Diarrhoea and pneumonia – regarded as relatively minor illnesses for most people living in high-income countries – are together the leading causes of death for children worldwide. In 2011, they were responsible for two million deaths of children under five, despite the fact that they can be treated and prevented at relatively low cost.
A new Lancet Series on childhood diarrhoea and pneumonia, from a consortium of academics and public health professionals led by Professor Zulfiqar Bhutta of Aga Khan University in Pakistan, provides the evidence for integrated global action on childhood diarrhoea and pneumonia, including which interventions can effectively treat and prevent them, and the financial cost of ending preventable deaths from childhood diarrhoea and pneumonia by 2025.
The Series is published to coincide with the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD), a UNICEF and WHO publication which provides a guide for governments and their partners to plan integrated approaches for the prevention and control of pneumonia and diarrhoea.
The Series will be launched in collaboration with Aga Khan University at a special event at the Royal College of Paediatrics and Child Health in London (9:00am – 12:00pm) on Friday April 12. The Series booklet and an Executive Summary will be available at the launch, and journalists are invited to register at: http://childsurvival.eventbrite.co.uk/. The event programme is available at http://download.thelancet.com/flatcontentassets/pdfs/TLCPD.pdf.
Series 1: Diarrhoea and pneumonia responsible for two million child deaths in 2011
Pneumonia and diarrhoea account for over a quarter (28•5%) of all deaths in children worldwide, and were responsible for around two million child deaths in 2011, according to new estimates in the first Series paper. Diarrhoea caused around 700 000 deaths in children under five, and pneumonia 1•3 million deaths in the same age group. Over two thirds (72%) of deaths from diarrhoea and over four fifths (81%) of pneumonia deaths are in children under two years old.
The researchers found that sub-Saharan Africa and south-east Asia experienced the highest burden of these diseases, with nearly three quarters (74%) of deaths from diarrhoea and pneumonia occurring in just fifteen countries [1]. Although mortality rates from the diseases are falling in most areas, some countries are still experiencing a growing number of deaths each year, including Afghanistan, Burkina Faso, Democratic Republic of Congo, Cameroon, Chad, and Mali.
According to Professor Robert Black of Johns Hopkins University, USA, "While diarrhoea and pneumonia have very different symptoms and causes, several risk factors for the two diseases are the same, including under-nutrition, sub-optimal breastfeeding, and zinc deficiency, meaning that they can be effectively prevented and treated as part of a coordinated programme." Mass vaccination campaigns will need to play an important role, and the authors estimate that nearly a third of episodes of severe diarrhoea could be prevented by widespread vaccinations against rotavirus and cholera, with up to two thirds of pneumonia deaths thought to be vaccine preventable.
Series 2: Modest further investment could eliminate diarrhoea deaths in just over a decade
The second Series paper evaluates the evidence for possible preventive and therapeutic interventions against childhood diarrhoea and pneumonia, and identifies 15 key interventions [2] – including vaccinations, zinc supplementation, and breastfeeding promotion – which have the potential to save millions of children's lives. The authors estimate that if these interventions continue to be implemented at current levels in 75 Countdown countries [3], around half of all child deaths due to diarrhoea and pneumonia could be prevented by 2025, at a cost of US$3•8bn.
However, if these interventions were scaled up to 80% coverage or more, deaths from diarrhoea could be effectively eliminated (95% prevented), and around two thirds (67%) of deaths from pneumonia prevented by 2025, at a total cost of US$6•7bn – less than a quarter of the estimated cost of the 2012 London Olympics [4].
While this may seem like an ambitious target, co-authors Professors Harry Campbell and Igor Rudan of the University of Edinburgh, UK, say "Many of the interventions exist within present health systems, although their coverage and availability to poor and marginalised populations varies greatly. For instance, about four decades after findings showed the effectiveness of oral rehydration solution in population settings, global coverage rates are abysmally low. Despite persistent burden, childhood deaths from diarrhoea and pneumonia are avoidable and these interventions can save most of these avoidable deaths."
Series 3: Diarrhoea and pneumonia remain low on list of worldwide priorities, despite huge global impact
The third Series paper, by a team of researchers from Boston University School of Public Health, WHO, UNICEF, and the Clinton Health Access Initiative, presents the results of a broad consultation of health care practitioners in the field, identifying the barriers to intensifying evidence-based efforts to reduce the number of deaths from diarrhoea and pneumonia. Despite the enormous global impact of these two diseases, most public health practitioners felt that they are perceived to be low on the list of worldwide priorities, far below HIV / AIDS or malaria. Other key barriers included inadequate training and support for health workers, poor national coordination, and sporadic availability of key commodities – scarcely half of children with severe acute pneumonia receive antibiotics, while only a third of children with acute diarrhoea receive oral rehydration salts, and fewer than 1% receive zinc supplements. The authors suggest that one reason why many of the barriers identified remain, despite being relatively easily solvable problems, is that recent child survival investments in low-income and middle-income countries have favoured technically sophisticated, expensive solutions targeting specific pathogens or diagnostic challenges, at the expense of broader-based investments in health care systems. According to the authors, "The solutions to reducing childhood pneumonia and diarrhoea deaths are well within our capacity…[but] the pathway…depends on how we prioritise child survival and the investments we choose to make."
Series 4: Ending all child deaths from pneumonia and diarrhoea by 2035 is achievable
In the final Series paper, Drs Mickey Chopra of UNICEF and Elizabeth Mason of the World Health Organization (WHO), representing the Series authors, propose a "bold goal" of ending all preventable child deaths from pneumonia and diarrhoea by 2035. The authors say that this goal is achievable, but will depend on increased international awareness of the scale of the problem, strengthening leadership, and co-ordinated international action and investment. According to Series lead Professor Zulfiqar Bhutta, "The magnitude of the effort needed to eliminate preventable deaths from diarrhoea and pneumonia should not be underestimated. However, this Series and the accompanying Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea [GAPPD] provide a very clear set of priorities and actions that, if implemented, offer an unprecedented opportunity to eliminate preventable child deaths caused by these two diseases."
NOTES TO EDITORS:
[1] Afghanistan, Angola, Burkina Faso, China, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Kenya, Mali, Niger, Nigeria, Pakistan, Tanzania, and Uganda
[2] The 15 key interventions identified by the authors are: pneumococcal vaccine (for pneumonia); case management of neonatal infections; breastfeeding promotion; case management of pneumonia infections; improved water source; zinc supplementation; Hib vaccine (for pneumonia); hand washing with soap; improved sanitation; oral rehydration solution; rotavirus vaccine (for diarrhoea); hygienic disposal of children's stools; vitamin A supplementation; zinc for treatment of diarrhoea; and antibiotics for dysentery
[3] 75 Countdown countries represent those with more than 98% of the global burden of maternal, newborn and child mortality: http://www.countdown2015mnch.org/country-profiles
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The Lancet