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Pneumonia

Strategy Overview

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By immunizing children against pneumococcus in the world’s poorest countries, we can save the lives of millions of children.

our goal:

to significantly reduce childhood deaths from pneumonia.

The Challenge
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At A Glance

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Pneumonia is the leading cause of death among children under age 5, with more than 99 percent of those deaths occurring in the developing world.

Childhood deaths from pneumonia are preventable using existing vaccines, diagnostic tools, and treatments.

We work to improve the development and delivery of pneumonia vaccines and expand the use of antibiotic treatments and diagnostic tools. 

We support the goals of the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD), an effort led by the World Health Organization and UNICEF to accelerate disease prevention and control. 

Our Pneumonia strategy is led by Keith Klugman, Director of Pneumonia in the foundation’s Global Health Division.

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Even as global child deaths have declined from 12.6 million to 6.6 million over the last two decades, pneumonia has remained the world’s leading cause of death among children under age 5. Despite available interventions, pneumonia claimed the lives of 1.3 million children in 2011 and was responsible for 18 percent of child deaths worldwide—nearly all of them in developing countries, particularly in Sub-Saharan Africa and South Asia.

Because pneumonia can be caused by a number of viruses and bacteria, multiple interventions are needed to reduce childhood mortality from the disease. Effective vaccines are available for Streptococcus pneumoniae (the pneumococcus) and Haemophilus influenzae type b (Hib), the most common bacterial causes after the first month of life.  Some viral and bacterial pathogens, however, disproportionately kill infants before they can be immunized.

Childhood deaths from pneumonia are preventable using vaccines, diagnostic tools, and treatments, but issues of availability, access, and cost remain obstacles in the developing world. Nearly half of early childhood deaths from pneumonia are estimated to result from lack of, or delay in appropriate diagnosis and treatment. In resource-limited settings, factors such as malnutrition, HIV infection, and indoor air pollution increase children’s risk of developing pneumonia. 

The Opportunity
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The global health community has adequate tools and is developing better ones to significantly protect children from pneumonia in the developing world.

Vaccines have already helped to substantially reduce childhood pneumonia. But vaccine coverage must be improved, and lower-cost vaccines are needed where the burden of pneumonia is highest, particularly in India and Nigeria. Vaccinating women during pregnancy has the potential to protect young infants by passing natural antibodies from mother to her baby. This approach, maternal immunization, has yet to be widely implemented beyond prevention of neonatal tetanus. Creating some momentum recently, the World Health Organization (WHO) recommended influenza vaccination for pregnant women as the focus of its strategy to prevent deaths from influenza. Early treatment is also critical. If properly diagnosed, childhood pneumonia can be effectively treated with a three-day course of antibiotics at a cost of only 21 to 42 U.S. cents.

Fortunately, awareness of pneumonia as a major global health problem has increased. In 2013, WHO and UNICEF launched the integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD) to fight the diseases. The GAPPD calls for the use of proven interventions, including vaccination against measles, pertussis, pneumococcus, and Hib; exclusive breastfeeding in the first six months of life; and improved case management in communities.

Our Strategy
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The Bill & Melinda Gates Foundation’s pneumonia strategy broadly reflects the Protect, Prevent, Treat framework used by the GAPPD. We focus on the most prevalent causes of childhood pneumonia—the pneumococcus, influenza, and RSV—and we are continuing our longstanding investment in vaccines against meningococcus, which despite it not being a major cause of pneumonia, continues to cause epidemic meningitis. In addition, we are developing a platform for maternal immunization to protect mothers and their newborns from pathogens that bear a disproportionate mortality burden in the neonatal period, including RSV, influenza, pertussis, tetanus and the group B streptococcus.

A nurse prepares pneumococcal vaccine at a clinic in Nairobi, Kenya.

Our key partner in increasing access to pneumococcal vaccines is the GAVI Alliance, a public-private partnership that funds vaccines for children in the world’s poorest countries. By immunizing children against Hib and pneumococcus in these countries, we can save the lives of 2.9 million children and prevent 52 million cases of pneumonia. 

Our top priority is to promote full-scale delivery of currently available pneumococcal and meningococcal vaccines and to support the development of new vaccines to improve coverage, efficacy, safety, and cost effectiveness.

Because vaccines cannot prevent all cases of pneumonia and because the incidence of this disease remains high, we also work to improve access to appropriate diagnostic and treatment options in public and private healthcare systems. Saving lives through improved access to diagnosis and treatment is particularly critical in countries where the introduction of vaccines is lagging. This includes interventions at multiple points in the continuum of care ranging from improving care-seeking practices to guiding informal care providers in appropriate disease management.

Other priorities include improving the quality of pneumonia-related data collection, advocating for increased international funding, and researching the links between pneumonia and indoor air pollution.

Our strategy complements efforts by several other foundation programs, including those for vaccine delivery; nutrition; maternal, newborn, and child health; and enteric and diarrheal diseases.

Areas of Focus
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Our work focuses on seven priority initiatives: pneumococcus, meningococcus, diagnosis and treatment, strategic information and advocacy, RSV, influenza, and risk factors. While pneumonia affects people of all ages, our priority is children under age 5.

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Pneumococcus

The pneumococcus is the leading cause of pneumonia and is responsible for at least 40 percent of cases in children under age 5. We work to broaden access to the two commercially available pneumococcal conjugate vaccines (PCVs) while also investing in the development, regulatory approval, and deployment of newer and improved vaccines.

We have worked with the GAVI Alliance to implement the Advance Market Commitment for Pneumococcal Vaccines, an innovative financing mechanism that accelerates late-stage development and manufacturing of pneumococcal vaccines for developing countries. In order to help lower the price of these costly vaccines, particularly for high-burden areas, we are working with PATH and the Serum Institute of India to develop and introduce additional pneumococcal conjugate vaccines to the market.

Meningococcus

Launch day for the MenAfriVac vaccine in Burkina Faso in 2010. (Photo © PATH / Gabe Bienczycki)

In an effort to eliminate epidemic meningitis A in Africa, we support the Meningitis Vaccine Project, a collaboration that also includes PATH, WHO, African health ministers, and the Serum Institute of India. The project has developed an affordable vaccine called MenAfriVac—the first vaccine developed specifically for Africa—that provides lasting protection from life-threatening meningococcal meningitis, a bacterial infection of the fluid surrounding the brain and spinal cord.

MenAfriVac was first introduced in Burkina Faso in 2010. Initial data from more than 100 million administered doses in Sub-Saharan Africa suggests that it is effective in reducing meningococcal A outbreaks; the meningitis A bacterium has been nearly eliminated in vaccinated populations so far. Our strategy supports efforts to make MenAfriVac available to infants, to promote its inclusion in routine immunization programs, and to monitor the evolution of the disease and the potential need for meningitis interventions beyond this new vaccine. 

Treatment Innovations and Delivery

Urgent work is needed to ensure that children who are sick with a severe respiratory illness receive appropriate care. Many children die because they are not able to receive appropriate care quickly. Children who do reach a provider might be misdiagnosed or not given the appropriate antibiotic, amoxicillin. Sometimes the provider might not recognize that the child’s condition is severe or that the child is at increased risk due to young age or malnutrition. In many instances, such cases require referral to a facility where supportive care interventions such as oxygen are available.

We work closely with other teams at the foundation to improve access to effective treatment for children with pneumonia, with a special focus on Nigeria, northern India, Ethiopia, the Democratic Republic of the Congo, and Pakistan—the countries with the greatest number of pneumonia deaths. Our work includes generating evidence to improve care for infants and children with pneumonia in limited-resource settings, advocating for policy changes and increased financial support to expand the availability of key treatment commodities (including amoxicillin DT, pulse oximetry, and oxygen), and demonstrating how appropriate pneumonia care reduces mortality in order to accelerate improvements in case management on a broad scale.

Strategic Information and Advocacy

We invest in the collection and use of high-quality data on the causes and global burden of pneumonia, which will contribute directly to vaccine development, better treatments, improved service delivery, innovation in diagnostics and treatment, and better reporting on causes of death.

We also work to raise the profile of pneumonia as a critical child health issue. Our priorities include ensuring sufficient funding for critical vaccines; supporting vaccine and child health advocates; and building political will at the global and country levels for evidence-based pneumonia prevention and treatment. We also seek to increase resources dedicated to immunization programs and to ensure government follow-through on important global health initiatives such as the Global Vaccine Action Plan for the Decade of Vaccines. 

Respiratory Syncytial Virus

RSV is one of the most common causes of childhood lung infections, mainly in the first six months of life. Unlike other causes of pneumonia addressed by our strategy, there is no existing vaccine for RSV. We support the development of maternal RSV vaccines. We also work to improve global data collection on mortality and morbidity related to RSV and on the long-term consequences of severe RSV infections. This information will help in evaluating the potential impact and cost effectiveness of RSV vaccines that are under development.

Influenza

A health worker in Bihar, India, uses a Mobile Kunji device during a routine prenatal visit.

We aim to address gaps in data on influenza in developing regions, assess existing strategies to stimulate demand for seasonal influenza vaccines, and ensure that pregnant women and young children in resource-limited settings can access affordable, effective vaccines.

Existing influenza vaccines are the basis of our maternal immunization strategy, which may pave the way for additional vaccines for pregnant women. We work with global partners to identify and address scientific, technical, regulatory, operational, and financial challenges to broadening maternal immunization efforts, which serve to protect pregnant mothers and their babies. We also support research to further understand the benefits of maternal influenza immunization on the developing fetus and work to develop improved influenza vaccines for children under age 2. 

Risk Factors

Along with our efforts to broaden immunization against pneumonia and improve treatment, we work to reduce environmental risk factors. Adequate nutrition and breastfeeding—addressed as part of the foundation’s nutrition strategy—are key factors in ensuring that children’s immune systems are equipped to fight off infection.

Reducing indoor air pollution is also likely to lessen the risk of pneumonia by decreasing chronic inflammation in the lungs. We invest in limited research to fill fundamental gaps in knowledge about the dose-response relationship between indoor air pollution and childhood pneumonia. We also support efforts to improve monitoring technology to measure personal particulate matter exposure and to establish surrogate endpoints for subsequent clinical trials. Our work in this area will evolve as our understanding of the link between indoor air pollution and pneumonia grows. 
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