Accelerated Development and Introduction Plans (ADIPs) for Pneumococcal Conjugate Vaccines: Burden of Pneumococcal Disease in children in Bangladesh

ADIPs: Funded by GAVI | 2004-2008


We have conducted this to enhance laboratory capacity to isolate and characterize S. pneumoniae in Bangladesh for documenting the contribution of pneumococci as causes of severe disease in children, to provide local information on the most common serotypes causing disease and antimicrobial resistance patterns and to establish population-based incidence of pneumonia and laboratory-confirmed invasive pneumococcal disease that can be used to monitor the impact of vaccination.


Streptococcus pneumoniae (pneumococcus) causes a variety of respiratory illnesses.  About 28% of community acquired bacterial pneumonia in children is attributable to S. pneumoniae in developing countries. Pneumococcal disease probably causes 1-2 million deaths in children <5 years of age every year, mostly in developing countries.  Most deaths are associated with meningitis or pneumonia which also result in other serious complications, chronic sequelae and substantial direct and indirect costs.  A recently published analysis estimated 1.6 to 2.2 million children die from acute respiratory infection (ARI) worldwide each year with about 30% in Southeast Asia, including Bangladesh.  While infrequently leading to death, other manifestations of pneumococcal disease, like non-focal bacteremia (septicemia), acute otitis media and sinusitis are also responsible for substantial suffering, long term sequelae, and economic burden.  The rapid emergence of multi-drug-resistant S. pneumoniaehas raised the stakes; more expensive antimicrobial regimens are being prescribed to treat presumed pneumococcal disease and treatment failures (especially for meningitis) have been documented. S. pneumoniae is not widely recognized as a priority public health problem in Bangladesh.  Blood cultures are not done routinely, so the importance of pneumococci is not appreciated.  With the advent and availability of a highly effective vaccine to prevent pneumococcal disease, this knowledge gap will serve as a substantial barrier to optimal use of this prevention modality. This project aimed to address the knowledge gap and provides a means to define the impact of Streptococcus pneumoniaein ways that will be important to decision-makers and stakeholders.


We enhanced the capacity to isolate S. pneumoniae from normally sterile sites at key hospitals by creating a network for hospital surveillance.  A medical officer were identified at each of the hospitals who maintained the day to day liason with clinicians at the hospital and study staff.  The medical officer was responsible for encouraging and facilitating other clinicians at each hospital to obtain a blood culture when children <5 years of age are hospitalized with signs and symptoms for pneumonia, severe pneumonia, meningitis or sepsis, and a lumbar puncture for evaluation of cerebrospinal fluid (CSF), including culture.  During the day, medical officers was based at pediatric wards and identified children meeting case definitions upon admission. He also assured that the clinician receives results from blood or CSF culture processing.  kept record of outcome for each patient from whom a blood culture is obtained, including mortality, complications, therapy, and duration of hospitalization using a standardized data collection instrument.  This enabled us to estimate the direct economic impact and mortality for pneumococcal disease.  The standardized form was used to collect information about pre-hospitalization antimicrobial therapy which helped in interpreting negative blood cultures– by comparing blood isolation rates among pre-treated and untreated children, we estimated undetected S. pneumoniae among pre-treated children.  We have provided information to clinicians on drug resistance by defining the magnitude and patterns of drug resistance in Bangladesh.  We also haracterized serotype distribution of pneumococci—earlier data principally from a single hospital in Dhaka painted a somewhat gloomy picture of the potential coverage of new pneumococcal conjugate vaccines in Bangladesh.  More systematically collected and representative data are  immensely helpful in forecasting the impact of introduction of new vaccines. We also established population-based incidence rates of pneumonia and pneumococcal disease for urban and rural areas.  Incidence rates provides solid bases to understand the burden of disease; ancillary costing studies will provide information on economic burden—these data should make it possible for public health and financial policy makers to weigh the value of prevention of pneumococcal disease in the context of other pressing priorities.