Every 15 seconds, a child somewhere in the world dies of pneumonia. That’s 5,500 child deaths every day, and 2 million child deaths every year.* Thus, pneumonia is the biggest killer of children in the world. Despite this overwhelming statistic, pneumonia prevention and treatment strategies remain severely underfunded and are rarely mentioned in the news media.

On 2nd November 2009, the first World Pneumonia Day was celebrated in The Gambia to highlight the devastating burden of the disease. The programme at Fajikunda Health Centre was declared open by Mrs Ramou Cole-Ceesay, Assistant Director – Family Health & Disease Control, Ministry of Health. In her opening speech she said ‘In The Gambia pneumonia is one of the leading causes of morbidity and mortality among children under five years of age, competing seriously with other diseases such as malaria and diarrhoea. [However], recently the Ministry of Health & Social Welfare through its Expanded Programme on Immunisation has introduced PCV-7 – pneumococcal conjugate vaccine - to prevent children from getting the disease…and with this latest intervention we hope that illness and death due to pneumonia will be drastically reduced [in The Gambia].’

The introduction of PCV-7 into The Gambia marks another milestone in the longstanding partnership between the people, the Government of The Gambia and the MRC in terms of pneumonia research. As Dr Stephen Howie, interim head of MRC (UK) The Gambia’s Bacterial Diseases Programme says ‘There is no doubt that pneumonia is a major problem in The Gambia as well as worldwide,. But The Gambia is leading the world in not forgetting pneumonia - we have a proud record and I think the Government is to be congratulated on this.’

Dr Orin Levine, Executive Director of the PneumoADIP at Johns Hopkins Bloomberg School of Public Health has said. “No other country has contributed as much to our understanding of the burden of pneumococcal disease and the value of pneumococcal vaccines as The Gambia.”* The MRC has had a large role in this success, in partnership with the Gambia Government and others. For over two decades, the MRC has been conducting research into pneumonia - and many other causes of childhood death. As Dr Howie comments ‘Years ago, Professor Brian Greenwood and others investigated the burden of disease and the causes of death in young Gambian children, and in one of the studies from Basse that is still quoted often, pneumonia was the found to be the leading cause of death in children under twelve months of age.’

That early work on disease burden and subsequent studies that looked at what was causing pneumonia, led by Professor Richard Adegbola amongst others, led to the realization that pneumococcus – and Haemophilus influenzae type b (Hib) – were major causes of disease and death in The Gambia. Hib was addressed first, followed by pneumococcus. Dr Howie continues ‘The Pneumococcal Vaccine Trial that was conducted in the Upper River Region of The Gambia is obviously a major landmark in international health, showing a 16% reduction in all-cause mortality in the vaccine group. MRC has been able to contribute to this process all along, by demonstrating the burden of disease and doing the trial to show that the vaccine would work and then in assisting with applications for the vaccine. Working together with the Gambia Government, we have been trying to make sure that in the end we could actually get a vaccine here that would save lives.’

Vaccine development and adoption is a long process: it took about twenty years from the earliest Hib studies to the routine introduction of the vaccine into The Gambia’s immunization programme in 1997. Currently, the MRC in collaboration with the Ministry of Health is conducting surveillance for evidence of Hib disease, funded by the GAVI’s Hib Initiative, to see whether the vaccine is still working the way it did when it was first introduced. Dr Howie says ‘The preliminary indications are that the Hib vaccine is still an excellent vaccine doing excellent work in the population. But we need to finish that work and be able to say this with certainty – and it’s a message The Gambia can go on to share with the world.’

The impact of the recently-introduced pneumococcal vaccine will also need to be monitored, and Dr Grant MacKenzie is currently leading a PneumoADIP-funded pneumococcal surveillance project in the Upper River Region of The Gambia to do just that. The PCV-7 vaccine covers 7 out of the 91 known types of pneumococcus (called ‘serotypes’). Work on better identifying these serotypes using molecular methods is being led at MRC by Dr Martin Antonio. There is some concern that serotypes not covered by the vaccine might increase to fill the vacuum left by those that are eliminated when the vaccine is introduced (‘serotype replacement’). Professor Adegbola led research in The Gambia looking hard at this issue, and since his recent departure to work with the Bill and Melinda Gates Foundation MRC has welcomed Dr Anna Roca who is leading the completion of this work.

Unfortunately, the pneumonia story does not end with vaccination. Dr Howie continues ‘Vaccination is really important in terms of prevention: we know vaccines work so we are keen to support research around that. But it’s not going to be the whole answer; we certainly expect to see some reduction in pneumonia but it’s not all going to go away by any means and the prospects of that through vaccination are still some way ahead.’

Understanding more about prevention
In addition to vaccine research, MRC is conducting studies on a number of risk factors for pneumonia including cooking smoke exposure, contact with the disease (sharing a bed with someone who’s coughing), nutritional issues such as diet, breastfeeding, weaning and the nutritional status of children. ‘The point of studying these things’ says Dr Howie ‘is that we may be able to identify risk factors that we can do something about.’

Improving our understanding of pneumonia aetiology ‘Aetiology’ refers to the organisms, called pathogens, causing pneumonia. MRC is building on its earlier studies of pneumonia aetiology by applying new laboratory technologies, including molecular analysis led by Dr Gerard Morris, to try to overcome the limitations of previous approaches. It is hoped this work will contribute to future vaccine development and to better diagnosis for patients.

Treatment
MRC is also investigating how children infected with pneumonia can get better faster and reduce their chances of dying. Dr Howie says ‘We know that antibiotics are really important and work on these has been done in The Gambia and many other countries. There are indications that zinc given during a pneumonia illness may be important to hastening recovery. There is some positive evidence from South Asia, but really no evidence from Africa. It’s important that we are in a position to answer this question: zinc supplementation seems to work for diarrhoea, so it might work for pneumonia.’

Children with very severe pneumonia need oxygen; without oxygen they are much more likely to die. The problem is that there is not enough to go around in resource poor settings and the oxygen available may not be as well used as it could be. Dr Howie says ‘We’ve been trying to work out how we can get oxygen to the children who need it so they can be properly treated and to reduce their chance of dying. We’ve been working on this with the Gambia Government for a number of years and we are making progress. Currently we are investigating how to develop an oxygen supply that will work even if you have trouble with transportation, electricity, maintenance – a system that will be able to deliver oxygen, given the reality of a developing country health facility.’

Saving children
The MRC Unit in The Gambia is currently migrating its research from a disease-based to a theme-based approach: Child Survival, Vaccines and Disease Elimination & Control. Pneumonia research overlaps all of the themes. As Dr Howie says ‘I am very excited that MRC has chosen Child Survival as one of its core themes… ultimately what really matters to me and I think that what really matters to the MRC is that children survive and do well, and pneumonia is important because it is one of the things that kills children in The Gambia…The programme we have currently is strong and I am hoping that we will see fruit from the things we are now working on in the years to come.’

The scientific input, technical skills, support, advocacy and planning are the things the MRC has been able to contribute to the Gambia Government’s fight against pneumonia over the years. As Dr Howie concludes ‘We are very glad to be able to contribute in this way, because in the end it’s going to save lives and that’s what we want.‘

*http://sabin.org/