Pneumonia and malaria are common causes of childhood morbidity and mortality in many developing countries and simple guidelines have been proposed to facilitate their diagnosis by relatively unskilled health workers. We have studied children in The Gambia attending out-patient and under-five clinics with clinically suspected pneumonia (cough or difficulty in breathing and a raised respiratory rate) during periods of high or low malaria transmission. During a period of high malaria transmission, 33% of these children had radiological evidence of pneumonia (with or without malaria parasitaemia) compared to 38% who had malaria parasitaemia, no radiological evidence of pneumonia and no other obvious cause of fever. Corresponding figures during a period of low malaria transmission were 48% and 6% respectively. The clinical overlap between pneumonia and malaria has important implications for case management strategies and evaluation of disease-specific interventions in regions in which both pneumonia and malaria are prevalent.

Nasopharyngeal carriage of pneumococci is more prevalent among young Gambian children than among adults and invasive infections are probably acquired more frequently from siblings than from parents. However, further studies are needed to confirm this hypothesis with more discriminating markers than polysaccharide serotyping.

Verbal autopsies are being used widely to describe the causes of mortality and to assess the effect of interventions against specific diseases in developing countries where many deaths occur at home. A verbal autopsy has been in use in the Upper River Division of The Gambia since 1988. In this paper we present the results of a validation study of this technique. One hundred and forty-one verbal autopsies were reviewed on two occasions by the same three physicians. In 38 (27%) of the cases, the first and subsequent diagnoses differed. In 94 children admitted to Basse Health Centre, the results of verbal autopsies were compared with the diagnoses made by a paediatrician--only 44 (47%) matched. The poor sensitivity and specificity of the verbal autopsy in this study may have been due to the confounding effect of malaria, which can be difficult to distinguish from other causes of death in this community.

About 60% of invasive pneumococcal infection in children in this community could potentially be prevented by a nine-valent pneumococcal conjugate vaccine (types 1, 4, 5, 6B, 9, 14, 18, 19F and 23) given at the ages of 2, 3 and 4 months.