Opinion: Preventing pneumonia must involve more than tech tools

Pneumonia is the single largest infectious cause of death in children worldwide. In 2015, the infection caused over 920,000 deaths of children under 5. In the same year, India, Nigeria, Indonesia, Pakistan, and China accounted for more than 54% of all global pneumonia cases. In addition, 49% of global pneumonia deaths occurred in India, Nigeria, Pakistan, the Democratic Republic of the Congo, and Ethiopia.

Pneumonia is caused by viruses or bacteria — and in well-equipped hospitals, diagnoses of pneumonia could be done using chest x-rays, CT scans, blood and sputum cultures, and other invasive tests. However, facilities for these tests are not readily available in resource-poor settings in Africa, Asia, and Latin America which also have high burdens of pneumonia.  

Recently, the Butterfly iQ, a hand-held ultrasound scanner that can be connected to an iPhone, was used to successfully diagnose pneumonia in children in resource-poor settings. This is a very timely lifesaving invention, and the developers should be commended. In 2017, the Butterfly iQ received FDA clearance and in 2018, the company raised $250 million in a Series D funding with participation of organizations such as the Bill & Melinda Gates Foundation and other investors.

But as promising as Butterfly iQ may be, it can be constrained in the impact it can make in the prevention and treatment of pneumonia and should not be treated as the ultimate solution. Tech is great — resource-poor settings often require simpler solutions to health challenges.

As basic as the Butterfly iQ is, it still requires a smartphone to function. Smartphones are not widespread in resource-poor settings due to poverty and poor data connectivity. There are more than 170 million registered mobile phone users in Nigeria, but just 15% of them are smartphone users. Butterfly iQ uses pediatricians based in Canada to read and interpret ultrasound photos, rather than relying on Nigerian doctors, which would save money and time — Nigeria’s time zone is between five and eight hours ahead of Canada.

Taking a step back, the World Health Organization and UNICEF integrated Global Action Plan for Pneumonia and Diarrhoea is three-pronged: prevention, treatment, and protection.

Prevention and protection against pneumonia are separate from what the Butterfly iQ can do and are very important because even if pneumonia is properly diagnosed, treatment may not be readily available in low-resource settings.

Thus, as governments, civil society organizations, philanthropists, and private sector actors across Asia, Africa, and Latin America consider scaling up the Butterfly iQ or other tech-based technologies, it is important to also focus on four other interventions that, if not provided, could reduce the impact of the Butterfly iQ.  

First, vaccination is one of the most cost-effective public health interventions. Haemophilus influenzae type b vaccine, or Hib, is used to immunize babies against pneumonia. The Hib vaccine is given in three doses, every two months starting at two months of age. The returns on investment of Hip B is equal to nine times the cost of vaccination.

Governments in Africa, Asia, and Latin America must begin to fund childhood vaccinations and stop the overdependence on Gavi, the Vaccine Alliance and other donors. A vehicle to increasing routine immunization in resource-poor settings is through a public-funded universal health coverage health system.

Second, malnutrition is a serious risk factor for pneumonia and should be addressed. Unfortunately, millions of children still suffer from it in Africa, Asia, and Latin America. Generally, malnutrition is implicated in about 45% of the causes of under-5 mortality. Consequently, advocacy by health workers for exclusive breastfeeding of infants within the first six months of life is imperative. As the weaning period approaches, mothers and caregivers must be taught how to make use of locally available foods to prepare complementary feeds that are affordable.

Third, pneumonia is airborne and is spread easily in communities with poor sanitation and poor hygiene practice. Poor sanitation and lack of access to clean water are two peas in the same pod. Health promotion by community health workers is an important way of reducing the risk of pneumonia in these communities and should include risk communication on sneezing into the elbows, proper handwashing techniques, good waste disposal, and provision of clean water.

Fourth, viral pneumonia is common in the immunocompromised such as people living with HIV. This is an opportunistic infection called Pneumocystis Carinii Pneumonia, according to the United States Centers for Disease Control. Therefore, chemoprophylaxis with the antibiotic cotrimoxazole for such individuals must be prioritized by governments as they procure drugs for managing HIV. Also, agencies intervening in HIV/AIDS must ensure that cotrimoxazole is one of the essential drugs stocked in health facilities.

These four preventative and protective interventions would ensure children do not acquire pneumonia. But for those who do still have it, after diagnosis with the Butterfly iQ, instituting standard management protocols are imperative if the child is to survive.

WHO recommends antibiotic treatment using Amoxyl for bacterial pneumonia and provision of oxygen for complicated cases of pneumonia. To mitigate the frequent stock out of Amoxyl, governments across Africa, Asia, and Latin American can learn from the South African experience in bulk purchasing of drugs and other commodities for public sector health facilities.

The South African government issues tenders for essential medicines and other commodities sold in all pharmacies in the public health care system. Applying bulk purchasing of drugs drives down costs by engendering price competition.

When governments and other civil society actors in resource-poor settings prioritize preventative, protective, and curative interventions against pneumonia, then tech innovations such as Butterfly iQ would really begin to reduce morbidities and mortalities due to pneumonia.