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Johns Hopkins Bloomberg School of Public Health


Date: Apr 2013

By Dr. Kate O’Brien

This week scientists came together to declare that we will eradicate polio in 5 years. It’s an achievable goal, and admittedly an aspirational one. But, if we as a global community leverage proven strategies and follow through on commitments made, it will be met. It is amazing to think that this goal, which just two decades ago seemed impossible to many, is now firmly in our sights. It also gives me confidence that we can reach other goals, such as reducing preventable childhood deaths to a degree that any such death is seen as a shocking, rare event rather than predictable and intractable. This challenge, which the global health community laid out in last year’s Promise Renewed initiative may seem daunting, given that despite recent declines, 6.9 million children died in 2011. However, when you consider that worldwide polio cases have dropped by 99% since the Global Polio Eradication Initiative began in 1988, it is clear these problems are surmountable. Like polio eradication, we need a concrete approach to tackling the leading child killers, and we made a big step forward with today’s launch of the Integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD). Released by WHO and UNICEF, GAPPD clearly outlines the steps we must take to eliminate the two leading killers of young children in 20 years.

GAPPD cover

The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD)

Most of my professional life has been spent assessing and applying interventions to reduce pneumonia and diarrhea, both in the United States among American Indian communities and around the world in the communities where most child deaths still occur. I’ve seen the burden of these diseases in the numbers we calculate and on the faces of the patients I’ve treated. I’ve also seen that we have the tools we need to stop children from dying or suffering from severe pneumonia and diarrhea. When I worked in Haiti, the ward was full of children, over a third of whom would die in those beds. Nearly all of the illnesses these children had were fully preventable, mostly through the use of vaccines but also through other simple, sensible interventions. The interventions we have work, and the task we have is to figure out how to use them most effectively, to know if what we are doing is working, and to make adjustments in optimizing their impact. This feedback loop can only be put in place when we can measure the impact of what we’re doing. We may not be able to measure with absolute precision, but with enough precision to know if our time and treasure is being wisely spent.

We know what we need to do to tackle pneumonia and diarrhea, and establishing clear evidence on the burden of disease and on interventions that work creates the platform from which we can prioritize our efforts. A new series published in the Lancet today in conjunction with GAPPD provides updated evidence on this front. One of the papers, led by faculty in our Department of International Health at Johns Hopkins provides updated mortality estimates for pneumonia and diarrhea – together responsible for more than 2 million child deaths in 2011.

We also have a clear understanding of which interventions work, and we know that many of them overlap. As my colleague Bob Black pointed out in the Lancet series launch, while diarrhea and pneumonia have very different symptoms and causes, several risk factors for the two diseases are the same, including under-nutrition, suboptimal breastfeeding, and zinc deficiency, meaning that they can be effectively prevented and treated as part of a coordinated program. We also know that vaccination campaigns will play an important role. A second paper in the Lancet evaluated 15 key interventions using the Lives Saved Tool. It found that nearly one third of severe diarrhea episodes could be prevented by widespread vaccination against rotavirus and cholera, while up to two thirds of pneumonia deaths could be prevented by implementation of pneumococcal and Haemophilus influenzae type b vaccines. With ambitious scale-up – 80% coverage or more – the authors estimated all 15 interventions could effectively eliminate (95% prevented) diarrheal deaths and prevent around two-thirds of pneumonia deaths by 2025. All this at a total cost of just USD6.7 billion.

GAPPD and the Lancet series reflect years of work toward a consensus among all stakeholders that we must target our efforts on proven interventions, and we must work together in an integrated way. Many of the interventions for childhood diseases overlap, and can be delivered more efficiently if all parties work together. This integration will not only result in better care for each child, it is also crucial in resource-poor settings, where countries simply cannot afford to maintain siloed efforts and where partnering countries and organizations are increasingly demanding more impact for their investments.

We have the evidence, and our marching orders are clear. With polio eradication beckoning our efforts, it is the time to leverage this energy, know-how, and confidence by fulfilling our promises and advocating for all stakeholders – donors, governments, civil society, and other leaders – to fulfill theirs. We can all take inspiration and insight from polio eradication efforts and make the end of preventable pneumonia and diarrhea deaths a reality.


Kate O’Brien, MD, MPH is Acting Executive Director of IVAC. A pediatric infectious disease physician, epidemiologist, and vaccinologist, she previously served as Deputy Director of IVAC. She also serves as Associate Director of the Center for American Indian Health.

By Dr. Juliet Otieno

This the second blog in a series from the Pneumonia Etiology Research for Child Health or PERCH study team. PERCH is a multi-country case-control study of the etiology of severe and very severe pneumonia in children aged 1-59 months. Led by IVAC and funded by the Bill & Melinda Gates Foundation, PERCH operates seven research sites throughout Africa and Asia.

As a Kenyan doctor, having completed my internship at a rural mission hospital and worked as a junior doctor in a paediatric hospital for just over a year, I found myself two years ago in a small rural town, Kilifi, in the heart of a study on the causes of childhood pneumonia, the Pneumonia Etiology Research for Child Health or PERCH. When I began working with the PERCH study, a study on the “causes” of pneumonia initially seemed to me as a rather counter-intuitive approach to the problem at hand. I had spent years cramming the national diagnostic and treatment guidelines for pneumonia and I was pretty confident in the management of children with acute and chronic respiratory illnesses. I did not need the much-cited research to know what pneumonia looks like or to understand its burden on our children.

physicians examine chest x-ray

Physicians from three different PERCH sites, Dr. Juliet Otieno, Dr. Bernard Ebruke, and Dr. David Moore, examine a chest x-ray of a patient with pneumonia during a cross-site visit in South Africa.

Childhood pneumonia is a topic I have always been able to easily relate to, starting from my days as a medical student in the busy paediatric wards where most of the very sick children had respiratory illnesses. While efforts have been instituted to ensure early recognition and treatment of children with pneumonia, unfortunately a child succumbing to death from a respiratory illness is still seen as an unfortunate but inevitable eventuality in most of our hospitals in Kenya.

Two years later, I have had many epiphanies along the way about the importance of investigating the causes of pneumonia, but a recent one has been particularly influential and has changed my mindset completely. I recently had the opportunity to attend a cross-site visit to Chris Hani Baragwanath Hospital in Johannesburg, South Africa – another PERCH study site – where I had a chance to look at a histopathology slide of lung tissue from a child who died of pneumonia. Post-mortem lung biopsy studies are carried out as part of the PERCH study in some of the participating sites because they can give researchers a much more direct, accurate diagnosis of etiology in fatal pneumonia cases. (Learn more in this 2011 article in Clinical Infectious Diseases.)

This particular post-mortem lung specimen we were examining was from a child who presented with clinical features consistent with pneumonia caused by pulmonary tuberculosis and was treated for this condition without success and died. The post-mortem analysis revealed that the child did not have TB, a bacterial infection, but instead the pneumonia had been caused by florid cytomegalovirus infection, a virus that spreads through bodily fluids and is especially dangerous for patients with compromised immune systems. If the doctors caring for him had known this, they would have treated him differently, and he might have lived. Unfortunately, we cannot get such an accurate picture of the pathogens present in the lung with current tests available for patients. It dawned on me just then how important post-mortem results are in defining the epidemiology of pneumonia in a particular setting, made possible through studies like PERCH, and which help doctors see the range of pathogens that are causing child deaths in their hospitals, so they might be more aware and ready to treat them.

I left wondering what definitive pathogens we would find if we carried out post-mortem studies on fatal pneumonia cases in Kilifi, and how this would influence our clinical management of pneumonia. Would we only find the “traditional” bacteria we expect? Or would we be opened to a whole new world of “atypical” bacteria that we occasionally treat as a last ditch resort? Would we see that the recently introduced vaccine against the streptococcal pneumonia bacteria caused a significant reduction in one of the most common “traditional” pneumonia-causing bacteria? Would our very definition of “atypical” pathogens be challenged? Would we be more confident in administering relevant antimicrobial treatment – albeit a non-conventional approach – in a more timely manner? I also wondered how post-mortem findings would compare to the induced sputum test results we gather through PERCH, which get us as close as we can to the lung while the child is living, but are still unproven, and leave us wondering if we’re really getting at the source of the infection. Most importantly, I wondered if all this knowledge could be the answer needed to save lives, reduce unnecessary use of antibiotics that can lead to resistance, and decrease the burden of pneumonia morbidity in our paediatric ward?

Otieno demonstrates NP swab

Dr. Otieno demonstrates a nasopharyngeal swab during a training session.

At a clinical level, results from post-mortem studies are easily interpretable and could improve the outcome of pneumonia cases at our hospital. At the same time, they are often difficult because they require gaining consent from a grieving parent. But because I now understood the value of post-mortem studies in protecting all our children from fatal pneumonia, I went home with a stirring in my heart to test the waters of community acceptance. I was reminded of a common saying, “better the devil you know than the devil you do not know,” for despite the challenges associated with post-mortem studies, knowledge of the bugs causing pneumonia today would give us the best chance at saving lives in the future, rather than continuing to treat what we don’t know or what we only think we know.

I am grateful for the opportunity to visit another PERCH research site in South Africa and learn from my colleagues across the continent. I come away from the experience having realized that the value of postmortem analysis in pneumonia etiology studies cannot be understated.  Working in this multi-site project has brought back the nostalgia of my internship year, including the steep learning curve, but also the accompanying fulfillment at the end of each day.

I also have a deeper appreciation that the PERCH study is indeed a landmark study. Working on this project has been an exciting experience and has given me the unique opportunity to be part of the global effort to protect millions of children around the world from pneumonia, and it has shaped my career trajectory towards pneumonia prevention strategies.


Juliet Otieno, MD, is a Clinical Research Training Fellow at Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme and a member of the PERCH study team.