advanced search

<< Back To Home

CSU 69/2009: MORTALITY FROM PNEUMOCOCCAL DISEASE AND HIB

Tuesday, 3rd of November 2009

           CSU 69/2009: MORTALITY FROM PNEUMOCOCCAL DISEASE AND HIB
 
 Do pneumococcal disease and Hib kill more children than malaria, TB and HIV
 combined?
 This is the conclusion of two literature reviews in The Lancet complemented
 by a discussion article in the American Journal of Epidemiology,
 accessible to Internet users at
 http://aje.oxfordjournals.org/cgi/reprint/kwp316v1
 
 These conditions are preventible through routine immunization. The obvious
 conclusion is that any country seeking to reach MDG 4 needs immediately to
 introduce pneumococcal and Hib vaccine, and to strengthen routine
 vaccinations to a point where pneumonia and Hib are no longer major
 contributors to under five mortality.
 
 Full text of the commentary by Rudan and Campbell, reproduced below, is at
 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736
 (09)61608-1/fulltext?_eventId=login
 
 The pneumonia article is at
 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736
 (09)61204-6/fulltext
 
 The Hib article is at
 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736
 (09)61203-4/fulltext
 
 
 
 Good reading.
 
 BD
 
 The Lancet, Volume 374, Issue 9693, Pages 854 - 856, 12 September 2009
 The deadly toll of S pneumoniae and H influenzae type b
 
 
 
 Igor Rudan a b(Embedded image moved to file: pic19854.gif)Email Address,
 Harry Campbell b
 Before 2000, the world of global child health was a very different place
 than it is today. The links between health information from the field in
 low-income countries and global child-health policies were weak.1 The
 agenda was driven by panels of experts with decisive influence on donors
 and policy makers, but there was little consensus among them on key issues.
 2 Over the years, this reliance on expert opinion has led to snowballing
 support for some issues over others and striking inequities between
 investments in research and development across different diseases.3 The
 legacy of relying on expert opinion rather than a critical review of the
 evidence has recently been exposed. In 2007, HIV/AIDS, malaria, and
 tuberculosis—diseases for which advocacy has been more successful—have each
 received between ten and 50 times more research and development funding for
 a given global disease burden than for bacterial pneumonia, meningitis, or
 diarrhoea—diseases that have attracted less international attention and
 support.4
 But in The Lancet today, Katherine O'Brien,5 James Watt,6 and their
 colleagues reveal for the first time that Streptococcus pneumoniae
 (pneumococcus) and Haemophilus influenzae type b (Hib)—the pathogens
 responsible for most child deaths from bacterial pneumonia and
 meningitis—are directly responsible for just as many child deaths as
 HIV/AIDS, malaria, and tuberculosis combined. This finding is shocking
 because vaccines against both pathogens are readily available and have been
 consistently safe and effective in trials in developing countries.7
 Since 2000, the link between evidence and global child-health policies has
 been steadily improving. First, the UN has set an overarching goal
 (Millennium Development Goal 4 [MDG 4]), which called on all stakeholders
 to reduce global child mortality by two-thirds between 1990 and 2015.8 This
 noble aim has gained widespread support among key stakeholders—national
 governments, donors, and researchers alike. It helped to focus efforts and
 investments related to child survival and to garner political support. It
 also created a pressure for the available health information from
 developing countries to be critically evaluated and then used for policy
 development to promote progress towards achievement of MDG 4.
 Several important initiatives were supported in parallel to improve the
 link between health information and investment policies—eg, Global Burden
 of Disease work, Health Metrics Network, Demographic Health Surveys, and
 others. An independent group of technical experts—the Child Health
 Epidemiology Reference Group (CHERG)—was sponsored by the Bill & Melinda
 Gates Foundation, WHO, and later UNICEF to define the key causes of child
 deaths with use of the best available evidence from low-income countries.9
 The Lancet has played a key role in providing a high-profile platform for
 CHERG's results, which ensured that the evidence from developing countries
 reached wide audiences and influenced policy makers. Since 2003, the
 partnership between CHERG and The Lancet had a major effect in promoting an
 evidence-based approach that identifies the real priorities in global child
 health. It has highlighted the relatively neglected conditions, pneumonia
 and diarrhoea, as the major causes of child death and has also drawn
 attention to the importance of neonatal deaths.9 The leaders of G8
 countries have just recognised and committed support to these efforts in a
 recent declaration.10
 
 O'Brien, Watt, and colleagues deliver the first global estimates of
 morbidity and mortality from diseases caused by the S pneumoniae and Hib in
 children aged 1 month to 5 years. These studies show that pneumococcus
 (causing pneumonia, meningitis, and sepsis) is the leading bacterial cause
 of death in young children worldwide. An estimated 14·5 million episodes of
 serious pneumococcal disease occurred in 2000 in children aged 1—59 months
 and caused 826 000 deaths (uncertainty range: 582 000—926 000).
 Additionally, Hib caused 8·13 million serious illnesses and 371 000 deaths
 (247 000—527 000). 91 000 deaths due to pneumococcus and 8100 deaths due to
 Hib occurred in HIV-positive children.
 
 To produce these estimates at the global and national level, a partnership
 between PneumoADIP and the Hib Initiative (of the GAVI Alliance) and WHO
 was formed. A systematic review identified and critically reviewed over
 15 000 articles in many languages. Although the final estimates are based
 on a disappointingly small evidence base, this exercise was thorough and
 the estimates can be considered the most authoritative available.
 Nevertheless, several important areas of uncertainty remain. There are
 several countries with very large child populations but with very few
 country-specific data. The pneumococcal-specific and Hib-specific pneumonia
 incidence and mortality estimates are indirect and based on inferences from
 only a few vaccine-probe studies and published estimates of overall
 pneumonia mortality (themselves based on limited data). The varying
 approaches to the estimation of pneumonia, meningitis, and invasive disease
 make comparability of estimates across syndromes problematic.11 And these
 estimates do not take into account the disease burden in the neonatal
 period or important interactions with other key pathogens in causing child
 deaths.12
 
 Effective pneumococcal and Hib vaccines exist and can be successfully
 integrated into national immunisation programmes.7, 13 Today's new
 estimates suggest that achieving high coverage with these vaccines could
 prevent a substantial proportion of child mortality globally. Current
 immunisation coverage with these vaccines is a striking example of global
 inequity: children in countries that do not yet use the vaccines have about
 a 40-fold greater risk of dying from pneumococcus or Hib than children in
 countries that include them in their routine immunisation programmes.14 The
 two studies in The Lancet today5, 6 are an important international
 health-policy contribution to strengthen the case for action to counter
 this shameful inequity.
 We declare that we have no conflicts of interest.
 References
 1 Rudan I, Lawn J, Cousens S, et al. Gaps in policy-relevant information on
 burden of disease in children: a systematic review. Lancet 2005; 365:
 2031-2040. Summary | Full Text | PDF(374KB) | CrossRef | PubMed
 2 Rudan I, El Arifeen S, Black RE, Campbell H. Childhood pneumonia and
 diarrhoea: setting our priorities right. Lancet Infect Dis 2007; 7: 56-61.
 Summary | Full Text | PDF(91KB) | CrossRef | PubMed
 3 Enserink M. Some neglected diseases are more neglected than others.
 Science 2009; 323: 700. PubMed
 4 Moran M, Guzman J, Ropars A-L, et al. Neglected disease research and
 development: how much are we really spending?. PLoS Med 2009; 6: e30.
 CrossRef | PubMed
 5 O'Brien KL, Wolfson LJ, Watt JP, et alfor the Hib and Pneumococcal Global
 Burden of Disease Study Team. Burden of disease caused by Streptococcus
 pneumoniae in children younger than 5 years: global estimates. Lancet 2009;
 374: 893-902. Summary | Full Text | PDF(540KB) | CrossRef | PubMed
 6 Watt JP, Wolfson LJ, O'Brien KL, et alfor the Hib and Pneumococcal Global
 Burden of Disease Study Team. Burden of disease caused by Haemophilus
 influenzae type b in children younger than 5 years: global estimates.
 Lancet 2009; 374: 903-911. Summary | Full Text | PDF(529KB) | CrossRef |
 PubMed
 7 Madhi SA, Levine OS, Hajjeh R, Mansoor OD, Cherian T. Vaccines to prevent
 pneumonia and improve child survival. Bull World Health Organ 2008; 86:
 365-372. CrossRef | PubMed
 8 Murray CJ, Laakso T, Shibuya K, Hill K, Lopez AD. Can we achieve
 Millennium Development Goal 4? New analysis of country trends and forecasts
 of under-5 mortality to 2015. Lancet 2007; 370: 1040-1054. Summary | Full
 Text | PDF(997KB) | CrossRef | PubMed
 9 Bryce J, Boschi-Pinto C, Shibuya K, Black REWHO Child Health Epidemiology
 Reference Group. WHO estimates of the causes of death in children. Lancet
 2005; 365: 1147-1152. Summary | Full Text | PDF(611KB) | CrossRef | PubMed
 10 G8 Leaders Declaration. Responsible leadership for a sustainable future.
 http://www.g8italia2009.it/static/G8_Allegato/G8_Declaration_08_07_09_final,0.pdf
 . (accessed July 15, 2009).
 11 Lanata CF, Rudan I, Boschi-Pinto C, et al. Methodological and quality
 issues in epidemiological studies of acute lower respiratory infections in
 children in developing countries. Int J Epidemiol 2004; 33: 1362-1372.
 CrossRef | PubMed
 12 Bahl R, Martines J, Ali N, et al. Research priorities to reduce global
 mortality from newborn infections by 2015. Pediatr Inf Dis J 2009; 28
 (suppl 1): S43-S48. PubMed
 13 Simoes EAF, Cherian T, Chow J, et al. Acute respiratory infections in
 children. http://files.dcp2.org/pdf/DCP/DCP25.pdf. (accessed July 15,
 2009).
 14 Bryce J, Terreri N, Victora CG, et al. Countdown to 2015: tracking
 intervention coverage for child survival. Lancet 2006; 368: 1067-1076.
 Summary | Full Text | PDF(472KB) | CrossRef | PubMed
 a Croatian Centre for Global Health, University of Split Medical School,
 21000 Split, Croatia
 b Centre for Population Health Sciences, the University of Edinburgh
 Medical School, Edinburgh, UK