March Issue 2013

It was early morning. A young couple rushed into the hospital as fast as they could; Yousuf, the father, was carrying his son Sami in his arms. The child’s breathing was shallow and the fever and chill had made him listless. Mariam, his mother, had sat up all night, anxiously waiting for morning. The couple lived in a troubled area; there had been firing and tyres were being burnt on the main road outside their house; travelling at night might have invited further trouble. Sami was by turns nauseous, complaining of abdominal pains and moaning softly in his half- asleep state.
Sami is just one of the millions infected with pneumonia, which remains the number one killer of children under the age of five. In Pakistan alone, about 30,000 children die every year from the disease. According to WHO, incidences of childhood pneumonia in Northern Areas at higher altitudes is even greater than near the plains.

Globally, about four million people lose their lives to this disease, the majority being from the developing world. Pneumonia and its complications are also considered the number one cause of deaths that could have been prevented by administering vaccines.

Women are half as more likely to report the illness as compared to men, and the infection was more likely to be prevalent in rural areas.

In a country like Pakistan, with urban crowding in a large proportion of katchi abadi populations and a relatively high number of poor and malnourished people, the situation becomes even more complicated. Facilities for care and treatment are scarce and awareness of simple health measures remains equally limited. The past decade, in particular, has seen a greater risk of the infection spreading, with growing pollution and natural calamities increasing the risk of contagion. Although this serious infection mostly affects vulnerable children and adults above the age of 65, older children and young adults can also develop pneumonia.Crowded places, apartment buildings and other confined spaces, including hospitals where healthy persons may be exposed to patients, present the ideal ground for the transmission of germs. Pneumonia spreads fast and easily, just as coughs and colds do, via saliva droplets. Infection is usually transmitted from one person to another in the course of daily activities. When not too serious, pneumonia can be treated at home with orally administered antibiotics; however, serious cases require hospitalisation.

It’s time to seek help when fever or cough with phlegm do not improve or worsen with time, or when shortness of breath emerges with the usual daily activities, or when chest pain occurs with breathing. Also, seek a doctor if you suddenly feel worse after colds or a case of the flu.

Dr Tasnim Ahsan, Professor of Medicine and Executive Director at the Jinnah Postgraduate Medical Centre, expressed her concern about the groups of people susceptiple to pneumonia and its complications. “Children and the elderly, yes, but also women during pregnancy — they’re more susceptible to infection then, and any infection can be dangerous.

In a country like Pakistan, with urban crowding in a large proportion of katchi abadi populations and a relatively high number of poor and malnourished people, the situation becomes even more complicated. Facilities for care and treatment are scarce and awareness of simple health measures remains equally limited. The past decade, in particular, has seen a greater risk of the infection spreading, with growing pollution and natural calamities increasing the risk of contagion.

“Normally, respiratory passages are capable of eliminating infection-producing organisms, but the danger happens when the infection reaches the lower respiratory tract. Therefore, anyone with predisposing conditions like colds or flu, or an underlying history of abnormalities, is endangered.

“Preventive measures are most important: they include avoiding overexposure to cold, bouts of flu, or anything that can lower bodily immunity. The prophylactic vaccine is a must for older people — in fact, both flu vaccine and pneumococcal vaccine. It may be expensive, but the pneumococcal is only given once in five years and is well worth it. (And the latest vaccines only need to be taken once in a lifetime). Those who are predisposed to such infections should wear face masks; these are also important because tuberculosis pneumonia is fairly common, and is transmitted aerially with ease.” Ahsan adds that our biggest problem remains poverty. “It has not been possible, for instance, to provide satisfactory medicare to all those who suffered in the recent floods”

Once the pneumonia germ attacks a susceptible individual, the effect is insidious. It invades the lung tissue, causing inflammation of the lungs, with fluid collecting in and around the air sacs of the lungs and the alveoli, making it difficult for a patient to breathe normally.

Pneumonia is caused not just by one, but several kinds of organisms such as bacteria, viruses, mycoplasma and even fungi. Several other factors influence the severity of the disease: the general health of the patient and the presence of underlying illnesses such as diabetes, cardiac disease, hypertension and liver or kidney problems. Sometimes even long-term treatment in a hospital can lower the body’s immunity, making the person more prone to infection.
The most common variety of causative microbe is a specific bacterium called pneumococci. The infection thus caused is fairly severe, but luckily, most types are treatable with antibiotics.

Another milder form of pneumonia stems from mycoplasma infection (mycoplasma is a microorganism). It is so mild that those suffering from mycoplasma -linked pneumonia are not even aware of the illness; they’re referred to as having ‘walking pneumonia.’ Sometimes there is cough and cold with a little mucus, mild flu-like symptoms, and/or sore throat, headache, fatigue and persistent weakness. The danger of walking pneumonia is that it’s virtually asymptomatic: you may be carrying the bug without being aware of it, and can freely infect others. Yet it can also be dangerous, just as any infection can be.

Viral or pneumococcal pneumonia can be so critical that hospitalisation is the only answer. Some commonly occurring symptoms are shortness of breath, pain in breathing, rapid heart and breathing rate, nausea, vomiting, diarrhoea, cough with green or yellow mucus, fever around 100 degrees Fahrenheit, shaking chills and change in mental status causing confusion and unclear thinking. Often, the amount of oxygen in the blood may drop.

Symptoms can be mild to severe, depending on the age and general health of the patient and the presence or absence of underlying causes. Complications sometimes develop in patients who are at higher risk. Meningitis (inflammation of the covering of the brain) is a frequent complication. Pneumonia can also lead to ear infections or other complications. Chicken pox in otherwise healthy adults can lead to varicella pneumonia, where the chicken pox virus infects the lungs; it carries significant risk of morbidity and possibility of mortality, despite mechanical respiratory support and antiretroviral therapy.

Another critical complication is bacteraemia, where fluid accumulates in the pleura or the covering of the lungs. This fluid can become infected, causing an abscess. Bacteraemia is a serious complication when the pneumonia infection spreads from the lungs to the blood stream, and then to organs within the body. Bacteraemia can also cause the blood pressure to drop dangerously low.

At times the infection is so apparently mild as to be asymptomatic; one 60-year- old woman had no symptoms at all — no fever, no cough, only fatigue. She put it down to general tiredness. A few days days later, while at a clinic for an eye examination, she found she couldn’t breathe, and was rushed to hospital, where she was put on oxygen. She passed out while in hospital, and remained unconscious for 11 days; it was bacterial pneumonia. She was hospitalised for 16 days. That was, as she herself says, a close call and it took her more than a month to recover. Improvement in the patient’s condition usually occurs after three to five days following treatment, though fatigue and a mild but persistent cough may continue for as long as a month or even more. It’s necessary to ensure adequate rest periods, lots of fluid intake, naps in the daytime and plenty of sleep at night.

Antibiotics are generally effective, but strains of bacteria including pneumococci are emerging that are resistant to antibiotics. Therefore it is all the more important to ensure that the full course of antibiotic treatment is completed, which is usually five to seven days. This is essential even when the patient is beginning to feel better.
As with any disease, prevention is better than cure. Dr D.S. Akram, Professor of Paediatrics at Karachi’s Civil Hospital, says, “Children under five are the most susceptible; pneumonia is the commonest infection affecting children. Approximately 19 per cent of infant mortality is due to pneumonia, and mortality is higher in younger children. Just two organisms are responsible for over 30 per cent of the cases that we see — pneumococcus and H. influenzae. Other infections causing serious ailments in children are measles and pertussis (whooping cough). Pakistan has vaccines against them all.”

Dr Akram recommends important preventive measures including immunisation with vaccine, breastfeeding, proper ventilation in the house, frequent hand washing, vitamin supplementation after measles, and provision of zinc.
“Our job,” says Prof Nadeem Rizvi, Chairman of the Pakistan Chest Society, “is to highlight the fact that vaccines are available, and we need to educate the public by increasing awareness.

“Pneumonia in the elderly has long been a point of concern,” says Dr Rizvi. “Pneumonia from bacterial and viral agents is the fourth leading cause of death in persons aged 65 and above. If untreated, the disease leads to further complications. Pneumonia is also the largest cause of hospitalisation during the Hajj season.”

Currently available vaccines are effective against several strains of bacteria, but these vaccines are also complex and expensive to manufacture, and several more are at the development stage. Pakistan is the first country in South Asia to introduce pneumococcal vaccine; the vaccine for children is now available free of charge at major public hospitals throughout the country, courtesy UNICEF, WHO, Global Alliance for Vaccines Initiative, and the Gates Foundation. Vaccine is available under the brand names Synflorix and Prevnav; protection lasts three years, making the vaccine useful when children are most at risk. The adult vaccine is effective for five years. Occasionally, relatively mild side-effects may occur — soreness at the place of vaccination, swelling, fever or muscular pain; these soon subside — but protection is all-important.

Safeguard your health, take these basic precautions, and hopefully you’ll be fine!