and treatment (appropriate antibiotics).

GAPP estimates that scaling up coverage of these key interventions to 90% could help prevent more than two-thirds of childhood pneumonia deaths worldwide.

With the roll out of the new vaccine, the advocates are hoping to reach 1.5m children below the age of one year and these must receive three doses of PCV-10 after six, 10 and 14 weeks.

The ministry of Health with its implementing partners, Global Alliance for Vaccine Initiative (Gavi), UNICEF and World Health Organization (WHO) have started vaccination in Busoga region and will later cover Teso, Bugisu, Karamoja, western and southern regions of the country by the end of the year.