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First World Pneumonia Day Reveals Global Burden

CDC's public health professionals join with others to help

Published: November 6, 2009

Children being treated for pneumonia at hospital in India
Children being treated for pneumonia at a hospital in India. Pneumonia kills approximately 2 million children less than five years of age each year worldwide. Resource-poor countries such as India are particularly hard hit.

Pneumonia is a leading killer of both children and adults around the globe. Few know that pneumonia kills approximately 2 million children under the age of five years worldwide each year. Resource-poor countries are particularly hard hit—for every child who dies of pneumonia in a developed country, more than 2,000 children die of pneumonia in developing countries. In the US, over 1 million children and adults are admitted to the hospital for pneumonia each year.

November 2nd was the first World Pneumonia Day. A diverse group of health, humanitarian, business and industry, advocacy, faith based and community organizations have come together to increase worldwide awareness about the global burden of pneumonia and the prevention and treatment options that will have the greatest impact on reductions in child mortality and morbidity. CDC has provided technical assistance to this coalition.

Beyond World Pneumonia Day, CDC is actively involved in the detection, prevention and treatment of pneumonia globally. An array of research and surveillance activities and laboratory training programs to help build capacity in developing countries, global health policy, communication and public health education are underway. The agency is one of four WHO Collaborating Centres and Reference Laboratories working with 94 countries worldwide. CDC is working with countries to reduce mortality by two-thirds by 2015 among children aged <5 years.

Active Bacterial Core Surveillance (ABCs)

Dr. Chris Van Beneden
Chris Van Beneden outside of the CDC offices on Clifton Road in Atlanta.

Chris Van Beneden, MD, MPH, a CDC medical epidemiologist says, "Pneumonia is a problem in every part of the world." The Active Bacterial Core surveillance (ABCs), a core component of the Emerging Infections Program (EIP) Network that Van Beneden has directed since 2001, collects data to track and reduce severe diseases including bacteremic pneumonia. The program is a collaboration between CDC and multiple state health departments and universities participating in the EIP network.

ABCs conduct active, laboratory- and population-based surveillance, including the collection of all available bacterial isolates, for invasive bacterial infections of public health importance—actively monitoring severe infections caused by six bacteria—including Streptococcus pneumoniae, the most common bacterial cause of pneumonia. The program has surveillance officers in 10 geographically diverse ABCs sites across the country. A number of epidemiologists and microbiologists at CDC are active members of the ABCs team and collaborate with academic partners, public health policy makers, industry, and epidemiology and public health students.

Data from ABCs helps public health officials develop vaccine recommendations and monitor the effectiveness of new vaccines. The ABCs team has collaborated with the World Health Organization and other international partners to strategize about the most effective use of meningococcal and pneumococcal conjugate vaccines worldwide. As part of the agency's broad efforts to address H1N1, the ABCs team is currently collaborating with the Influenza Division to learn more about the interaction between influenza and bacterial pneumonia.

Worldwide Laboratory Training

CDC's Maria da Gloria Carvalho, a microbiologist in the Streptococcus Laboratory, began working with Streptococcus and related pathogens 14 years ago as a graduate student in Brazil. Now she is the point person for the the Streptococcus Laboratory's world-wide laboratory support for pneumococcal surveillance, and travels the globe to conduct laboratory training and assessments.

Maria da Gloria Carvalho demonstrates pneumococcal serotyping techniques to laboratorians
Maria da Gloria Carvalho, a microbiologist in CDC's Streptococcus laboratory, demonstrates pneumococcal serotyping techniques to laboratorians from the Mongolia Ministry of Health in Ulaanbaatar, Mongolia.

About her collaborative work with the World Health Organization (WHO), the London School of Hygiene & Tropical Medicine, PneumoADIP and Hib Initiative programs, and Ministry of Health Laboratories in developing countries, she says, "Our work may help to sensitize the global health community of the need to allocate more resources for global vaccination efforts."

Carvalho is also active in the development of accurate, transferrable, and sustainable molecular technologies for pneumococcal diagnostics and serotyping and is helping to establish a global pneumococcal strain bank of well characterized invasive isolates, which will be made available to vaccine researchers throughout the world.

In addition, the Strep Lab and epidemiologists are working on the largest population-based invasive streptococcal surveillance program in North America (ABCs) and has been instrumental in diagnosing pneumococcal disease as the most prevalent bacterial co-infection associated with H1N1 deaths. Carvalho stresses, "We've got to do a better job in broadcasting the everyday unacceptable losses caused by this disease (3 preventable deaths per minute, 1.6 million/year); the work we do in the labs at CDC, in the field, and for publications puts us in a privileged position to help with that."

Investigating Emerging Infections

The CDC International Emerging Infections Program (IEIP) works with the governments of Thailand, Kenya, Guatemala, Egypt, China, and Bangladesh to build laboratory capacity and implement effective surveillance for pneumonia. Sonja Olsen, PhD, is lead for the Global Activities Team in the Division of Emerging Infections and Surveillance Services (DEISS). She first became involved with pneumonia work when, in 2001, she relocated to Thailand to set up CDC's first IEIP. Now back in Atlanta, she coordinates scientific and programmatic activities for the IEIP, including pneumonia surveillance, a core activity at each of the IEIP international sites.

The high-quality data that Olsen and her team collect can be used to provide policymakers with scientific evidence to inform and guide policy decisions to protect the public's health. For example, they have worked with partners to collect data on disease incidence and cost that can be used to weigh the value of vaccine introduction on influenza-associated pneumonia in Thailand.

About her work, Olsen comments, "My first, and largest, project so far has been to work with the Thailand Ministry of Health to establish active, population-based surveillance for pneumonia. Every day, my interest in pneumonia continues to grow because there is such a variety of pathogens that can cause pneumonia and this makes prevention and treatment more complex."

Preventing Pneumonia in US Healthcare Facilities

Medical officer Shelley Magill, MD, PhD, and her colleagues in the Division of Healthcare Quality Promotion (DHQP) are analyzing National Healthcare Safety Network (NHSN) data to determine incidence rates and the distribution of pathogens that cause ventilator-associated pneumonia (VAP). For critically ill patients who require a ventilator to breathe for them, VAP is a common and serious complication. It results in prolonged hospital stays and increased treatment costs. The CDC's National Nosocomial Infection Surveillance System (NNIS) reported that in 2002 patients receiving continuous mechanical ventilation had 6 to 21 times the risk of developing healthcare–associated pneumonia, compared with patients who were not receiving mechanical ventilation.

H1N1 Focus of Pathology Work

Dianna Blau
Dianna Blau, in NCZVED, looks at the vast number of slides prepared and examined to identify bacterial co-infections in fatal cases of pandemic H1N1.

Dianna Blau, DVM, PhD, a second year Epidemic Intelligence Service Officer in CDC's Infectious Diseases Pathology Branch (IDPB) and her coworkers are currently tracking pathology data on fatal H1N1 flu cases. They analyze specimens that have come to CDC from state and local health departments, medical examiners, labs, and hospitals. Research during previous influenza pandemics has suggested that many cases of fatal influenza are due to bacterial co-infections, such as pneumonia. IDPB's research that showed bacterial pneumonia is contributing to fatalities in people with 2009 H1N1 flu, similar to previous pandemics, was recently published in the MMWR.

Dean Erdman, DrPH, deputy branch chief and team lead for the Respiratory Viruses Diagnostics Program and 20-plus-year veteran of the Division of Viral Diseases, says, "One of our main challenges is to keep the spotlight on the non-influenza respiratory viruses."

Dean D. Erdman, team leader, and laboratory technician, and Brett Whitaker, of the Non-influenza Respiratory Virus Diagnostics Program, do real-time PCR testing to investigate a suspected outbreak of rhinovirus initially thought to be due to influenza H1N1.

Erdman's team is working to develop new molecular diagnostic tools that make it easier to detect and identify the non-influenza respiratory viruses. The team strives to make these tools available to less developed countries to help them better define the burden of pneumonia in underserved populations and better respond to outbreaks of respiratory disease. Other activities include working with the Influenza Division and other CDC programs on a two-year study to define the etiology of pneumonia in the US, and collaborating with study sites in Chicago, Memphis, Nashville, and Salt Lake City to test persons admitted to hospitals with community-acquired pneumonia.

New Pneumococcal Vaccines

Matthew Moore, MD, MPH, an epidemiologist in the Division of Bacterial Diseases (DBD) has, for the past five years, looked at the effects of PCV7 on pneumococcal disease in the US through the ABCs system, including the potentially concerning phenomenon of "serotype replacement" where strains not covered by a vaccine emerge as others are eliminated by that vaccine.

"It's enormously gratifying to work on a problem as ‘big' as pneumonia—you work with laboratorians, epidemiologists, and policy and program experts—there won't be success without these collaborations. Together, we can actually get something done," he said.

Jacquelyn Sampson
Jacquelyn Sampson, microbiologist, prepares an agarose gel for visualizing polymerase chain reaction (PCR) products. She is one of 50 women named as inventors on US patents issued for CDC inventions.

Moore's research is not limited to pneumococcal disease in the US. He has traveled the globe delivering presentations on the US experience with pneumococcal conjugate vaccine. Over the years, he has fostered collaborations with the Thailand International Emerging Infections Program and the Thai Ministry of Public Health to improve diagnostic testing for pneumonia and to encourage introduction of pneumococcal vaccines.

Microbiologist Jacquelyn Sampson, received the 2009 CDC Director's Innovation Award in research and technology, presented for the team's development of a novel Streptococcus pneumoniae Common Protein Vaccine Component. Sampson comments, "Back in 1990, our lab identified a pneumococcal protein, pneumococcal surface adhesin A protein or PsaA, as we call it. The exciting part is I never thought PsaA would be used for vaccination. We used the protein in our lab in an in-house diagnostic test. Ironically, it's much more promising as a vaccine than it is for diagnostic assays."

Through a series of immunologic and molecular studies, the pneumococcal surface adhesion A (PsaA) protein was identified and determined to be a novel protein that is common to all strains of Streptococcus pneumoniae.

Non-Vaccine Interventions to Prevent Pneumonia

Adam Cohen meets with local project staff
Adam L. Cohen meets with local project staff for an update on the use of clean-burning stoves in village homes in rural western Kenya.

Promoting Clean Burning Stoves in Rural Kenya

In the villages of rural western Kenya, in sub-Saharan Africa, traditional open fire pits are used in homes for cooking and heating. As is tradition, women often keep their young children nearby while cooking, and fam¬ily members sometimes sleep in cooking rooms, which may not be vented to the outdoors. As a result, all breathe in particulate matter—carbon monoxide, greenhouse gases, and other pollutants. To address the problem, CDC partnered with the World Health Organization, the Kenya Ministry of Health, the Safe Water and AIDS Project (a Kenyan non-governmental organization), and others to encourage the use of locally crafted, low-cost, clean-burning stoves (Jiko Kisasa stoves) in 10 Kenyan villages. Unlike the traditional fire pits, the clean-burning stoves contain the fire and help to prevent release of particulate matter into the air.

A Handwashing Study in Bangladesh

Benjamin Silk (center rear) with Moshtaq Ahmed (right), and field research assistants
Benjamin Silk (center rear) with Moshtaq Ahmed (right) and field research assistants during training for the handwashing study in Dhaka, Bangladesh.

The agency leads international studies to prevent pneumonia through non-vaccine interventions, such as one to measure associations between handwashing with soap, influenza and radiologically-confirmed pneumonia among young children living in a slum area of Dhaka, Bangladesh. CDC has partnered with the International Centre for Diarrhoeal Disease Research, Bangladesh, and the University of Buffalo's School of Public Health and Health Professions in a study to examine associations between hygiene behaviors and rates of respiratory diseases. Bars of soap designed to closely resemble locally available soaps have been equipped with a motion sensor and an embedded data logging device. The study combines surveillance data from the motion sensor with data from household observations and interviews.

Measles: Providing a Solution for Vaccine Introductions

Stephen Cochi, MD, MPH, a senior advisor in CDC's Global Immunization Division (GID), comments that "Primary prevention of pneumonia is particularly interesting because there is no one magic bullet, but an array of different vaccines and tools—including measles, Hib and pneumococcal conjugate vaccines."

He adds, "Research and vaccine development to prevent measles is an example of what can be done. There has been a major impact on childhood pneumonia through the use of vaccines, an approach now being taken with the introduction of Hib and pneumococcal conjugate vaccines."

In collaboration with partners, GID and its 30 field staff are part of the Measles Initiative that is active in 47 of the world's poorest countries where they implement mass vaccination campaigns and strengthen routine immunization. These countries account for more than 95 percent of all measles-related pneumonia and deaths. Cochi spends about 40 percent of the year traveling internationally to help accomplish GID's mission, saying that he "feels fortunate to have the opportunity to be up close and personal with partners working on global initiatives to improve world health."

Different Approaches Reduce Burden

It will take many different approaches to reduce the burden of pneumonia. On November 2, WHO and UNICEF released the Global Action Plan for the Prevention and Control of Pneumonia (GAPP), which outlined a six-year plan for the worldwide scale-up of a comprehensive set of interventions to control the disease. CDC staff will be actively involved in continuing the agency's efforts to detect, prevent, and treat pneumonia, in collaboration with partners worldwide.

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