posts: 27064

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                        "text": "There are a number of ways we could reduce the number of children dying from pneumonia, including eliminating the major risk factors such as ",
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                        "url": "https://ourworldindata.org/hunger-and-undernourishment",
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                                "text": "undernutrition",
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                        "text": " and ",
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                        "url": "https://ourworldindata.org/indoor-air-pollution",
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                                "text": "air pollution",
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                        "text": ", and providing better ",
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                        "url": "https://ourworldindata.org/grapher/pneumonia-careseeking",
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                                "text": "access to treatment",
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                        "text": ".",
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                        "text": "But we have another highly effective intervention: a ",
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                        "url": "https://ourworldindata.org/vaccination",
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                                "text": "vaccine",
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                        "text": " against the major pathogen responsible for pneumonia in children. ",
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                                "text": "Streptococcus pneumoniae ",
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                        "text": "is the leading cause of pneumonia in children under 5 \u2014 it was responsible for 52% of all fatal pneumonia cases in children in 2016.{ref}Troeger, C., Blacker, B., Khalil, I. A., Rao, P. C., Cao, J., Zimsen, S. R., ... & Adetifa, I. M. O. (2018). ",
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                        "url": "https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(18)30310-4/fulltext",
                        "children": [
                            {
                                "text": "Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990\u20132016: a systematic analysis for the Global Burden of Disease Study 2016.",
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                        "children": [
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                                "text": " The Lancet Infectious Diseases",
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                        "text": ", ",
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                                "text": "18",
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                        "text": "(11), 1191-1210.{/ref} Pneumococcal vaccines are vaccines that target ",
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                        "children": [
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                                "text": "S. pneumoniae",
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                        "text": " bacteria. Here we look at their effectiveness and how we can maximise the number of children they save.",
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                "text": [
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                        "text": "The coverage of pneumococcal vaccines is still low",
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                        "text": "Since the World Health Organisation (WHO) started recommending including pneumococcal vaccines in national immunisation programmes for children in 2007, there has been a progressive increase in the number of countries using the vaccine. You can see the uptake in the vaccine across the world using the \u2018play\u2019 button on the map below. ",
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                        "text": "But the coverage of pneumococcal vaccines is still low in many countries. In India and Nigeria \u2013 the two countries with the ",
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                        "url": "https://ourworldindata.org/grapher/number-of-deaths-from-pneumonia-in-children-under-5",
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                                "text": "greatest number",
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                        "text": " of childhood deaths from pneumonia in 2019 \u2013 only 44% and 58% of one-year-olds are vaccinated, respectively.\u00a0 ",
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                        "text": "In 2018, less than half (47%) of one-year-olds in the world received the full course of pneumococcal vaccination. This means that 55 million children who could be protected by the vaccine are still not vaccinated against it\u00a0\u2014 an appallingly high number for a vaccine that not only protects from pneumonia, the leading cause of childhood death, but also a range of other diseases (as discussed below).{ref}Who.int. (2019) \u2013 ",
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                        "url": "https://www.who.int/news-room/fact-sheets/detail/immunization-coverage",
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                                        "text": "Immunization coverage",
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                        "text": ". [online] [Accessed 10 Sep. 2019]. ",
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                        "url": "http://view-hub.org/viz/",
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                                "text": "http://view-hub.org/viz/",
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                        "text": " (Go to PCV \u2014>\u00a0 PCV - Vaccine Access \u2014> Children without Access){/ref}",
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                "url": "https://ourworldindata.org/grapher/share-of-one-year-olds-who-received-the-final-dose-of-pneumococcal-vaccine",
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                "text": [
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                        "text": "How do pneumococcal vaccines work?",
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                                "text": "Streptococcus pneumonia",
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                        "text": ", often simply referred to as pneumococcus, is a bacterium that is often found in the upper respiratory tract of healthy people. Generally, the bacterium is harmless or causes milder illnesses such as bronchitis, sinusitis, and ear infections. Pneumococcal vaccines are effective against these milder illnesses as well, but importantly also protects from what is called pneumococcal invasive disease (PID). PID occurs when the pneumococcus moves from colonizing the upper respiratory tract to colonizing sites that are normally sterile, such as blood, cerebrospinal fluid or pleural cavity (fluid-filled space surrounding the lungs).{ref}Hanada, S., Pirzadeh, M., Carver, K. Y., & Deng, J. C. (2018). ",
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                    {
                        "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6250824/",
                        "children": [
                            {
                                "text": "Respiratory Viral Infection-Induced Microbiome Alterations and Secondary Bacterial Pneumonia.",
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                        "children": [
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                                "text": "Frontiers in immunology",
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                        "text": ", ",
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                                "text": "9",
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                        "text": ", 2640.{/ref} Bacterial invasion leads to life-threatening diseases such as sepsis, meningitis and severe pneumonia.\u00a0",
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                        "text": "There are two types of pneumococcal vaccines available: conjugated polysaccharide pneumococcal vaccine (PCV) and non-conjugated polysaccharide pneumococcal vaccine (PPSV). Both vaccines are designed to elicit immune responses against multiple serotypes of pneumococcus, which are defined by the different immune responses to the sugars found on the bacterial surface.{ref}Song, J. Y., Nahm, M. H., & Moseley, M. A. (2013). ",
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                        "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546102/",
                        "children": [
                            {
                                "text": "Clinical implications of pneumococcal serotypes: invasive disease potential, clinical presentations, and antibiotic resistance",
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                        "text": ". ",
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                        "children": [
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                                "text": "Journal of Korean medical science",
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                        "text": ", ",
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                                "text": "28",
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                        "text": "(1), 4-15.{/ref} To be broadly effective, the vaccines need to protect against a certain number of these pneumococcal serotypes, but it is not necessary to include all possible serotypes because only a limited subset is responsible for 70%-80% of invasive pneumococcal disease.{ref}The number of serotypes included in the vaccine is generally indicated in its name, e.g. PCV13 is pneumococcal conjugate vaccine effective against 13 bacterial serotypes. Vaccines including progressively more serotypes have been introduced over the years, PCV7 was introduced in 2000 and today the most commonly used PCV13 was introduced in 2010.",
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                        "text": "Hausdorff, W. P., Feikin, D. R., & Klugman, K. P. (2005). ",
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                    {
                        "url": "https://www.ncbi.nlm.nih.gov/pubmed/15680778/",
                        "children": [
                            {
                                "text": "Epidemiological differences among pneumococcal serotypes.",
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                        "children": [
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                                "text": "The Lancet infectious diseases",
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                        "text": ", ",
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                                "text": "5",
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                        "text": "(2), 83-93.{/ref} However, as we\u2019ll discuss later, this variety of different pneumococcal serotypes is important to keep in mind because as vaccine coverage increases we may see a replacement of the vaccine-included serotypes with the less dominant ones, which will mean new vaccine versions will be required.\u00a0\u00a0",
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                        "text": "While there are two types of pneumococcal vaccines available, for children under two years old only the conjugated (i.e. PCV) vaccines are recommended because the non-conjugated versions (i.e. PPSV) are not effective at such a young age.{ref}The current non-conjugate vaccine, PPSV23, is generally only given to adults or as a single dose following two immunisations with PCV13 in children older than 2.",
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                        "text": "Golos, M., Eliakim\u2010Raz, N., Stern, A., Leibovici, L., & Paul, M. (2016). ",
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                    },
                    {
                        "url": "https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012306/full",
                        "children": [
                            {
                                "text": "Conjugated pneumococcal vaccine versus polysaccharide pneumococcal vaccine for prevention of pneumonia and invasive pneumococcal disease in immunocompetent and immunocompromised adults and children.",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-link"
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                        "children": [
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                                "text": "Cochrane Database of Systematic Reviews",
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                        "text": ", (8).{/ref}\u00a0",
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                "text": [
                    {
                        "text": "How effective are pneumococcal vaccines?",
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                        "text": "In clinical trials PCV has shown 80% efficacy in reducing invasive pneumococcal disease caused by the bacterial serotypes included in the vaccine formulation. Vaccinated children are 27% less likely to be diagnosed with pneumonia and 11% less likely to die from it.{ref}The 27% refers to X-ray-defined cases of pneumonia. For clinically defined pneumonia, a less accurate diagnosis than X-ray-defined cases, the number is 6%. Both of these indicators refer to cases of pneumonia caused by any pathogen not only pneumococcus.\u00a0\u00a0Lucero, M. G., Dulalia, V. E., Nillos, L. T., Williams, G., Parre\u00f1o, R. A. N., Nohynek, H., ... & Makela, H. (2009). ",
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                        "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464899/",
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                            {
                                "text": "Pneumococcal conjugate vaccines for preventing vaccine\u2010type invasive pneumococcal disease and X\u2010ray defined pneumonia in children less than two years of age",
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                        "text": ". ",
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                        "children": [
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                                "text": "Cochrane Database of Systematic Reviews",
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                        "text": ", (4).{/ref} ",
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                        "text": "Several studies have attempted to estimate how many lives PCV vaccination has saved and could possibly save. One ",
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                    {
                        "children": [
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                                "text": "Lancet ",
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                        "text": "study concluded that between 2000 and 2015, in 120 countries the number of childhood deaths caused by pneumococcus fell from 600,000 to 294,000 \u2014 a decline of 54%. Most of this decline was attributed to the PCV vaccines: over this period, it\u2019s estimated these vaccines saved the lives of 250,000 children. The majority of these deaths would have been caused by pneumonia, but the vaccine also prevented deaths from pneumococcal meningitis and other diseases.{ref}Wahl, B., O'Brien, K. L., Greenbaum, A., Majumder, A., Liu, L., Chu, Y., ... & Rudan, I. (2018). ",
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                    {
                        "url": "https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30247-X/fulltext",
                        "children": [
                            {
                                "text": "Burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in the era of conjugate vaccines: global, regional, and national estimates for 2000\u201315.",
                                "spanType": "span-simple-text"
                            }
                        ],
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                        "children": [
                            {
                                "text": " The Lancet Global Health",
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                        "spanType": "span-italic"
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                    {
                        "text": ", ",
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                        "children": [
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                                "text": "6",
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                        "text": "(7), e744-e757.{/ref}\u00a0",
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                "text": [
                    {
                        "text": "How many child deaths could be averted by pneumococcal vaccines?",
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                        "text": "The chart shows how estimates of the potential impact of the pneumococcal vaccine.",
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                        "text": "It is based on a recent study published in ",
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                        "children": [
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                                "text": "The Lancet Global Health",
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                        "text": " journal, which calculated that if the PCV vaccine coverage would reach at least the levels of the ",
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                    {
                        "url": "https://ourworldindata.org/grapher/share-of-children-immunized-dtp3",
                        "children": [
                            {
                                "text": "vaccination against diphtheria, tetanus and pertussis",
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                        "text": " (DTP3), the lives of 399,000 children under 5 could be saved.{ref}Chen, C., Liceras, F. C., Flasche, S., Sidharta, S., Yoong, J., Sundaram, N., & Jit, M. (2019). ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "url": "https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30422-4/fulltext",
                        "children": [
                            {
                                "text": "Effect and cost-effectiveness of pneumococcal conjugate vaccination: a global modelling analysis.",
                                "spanType": "span-simple-text"
                            }
                        ],
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                    {
                        "children": [
                            {
                                "text": " The Lancet Global Health",
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                            }
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                        "spanType": "span-italic"
                    },
                    {
                        "text": ", ",
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                        "children": [
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                                "text": "7",
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                        "text": "(1), e58-e67.{/ref} Additionally the researchers estimate that 54.6 million pneumonia episodes annually could be averted.",
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                        "text": "These number estimate the impact of the PCV vaccination relative to a world without that vaccine \u2013 since the vaccine is already used it means that some of these lives are already being saved by the PVC vaccination. However, in many countries ",
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                        "url": "https://ourworldindata.org/grapher/diphtheria-tetanus-pertussis-vaccine-vs-pneumococcal-vaccine-coverage",
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                                "text": "PCV vaccination rates still fall far below the DTP3 rates",
                                "spanType": "span-simple-text"
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                        ],
                        "spanType": "span-link"
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                        "text": ", making clear that we still haven\u2019t used the pneumococcal vaccine to its full potential.",
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                "text": [
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                        "text": "What can we do to improve the coverage and effectiveness of\u00a0 pneumococcal vaccines?",
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                        "text": "A continued increase in immunization coverage and the introduction of PCV vaccines into countries which don\u2019t yet use them is important if we want to make use of the full potential of pneumococcal vaccines.\u00a0",
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                        "text": "PCV vaccines are amongst the most expensive vaccines in national immunisation programmes. The price ranges from $3.05 per dose in GAVI{ref}\u00a0GAVI (Global Alliance for Vaccines and Immunisation) is a non-profit organisation that provides access to vaccination programs for low-income countries by providing financial support and individual expertise.{/ref} supported low-income countries to $169 in high-income countries such as the United States.{ref}O'Brien, K. L. (2018). ",
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                    {
                        "url": "https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30684-9/fulltext?elsca1=etoc",
                        "children": [
                            {
                                "text": "When less is more: how many doses of PCV are enough?.",
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                        "children": [
                            {
                                "text": " The Lancet Infectious Diseases",
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                        "spanType": "span-italic"
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                        "text": ", ",
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                        "children": [
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                                "text": "18",
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                        "text": "(2), 127-128.{/ref} For low-middle-income countries who are transitioning from GAVI support the increasing future costs of vaccination place a considerable strain on national healthcare budgets.{ref}For example Kenya has recently entered a transition phase during which it will pay a larger and larger portion of the PCV vaccine cost. By 2027 Kenya will have to pay the full $9 price for a three-dose course child vaccination. The 2016 ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "url": "https://databank.worldbank.org/Kenya-healthcare-per-capita-/id/58f0a890",
                        "children": [
                            {
                                "text": "per capita healthcare expenditure in Kenya",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-link"
                    },
                    {
                        "text": " was around $66 (5% of the GDP), clearly $9 per child is not a trivial cost.",
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                    }
                ],
                "parseErrors": []
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            {
                "type": "text",
                "value": [
                    {
                        "text": "Simonsen, L., van Wijhe, M., & Taylor, R. (2019). ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "url": "https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30562-X/fulltext",
                        "children": [
                            {
                                "text": "Are expensive vaccines the best investment in low-income and middle-income countries?",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-link"
                    },
                    {
                        "text": ". ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "children": [
                            {
                                "text": "The Lancet Global Health",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-italic"
                    },
                    {
                        "text": ", ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "children": [
                            {
                                "text": "7",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-italic"
                    },
                    {
                        "text": "(5), e548-e549.",
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                    }
                ],
                "parseErrors": []
            },
            {
                "type": "text",
                "value": [
                    {
                        "text": "Ojal, J., Griffiths, U., Hammitt, L. L., Adetifa, I., Akech, D., Tabu, C., ... & Flasche, S. (2019). ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "url": "https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30562-X/fulltext",
                        "children": [
                            {
                                "text": "Sustaining pneumococcal vaccination after transitioning from Gavi support: a modelling and cost-effectiveness study in Kenya.",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-link"
                    },
                    {
                        "children": [
                            {
                                "text": " The Lancet Global Health",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-italic"
                    },
                    {
                        "text": ", ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "children": [
                            {
                                "text": "7",
                                "spanType": "span-simple-text"
                            }
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                        "spanType": "span-italic"
                    },
                    {
                        "text": "(5), e644-e654.{/ref}\u00a0",
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                    }
                ],
                "parseErrors": []
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            {
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                "value": [
                    {
                        "text": "But given the high burden of pneumococcal diseases, even at high prices, PCV vaccines are considered to be cost-effective, with an estimated return of investment in low- and middle-income countries of around 3.{ref}The return of investment was estimated for a projected coverage for individual countries for the decade between 2011 and 2020. It means that the economic benefits (as measured by the costs of vaccination program subtracted from the reduced costs of treatment and productivity loss) of using the vaccine are 3 times higher than no vaccine use.\u00a0",
                        "spanType": "span-simple-text"
                    },
                    {
                        "spanType": "span-newline"
                    },
                    {
                        "text": "To reduce costs, some countries may also consider switching to a two rather than three dose immunization schedule, but more research on the effectiveness of this schedule in different countries is needed. See O'Brien et al. (2018) reference.",
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                ],
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                "type": "text",
                "value": [
                    {
                        "text": "Nakamura, M. M., Tasslimi, A., Lieu, T. A., Levine, O., Knoll, M. D., Russell, L. B., & Sinha, A. (2011). ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "url": "https://academic.oup.com/inthealth/article-lookup/doi/10.1016/j.inhe.2011.08.004",
                        "children": [
                            {
                                "text": "Cost effectiveness of child pneumococcal conjugate vaccination in middle-income countries.",
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                        ],
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                    },
                    {
                        "children": [
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                                "text": "International health",
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                        "text": ", ",
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                        "children": [
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                                "text": "3",
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                    {
                        "text": "(4), 270-281.",
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            {
                "type": "text",
                "value": [
                    {
                        "text": "Ozawa, S., Clark, S., Portnoy, A., Grewal, S., Brenzel, L., & Walker, D. G. (2016). ",
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                    },
                    {
                        "url": "https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.1086?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed",
                        "children": [
                            {
                                "text": "Return on investment from childhood immunization in low-and middle-income countries, 2011\u201320.",
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                        ],
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                    },
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                        "children": [
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                                "text": "Health Affairs",
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                        "text": ", ",
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                        "children": [
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                                "text": "35",
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                        "text": "(2), 199-207.",
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            {
                "type": "text",
                "value": [
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                        "text": "Center, I. V. A. (2017). ",
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                    },
                    {
                        "url": "https://www.jhsph.edu/ivac/wp-content/uploads/2018/05/PCVEvidenceBase-Jan2017.pdf",
                        "children": [
                            {
                                "text": "The evidence base for pneumococcal conjugate vaccines (PCVs): data for decision-making around PCV use in childhood.",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-link"
                    },
                    {
                        "children": [
                            {
                                "text": "Baltimore (MD): Johns Hopkins University",
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                    {
                        "text": ".",
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            {
                "type": "text",
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                        "text": "Goldblatt, D., Southern, J., Andrews, N. J., Burbidge, P., Partington, J., Roalfe, L., ... & Snape, M. D. (2018). ",
                        "spanType": "span-simple-text"
                    },
                    {
                        "url": "https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30654-0/fulltext",
                        "children": [
                            {
                                "text": "Pneumococcal conjugate vaccine 13 delivered as one primary and one booster dose (1+ 1) compared with two primary doses and a booster (2+ 1) in UK infants: a multicentre, parallel group randomised controlled trial.",
                                "spanType": "span-simple-text"
                            }
                        ],
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                    },
                    {
                        "children": [
                            {
                                "text": "The Lancet Infectious Diseases",
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                        "text": ", ",
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                                "text": "18",
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                        "text": "(2), 171-179.",
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                "type": "text",
                "value": [
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                        "text": "O'Brien, K. L. (2018). ",
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                        "url": "https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30684-9/fulltext?elsca1=etoc",
                        "children": [
                            {
                                "text": "When less is more: how many doses of PCV are enough?.",
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                        "children": [
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                                "text": " ",
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                        "children": [
                            {
                                "text": "The Lancet Infectious Diseases",
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                    },
                    {
                        "text": ", ",
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                        "children": [
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                                "text": "18",
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                        "text": "(2), 127-128.{/ref}\u00a0",
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                        "text": "PCV vaccines include a limited subset of possible pneumococcal serotypes. The distribution of pneumococcal serotypes is known to vary between countries and PCV vaccines include the ones that are most common globally. ",
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                        "text": "Which non-vaccine serotypes are most common in a particular country, may affect the potential for a particular vaccine\u2019s impact. However, not all countries collect data on serotype distribution, and an assessment of the potential impact is therefore compromised.{ref}Adegbola, R. A., DeAntonio, R., Hill, P. C., Roca, A., Usuf, E., Hoet, B., & Greenwood, B. M. (2014). ",
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                    },
                    {
                        "url": "https://www.ncbi.nlm.nih.gov/pubmed/25084351",
                        "children": [
                            {
                                "text": "Carriage of Streptococcus pneumoniae and other respiratory bacterial pathogens in low and lower-middle income countries: a systematic review and meta-analysis",
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                        "text": ". ",
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                                "text": "PloS one",
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                        "text": ", ",
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                                "text": "9",
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                        "text": "(8), e103293.{/ref} {ref}Megiddo, I., Klein, E., & Laxminarayan, R. (2018). ",
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                    },
                    {
                        "url": "https://gh.bmj.com/content/3/3/e000636",
                        "children": [
                            {
                                "text": "Potential impact of introducing the pneumococcal conjugate vaccine into national immunisation programmes: an economic-epidemiological analysis using data from India.",
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                        "children": [
                            {
                                "text": " BMJ global health",
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                        "text": ", ",
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                        "text": "(3), e000636.{/ref} {ref}Johnson, H. L., Deloria-Knoll, M., Levine, O. S., Stoszek, S. K., Hance, L. F., Reithinger, R., ... & O'Brien, K. L. (2010). ",
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                    },
                    {
                        "url": "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000348",
                        "children": [
                            {
                                "text": "Systematic evaluation of serotypes causing invasive pneumococcal disease among children under five: the pneumococcal global serotype project.",
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                            }
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                                "text": "PLoS medicine",
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                        "text": ", ",
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                        "text": "(10), e1000348.{/ref} Notably, since the PCV vaccine was introduced, there has been a rise in pneumococcal invasive disease incidences caused by the less common serotypes. This suggests that, by reducing the prevalence of vaccine-included serotypes, the vaccine unintentionally provides space for non-vaccine serotypes, against which it works less well.{ref}World Health Organization. (2010). ",
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                    },
                    {
                        "url": "https://www.who.int/wer/2010/wer8543.pdf?ua=1",
                        "children": [
                            {
                                "text": "Changing epidemiology of pneumococcal serotypes after introduction of conjugate vaccine: July 2010 report.",
                                "spanType": "span-simple-text"
                            }
                        ],
                        "spanType": "span-link"
                    },
                    {
                        "children": [
                            {
                                "text": " Weekly Epidemiological Record [Relev\u00e9 \u00e9pid\u00e9miologique hebdomadaire",
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                            }
                        ],
                        "spanType": "span-italic"
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                    {
                        "text": "], ",
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                    {
                        "children": [
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                                "text": "85",
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                        "text": "(43), 434-436.{/ref} This means that the vaccine's effectiveness may decrease over time, if the serotype formulation of PCV is not continually reevaluated. In the future, new versions of pneumococcal vaccines may be needed that work better independently of the bacterial serotype. Such vaccines are already in development.{ref}Pichichero, M. E. (2017). ",
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                    },
                    {
                        "url": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277969/",
                        "children": [
                            {
                                "text": "Pneumococcal whole-cell and protein-based vaccines: changing the paradigm",
                                "spanType": "span-simple-text"
                            }
                        ],
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                    },
                    {
                        "text": ". ",
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                    {
                        "children": [
                            {
                                "text": "Expert review of vaccines",
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                        "text": ", ",
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                        "children": [
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                                "text": "16",
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                        ],
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                    },
                    {
                        "text": "(12), 1181-1190.{/ref} {ref}Ginsburg, A. S., Nahm, M. H., Khambaty, F. M., & Alderson, M. R. (2012). Issues and challenges in the development of pneumococcal protein vaccines. Expert review of vaccines, 11(3), 279-285{/ref} ",
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