Indonesia's plan to expand its vaccination programs to curb pneumonia, one of the leading causes of death among children in the country, has fallen through as the COVID-19 pandemic disrupts vaccine procurement.
The pneumococcal conjugate vaccine (PCV) program was expected to be introduced this year in East Java and West Java, the Health Ministry's director for direct infectious diseases, Siti Nadia Tarmizi, told The Jakarta Post on Tuesday. But the plan failed due to the COVID-19 outbreak.
The expansion would have followed the pilot project carried out in several regions in West Nusa Tenggara and Bangka Belitung that started in 2017 and 2018, respectively. The plan was to gradually add more provinces to the list until the project reached all the country's 34 provinces by 2024 as part of the national childhood immunization program, Nadia said.
So far, parents can get a PCV for their children by paying for it on their own instead of getting it free from the government. However, pneumonia cases are more commonly found among children from lower-income families or in villages, Nadia said.
The PCV immunization program was still running this year in the two pilot provinces, Nadia said, but not as optimally as planned due to “some obstacles, including in vaccine procurement and execution in the field”. It is expected to resume next year.
As was the case with other state agencies, the ministry also had to reallocate its budget to cushion COVID-19 impacts — though its sluggish spending later came under fire.
“We often forget about pneumonia because it's not a new disease [...] But pneumonia is not just another disease that is no longer a problem in Indonesia,” Nadia said, pointing to the fact that up to 20 percent of deaths among Indonesian children were caused by pneumonia, as opposed to other countries' below 1 percent.
Indonesia committed to PCV procurement earlier this year through the Advance Market Commitment, a special mechanism of public-private global vaccine alliance Gavi that enables access to the costly vaccines for a quarter of the price.
The commitment comes amid the government's target to suppress its child mortality rate, including by reducing pneumonia cases to 3.3 percent by 2024 and less than 1 percent by 2030, according to Nadia.
The country has seen its pneumonia prevalence increase to 2 percent in 2018 from 1.85 percent in 2013, according to the 2018 Basic Health Survey (Riskesdas).
Nationwide, the 2019 Health Profile showed that 468,172 Indonesian children under the age of five suffered from pneumonia, 551 of whom died that year. The disease was the largest cause of death among children aged between 29 days and 11 months in 2019, at 15.9 percent, and the second-leading cause of death among children between 12 and 59 months, at 9.5 percent.
Since the start of the outbreak, coverage rates for most childhood vaccinations have dropped as health facilities suspend several services and parents avoid visiting hospitals and clinics over fears of COVID-19, because children at more risk of catching pneumonia.
This has also prompted fears of future outbreaks that should have been preventable.
Nastiti Kaswandani, a pediatric pulmonologist and member of the Indonesian Pediatric Society, said there were at least five vaccines related to pneumonia that should not be neglected, namely to protect against diphtheria, tetanus and pertussis, haemophilus influenzae type B, pneumococcus, measles, as well as flu shots. However, she added, other childhood vaccines were just as important to indirectly immunize children against various diseases.
“If we've heard about the relatively high rate of [COVID-19] deaths among children [in Indonesia]. One of the suspected reasons behind this is that the children hadn’t received all their vaccinations before the pandemic,” Nastiti said in a discussion held by Save the Children Indonesia ahead of International Pneumonia Day.
"So, when exposed to COVID-19, children could get [other] infections that should've been protected by immunization [...] With COVID-19, the presence of double or secondary infections could worsen their conditions.”
Data from the Health Ministry published on Oct. 8, showed that from a sample of 6,383 confirmed COVID-19 cases, pneumonia accounted for the largest share of underlying conditions with 2,655 people. From a sample of 1,108 deaths, 347 had pneumonia; four were children aged below the age of 1, and two aged between 6 and 17 years old.
Other risk factors include malnutrition and stunting, which remains a problem in Indonesia, insufficient breastfeeding, lack of vitamins, as well as exposure to pollution such as cigarette smoke at home. Smoking prevalence among children aged between 10 and 18 years old, for instance, also rose to 9.1 percent in 2018 from 7.2 percent in 2013, according to Riskesdas 2018.
“Even from second-hand smokers, [the toxic residue from] the smoke sticking on clothes could be inhaled [by children]," Nastiti said.
Nadia said the increase in the prevalence of pneumonia was related to these risk factors, so behavioral changes were also required aside from early detection programs, especially in remote areas. This is because not many parents can identify pneumonia symptoms in their children, which could make the disease progress more rapidly, she added.
"We have to fix these factors, in addition to administering pneumonia vaccines.”