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For the past 30 years the dominant role of acute respiratory infections, especially pneumonia, as a cause of illness and death in children in the developing world has been appreciated. The strategy employed throughout the developing world to address the problem was based on the early detection and treatment of likely pneumonia cases at the community level by primary healthcare workers using a strategy developed in Papua New Guinea in the 1970s.1 The strategy relied on two physical signs—fast breathing (to identify possible pneumonia cases in need of antibiotics) and lower chest wall indrawing (to identify more severe cases in need of admission). Originally a programme, solely for the management of acute respiratory infection cases, this was integrated, in 1991, into a broader case management strategy for young children, Integrated Management of Childhood Illness (IMCI).2 IMCI has since formed the basis of child survival strategies throughout the developing world. The effectiveness of this approach is uncertain, although it is clear that child mortality has since fallen throughout most of the developing world. Studies of the aetiology of severe pneumonia have repeatedly shown the dominant bacterial causes to be Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae (usually type b or Hib), and these are generally assumed to be responsible for most deaths.
In a global public health effort that is unprecedented since the UNICEF-WHO led Universal Childhood Immunisation campaign of the 1980s, the international community is in the process of rolling out new expensive vaccines, including Hib and pneumococcal conjugate vaccines (PCVs) into the poorest countries of the world (http://www.gavi.org/support/nvs/pneumococcal/).3 This is not just the latest in a series of new vaccines to be added to national programmes. Hib and PCV introduction represent a direct attack on the leading cause of child illness and death in the world today, …
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