P re v e n t i o n a n d C o n t ro l o f

C h i l d h o o d P n e u m o n i a an d
Diarrhea
Daniel T. Leung, MD, MSca,b,*,
Mohammod J. Chisti, MBBS, MMed, PhDc, Andrew T. Pavia,

MD

KEYWORDS
 Pneumonia  Diarrhea  Vaccines  Global burden  Etiology
KEY POINTS
 Pneumonia and diarrhea are the 2 major preventable causes of childhood deaths in young
children in low- and middle-income countries.
 Public health interventions, including nutritional rehabilitation, zinc supplementation,
exclusive breastfeeding, and water-sanitation-and-hygiene strategies, have all contributed toward marked reductions in mortality; however, current coverage of these costeffective interventions remains low.
 Respiratory syncytial virus, Streptococcus pneumoniae, and Haemophilus influenza are
the leading causes of childhood pneumonia; the last two can be prevented through
vaccination.
 Vaccines against diarrheal pathogens include that against cholera and rotavirus; development of vaccines against other leading causes of diarrhea, such as norovirus, Cryptosporidium, Shigella, Campylobacter, and enterotoxigenic Escherichia coli, are urgently
needed.
 Successful implementation of the World Health Organization/United Nations Childrens
Funds Integrated Global Action Plan for the Prevention and Control of Pneumonia and
Diarrhea will need strong commitment from national governments, the private sector,
and other stakeholders.

a
Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, 30 North 1900 East, SOM Room 4C416B, Salt Lake City, UT 84132, USA; b Division of Microbiology and Immunology, Department of Pathology, University of Utah School of Medicine, 15
North Medical Drive East, Salt Lake City, UT 84132, USA; c Centre for Nutrition and Food Security, ICU and Respiratory Wards, Dhaka Hospital, International Centre for Diarrhoeal Disease
Research, GPO Box 128, Dhaka 1000, Bangladesh; d Division of Pediatric Infectious Diseases,
Department of Pediatrics, University of Utah School of Medicine, 30 North 1900 East, Salt
Lake City, UT 84132, USA
* Corresponding author. Division of Infectious Diseases, University of Utah School of Medicine,
30 North 1900 East, SOM Room 4C416B, Salt Lake City, UT 84132.
E-mail address: Daniel.leung@utah.edu

Pediatr Clin N Am 63 (2016) 6779

http://dx.doi.org/10.1016/j.pcl.2015.08.003
pediatric.theclinics.com
0031-3955/16/$ see front matter 2016 Elsevier Inc. All rights reserved.

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INTRODUCTION

Pneumonia and diarrhea are the 2 leading infectious causes of death in children
younger than 5 years worldwide, responsible for more than 1.5 million deaths annually.
They accounted for 15% and 9%, respectively, of the 6.3 million deaths in children
younger than 5 years that occurred globally in 2013.1,2 There are an estimated
1.7 billion episodes annually of diarrhea and more than 150 million episodes of pneumonia. Marked decreases in mortality due to pneumonia and diarrhea over the past
decade have been noted.3 Between 2000 and 2013, there was an estimated 44%
reduction in deaths due to pneumonia and 54% reduction in deaths due to diarrhea
among children younger than 5 years.2 Despite this, pneumonia and diarrhea continue
to cause significant morbidity and mortality in young children worldwide, particularly
those in Asia and Africa. Thus, efforts at optimizing prevention and control are needed.
In this review, the authors describe strategies aimed at preventing and controlling
childhood pneumonia and diarrhea.
GLOBAL BURDEN

The World Health Organization (WHO) estimates that each year, there are greater than
150 million cases of pneumonia in children younger than 5 years, including 20 million
cases that require hospitalization. Most of the morbidity and mortality worldwide due
to pneumonia occur in low- and middle-income countries (LMICs). Using vital registration and verbal autopsy data, the Child Health Epidemiology Reference Group estimated the total number of pneumonia deaths in children younger than 5 years
worldwide to be approximately 935,000.3 Up to half of the deaths from pneumonia
occurred in sub-Saharan Africa and approximately a third in Southern Asia. There
were regional variations in the percentage of deaths attributable to pneumonia: from
5% of deaths in developed regions to 16% of deaths in sub-Saharan Africa. Most
notably, 96% of episodes of pneumonia, and 99% of deaths from pneumonia, take
place in LMICs.4
Although second to pneumonia in mortality burden, diarrheal illnesses occur more
frequently. Children in LMICs who are younger than 5 years have an average of
2.9 episodes per year of diarrhea, accounting for nearly 1.7 billion episodes of diarrhea
yearly,5 resulting in more than 578,000 deaths per year.3 The peak age of diarrheal disease incidence is during , from 6 to 11 months of age5; most of the deaths due to diarrhea occur in the first 2 years of life.6
CAUSES OF PNEUMONIA

Because of logistical and ethical limitations, direct sampling of infected lung tissue is
not commonly performed; our knowledge of the causes of pediatric pneumonia is
based mostly on studies using various indirect sampling methods, such as nasopharyngeal swab, blood cultures, or induced sputum (Box 1). A large 10-country study
conducted more than 25 years ago revealed respiratory viruses, especially respiratory
syncytial virus (RSV), to be the leading cause of childhood pneumonia,12 with the most
common bacterial causes being Streptococcus pneumoniae, followed closely by Haemophilus influenzae. More contemporary studies have continued to identify RSV as
the most common respiratory virus responsible for pneumonia worldwide, though
improved molecular diagnostics have also implicated rhinovirus, influenza virus, human metapneumovirus, and adenovirus, with significant geographic variations.79
Although viruses are detected in most cases of pneumonia, given the high frequency
of copathogen isolation, their contribution to severe pneumonia is unclear. Notably,

Childhood Pneumonia and Diarrhea

Box 1
Top pathogens causing childhood pneumonia and diarrhea
Pneumonia710
Bacterial
Streptococcus pneumoniaea
Haemophilus influenzaea
Mycoplasma pneumonia
Staphylococcus aureus
Viral
Respiratory syncytial virus
Influenza A or B virusa
Human rhinovirus
Human metapneumovirus
Adenovirus
Parainfluenza virus
Diarrhea6,11
Bacterial
Shigella
Enterotoxigenic Escherichia coli
Campylobacter
Aeromonas
Vibrio choleraea
Viral
Rotavirusa
Norovirus
Astrovirus
Adenovirus
Protozoal
Cryptosporidium
a

Vaccine available.

a recent study from Gambia involving lung aspirates in children younger than 5 years
with severe pneumonia demonstrated S pneumoniae to be present in 91% of lung
aspirates, followed by H influenzae at 23%, and Staphylococcus aureus in 6%; in
this small study, no viruses were present in greater than 5% of samples.10 The authors
have also shown that the causes of pneumonia in children with severe acute malnutrition differ from that of well-nourished children, with gram-negative bacteria being
more common in those malnourished.13 The Pneumonia Etiology Research for Child
Health study, a 7-country case-control study of severe pneumonia in hospitalized children14 and a similar study using the Global Approach to Biological Research, Infectious Diseases, and Epidemics in Low-Income Countries network in 9 countries15
are both ongoing and are expected to provide more updated and comprehensive
data regarding the causes of pneumonia in LMICs.
CAUSES OF DIARRHEA

The etiologic determination of diarrheal disease and deaths are limited by the large
number of pathogens present in the stool of children in LMICs, even during periods
of relative health. For example, Bangladeshi infants without evidence of diarrhea
had an average of 4.3 enteropathogens detected, compared with an average of 0.5
in infants from the United States.16 The past decade saw the completion of 2 large

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multi-country studies using modern molecular diagnostic tools to provide insight into
the cause and consequences of acute infectious diarrhea in children of LMICs
(see Box 1).
The Global Enterics Multicenter Study, a 3-year cross-sectional case-control study,
investigated the cause and incidence of moderate to severe diarrhea of more than
22,000 children at 7 sites in Africa and Asia.6 It found that most cases were due
to 4 pathogens: rotavirus, Cryptosporidium, Shigella spp, and heat-stable toxinproducing enterotoxigenic Escherichia coli (ST-ETEC). Rotavirus was the top attributable cause of diarrhea in children younger than 24 months of age, and Shigella was the
top cause for those 2 to 5 years old. Other notable pathogens among the top causes
included Vibrio cholerae, Campylobacter jejuni, adenovirus 40/41, and Aeromonas
spp; but there was substantial geographic variation.
The Interactions of Malnutrition and Enteric Infections: Consequences for Child
Health and Development project is a multi-site cohort that involved intensive surveillance for diarrhea and monthly asymptomatic stool collection from children, from birth
to 24 months. Investigators found norovirus, rotavirus, Campylobacter, astrovirus, and
Cryptosporidium to be the top causes of diarrhea in the first year of life, with the addition of Shigella spp in the second year.11 These studies combine to demonstrate that
bacterial, viral, and protozoal causes all play important roles in childhood diarrhea.
PUBLIC HEALTH MEASURES FOR PREVENTION OF CHILDHOOD PNEUMONIA AND
DIARRHEA

Pneumonia and diarrheal disease share several risk factors, including malnutrition,
poor hygiene, poor socioeconomic status, lower education status, and lack of breastfeeding.17 The authors have shown in a systematic review that young children with
severe malnutrition are at an increased risk of death from pneumonia13 and have
high rates of death even after hospital discharge.18 The authors have reported that
severe acute malnutrition is associated with concurrent pneumonia and diarrhea; children with both illnesses have a greater than 80-fold increased risk of death compared
with those with diarrhea alone.19 Inpatient nutritional rehabilitation of malnourished
children has been demonstrated to dramatically reduce case fatality rates, especially
when implemented in units with standardized protocols and trained staff.20,21 Interventions used in such units include appropriate rehydration therapy, targeted feeding,
empiric antibiotics directed against gram-negative organisms, vitamin A supplementation, and management of hypoglycemia. Of the nutritional supplementation interventions studied, preventative zinc supplementation has been shown to reduce the
incidence of diarrhea and pneumonia by more than 20% and all-cause mortality by
18% among children 12 to 59 months of age.22 Additionally, exclusive breastfeeding
of infants reduces deaths due to both pneumonia and diarrhea,23 especially in the first
6 months of life.24,25
Diarrheal diseases have long been associated with ingestion of contaminated food
and water. With the increasing recognition of viral causes of both pneumonia and diarrhea that may be transmitted person to person, efforts have also focused on strategies
to improve water, sanitation, and hygiene (WASH) at the household level. Interventions, such as the encouragement of hand washing with soap, improving water quality,
and proper disposal of excreta, have all been demonstrated to reduce diarrheal
burden.26 There are limited data behind the prevention of pneumonia through
WASH interventions,27 though a recent estimate suggested that hand washing with
soap could prevent more than 600,000 deaths from diarrhea and pneumonia
combined.28

Childhood Pneumonia and Diarrhea

The aforementioned preventive and protective measures form the backbone of

public health efforts for children in LMICs. The marked reductions in mortality in the
past decade have been in large part due to such nonspecific interventions. The
remainder of this review focuses on the use of preventive vaccines for diarrheal and
respiratory pathogens. Conjugate vaccines for H influenza type B and S pneumoniae
and rotavirus vaccines have significantly decreased the burden of pneumonia and
diarrhea in high-income countries (HICs). The uptake of these vaccines and the potential development of new vaccines are expected to further enhance the reductions in
childhood mortality in LMICs.
VACCINES TO PREVENT CHILDHOOD PNEUMONIA

Children younger than 2 years bear a large burden of bacterial respiratory infections,
and polysaccharide antigens are poorly immunogenic in such children. The development of polysaccharide-protein conjugate vaccines has dramatically enhanced the
prevention of pneumonia worldwide. Conjugate vaccines take advantage of a carrier
protein to elicit a T celldependent antibody response to bacterial polysaccharide
antigens. Conjugate vaccines against S pneumoniae and H influenzae type B, the
top 2 causes of bacterial lower respiratory tract infections worldwide, are highly effective. Vaccines against the influenza virus are available but not widely used in LMICs; no
vaccine is yet available against RSV, the most common cause of viral pneumonia.
VACCINES AGAINST STREPTOCOCCUS PNEUMONIAE (PNEUMOCOCCUS)

The development of a pneumococcal vaccine that is effective in young children has

been of great benefit to children worldwide. Available pneumococcal vaccines include
7-, 9-, 10-, 11-, 13-, and 15-valent conjugate vaccines and a 23-valent polysaccharide
(nonconjugated) vaccine. Currently used conjugate vaccines worldwide include the
13-valent conjugate vaccines (pneumococcal conjugate vaccine 13 [PCV13]), which
use CRM197 (diphtheria toxin mutant) as a carrier, and the 10-valent conjugate
(PCV10), which uses 3 proteins: the diphtheria toxoid, the tetanus toxoid, and nontypeable H influenzae protein D.
PCVs prevent invasive pneumococcal disease (IPD), including meningitis, sepsis,
and otitis media as well as pneumococcal pneumonia. In a meta-analysis that included
6 randomized controlled trials conducted in children younger than 2 years in Africa, the
United States, Philippines, and Finland, the pooled efficacy of PCV7 was 80% for vaccine-serotypeassociated IPD and 58% for all-serotype IPD. The effect of PCV7 on
pneumonia was lower: the pooled efficacy for radiologically defined pneumonia was
27% and for clinical pneumonia 6%.29 This finding likely reflects the importance of
other pathogens in addition to S pneumoniae in childhood pneumonia. Several studies
have suggested additional benefits of PCV beyond prevention of pneumococcal pneumonia in those vaccinated, including prevention of viral-attributed pneumonia,30
reduction in IPD in older unvaccinated age groups due to herd immunity,31 and
serotype-associated IPD in younger unvaccinated age groups.32
The introduction of PCVs has had substantial impact on the burden of pneumococcal
disease in every country where it has been widely adopted. The impact may be higher
among young children in LMICs than those in HICs. A meta-analysis of serotypes
causing IPD worldwide estimated that 49% to 88% of pneumococcal deaths in Africa
and Asia are caused by serotypes covered in in PCV10 and PCV13.33 Since 2006, the
WHO has recommended that PCV be included in all routine immunization programs.
The uptake of PCV in LMICs has been limited, however, in large part because of
the high cost of PCV. In response to this, the Global Alliance for Vaccines and

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Immunization (GAVI) has worked to accelerate the introduction of PCVs in LMICs by

working with manufacturers to commit supply and ensuring predictable vaccine pricing for the PCV10 and PCV13 vaccines. In total, more than 125 countries, including 50
GAVI-supported countries, have introduced universal PCV to their immunization programs, though greater than 50% of the worlds infants still do not have access to
PCV,34 most notably many of those living in Asian LMICs.
Large randomized studies of 10- and 13-valent PCVs have not been conducted in
LMICs, and their effectiveness is inferred from comparable immunogenicity as
PCV7. With the use of PCV7, surveillance studies in HICs demonstrated a plateau in
the reduction of pneumococcal infection rates in some populations due to serotype.35
Notably, there are more than 90 pneumococcal serotypes. Although the factors that
drive the epidemiology of S pneumoniae are complex and poorly understood,
further serotype replacement seems likely. Vaccines aimed at inducing serotypeindependent immunity are in early stages of development and hold promise of not
being subject to serotype replacement.36
VACCINES AGAINST HAEMOPHILUS INFLUENZAE TYPE B

As with pneumococcal vaccines, the first Haemophilus influenzae type b (Hib) vaccines were polysaccharide formulations that were poorly immunogenic in young children.37 However, since 1987, several Hib conjugate vaccines (HibCVs) have become
available, including ones conjugated to an outer membrane vesicle of Neisseria meningitidis and one conjugated to tetanus toxoid; HiBCVs have been combined with
other childhood vaccines. Initial randomized controlled trials (RCTs) of HibCVs
showed greater than 95% efficacy against invasive disease38; the introduction of
HibCV has nearly eliminated invasive Hib disease from countries where the vaccine
is widely used, including countries in sub-Saharan Africa.39
In 2006, the WHO issued a recommendation for the adoption of HibCVs in routine
immunization programs worldwide. In response to the slow uptake of HibCV in LMICs,
the Hib initiative was launched by GAVI to disseminate data regarding the burden of
disease and provide advocacy for its introduction in low-income countries. Currently,
more than 190 countries have introduced a Hib-containing vaccine into their national
immunization program,34 including all 73 GAVI countries. However, it is estimated that
more than a third of infants worldwide are still not reached by the current immunization
coverage.34
VACCINES AGAINST INFLUENZA VIRUS

Despite the large burden of respiratory illness due to influenza virus infection among
young children and the longstanding availability of the influenza vaccine in HICs, vaccines against influenza have not been widely implemented in any LMICs. The biggest
reason is likely the cost and logistical resources needed to implement yearly immunizations. Inactivated influenza vaccines (IIVs) are produced to match influenza strains
that circulate at the end of the last season. Efficacy depends on the degree of matching to actual circulating strains, and studies evaluating IIVs in children are limited. In a
recent large multi-country RCT, a quadrivalent IIV had an efficacy of 60%.40 On the
other hand, the single-dose live attenuated influenza vaccine (LAIV) holds promise
to be an effective and less costly option for LMICs. In contrast to IIVs, a large number
of RCTs have shown that LAIVs are effective in preventing influenza illness in young
children.41 Furthermore, there is evidence that LAIVs may have activity against mismatched strains and possibly provide longer duration of protection than IIVs. A
cost-effectiveness analysis conducted in Thailand showed vaccination with LAIV to

Childhood Pneumonia and Diarrhea

be highly cost-effective, more than for IIV vaccine.42 Current research efforts are
focused on the feasibility of influenza vaccine implementation43 as well as the protection of infants through vaccination during pregnancy.44
VACCINES TO PREVENT CHILDHOOD DIARRHEA

Currently, there are few vaccines available for the prevention of childhood diarrhea.
The rotavirus vaccine, highly efficacious and widely available in most HICs, has shown
lower efficacy in some LMICs. Efforts to include it in national immunization programs
have been slow. Recent enhancement and development of the oral cholera vaccine
(OCV) has increased its availability, and the WHO now recommends it for use in
both endemic and epidemic areas. The authors review these two available vaccines
later. Vaccines against norovirus, Shigella, and ETEC are in advanced stages of development; given the surprisingly high burden of illness caused by Cryptosporidium,
efforts are underway to increase our understanding of its host-pathogen relationship
that could allow development of effective vaccines.
VACCINES AGAINST ROTAVIRUS

Rotavirus is the most common cause of diarrhea in the first year of life,6 which is the
age with the highest incidence of, and deaths due to, diarrheal illness. The WHO has
recommended that rotavirus vaccine for infants be included in national immunization
programs. Two live attenuated oral rotavirus vaccines are available worldwide: a
3-dose pentavalent human-bovine reassortment vaccine containing serotypes G1,
G2, G3, G4, and P1[8] (RV5) and a 2-dose monovalent vaccine derived from serotype
combination G1P[8] (RV1), which likely has cross-protection against most other
serotypes.
Several studies have shown that both rotavirus vaccines are effective in preventing
gastroenteritis due to rotavirus in a variety of geographic settings. In large placebocontrolled studies of RV5 and RV1,45,46 the vaccines were associated with approximately 90% efficacy against incidence of, hospitalization for, and emergency visits
due to severe rotaviral gastroenteritis. The rotavirus vaccine has also been associated
with a decrease in all-cause gastroenteritis and indirect protection of unvaccinated
older siblings.47 A total of 79 countries have introduced a rotavirus vaccine into their
national immunization program, though an estimated three-quarter of the worlds infants still do not have access to the rotavirus vaccine,34 including most infants living
in South and Southeast Asia.
Currently available rotavirus vaccines have lower immunogenicity and effectiveness
in LMIC settings than seen in studies from North America, Europe, and South America.
Large multi-country studies from sub-Saharan Africa48,49 and Asia50 showed vaccine
efficacy estimates of 40% to 50%, a substantially lower number. Issues regarding
immunogenicity, and the possible deleterious effect of environmental enteropathy,
malnutrition, and alterations in gut microbiota, are currently being examined in the
multi-site birth cohort Performance of Rotavirus and Oral Polio Vaccines in Developing
Countries study.51 Adjunctive interventions may be needed to optimize the delivery
and efficacy of rotavirus and other oral vaccines in developing countries.
VACCINES AGAINST VIBRIO CHOLERAE

Despite being available for several decades, vaccines against cholera have not been
widely used in endemic countries because of concerns regarding efficacy, duration of
protection, and costs. Recently, in efforts spearheaded by the International Vaccine

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Initiative, an existing OCV produced and originally implemented in Vietnam was

enhanced to meet WHO prequalification standards and licensed in India. This vaccine,
Shanchol, is a bivalent (O1 and O139) heat- and formalin-killed whole-cell V cholerae
vaccine, given as 2 doses 14 days apart. Unlike its precursor Dukoral, it does
not contain a recombinant cholera toxin subunit. In a large double-blind clusterrandomized placebo-controlled trial in Kolkata, India, the vaccine was found to have
a protective efficacy of 65% at 5 years of follow-up.52
In 2011, the WHO recommended that OCVs be used in both endemic and epidemic
settings; in 2012, in response to recent epidemics, such as in Haiti and sub-Saharan
Africa, the WHO established a global stockpile of OCV. Despite the high burden of
cholera in young children,53 OCVs have a lower protective efficacy and a shorter duration of protection in young children less than 5 years of age than in older persons.54
The reasons for this are not fully understood. The authors have shown that children
aged 24 to 59 months mount lower V cholerae polysaccharide-specific responses
to OCV than older children and adults.55 Given the logistical difficulties of completing
a multiple-dose regimen in settings where cholera is present, efforts to study alternative dosing schedules of currently available OCVs are underway; several single-dose
live-attenuated OCVs are under development.56
INTEGRATED GLOBAL ACTION PLAN FOR THE PREVENTION AND CONTROL OF
PNEUMONIA AND DIARRHEA

Despite the availability of effective cost-effective interventions to end preventable

childhood deaths from diarrhea and pneumonia, access is low in many LMICs.57 There
are many barriers to the implementation and scale-up of interventions to end preventable deaths in children from pneumonia and diarrhea (Box 2 and Fig. 1).58,59 Following
a series of regional and country workshops and subsequent follow-up and feedback
from health care workers, the WHO conceptualized a protect, prevent, and treat
Box 2
Barriers to the implementation and scale-up of pneumonia and diarrhea interventions
 Lack of specific policy guidance for child health, CCM, or use of antibiotics and other
essential health commodities by CHW
 Lack of harmonization, coordination, and collaboration between programs and sectors
 Insufficient involvement with the private sector
 Suboptimal vaccine coverage
 Financial constraints
 Scarcity of human resources
 Lack of adequate training for health care providers
 Lack of adequate health commodities and supplies (eg, antibiotics, zinc, vaccines)
 Health care access issues due to geographic and financial barriers
 Poor surveillance
 Inadequate monitoring and evaluation
Abbreviations: CCM, community case management; CHW, community health workers.
Data from Qazi S, Aboubaker S, MacLean R, et al. Ending preventable child deaths from
pneumonia and diarrhea by 2025: the integrated global action plan for pneumonia and diarrhea. Arch Dis Child 2015;100(Suppl 1):s238.

Childhood Pneumonia and Diarrhea

Fig. 1. WHO/UNICEF framework to protect, prevent, and treat pneumonia and diarrhea in
children less than five years of age. (Used with permission from WHO/UNICEF. Ending preventable child deaths from pneumonia and diarrhea by 2025: the integrated global action
plan for pneumonia and diarrhea. Geneva (Switzerland): WHO; 2013).

framework to reduce morbidity and mortality from pneumonia and diarrhea in

LMICs.59 In 2013, the WHO and The United Nations Childrens Fund (UNICEF)
launched the Integrated Global Action Plan for the Prevention and Control of
Pneumonia and Diarrhea (GAPPD) with a goal to eliminate child deaths from pneumonia and diarrhea by 2025.60 Community-based delivery platforms have been
proposed to reach the poorest, hard-to-reach populations and reduce health care
inequalities.17
Progress has been made in improving access to childhood vaccines to prevent
pneumonia and diarrhea. Given the various challenges in modern vaccine development (eg, lack of investments, decreasing number of vaccine manufacturers), establishment of a global vaccine-development fund has been proposed.61 Most experts in
the field envision that GAPPD goals can be achieved, though successful implementation of the WHO/UNICEF Integrated GAPPD will need strong commitment from
national governments, the private sector, and other stakeholders.59
SUMMARY

Despite marked reductions in the past decade, pneumonia and diarrhea continue to
be the leading killers of young children worldwide. There are now several effective
and relatively low-cost interventions to control these diseases, and organizations
such as GAVI have enabled many countries to implement pathogen-specific vaccines
into their national immunization programs. Effective vaccines are needed against other
major killers of children including RSV, ETEC, and norovirus. Further progress in this
field will continue to depend on international commitment to fund, communicate,
and advocate for the needs of these children.
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