Pneumonia is a frequent complication, and the risk of death during recovery is seven times higher than for non-malnourished children. They are also more likely to have missed routine vaccines and are the children we know least about when it comes to how well vaccines work. Sydney ID researcher Dr Nick Fancourt,  a paediatrician at The Children's Hospital at Westmead and a Sydney Horizon Fellow in Sydney Medical School, is trying to change that. His fellowship focuses on immunology and pneumonia in malnourished children, with much of the work based in Timor-Leste.

At the centre of it is OPTIMAL (Opportunistic Pneumococcal Immunisation Trial in Malnutrition), an NHMRC-funded randomised trial and the first vaccine clinical trial ever conducted in Timor-Leste.

When a severely malnourished child is admitted to hospital, it is often the best opportunity to catch them up on missed vaccines. But malnutrition causes an immune dysfunction that can affect vaccine responses. Pneumococcal conjugate vaccines (PCVs) are an effective part of global pneumonia control efforts, but a lack of evidence has prevented immunisation strategies tailored to malnourished children. Nick leads the OPTIMAL trial to provide this evidence. The trial is administered through the Menzies School of Health Research in collaboration with the Murdoch Children’s Research Institute and University of Western Australia, and Timor-Leste’s National Referral Hospital and National Health Laboratory.

The trial builds on work with Timorese partners that began when Nick moved to Dili in 2018. Hospital surveillance led by Nick's team at the National Referral Hospital showed frequent admissions for malnutrition and the high burden of pneumonia among them. That work also contributed to the evidence base for Timor-Leste's decision to introduce a PCV into its national immunisation program in 2023. Timor-Leste became the first country with no previous PCV use to start routine infant vaccination with Pneumosil, a lower-cost PCV that has made vaccination in low-resource settings more achievable. The team ran community carriage surveys before the vaccine was introduced and again two years later, to give real-world data on Pneumosil that other countries can use. A Sydney Southeast Asia Centre Ignition Grant has subsequently supported work on how to lift PCV coverage and reach high-risk groups.

"Malnourished children are the ones pneumonia hits hardest, and they've been left out of most vaccine research," Nick says. "We need to know whether the opportunity to vaccinate them in hospital actually protects them, or whether other strategies are needed."

Much of the work is led by Timorese researchers including Dr Nevio Sarmento, who completed his PhD under Nick's supervision and is now President of the Timor-Leste National Public Health Institute. This year the team had five pieces of work presented at the International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD-14) in Copenhagen, where Nick gave the opening plenary.

Closer to home, Nick is a member of Sydney ID's Vaccines and Immunisation Leadership Group. At Westmead he is an investigator on a study that that monitors pneumococcal serotypes carried by children hospitalised with pneumonia after Australia’s move to a 20-valent PCV, and a clinical trial of steroid use in severe pneumonia. He is also part of a new NHMRC Centre of Research Excellence on innovative solutions for pneumococcal vaccine.

Discover more about Dr Nick Fancourt's research in his #WeAreSydneyID video ⬇️