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Fighting a forgotten killer in the land of Chinggis Khan

Last year, over six million children died before their fifth birthday. That’s more than the entire population of young children in Australia today. But the vast majority of these deaths take place out of our sight, and so for the most part, out of our minds.

What kills most children in the world today? When asked this question, most people say malaria, or HIV. Or sometimes cars, or guns. Ebola may have had a mention in recent months.  The sad reality though, is that the leading cause of death among young children is easily prevented, and easily treated. It’s pneumonia, and it kills over a million young children every year. That’s more than AIDS, malaria and tuberculosis combined. Despite this, here in our comfortable existence, it’s a disease that seems to have lost the aura of fear and dread that all those other “scary” diseases still conjure.

A photo I took on a recent trip to Mongolia
A photo I took on a recent trip to Mongolia

Pneumonia is not straight-forward. Pneumonia is an infection of the lungs, and the invading bug could be any one (or more) of a number of viruses or bacteria. There is one bug that is particularly nasty. It’snot only a major cause of pneumonia, but it is the culprit in many of the most severe cases of the condition. It also invades the blood causing sepsis, and the brain, resulting in meningitis. It is a bacteria called Streptococcus pneumoniae, or the pneumococcus. But here’s the silver lining – there is a vaccine. In Australia, as in much of developed world, this vaccine has been in use for almost 15 years.

However, in developing countries the burden of pneumococcal disease is the greatest; poor living conditions allow the bug to thrive, and limited access to health services means the simple course of antibiotics needed to stop the disease from wreaking havoc will not reach the sick child. And it is in these countries that vaccine introduction has been slowest. The vaccine is costly, and already-stretched government health budgets face a multitude of competing priorities. While progress has been slow, many African and Latin American nations are introducing the vaccine, or have plans to introduce it. But in Asia, very few countries have so far included it in their vaccine schedules.

I am pictured here with members of the team
I am pictured here with members of the team

Cost aside, one reason for the slow uptake in Asia is a lack of evidence. Not a lack of evidence that the vaccine works –large trials and population studies have clearly demonstrated that this vaccine is highly effective in preventing pneumococcal disease. What’s not known in Asia is how much of the pneumonia observed in these countries is caused by the pneumococcal bug. Based on experience in other populations, it is likely that it is quite a lot. But so far there is limited evidence that can help policymakers in Asian countries decide whether this vaccine is a worthwhile investment for their country.

Mongolia is an Asian nation of around three million people, land-locked between two giant neighbours, China and Russia. Mongolia experiences a very harsh climate, with winter temperatures often dropping as low as -50 degrees Celsius.  Poverty, poor nutrition, overcrowding and air pollution create an environment that puts young children at great risk of poor health, including pneumonia. During Winter, the hospital wards overflow with children suffering from respiratory infections. This is of course very distressing for families of sick children, sometimes with a tragic outcome, and also places an enormous burden on the health system.

Recognising the high rates of pneumonia among children, the government of Mongolia is planning to introduce the pneumococcal vaccine, starting in 2015. Naturally, they want to know what impact the vaccine will have on disease rates. At Murdoch Children's Research Institute, we are working in partnership with the Mongolian Ministry of Health and with the World Health Organization to evaluate this. Our team are putting systems in place to monitor the number of children admitted to hospital with pneumonia, and the severity of their disease, and to document what proportion of these children show the hallmarks of infection with the pneumococcus.

Gavi is an international alliance that is working to make access to vaccines a reality for the poorest people in the world. Gavi is supporting a number of pneumococcal vaccine impact evaluation activities in Asia, including our activity in Mongolia.  The work we are undertaking will produce evidence that can help guide Mongolia’s vaccine policy, and we hope this will also help fill the evidence gap that is impeding more widespread introduction of this life-saving vaccine in Asian countries.

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