We are not on track to achieve Millennium Development Goal 4.  During the recent UN Summit on the MDGs there was a lot of discussion about exactly where we stood, about how the overall story was one of great progress, and that even among the poorest countries there were some countries that have been doing remarkably well.  This is all true, but even the most optimistic estimates of child mortality declines, those recently released by the Institute for Health Metrics and Evaluation, suggests that mortality reductions have been far too low to put us on track to achieve a two thirds reduction in child mortality from 1990 levels by 2015.  The numbers just does not work out.
Does that mean that there is no hope left?  Not necessarily – but it would require there to be a major acceleration in child mortality rates by getting highly effective interventions against the major killers of children in the developing world.  Wouldn’t it be great if there was an intervention that already exists, that is likely to be effective at reducing a major fraction of an important disease, with say just a shot in the arm, that we are currently underutilizing, and that could potentially be rolled out tomorrow?
Well, actually such an intervention sort of exists: the pneumococcus vaccine.  Streptococcus pneumoniae is a major disease causing agent, the bacteria is believed to be responsible for about 800,000 child deaths from pneumonia every year (roughly 10% of all child mortality at current levels). And an effective vaccine against the bacteria has been on the market for about a decade – I gave it to my little boy Nicolas received it last month.  So why does it not get used more widely in the developing world?
One of the tricky things about developing a vaccine against this bacteria is that there is not just one “kind” of the bacteria, in fact there are many, and developing a vaccine that provides coverage to more and more strains of the bacteria becomes more and more complicated – and more expensive –  so only a subset of kinds are usually included.  The first vaccine that went on market was seven valiant meaning it protected against seven kinds of the bacteria – the seven kinds that were thought to be most prevalent in the developed world where the vaccine was to be marketed.  Higher valent formulations have since been developed and approved for use around the world, but the thinking has always been these bacteria were unlikely to provide coverage against a major share of the types of bacteria present in the developing world.  To date, Rwanda is the only developing county to have introduced the vaccine.
A new paper released earlier this week in PLoS Medicine, however, provides some surprising data that suggests that the assumption that the current vaccines would not provide be particularly useful in the developing world was perhaps too pessimistic.  Using more data than ever analyzed before, in particular from the African region, the authors find that some of the newer forms of the vaccine that are currently on market might actually protect against upwards of 70-80% of the strains in the worst affected ares of the world – about 2-3 times what I thought was possible – so this is particularly exciting news.  Although not perfect, and going forward I believe it is going to be harder and harder to develop such perfect vaccines, it suggests that rapid scale up of the use of the vaccine formulation on market might represent an underutilized intervention to reduce child mortality.
Clearly things are never as easy as the scenario I paint here – that the vaccine could just be rolled out tomorrow.  Vaccine manufacturing would need to be scaled up, which can be tricky, there might be some offsetting effects of the vaccine from non-targeted strains, and the vaccines still need to be distributed and delivered.  Plus, even if deaths from the S. pneumonia were eliminated we would still not achieve MDG4.  But if we are still willing to commit to the MDG framework and continue to strive to achieve the health related goals, we need to focus on any underutilized interventions we can to accelerate progress.  If we are not going to try, then we might as well give up now.  I know that if I had a billion bucks or so to invest in global health over the next few years to reduce child mortality, I know where I would put my money.
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