Crying out for action: Protect children from pneumonia in Africa’s most fragile countries

By Dr. Anita Shet and Dr. Dickson Awah

Originally posted on

On a busy street in N’Djamena, Chad, a town crier announces the start of a measles vaccine campaign. A year ago, the same town crier was rallying for COVID-19 vaccine campaigns. Conflict was no stranger to the people of Chad, but his call to arms was to confront deadly infection-causing pathogens that kill young children with impunity and stop these invaders with the best tool we have: vaccines.

UNICEF/Somalia (2022)

With COVID-19 receding in the rear-view, health advocates are shifting their focus onto pneumonia. In 2020, more than 700,000 children in the world died from pneumonia globally before they turned five years old. Many of these infections are caused by pneumococcus, a bacterial pathogen against which we have robust and safe vaccines, called pneumococcal conjugate vaccines (PCV). Used in high-income countries since 2000, PCVs have averted 175.2 million cases of all pneumococcal diseases and 624,904 deaths globally between 2010-2019. Yet more than 20 years later, the vaccine has not yet reached many vulnerable children predominantly living in low- and middle-income countries. Vaccination data from 2021 indicate that less than half of the world’s children have received PCV, and there are still 39 countries that are yet to introduce PCV in their national immunization schedules.

Within four large countries in Africa—Chad, Guinea, South Sudan and Somalia—child deaths due to pneumonia alone are unacceptably high at over 49,000 in 2017. The recently concluded Global Forum on Childhood Pneumonia in Madrid, Spain brought together leaders of these four countries to candidly discuss the barriers they face in introducing PCV. Despite PCV-related planning efforts for several years, they have had to handle multiple national priorities, including civil conflict, drought, famine, population displacement, and food insecurity. An outcome that generated real hope was the strong commitments expressed by the governments of Chad, Somalia, Guinea, and South Sudan to ensure PCV introduction within the next two years.

UNICEF/Somalia (2023)

A major barrier in PCV introduction is its high cost. Gavi, the Vaccine Alliance, that has since 2000 facilitated routine vaccinations of over 981 million children in 77 countries has stepped up to the forefront once again. Through Gavi support, these four countries can access PCVs at a lower cost, with a small contribution from the country to fulfil Gavi’s co-financing policy to ensure country ownership of vaccine financing. At the Global Forum on Childhood Pneumonia in Madrid, Gavi announced they would further provide the vaccines at no cost in South Sudan and Somalia, citing their extreme levels of conflict and drought. While this announcement was lauded globally, co-financing barriers still exist for Chad and Guinea, where 42% and 55% of the people live in poverty, respectively, and face conflict and deepening food insecurity. Continued global attention and joint investments are needed for these two countries to ensure that their government’s commitments are supported.

One silver lining from the pandemic years that can be capitalized upon is that despite the heavy toll COVID-19 exerted on health systems, it also created opportunities to strengthen vaccine delivery. For example, countries improved their ‘cold chain’, the system that chills vaccines, and trained their health workers on new delivery processes.

South Sudan demonstrated remarkable resilience despite heavy conflict and waves of refugees. A UNICEF representative from South Sudan described the upgrades made to health systems, “Equipment that was obsolete in the system is being replaced,” he said. “Facilities that were never equipped are being equipped, and upgrades are expanding the storage capacity.”

Investing in social and behavioral interventions such as leveraging communication champions to strengthen vaccine delivery and uptake, has been invigorated. “We have a platform of social mobilizers who support other vaccination campaigns,” said a UNICEF official in Somalia, indicating the network could be tapped for pneumonia vaccine-related outreach.

In Chad, a non-government organization (NGO) representative reflected on vaccine messaging. “For community mobilization, we used the whole lot of communication tactics—print, audio, visual, but also town criers,” said the representative, referring to traditional troubadours who move with donkeys, horses, or camels from community to community sharing information.

Despite efforts, barriers persist, we will continue to see children die needlessly unless urgent action is taken. The upcoming PCV Workshop in Chad in September 2023 will bring leaders of the four countries’ health and finance ministries together with world agencies and regional financing partners to identify solutions to remaining barriers hindering vaccine introduction and scale-up.

Bold efforts by leaders of some of Africa’s most fragile countries are aligned with community members, like the Chadian town crier, in taking critical steps to bring PCV to those in need. Children living in these countries have a right to be protected with the same basic vaccines that are available to other children across the world. The urgency for collective action is real. It is time to ensure that pneumonia will not prevent these children from experiencing a fifth birthday.

Anita Shet is the Director of Child Health at the Johns Hopkins International Vaccine Access Center, and Dickson Awah is the Country Director, Malaria Consortium, Chad. Dr. Shet and Dr. Awah developed the commentary with Baldeep Dhaliwal, Jasmine Huber and Rose Weeks, of the Global Advocacy for PCV project of the Johns Hopkins International Vaccine Access Center.
*Participants in some countries were interviewed under the condition of anonymity, with some citing a threat from civil unrest.

UNICEF/Chad (2023)