New Developments

Pneumonia has been frequently called the "silent killer” since little attention has traditionally been given to this crisis in comparison to HIV, malaria, and measles. Fortunately, it is receiving renewed attention with new programs, research, and investment dedicated to combating this disease.

In 2009, WHO and UNICEF developed the Global Action Plan for the prevention and control of Pneumonia (GAPP). The aim of the GAPP is to increase awareness of pneumonia as a major cause of child death as it calls to action a broad coalition of global and national policy-makers, donor agencies and civil society to scale up efforts to reduce the burden of pneumonia. The GAPP projects the cost of ramping up critical interventions of proven benefit such as exclusive breastfeeding, vaccination and treatment of pneumonia, and outlines the priority actions that are required to ensure progress (WHO, 2009).

Research

In August 2011, the Center of Global Health at Boston University in conjunction with John Hopkins and other institutions launched a study called Pneumonia Etiology Research for Child Health (PERCH) involving 12,000 children from 7 countries in Asia and Africa. Using a diagnostic test that can detect up to 30 pathogens in a specimen, one goal will be to identify causes of pneumonia that were previously unknown or missed. Findings of the PERCH study, the first of its kind in 20 years, will be vital to a more current understanding of pneumonia etiology.  As vaccines for the more common pathogens are developed and distributed, new research findings will guide efforts in addressing other causes of this condition (BUSPH Student Insider, 2011, Eureka Alert, 2011).

Another area of promising research has been micronutrient supplementation focused particularly on Vitamin A and zinc.  A recent Cochrane meta analysis of 10 studies showed overall no difference in the incidence of acute lower respiratory tract infections in Vitamin A supplementation (Chen et al, 2010). In 2 of the studies focused on those children with poor nutritional status, a reduction was seen (RR 0.38) (Chen et al, 2010). The analysis concludes with a recommendation for more research in this area (Chen et al, 2010).  A randomized controlled trial done in Bangladesh showed that a weekly intake of 70mg of zinc reduces pneumonia and mortality in young children (Brooks et al, 2005). Other studies have looked at iron and zinc supplementation and found reductions in incidence of disease of 40% (Sazawal, 2003).  In a 2010 meta analysis, zinc was found to decrease the incidence of ALRI  as defined by specific clinical criteria (IRR 0.65), but had no effect on lower-specificity ALRI case definitions based on caregiver report (Roth et. al, 2010).  Further research, using clear case definitions, should be done to assess the optimum dose and length of protection time offered by zinc supplementation as well as the synergistic effects of micronutrient supplements (such as zinc with Vitamin A and iron). 

A major focus is in creating and disseminating new and existing vaccines for children in developing countries. As noted earlier, another treatment focus is to use a multidimensional approach, since ARIs are linked to a number of risk factors.  

Viruses, such as RSV and PIV, are another common cause of acute lower respiratory infections in children worldwide. RSV in particular is the most important cause of lower respiratory tract illness in infants and children worldwide (WHO, 2009). Development of vaccines for respiratory infections caused by viruses, such as RSV and PIV vaccines, are ongoing. Unfortunately, efforts have faced many challenges.  In the 1960s, candidate vaccines were put into use but ultimately failed due to negative immune responses in children that led to significant hospitalization and two infant deaths.  Vaccines contributing to more severe disease on subsequent exposure to the virus remains the largest obstacle to the generation of vaccines for viral ARIs (WHO, 2009).

Innovations in treatment of severe respiratory infections are also being developed, such as new oxygen delivery methods.  The main drawback of oxygen supplementation in developing countries has been the cost and significant infrastructural needs associated with traditional therapy.  However, new developments in pulse oximetry and the creation of oxygen concentrators are making this therapy more easily accessible.  Oxygen concentrators can replace tanked oxygen, and rely only on electricity and ambient air to produce a consistent and low cost supply of oxygen to treat hypoxaemia (Duke, 2008). Recent research has shown that improving oxygen supplies and the detection of hypoxaemia can reduce death rates from childhood pneumonia by 35%, and that they can be cheaper per life saved than other interventions such as the pneumococcal vaccine (Duke, 2010). 

Another important area of innovative research in the past decade has pointed to the importance of home based treatment of even severe cases of pneumonia.  Professor Donald Thea of Boston University and others have published ground breaking trials of home based oral antibiotic treatment of even severe cases of pneumonia and found them to be just as effective, if not more so, than hospitalization of these children in a large multicenter trial in developing countries (Addo-Yobo, et al, 2004). These trials directly countered the prevailing WHO recommendations for hospitalization severe cases for IV therapy (Hazir et al, 2008)(Soofi et al, 2012).

Investment and New Programs

In 2010, a new vaccine was introduced for pneumococci, called PCV13. This vaccine provides protection against 13 common strains of bacterial pneumonia. A more exciting development is that GAVI in conjunction with other partners, have launched initiatives to make it available to children on a massive scale. As of November, 2011, 16 countries in Africa have launched nation-wide programs that are intended to reach millions of children. GAVI plans to roll out this vaccine to more than 45 countries by 2015, which can result in the averion of 700,000 deaths of children. It is predicted that by 2030, up to 7 million deaths can be prevented from pneumococcal diseases (http://www.gavialliance.org/support/nvs/pneumococcal/).

Nevertheless, as mentioned earlier, barriers to vaccine distribution and use still exist.  Chief among these is the issue of financing the development and production of these often expensive tools.

In the hopes of overcoming financial barriers to vaccines distribution, the Global Alliance for Vaccines and Immunization (GAVI) is supporting a new approach to funding called Advanced Market Commitments (AMC) for vaccines.  In this approach, donor countries purchase large amounts of vaccines at a given price, which is less expensive than normal market prices.  These vaccines are provided to recipient countries from whom there is demand for protracted periods of time at the agreed upon price.  This guaranteed demand from donor countries provides an incentive for vaccine makers to conduct research and develop vaccines where it might not have otherwise made economic sense for them to do so.  In addition, it allows recipient countries to rely on a guaranteed supply of vaccines for conducting immunization campaigns.  This is an example of a cutting edge approach to financing to meet donor, recipient, and industry needs which is making pneumococcal vaccines available to developing countries 20 years ahead of historical precedent (GAVI, 2007; de Quadros, 2009; WHO, 2008). In Uganda, for example, a 2008 study estimated that the introduction of the Hib vaccine into the national vaccination program, reduced the incidence of Hib meningitis by 85% and by the following year, the number of cases fell to nearly zero (Lee et al, 2008).

Special challenges

HIV presents a unique and important set of concerns related to ARIs. ARIs are often an opportunistic illness and are continuing to increase and spread among HIV positive children. The HIV epidemic has led to a dramatic increase in the HIV-related Pneumocystis pneumonia as mentioned in an earlier section (PCP), which is seen almost exclusively in immunocompromised patients (Aliouat-Denis, 2008). HIV also poses serious problems for the treatment of seropositive children, as many vaccines are not effective or raise safety concerns for immunocompromised children (Zar, 2004), although, the Pneumococcal Conjugate Vaccines have shown to be a promising prevention method to use with HIV seropositive children (Bliss et. al., 2008). According to the WHO, the case fatality rate for HIV-infected children with pneumonia in the hospital is almost five times as high as for non-HIV-infected children with pneumonia (WHO, 2008). Thus it is critical that widespread effective perinatal treatment be made available to prevent mother to baby transmission of HIV in the fight to reduce childhood deaths from pneumonia and other diseases (WHO, 2008).