Keith P. Klugman - Pneumonia director of the Bill & Melinda Gates Foundation (JP/Elly Burhaini Faizal)

Pneumonia is the leading cause of death among under-5 children in the world, including Indonesia. The Jakarta Post’s Elly Burhaini Faizal spoke with Keith P. Klugman, pneumonia director of the Bill & Melinda Gates Foundation, on the sidelines of his recent visit to Indonesia. Below are excerpts from the interview:

Question: Many experts consider introducing new vaccines, including the pneumococcal conjugate vaccine (PCV13), as a key step to combating child deaths from pneumonia. Why?

Answer: Pneumonia is the number one cause of death in children in poor countries. So in a country like Indonesia, especially in its poorest parts, [like] Aceh, [which has] the country’s highest child mortality, pneumonia will be the [most important] cause of those childhood deaths. You cannot reduce childhood deaths without reducing pneumonia.

Pneumonia deaths are caused mainly by bacteria and also viruses, and the most important bacterial cause of pneumonia is pneumococcus. The PCV vaccine has been shown to reduce childhood mortality and pneumonia mortality, especially for poor people. The vaccine was first given to children in the United States in 2000 but has now been rolled out in most countries. Over 50 percent of children in the world today have received the vaccine and in recent years, the children of Bangladesh have had the vaccine, Pakistan’s children have had the vaccine. We think that the introduction of PCV into Indonesia will be very important to achieve the goal of reducing child mortality, especially among the poorest children.

How effective are PCV vaccines in protecting our children and society from pneumonia?

[Unless] you immunize the children, the bacteria which go among all the children, and even also the same bacteria, go to infect all the people. Pneumonia […] kills young children. Pneumonia also kills elderly people. It’s the same bacteria. [...] As long as you immunize about 70 percent of the children, you can stop all of the pneumonia due to these bacteria in the whole community. If Indonesia introduces this vaccine in children, given the increasing problems that you have in Indonesia with air pollution, these increasing pneumonia deaths in the elderly will also be reduced.

So [...] if the vaccine is introduced, we will help Indonesia to measure the effect of pneumonia in children and in adults. We think if the vaccine is introduced, especially at an affordable price, it will help Indonesia save costs. Because the cost of the vaccine will be less than the cost of hospital for children for pneumonia and hospital for adults for pneumonia.

Expanding the vaccination coverage of PCV13 for children will place a huge financial burden on the government. How would we cope?

There is a possibility and offer from Gavi, the Vaccine Alliance. Gavi has a program that has saved more than 10 million children. Gavi will help the government to pay for this vaccine and make it affordable. The cost of the vaccine will be less than one-fifth of the [actual] cost. So there is an opportunity through Gavi until the end of this year to make this offer to Indonesia. And it’s a decision that has to be made by the health minister and the government.

Can Gavi’s offer be extended beyond Dec. 31?

I have been told that it is not possible. There has been a so-called pneumococcal Advance Market Commitment (AMC), which has been able to help many countries, including Pakistan, Bangladesh and India, to introduce PCV. We consider Indonesia to be a large country, which has an opportunity to have this vaccine. That’s why I have come urgently to the ministry. I believe there have been around two years of discussions with the previous health minister [Nila Djuwita Anfasa Moeloek] about this. We are excited that there is a new minister [Terawan Agus Putranto].

What if we don’t take up the Gavi’s offer for affordable PCV13?

Indonesia will have to graduate from Gavi’s support. Obviously, the Gates Foundation can try to work with companies to encourage them to work with Indonesia. But we won’t be able to guarantee the same price [after the Dec. 31 deadline]. We can try.

[…] In our support to Gavi, we are working with additional manufacturers or new manufacturers, including a manufacturer in India, to make PCV. If the vaccine is not through Gavi, the cost of the vaccine is between [US] $12 and $15 per dose. And the cost through Gavi is $2.90 per dose. As the vaccine needs to be given in three doses, the total cost will be about $9 per immunized child. If no decision can be made [by Dec. 31], we can continue to try to work with new manufacturers to reduce the cost.

But [the Gavi offer] is a special opportunity, especially […] [given] the saved costs from hospitalization of children and the elderly [for pneumonia].

The Indonesian Ulema Council (MUI) has not certified the measles-rubella vaccine as halal, which has led to parents rejecting it in some parts of Indonesia. Is PCV13 halal?

It’s not an animal product at all. PCV is different from the measles vaccine, which is a live vaccine made from live cells. PCV is not a live vaccine. So it cannot have this [halal] problem. This vaccine has been accepted even in Pakistan, Saudi Arabia and Bangladesh.

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