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CHERG - Child Epidemiology Reference Group

Haemophilus influenzae type b and Pneumococcal Conjugate Vaccines

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Theodoratou E, Johnson S, Jhasss A, Madhi SA, Clark A, Boschi-Pinto C, Bhopal S, Rudan I, and Campbell H. The effect of Haemophilus influenzae type b and pneumococcal conjugate vaccines on childhood pneumonia incidence, severe morbidity and mortality.  International Journal of Epidemiology 2010 April; 39 (Suppl 1): i72-i85.


  • According to a UNICEF-WHO report from 2006, over two million children die from pneumonia each year, accounting for almost one in five under-5 deaths worldwide. (1)
  • WHO recommends routine immunization programs including measles, pertussis, Haemophilus influenzae type b (Hib) conjugate and pneumococcal (PC) conjugate vaccines, in order to prevent pneumonia.
  • The majority of Global Alliance for Vaccines and Immunization (GAVI Alliance) eligible countries have now introduced Hib vaccine (, but the coverage of the PC vaccine is still very limited in the areas where it is needed most (2).

Intervention Effects

Hib Conjugate Vaccine on Pneumonia Morbidity 

  • Pneumonia and all-cause mortality outcomes were dropped because initial quality of evidence was very low
  • 4% (95% CI: 3, 6%) reduction in clinical pneumonia
  • 6% (95% CI: 1, 11%) reduction in clinical severe pneumonia
  • 18% (RR: 0.82, 95% CI: 0.67-1.02) reduction in radiologically confirmed pneumonia - Estimated by combining one RCT, two cRCTs and one case-control study that used systematic vaccine allocation.

Pneumococcal Conjugate Vaccines (all valent) on Pneumonia Morbidity

  • Pneumonia and all-cause mortality outcomes were dropped because initial quality of evidence was very low
  • 7% (95% CI: -2, 15%) reduction in clinical pneumonia
  • 7% (95% CI: -1, 14%) reduction in clinical severe pneumonia
  • 26% (RR:  0.74, 95% CI: 0.63-0.88) reduction in radiologically confirmed pneumonia

Intervention Recommendation

  • Findings of this review indicated that the summary effect of Hib and PC conjugate vaccines on radiologically confirmed pneumonia was 18% and26% respectively.  These estimates will be used as a severe morbidity proxy for pneumonia mortality in the LiST model.
  • Estimates of the direct effect of the vaccine should ideally be adjusted to account for the proportion of circulating pneumococci that are vaccine type; however, data on serotype distribution are currently incomplete. 
  • While one study showed a 13% reduction in radiologically confirmed pneumonia (95% CI: -7, 29%) among HIV+ children, more evidence is required to model the differential impact in HIV-affected regions.
  • Positive indirect vaccine effects are important; however, the dynamics of S. pneumonia in developing countries needs further study to delineate their potential impact.

References from Theodoratou Paper Cited Here

  1. UNICEF, World Health Organization. Pneumonia; the forgotten killer of children.  2008.
  2. Rudan I, El AS, Black RE, Campbell H. Childhood pneumonia and diarrhea: setting our priorities right. Lancet Infect Dis 2007; 7: 56-61.

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