- Email: [email protected]
Digital surveillance for enhanced detection and response to outbreaks
Comment
at a large enough scale are formidable. Additionally, the effectiveness of such approaches might be greatly reduced and insufficient to completely eliminate virus transmission. Thanks to the very professional, and often heroic, work of Médecins sans Frontieres and local partners, we know how to care for patients in such resource-poor settings and how to avoid Ebola transmission in hospital settings—a key component of the response, given that around 150 health-care workers have already died in this epidemic. What is less clear is how to significantly reduce transmission in the community, including how to manage holding centres and those who have fever, and what the incentives are to change risky traditional burial practices. This is a research agenda that could potentially have an immediate effect on epidemic control. Trials of experimental therapies, starting with the use of hyperimmune plasma or serum from convalescent patients, will begin soon, and should lead to much reduced mortality and transmission. The scale of the epidemic might have reached the point that it can no longer be controlled without a vaccine, and Ebola could become endemic in large communities. Whether the vaccine trials starting now can still make a difference in the present epidemic is unlikely, unless it continues for a very long time or Ebola becomes endemic in west Africa. Now is also the time to address the huge economic and societal havoc that Ebola is causing in the region, while planning for rebuilding of health systems and disease surveillance. For the first time in a period of peace, the military are engaging in epidemic control to a major degree. Other
nations should follow the USA’s initiative in Liberia. The Ebola crisis needs every institution to play its part since the effort is still not commensurate with the actual and potential threat to people in west Africa and possibly elsewhere. That includes also academic institutions and the UK National Health Service, as now made possible following a letter by the Chief Medical Officer inviting staff to volunteer in west Africa. Other outbreaks of Ebola will occur, as the populations exposed to the probable virus reservoir are expanding in Africa6 and the potential for a large epidemic remains where fertile ground for it exists. This has major implications for the future. A large epidemic can—and will—happen again, unless we always remain extremely vigilant , respond promptly, and have more to offer than isolation and quarantine. *Peter Piot, Jean-Jacques Muyembe, W John Edmunds London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK (PP, WJE); Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of the Congo (J-J M) [email protected] We declare no competing interests. 1 2
3 4
5 6
International Commission. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ 1978; 56: 271–93. WHO Ebola Response Team. Ebola virus disease in West Africa – the first nine months of the epidemic and forward projections. N Engl J Med 2014; published online Sept 23. DOI:10.1056/NEJMMoa1411100. Piot P. Ebola’s perfect storm. Science 2014; 345: 1221. WHO: Ebola Response Roadmap Situation Report. 24 September 2014. http://apps.who.int/iris/bitstream/10665/134771/1/ roadmapsitrep_24Sept2014_eng.pdf?ua=1 (accessed 29 Sept, 2014). Camacho A, Kucharski AJ, Funk S, Breman J, Piot P, Edmunds J. Potential for large outbreaks of Ebola virus disease. Epidemics (in press). Pigott DM, Golding N, Mylne A, et al. Mapping the zoonotic niche of Ebola virus in Africa. eLife 2014; 3: e04395.
Digital surveillance for enhanced detection and response to outbreaks
www.thelancet.com/infection Vol 14 November 2014
that governs international surveillance and response to global public health risks and emergencies.1 The document aims to strengthen state parties’ abilities to monitor, detect, assess, and report public health hazards in a way that does not adversely affect crossborder travel and trade.2 The regulations contain a decision-making matrix that guides state parties’ assessment and notification of potential public health
Denis Balibouse/Reuters/Corbis
In 2014, the Director-General of WHO declared two public health emergencies of international concern: poliomyelitis and Ebola virus disease. These declarations have refocused attention on the use of the International Health Regulations (2005) to identify public health emergencies and to the challenges that state parties face in their assessment. The International Health Regulations (2005) is the principal document
1035
Comment
For a HealthMap infographic on Ebola see http://www. healthmap.org/ebola For a HealthMap infographic on polio see http://www. healthmap.org/polio
1036
emergencies of international concern.2 The ultimate declaration of a potential public health emergency is made by the Director-General on the basis of information provided by state parties; WHO’s decisionmaking algorithm; the advice of an emergency committee; scientific evidence; and an assessment of risk to human health, of international spread, and of interference with international traffic (article 12.4), and this might include the use of digital surveillance (article 5.4). Many issues contribute to states parties not being able to do the necessary surveillance for the 2005 regulations. Low-resource counties are often already overburdened by endemic diseases such as diarrhoea, pneumonia, and HIV/AIDS. Countries affected by conflict, such as Afghanistan and Iraq, have had a deterioration in public health surveillance systems and have a scarcity of qualified physicians, epidemiologists, and laboratory workers.3,4 Most state parties exclusively rely on data generated by ministries of health, without much surveillance capacity from other ministries.5 In recent years, many public health events notifiable under the International Health Regulations (2005) have been identified through informal sources.6,7 This improvement is attributed, in part, to technological developments in surveillance capacity, including the emergence of web-based systems.8 Web-based early warning systems, such as HealthMap, BioCaster, Global Public Health Intelligence Network (GPHIN), MedISys, and ProMED-mail, collect disease-specific data from informal sources such as local news and social media. Web-based queries and participatory systems also produce cost-effective data for syndromic surveillance.9,10 Combined, these systems enhance both the timeliness and sensitivity of early disease detection.11 Retrospective review of polio and Ebola outbreaks reported through digital surveillance channels show this enhancement of reporting time. When reports of polio emerged in Cameroon on Oct 1, 2013, ProMED and GPHIN picked up the story from the Global Polio Eradication Initiative and published reports on Oct 24. The official WHO report was not published until Nov 21; 51 days after the outbreak began. Similarly, reports about polio were first made in Equatorial Guinea on Jan 19, 2014. ProMED published information on March 21, followed by a GPHIN alert
on March 27. The official WHO report was published on April 17; 88 days after reports first occurred. WHO declared the polio epidemic a public health emergency of international concern on May 5, 2014. For all seven WHO-reported polio outbreaks in 2013 and 2014, digital reports preceded official reports by an average of 14·6 days (range 0–40 days). The first public notification of the Ebola outbreak was retrieved on March 14, 2014, by HealthMap from a French news website with headlines reporting of a strange fever in Macenta, Guinea. The report described the deaths of eight people, and symptoms of anal and nasal bleeding that resembled Lassa fever. On March 22, WHO and the Sierra Leone Ministry of Health released a statement that Ebola might have spread into Sierra Leone; official case information was released on March 23. WHO declared the Ebola outbreak a public health emergency of international concern on Aug 8, 2014. As shown with polio and Ebola outbreak detection, digital surveillance could improve early detection and response to public health emergencies of international concern, and should be viewed as an essential complement to the available formal surveillance structure. Encouragement of countries to use digital surveillance should be a global public health priority. *Aranka Anema, Sheryl Kluberg, Kumanan Wilson, Robert S Hogg, Kamran Khan, Simon I Hay, Andrew J Tatem, John S Brownstein Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA, USA (AA, SK, JSB); Children’s Hospital Informatics Program at the Harvard–Massachusetts Institute of Technology, Division of Health Sciences and Technology, Boston, MA, USA (AA, SK, JSB); Division of International Nutrition, Department of Food, Nutrition and Health, Faculty of Land and Food Systems University of British Columbia, Vancouver, BC, Canada (AA); Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada (KW); Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada (RSH); British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada (RSH); Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada (KK); Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, UK (SIH); Fogarty International Center, National Institutes of Health, Bethesda, MD, USA (SIH, AJT); Department of Geography and Environment, University of Southampton, Highfield, Southampton, UK (AJT); and Flowminder Foundation, Stockholm, Sweden (AJT) [email protected]
www.thelancet.com/infection Vol 14 November 2014
Comment
JSB reports funding from Epidemico outside the submitted work. All other authors declare no competing interests. This work was supported by the National Library of Medicine, National Institutes of Health (R01LM010812), Bill & Melinda Gates Foundation (OPP1093011), and the Canadian Institutes of Health Research. AA and KK acknowledge support from the Canadian Institutes of Health Research. SIH is funded by a Senior Research Fellowship from the Wellcome Trust (095066), which also supports AM, and a grant from the Bill & Melinda Gates Foundation (OPP1093011). AJT is supported by funding from National Institutes of Health and National Institute of Allergy and Infectious Diseases (U19AI089674) and the Bill & Melinda Gates Foundation (OPP1106427 and OPP1032350). 1
2
3
4
WHO. Fifty-eighth World Health Assembly Resolution WHA58.3: Revision of the International Health Regulations. 2005. http://www.who. int/ipcs/publications/wha/ihr_resolution.pdf (accessed Sept 30, 2014). WHO. WHO’s Interim Guidance for the Use of Annex 2 of the IHR (2005): Decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern. 2008. http://www.who.int/ihr/Annex_2_Guidance_en.pdf (accessed Sept 30, 2014). Chrétien JP, Yingst SL, Thompson D. Building public health capacity in Afghanistan to implement the International Health Regulations: a role for security forces. Biosecur Bioterror 2010; 8: 277–85. Webster P. Reconstruction efforts in Iraq failing health care Lancet 2009; 373: 617–20.
5
6
7
8
9 10
11
Anema A, Druyts E, Hollmeyer HG, Hardiman MC, Wilson K. Evaluation of the functioning of the International Health Regulations (2005) annex 2. Global Health 2012; 8: 1. Olowokure B, Pooransingh S, Tempowski J, Palmer S, Meredith T. Global surveillance for chemical incidents of international public health concern. Bull World Health Organ 2005; 83: 928–34. Barboza P, Vaillant L, Mawudeku A, et al. Early alerting reporting project of the global health security initiative. evaluation of epidemic intelligence systems integrated in the early alerting and reporting project for the detection of A/H5N1 influenza events. PLoS One 2013; 8: 1–9. Brownstein JS, Freifeld CC, Madoff LC. Digital disease detection— harnessing the Web for public health surveillance. N Engl J Med 2009; 360: 2153–55. Hulth A, Gustaf R, Annika L. Web queries as a source for syndromic surveillance. PLoS One 2009; 4: e4378. Freifeld CC, Chunara R, Mekaru SR, et al. Participatory epidemiology: use of mobile phones for community-based health reporting. PLoS Med 2010; 7: e1000376. Barboza P, Vaillant L, Le Strat Y, et al. Factors influencing performance of internet-based biosurveillance systems used in epidemic intelligence for early detection of infectious diseases outbreaks. PLoS One 2014; 9: e90536.
Investment in pneumonia and pneumococcal research
www.thelancet.com/infection Vol 14 November 2014
in 2013 rated the threat level for S pneumoniae as severe.5 In the UK, during the period 1997–2010, investments for antimicrobial resistance seem historically inadequate,6 despite the concerns and urgency of the problem; however, focus seems to be increasing in this important area.5,7 An important factor in the assessment of investments in research is the stage of research and its position along the research and development pipeline. Our analysis shows that in the UK, pneumonia research is almost entirely preclinical (figure), accounting for 87·5% of the total funding for pneumonia-related research. Conversely, 5·0
4·0 Total funding (£, millions)
The worldwide burden of pneumonia is high—the disease caused 1·2 million deaths in 2010, mostly in children younger than 2 years.1 In the same year, at least 76·7 million disability-adjusted life-years (DALYs) were attributed to pneumonia and pneumococcal disease,2 although DALYs are inevitably increased in diseases that mostly affect young children. Infections of the lower respiratory tract (many of which are probably pneumonia-related) were the single largest cause of worldwide DALYs in children younger than 1 year.2 Streptococcus pneumoniae is the most common cause of pneumonia, although other bacteria, viruses, and fungi are also important sources of infection. The Research Investments in Global Health study3 analysed public and philanthropic infectious disease research funding awarded to UK institutions, and reported data about funding for respiratory infectious diseases.4 The total research investment in pneumonia (£27·2 million) relative to the 2010 burden was £0·58 per DALY, which is substantially lower than that for tuberculosis (£3·14) and influenza (£4·16), and also lower than investments for all other respiratory infectious diseases (where data were available) for which effective vaccinations are available and widely used, except for measles and pertussis. A threat report on antimicrobial resistance released by the US Centers for Disease Control and Prevention (CDC)
For more on research investments in globabl health see http:// www. researchinvestments.org
Preclinical Product development Phase 1–3 Implementation
3·0
2·0
1·0
0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year
Figure: Total public and philanthropic funding in pneumonia-related research in 1997–2010, including breakdown of stage of research
1037
at a large enough scale are formidable. Additionally, the effectiveness of such approaches might be greatly reduced and insufficient to completely eliminate virus transmission. Thanks to the very professional, and often heroic, work of Médecins sans Frontieres and local partners, we know how to care for patients in such resource-poor settings and how to avoid Ebola transmission in hospital settings—a key component of the response, given that around 150 health-care workers have already died in this epidemic. What is less clear is how to significantly reduce transmission in the community, including how to manage holding centres and those who have fever, and what the incentives are to change risky traditional burial practices. This is a research agenda that could potentially have an immediate effect on epidemic control. Trials of experimental therapies, starting with the use of hyperimmune plasma or serum from convalescent patients, will begin soon, and should lead to much reduced mortality and transmission. The scale of the epidemic might have reached the point that it can no longer be controlled without a vaccine, and Ebola could become endemic in large communities. Whether the vaccine trials starting now can still make a difference in the present epidemic is unlikely, unless it continues for a very long time or Ebola becomes endemic in west Africa. Now is also the time to address the huge economic and societal havoc that Ebola is causing in the region, while planning for rebuilding of health systems and disease surveillance. For the first time in a period of peace, the military are engaging in epidemic control to a major degree. Other
nations should follow the USA’s initiative in Liberia. The Ebola crisis needs every institution to play its part since the effort is still not commensurate with the actual and potential threat to people in west Africa and possibly elsewhere. That includes also academic institutions and the UK National Health Service, as now made possible following a letter by the Chief Medical Officer inviting staff to volunteer in west Africa. Other outbreaks of Ebola will occur, as the populations exposed to the probable virus reservoir are expanding in Africa6 and the potential for a large epidemic remains where fertile ground for it exists. This has major implications for the future. A large epidemic can—and will—happen again, unless we always remain extremely vigilant , respond promptly, and have more to offer than isolation and quarantine. *Peter Piot, Jean-Jacques Muyembe, W John Edmunds London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK (PP, WJE); Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of the Congo (J-J M) [email protected] We declare no competing interests. 1 2
3 4
5 6
International Commission. Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ 1978; 56: 271–93. WHO Ebola Response Team. Ebola virus disease in West Africa – the first nine months of the epidemic and forward projections. N Engl J Med 2014; published online Sept 23. DOI:10.1056/NEJMMoa1411100. Piot P. Ebola’s perfect storm. Science 2014; 345: 1221. WHO: Ebola Response Roadmap Situation Report. 24 September 2014. http://apps.who.int/iris/bitstream/10665/134771/1/ roadmapsitrep_24Sept2014_eng.pdf?ua=1 (accessed 29 Sept, 2014). Camacho A, Kucharski AJ, Funk S, Breman J, Piot P, Edmunds J. Potential for large outbreaks of Ebola virus disease. Epidemics (in press). Pigott DM, Golding N, Mylne A, et al. Mapping the zoonotic niche of Ebola virus in Africa. eLife 2014; 3: e04395.
Digital surveillance for enhanced detection and response to outbreaks
www.thelancet.com/infection Vol 14 November 2014
that governs international surveillance and response to global public health risks and emergencies.1 The document aims to strengthen state parties’ abilities to monitor, detect, assess, and report public health hazards in a way that does not adversely affect crossborder travel and trade.2 The regulations contain a decision-making matrix that guides state parties’ assessment and notification of potential public health
Denis Balibouse/Reuters/Corbis
In 2014, the Director-General of WHO declared two public health emergencies of international concern: poliomyelitis and Ebola virus disease. These declarations have refocused attention on the use of the International Health Regulations (2005) to identify public health emergencies and to the challenges that state parties face in their assessment. The International Health Regulations (2005) is the principal document
1035
Comment
For a HealthMap infographic on Ebola see http://www. healthmap.org/ebola For a HealthMap infographic on polio see http://www. healthmap.org/polio
1036
emergencies of international concern.2 The ultimate declaration of a potential public health emergency is made by the Director-General on the basis of information provided by state parties; WHO’s decisionmaking algorithm; the advice of an emergency committee; scientific evidence; and an assessment of risk to human health, of international spread, and of interference with international traffic (article 12.4), and this might include the use of digital surveillance (article 5.4). Many issues contribute to states parties not being able to do the necessary surveillance for the 2005 regulations. Low-resource counties are often already overburdened by endemic diseases such as diarrhoea, pneumonia, and HIV/AIDS. Countries affected by conflict, such as Afghanistan and Iraq, have had a deterioration in public health surveillance systems and have a scarcity of qualified physicians, epidemiologists, and laboratory workers.3,4 Most state parties exclusively rely on data generated by ministries of health, without much surveillance capacity from other ministries.5 In recent years, many public health events notifiable under the International Health Regulations (2005) have been identified through informal sources.6,7 This improvement is attributed, in part, to technological developments in surveillance capacity, including the emergence of web-based systems.8 Web-based early warning systems, such as HealthMap, BioCaster, Global Public Health Intelligence Network (GPHIN), MedISys, and ProMED-mail, collect disease-specific data from informal sources such as local news and social media. Web-based queries and participatory systems also produce cost-effective data for syndromic surveillance.9,10 Combined, these systems enhance both the timeliness and sensitivity of early disease detection.11 Retrospective review of polio and Ebola outbreaks reported through digital surveillance channels show this enhancement of reporting time. When reports of polio emerged in Cameroon on Oct 1, 2013, ProMED and GPHIN picked up the story from the Global Polio Eradication Initiative and published reports on Oct 24. The official WHO report was not published until Nov 21; 51 days after the outbreak began. Similarly, reports about polio were first made in Equatorial Guinea on Jan 19, 2014. ProMED published information on March 21, followed by a GPHIN alert
on March 27. The official WHO report was published on April 17; 88 days after reports first occurred. WHO declared the polio epidemic a public health emergency of international concern on May 5, 2014. For all seven WHO-reported polio outbreaks in 2013 and 2014, digital reports preceded official reports by an average of 14·6 days (range 0–40 days). The first public notification of the Ebola outbreak was retrieved on March 14, 2014, by HealthMap from a French news website with headlines reporting of a strange fever in Macenta, Guinea. The report described the deaths of eight people, and symptoms of anal and nasal bleeding that resembled Lassa fever. On March 22, WHO and the Sierra Leone Ministry of Health released a statement that Ebola might have spread into Sierra Leone; official case information was released on March 23. WHO declared the Ebola outbreak a public health emergency of international concern on Aug 8, 2014. As shown with polio and Ebola outbreak detection, digital surveillance could improve early detection and response to public health emergencies of international concern, and should be viewed as an essential complement to the available formal surveillance structure. Encouragement of countries to use digital surveillance should be a global public health priority. *Aranka Anema, Sheryl Kluberg, Kumanan Wilson, Robert S Hogg, Kamran Khan, Simon I Hay, Andrew J Tatem, John S Brownstein Department of Pediatrics, Harvard Medical School, Harvard University, Boston, MA, USA (AA, SK, JSB); Children’s Hospital Informatics Program at the Harvard–Massachusetts Institute of Technology, Division of Health Sciences and Technology, Boston, MA, USA (AA, SK, JSB); Division of International Nutrition, Department of Food, Nutrition and Health, Faculty of Land and Food Systems University of British Columbia, Vancouver, BC, Canada (AA); Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada (KW); Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada (RSH); British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada (RSH); Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada (KK); Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, UK (SIH); Fogarty International Center, National Institutes of Health, Bethesda, MD, USA (SIH, AJT); Department of Geography and Environment, University of Southampton, Highfield, Southampton, UK (AJT); and Flowminder Foundation, Stockholm, Sweden (AJT) [email protected]
www.thelancet.com/infection Vol 14 November 2014
Comment
JSB reports funding from Epidemico outside the submitted work. All other authors declare no competing interests. This work was supported by the National Library of Medicine, National Institutes of Health (R01LM010812), Bill & Melinda Gates Foundation (OPP1093011), and the Canadian Institutes of Health Research. AA and KK acknowledge support from the Canadian Institutes of Health Research. SIH is funded by a Senior Research Fellowship from the Wellcome Trust (095066), which also supports AM, and a grant from the Bill & Melinda Gates Foundation (OPP1093011). AJT is supported by funding from National Institutes of Health and National Institute of Allergy and Infectious Diseases (U19AI089674) and the Bill & Melinda Gates Foundation (OPP1106427 and OPP1032350). 1
2
3
4
WHO. Fifty-eighth World Health Assembly Resolution WHA58.3: Revision of the International Health Regulations. 2005. http://www.who. int/ipcs/publications/wha/ihr_resolution.pdf (accessed Sept 30, 2014). WHO. WHO’s Interim Guidance for the Use of Annex 2 of the IHR (2005): Decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern. 2008. http://www.who.int/ihr/Annex_2_Guidance_en.pdf (accessed Sept 30, 2014). Chrétien JP, Yingst SL, Thompson D. Building public health capacity in Afghanistan to implement the International Health Regulations: a role for security forces. Biosecur Bioterror 2010; 8: 277–85. Webster P. Reconstruction efforts in Iraq failing health care Lancet 2009; 373: 617–20.
5
6
7
8
9 10
11
Anema A, Druyts E, Hollmeyer HG, Hardiman MC, Wilson K. Evaluation of the functioning of the International Health Regulations (2005) annex 2. Global Health 2012; 8: 1. Olowokure B, Pooransingh S, Tempowski J, Palmer S, Meredith T. Global surveillance for chemical incidents of international public health concern. Bull World Health Organ 2005; 83: 928–34. Barboza P, Vaillant L, Mawudeku A, et al. Early alerting reporting project of the global health security initiative. evaluation of epidemic intelligence systems integrated in the early alerting and reporting project for the detection of A/H5N1 influenza events. PLoS One 2013; 8: 1–9. Brownstein JS, Freifeld CC, Madoff LC. Digital disease detection— harnessing the Web for public health surveillance. N Engl J Med 2009; 360: 2153–55. Hulth A, Gustaf R, Annika L. Web queries as a source for syndromic surveillance. PLoS One 2009; 4: e4378. Freifeld CC, Chunara R, Mekaru SR, et al. Participatory epidemiology: use of mobile phones for community-based health reporting. PLoS Med 2010; 7: e1000376. Barboza P, Vaillant L, Le Strat Y, et al. Factors influencing performance of internet-based biosurveillance systems used in epidemic intelligence for early detection of infectious diseases outbreaks. PLoS One 2014; 9: e90536.
Investment in pneumonia and pneumococcal research
www.thelancet.com/infection Vol 14 November 2014
in 2013 rated the threat level for S pneumoniae as severe.5 In the UK, during the period 1997–2010, investments for antimicrobial resistance seem historically inadequate,6 despite the concerns and urgency of the problem; however, focus seems to be increasing in this important area.5,7 An important factor in the assessment of investments in research is the stage of research and its position along the research and development pipeline. Our analysis shows that in the UK, pneumonia research is almost entirely preclinical (figure), accounting for 87·5% of the total funding for pneumonia-related research. Conversely, 5·0
4·0 Total funding (£, millions)
The worldwide burden of pneumonia is high—the disease caused 1·2 million deaths in 2010, mostly in children younger than 2 years.1 In the same year, at least 76·7 million disability-adjusted life-years (DALYs) were attributed to pneumonia and pneumococcal disease,2 although DALYs are inevitably increased in diseases that mostly affect young children. Infections of the lower respiratory tract (many of which are probably pneumonia-related) were the single largest cause of worldwide DALYs in children younger than 1 year.2 Streptococcus pneumoniae is the most common cause of pneumonia, although other bacteria, viruses, and fungi are also important sources of infection. The Research Investments in Global Health study3 analysed public and philanthropic infectious disease research funding awarded to UK institutions, and reported data about funding for respiratory infectious diseases.4 The total research investment in pneumonia (£27·2 million) relative to the 2010 burden was £0·58 per DALY, which is substantially lower than that for tuberculosis (£3·14) and influenza (£4·16), and also lower than investments for all other respiratory infectious diseases (where data were available) for which effective vaccinations are available and widely used, except for measles and pertussis. A threat report on antimicrobial resistance released by the US Centers for Disease Control and Prevention (CDC)
For more on research investments in globabl health see http:// www. researchinvestments.org
Preclinical Product development Phase 1–3 Implementation
3·0
2·0
1·0
0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year
Figure: Total public and philanthropic funding in pneumonia-related research in 1997–2010, including breakdown of stage of research
1037