Pneumonia and diarrhoea: tackling the deadliest diseases for the world’s poorest children

2,676 views

Published on

Pneumonia and diarrhoea are leading killers of the world’s youngest children, accounting for 29 per cent of deaths among children under age 5 worldwide – or more than 2 million lives lost each year. This report makes a remarkable and compelling argument for tackling pneumonia and diarrhoea, two of the leading killers of children under age five. The data in this report highlight a critically important point – children living in the poorest households are less likely than the children living in the richest households to benefit from preventive measures and, when they do become ill, to receive lifesaving treatments.

Published in: Education, Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,676
On SlideShare
0
From Embeds
0
Number of Embeds
573
Actions
Shares
0
Downloads
52
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Pneumonia and diarrhoea: tackling the deadliest diseases for the world’s poorest children

  1. 1. Pneumoniaand diarrhoeaTackling the deadliest diseasesfor the world’s poorest children
  2. 2. © United Nations Children’s Fund (UNICEF)June 2012Permission is required to reproduce any part of this publication. Permission will be freely granted toeducational or non-profit organizations. Others will be requested to pay a small fee.Please contact:Statistics and Monitoring Section – Division of Policy and StrategyUNICEFThree United Nations PlazaNew York, NY 10017USATel: 1.212.326.7000Fax: 1.212.887.7454This report will be available at <www.childinfo.org/publications>.For latest data, please visit <www.childinfo.org>.ISBN: 978-92-806-4643-6Photo credits: cover, © UNICEF/NYHQ2010-2803crop/Olivier Asselin; page vi, © UNICEF/NYHQ2004-1392/Shehzad Noorani; page 6, © UNICEF/INDA2012-00023/Enrico Fabian; page 12, © UNICEF/NYHQ2011-0796/Marco Dormino; page 19, © UNICEF/UGDA01253/Chulho Hyun; page 23, ©UNICEF/SRLA2011-0199/Olivier Asselin; page 25, © UNICEF/MLIA2010-00637/Olivier Asselin;page 29, © UNICEF/NYHQ2006-0949/Shehzad Noorani; page 31, © UNICEF/NYHQ2010-1593/Pierre Holtz; page 34, © UNICEF/INDA2010-00170/Graham Crouch; page 36, © UNICEF/INDA2010-00190/Graham Crouch; page 37, © UNICEF/NYHQ2010-3046/Giacomo Pirozzi; page 40, © ­ NICEF/ UNYHQ2012-0156/Nyani Quaryme.
  3. 3. Pneumoniaand diarrhoeaTackling the deadliest diseasesfor the world’s poorest children
  4. 4. Acknowledgements This report was prepared at UNICEF Headquar- Osman Mansoor, Colleen Murray, Thomas ters/Statistics and Monitoring Section by Emily O’Connell, Khin Wityee Oo, Heather Papowitz, White Johansson, Liliana Carvajal, Holly Newby Christiane Rudert, Jos Vandelaer, Renee Van de and Mark Young, under the direction of Tessa Weerdt and Danzhen You. Wardlaw. The authors would like to extend their grati- This report is one of UNICEF’s contributions to tude to Neff Walker, Ingrid Friberg and Yvonne the multistakeholder global initiative that has Tam ( Johns Hopkins University) for produc- been established to develop an integrated global ing the LiST modelling work under a tight action plan for prevention and control of pneu- timeline. Thanks also go to Robert Black and Li monia and diarrhoea. We thank Zulfiqar Bhutta Liu ( Johns Hopkins University) for providing for his feedback on the report and for his guid- the cause of death estimates, Richard Rhein- ance around the forthcoming global action plan. gans (University of Florida) for equity analy- sis on vaccinations, as well as Nigel Bruce and The authors acknowledge with gratitude the con- Heather Adair-Rohani (World Health Organi- tributions of the many individuals who reviewed zation) for text and data related to household this report and provided important feedback. air pollution. Special thanks to Elizabeth Mason, Cynthia Bos- chi-Pinto, Olivier Fontaine, Shamim Qazi and Further thanks to Robert Jenkins, Mickey Cho- Lulu Muhe of the World Health Organization. pra, Werner Schultink, Sanjay Wijesekera The report also benefited from the insights of (­ NICEF), and Jennifer Bryce (Johns Hopkins U Zulfiqar Bhutta (Agha Khan University), Robert University) for their guidance and support. Black (Johns Hopkins University), Kim Mulhol- land (London School of Hygiene and Tropical Special thanks to Anthony Lake, UNICEF’s Exec- Medicine), Richard Rheingans (University of utive Director, for his vision in promoting the Florida), and Jon E Rohde (Management Sci- equity agenda, which served as the inspiration for ences for Health). this report. Overall guidance and important inputs were While this report benefited greatly from the feed- provided by numerous UNICEF staff: David back provided by the individuals named above, Anthony, Francisco Blanco, David Brown, final responsibility for the content rests with the Danielle Burke, Xiaodong Cai, Theresa Diaz, authors. Therese Dooley, Ed Hoekstra, Elizabeth Horn- Phathanothai, Priscilla Idele, Rouslan Karimov, Communications Development Incorporated pro- Chewe Luo, Rolf Luyendijk, Nune Mangasaryan, vided overall design direction, editing and layout.ii
  5. 5. ContentsExecutive summary 1 Statistical tables 1 Demographics, immunization and nutrition 541 2 Preventative measures and determinants ofPneumonia and diarrhoea pneumonia and diarrhoea 60disproportionately affect the poorest 7 3 Pneumonia treatment, by background characteristic662 4 Diarrhoea treatment, by backgroundWe know what works 11 characteristic723Prevention coverage 13 BoxesVaccination13 1.1 Cholera, on the rise, affects the mostClean home environment: water, sanitation, vulnerable people9 hygiene and other home factors 15 2.1 The importance of evidence-basedNutrition20 communication strategies for child survival 12Co-morbidities22 3.1 Disparities in vulnerability and access reduce the impact of new vaccines 144 3.2 The importance of improved breastfeedingTreatment coverage 24 practices for child survival 21Community case management 24 4.1 The importance of integrated community caseTreatment for suspected pneumonia 25 management strategies 24Diarrhoea treatment 30 4.2 Diarrhoea treatment recommendations 32 5.1 Focus on the poorest children­– ­ he example t5 of Bangladesh39Estimated children’s lives saved by scaling 6.1 Global action plan for pneumonia and diarrhoea 41up key interventions in an equitable way 386 FiguresPneumonia and diarrhoea: a call to action 1.1 Pneumonia and diarrhoea are among theto narrow the gap in child survival 41 leading killers of children worldwide 7 1.2 Nearly 90 per cent of child deaths due toAnnex 1 pneumonia and diarrhoea occur in sub-SaharanAction plans for pneumonia and Africa and South Asia 8diarrhoea control43 1.3 Different patterns of child deaths in high- and low‑mortality countries: Ethiopia and Germany 10Annex 2 2.1 Many prevention and treatment strategies forTechnical background 45 diarrhoea and pneumonia are identical 11 3.1 Progress in introducing PCV globally,Notes49 particularly in the poorest countries, but a ‘rich‑poor’ gap remains 13References50 3.2 Closing the ‘rich-poor’ gap in the introduction of Hib vaccine in recent years 14 3.3 Few countries use the rotavirus vaccine, which is largely unavailable in the poorest countries 15 iii
  6. 6. 3.4 Substantial ‘wealth gap’ in measles vaccine 4.6 Gaps in appropriate careseeking for suspected coverage in every region 15 childhood pneumonia exist between rural and 3.5 Most children not immunized against pertussis urban areas . . . 28 live in just 10 mostly poor and populous 4.7 . . . and across household wealth quintiles 28 countries15 4.8 Every region has shown progress in appropriate 3.6 Water, sanitation and hygiene interventions are careseeking for suspected childhood pneumonia highly effective in reducing diarrhoea morbidity over the past decade 29 among children under age 5 16 4.9 Narrowing the rural-urban gap in careseeking 3.7 Use of an improved drinking water source for suspected childhood pneumonia over the is widespread, but the poorest households past decade29 often miss out 16 4.10 Across developing countries fewer than 3.8 Most people without an improved water a third of children with suspected pneumonia source or sanitation facility live in rural areas 17 receive antibiotics 30 3.9 Worldwide, 1.1 billion people still practice open 4.11 Children in rural areas are less likely to defecation—more than half live in India 17 receive antibiotics for suspected pneumonia . . .30 3.10 The poorest households in South Asia have 4.12 . . . as are the poorest children 31 barely benefited from improvements in 4.13 The lowest recommended treatment coverage sanitation17 for childhood diarrhoea is in Middle East and 3.11 Child faeces are often disposed of in an unsafe North Africa and sub‑Saharan Africa 32 manner, further increasing the risk of diarrhoea 4.14 Modest improvement in recommended in rural areas 18 treatment for diarrhoea in sub-Saharan Africa 3.12 New data available on households with a over the past decade 33 designated place with soap and water to 4.15 UNICEF has procured some 600 million ORS wash hands18 packets since 2000 33 3.13 Young infants who are not breastfed are at 4.16 Only a third of children with diarrhoea greater risk of dying due to pneumonia or in developing countries receive ORS 33 diarrhoea21 4.17 Low use of ORS in both urban and rural 3.14 Too few infants in developing countries are areas of every region 34 exclusively breastfed 22 4.18 The poorest children often do not receive 3.15 The incidence of low-birthweight newborns ORS to treat diarrhoea 35 is concentrated in the poorest regions and 4.19 Use of ORS to treat childhood diarrhoea has countries22 changed little since 2000 36 3.16 Least developed countries lead the way in 4.20 No reduction in the rural-urban gap in use of coverage of vitamin A supplementation 23 ORS to treat childhood diarrhoea 36 4.1 Most African countries have a community case 4.21 Most children with diarrhoea continue to be management policy, but fewer implement fed but do not receive increased fluids 37 programmes on a scale to reach the children 4.22 UNICEF has procured nearly 700 million zinc most in need 25 tablets since 2006 37 4.2 Many African countries with a government 5.1 Potential declines in child deaths by scaling community case management programme up national coverage to levels in the richest report integrated delivery for malaria, households38 pneumonia and diarrhoea 26 4.3 Fewer than half of caregivers report fast or difficult breathing as signs to seek Maps immediate care26 3.1 Household air pollution from solid fuel use is 4.4 Most children with suspected pneumonia concentrated in the poorest countries 19 in developing countries are taken to an 5.1 Scaling up national coverage to the level in the appropriate healthcare provider or facility 27 richest households could substantially reduce 4.5 Boys and girls with suspected pneumonia are under‑five mortality rates in the highest burden taken to an appropriate healthcare provider or countries40 facility at similar rates 27iv
  7. 7. Tables 3.1 Undernourished children are at higher risk of1.1 Child deaths due to pneumonia and diarrhoea dying due to pneumonia or diarrhoea 20 are concentrated in the poorest regions . . . 8 4.1 Limited data suggest low use of zinc to treat1.2 . . . and in mostly poor and populous countries childhood diarrhoea 37 in these regions 9 v
  8. 8. Executive summaryThis report makes a remarkable and compelling We know what needs to be doneargument for tackling two of the leading killers Pneumonia and diarrhoea have long beenof children under age 5: pneumonia and diar- regarded as diseases of poverty and are closelyrhoea. By 2015 more than 2 million child deaths associated with factors such as poor home envi-could be averted if national coverage of cost- ronments, undernutrition and lack of accesseffective interventions for pneumonia and diar- to essential services. Deaths due to these dis-rhoea were raised to the level of the richest 20 eases are largely preventable through optimalper cent in the highest mortality countries. This breastfeeding practices and adequate nutri-is an achievable goal for many countries as they tion, vaccinations, hand washing with soap, safework towards more ambitious targets such as uni- drinking water and basic sanitation, amongversal coverage. other measures. Once a child gets sick, death is avoidable through cost-effective and life-savingPneumonia and diarrhoea are leading killers of treatment such as antibiotics for bacterial pneu-the world’s youngest children, accounting for 29 monia and solutions made of oral rehydrationper cent of deaths among children under age 5 salts for diarrhoea. An integrated approachworldwide – or more than 2 million lives lost each to tackle these two killers is essential, as manyyear (figure 1). This toll is highly concentrated in interventions for pneumonia and diarrhoea arethe poorest regions and countries and among the identical and could save countless children’smost disadvantaged children within these societ- lives when delivered in a coordinated manneries. Nearly 90 per cent of deaths due to pneumo- (figure 2).nia and diarrhoea occur in sub-Saharan Africaand South Asia. An equity approach could save more than 2 million children’s lives by 2015The concentration of deaths due to pneumo- The potential for saving lives by more equitablynia and diarrhoea among the poorest children scaling up the proper interventions is large. Mod-reflects a broader trend of uneven progress in elled estimates suggest that by 2015 more than 2reducing child mortality. Far fewer children are million child deaths due to pneumonia and diar-dying today than 20 years ago – compare 12 mil- rhoea could be averted across the 75 countrieslion child deaths in 1990 with 7.6 million in 2010, with the highest mortality burden if nationalthanks mostly to rapid expansion of basic public coverage of key pneumonia and diarrhoea inter-health and nutrition interventions, such as immu- ventions were raised to the level in the richestnization, breastfeeding and safe drinking water. 20 per cent of households in each country. InBut coverage of low-cost curative interventions this scenario child deaths due to pneumonia inagainst pneumonia and diarrhoea remains low, these countries could fall 30 per cent, and childparticularly among the most vulnerable. deaths due to diarrhoea could fall 60 per cent (figure 3). Indeed, all-cause child mortality could There is a tremendous opportunity to narrow be reduced roughly 13 per cent across these 75the child survival gap between the poorest and countries by 2015.better-off children both across and within coun-tries – and to accelerate progress towards the Mil- Bangladesh provides an important example oflennium Development Goals – by increasing in a how targeting the poorest compared with better-concerted way commitment to, attention on and off households with key pneumonia and diar-funding for these leading causes of death that rhoea interventions could result in far moredisproportionately affect the most vulnerable lives saved. Nearly six times as many children’schildren. lives could be saved in the poorest households 1
  9. 9. Figure   Pneumonia and diarrhoea are among the leading killers of children worldwide 1 Global distribution of deaths among children under age 5, by cause, 2010 Pneumonia (postneonatal) 14% Other 18% Pneumonia Pneumonia (neonatal) 4% 18% Measles 1% Meningitis 2% Other postneonatal Other neonatal 35% AIDS 2% Diarrhoea Diarrhoea (postneonatal) 10% Injuries 5% 11% Diarrhoea (neonatal) 1% Malaria 7% Other postneonatal Other neonatal 35% Other 2% Preterm birth Tetanus 1% complications 14% Congenital abnormalities 4% Sepsis and meningitis 5% Intrapartum-related events 9% Note: Undernutrition contributes to more than a third of deaths among children under age 5. Values may not sum to 100 per cent because of rounding. Source: Adapted from Liu and others 2012; Black and others 2008. (roughly 15,400) compared with the richest ones Vaccination (roughly 2,800) by scaling up key pneumonia and New vaccines against major causes of pneu- diarrhoea interventions to near universal levels monia and diarrhoea are available. Many low- (figure 4). This analysis attaches crude estimates income countries have already introduced the to a well established understanding: target the Haemophilus influenzae type b vaccine, a clear poorest children with key pneumonia and diar- success of efforts to close the ‘rich-poor’ gap in rhoea interventions to achieve greater child sur- vaccine introduction – exemplifying the possi- vival impact. bility of overcoming gross inequalities if there is a focused equity approach with funding, global Are the children at the greatest risk of and national leadership and demand creation. pneumonia or diarrhoea reached with Pneumococcal conjugate vaccines are increas- key interventions? ingly available, and there is promise of greater This report is one of the most comprehen- access to rotavirus vaccine as part of comprehen- sive assessments to date of whether children at sive diarrhoeal control strategies in the poorest the greatest risk of pneumonia and diarrhoea countries in the near future. Nonetheless, dispar- are reached with key interventions. And the ities in access to vaccines exist within countries results are a mix of impressive successes and lost and could reduce vaccines’ impact (figure 5). opportunities. Reaching the most vulnerable children, who are2
  10. 10. Figure  Many prevention and treatment strategies for diarrhoea and pneumonia are identical 2 Diarrhoea Pneumonia P r e v e n t i o n Vaccination: Adequate nutrition for Vaccination: rotavirus, cholera, mothers and children PCVa, Hibb, pertussis   typhoid  Breastfeeding promotion and support Reduced household air Safe water and improved pollution sanitation Measles vaccination   Micronutrient supplementation (such as zinc, vitamin A) Hand washing with soap Prevention and treatment of co-morbidities (such as HIV)   Tr e a t m e n t Low-osmolarity ORS, zinc Improved care-seeking behaviour Antibiotics for pneumonia and continued feeding Improved case management Oxygen therapy Antibiotics for dysentery  at both the community (where indicated) and health facility levelsNote: A complete list of Child Health Epidemiology Reference Group review papers on the effects of pneumonia and diarrhoea interventions on childsurvival is available at www.cherg.org/publications.html. Effectiveness of pneumonia interventions was also recently reviewed by Niessen andothers (2009).a. Pneumococcal conjugate.b. Haemophilus influenzae type b.Source: Adapted from the Global Action Plan for Prevention and Control of Pneumonia and presentations in WHO regional workshops in 2011. Figure  In Bangladesh more children’s lives are savedFigure   Potential declines in child deaths by 4 by targeting the poorest households with key 3 scaling up national coverage to the levels pneumonia and diarrhoea interventions in the richest households Predicted numbers of deaths averted among children under age 5 ifPredicted trends in the number of deaths among children under age 5 if near universal coverage (90 per cent) of key pneumonia and diarrhoeanational coverage of key pneumonia and diarrhoea interventions were interventions were achieved among the poorest and richest 20 per cent inraised to the levels among the richest 20 per cent across 75 countries, Bangladesh (thousands)2012–2015 (millions) 20 Richest 20% Child deaths due Child deaths due Child deaths due to pneumonia to diarrhoea to other causes Poorest 20% 8 7.6 1.1 7.2 15 15.4 0.9 6.8 6.6 0.9 1.2 0.8 6 0.9 0.7 0.5 10 5.3 5.3 5.3 5.3 7.8 4 6.6 5 2.8 2 1.8 0.9 0 Total child Child deaths Child deaths deaths due to pneumonia due to diarrhoea 0 Note: Averted child deaths due to pneumonia and diarrhoea do not sum to 2012 2013 2014 2015 total averted child deaths because pneumonia and diarrhoea interventions have an effect on other causes of child mortality.Source: Lives Saved Tool modelling by Johns Hopkins University Bloomberg Source: Lives Saved Tool modelling by Johns Hopkins University BloombergSchool of Public Health (see annex 2). School of Public Health (see annex 2). 3
  11. 11. Figure  Substantial ‘wealth gap’ in measles vaccine Figure  Young infants who are not breastfed are 5 coverage in every region 6 at a greater risk of dying due to pneumonia or diarrhoea Share of children under one year of age who received a vaccine against measles, by household wealth quintile and region, 2000–2008 (per cent) Relative risk of pneumonia and diarrhoea incidence and mortality for partial 100 breastfeeding and not breastfeeding compared with that for exclusive Richest 20% breastfeeding among infants ages 0–5 months Poorest 20% Exclusive breastfeeding Partial breastfeeding 75 Not breastfeeding 15 Infants not breastfed are 15 times more likely 50 to die due to pneumonia than are exclusively 11 breastfed children 25 5 4 0 3 South Sub-Saharan East Asia Developing 2 2 2 Asia Africa and Pacifica countriesa 1 1 1 1 a. Excludes China. Incidence Mortality Incidence Mortality Source: UNICEF 2010, based on 74 of the latest available Multiple Indicator Pneumonia Diarrhoea Cluster Surveys and Demographic and Health Surveys conducted between 2000 and 2008. Source: Black and others 2008. Figure   Most people without an improved water Figure Every region has shown progress in 7 source or sanitation facility live in rural areas 8 appropriate careseeking for suspected childhood pneumonia over the past decade People without an improved sanitation facility, people practicing open defecation and people without an improved drinking water source, 2010 (millions) Share of children under age 5 with suspected pneumonia taken to an appropriate healthcare provider or facility, by region, around 2000 and Urban around 2010 (per cent) Rural 1,796 100 2000 2010 75 69 65 65 64 949 59 61 60 50 54 50 714 653 38 25 105 130 Without access Practicing Without access to to an improved open an improved sanitation facility defecation drinking water source 0 Sub-Saharan East Asia South Middle East Developing Source: WHO and UNICEF Joint Monitoring Programme for Water Supply Africa and Pacifica Asia and North Africa countriesa and Sanitation 2012. a. Excludes China. Note: Estimates are based on a subset of 63 countries with available data, covering 71 per cent of the under-five population in developing countries in 2000 and 73 per cent in 2010 (excluding China, for which comparable data are not available) and at least 50 per cent of the under-five population in each region. Data coverage was insufficient to calculate the regional average for CEE/CIS, Latin America and the Caribbean, and industrialized countries. Source: UNICEF global databases 2012, based on Multiple Indicator Cluster Surveys, Demographic and Health Surveys and other national surveys.4
  12. 12. often at the greatest risk of pneumonia and pneumonia receive antibiotics. The poorest chil-diarrhoea, through routine immunization pro- dren in the poorest countries are least likely togrammes remains a challenge but is essential to receive treatment when sick.realize the full potential of both new and old vac-cines alike. Treatment for diarrhoea Children with diarrhoea are at risk of dying dueInfant feeding to dehydration, and early and appropriate fluidExclusive breastfeeding during the first six replacement is a main intervention to preventmonths of life is one of the most cost-effec- death. Yet few children with diarrhoea in develop-tive child survival interventions and greatly ing countries receive appropriate treatment withreduces the risk of a young infant dying due to oral rehydration therapy and continued feedingpneumonia or diarrhoea (figure 6). Exclusive (39 per cent). Even fewer receive solutions madebreastfeeding rates have increased markedly of oral rehydration salts (ORS) alone (one-third),in many high-mortality countries since 1990. and the past decade has seen no real progressDespite this progress, fewer than 40 per cent in improving coverage across developing coun-of children under 6 months of age in develop- tries (figure 9). Moreover, the poorest childrening countries are exclusively breastfed. Optimal in the poorest countries are least likely to usebreastfeeding practices are vital to reducing ORS, and zinc treatment remains largely unavail-morbidity and mortality due to pneumonia and able in high-mortality countries. The stagnantdiarrhoea. low ORS coverage over the past decade indicates a widespread failure to deliver one of the mostWater and sanitation cost-effective and life-saving child survival inter-The Millennium Development Goal target on ventions and underscores the urgent need to refo-use of an improved drinking water source has cus attention and funding on diarrhoea control.been met globally as of 2010; a stunning suc-cess. Yet 783 million people still do not use an Figure Use of solutions made of ORS to treatimproved drinking water source, and 2.5 bil- 9 childhood diarrhoea has changed littlelion do not use an improved sanitation facility, since 2000mostly in the poorest households and rural areas; Share of children under age 5 with diarrhoea receiving ORS (ORS packet or90 per cent of people who practice open defeca- prepackaged ORS fluids), by region, around 2000 and around 2010 (per cent)tion, the riskiest sanitation practice, live in rural 100 2000areas (figure 7). Nearly 90 per cent of deaths due 2010to diarrhoea worldwide have been attributed tounsafe water, inadequate sanitation and poor 75hygiene. Hand washing with water and soap,in particular, is among the most cost-effectivehealth interventions to reduce the incidence ofboth childhood pneumonia and diarrhoea. 50Treatment for suspected pneumonia 37 39Timely recognition of key pneumonia symp- 30 28 30 31 31 30 32toms by caregivers followed by seeking appropri- 25 24ate care and antibiotic treatment for bacterialpneumonia is lifesaving. Careseeking for chil-dren with symptoms of pneumonia has increased 0 Middle East Sub-Saharan South East Asia Developingslightly in developing countries, from 54 per and North Africa Africa Asia and Pacifica countriesacent around 2000 to 60 per cent around 2010. a. Excludes China.Sub-Saharan Africa saw about a 30 per cent rise Note: Estimates are based on a subset of 65 countries with available data, covering 74 per cent of the under-five population in developing countriesover this period, driven largely by gains among (excluding China, for which comparable data are not available) and at leastthe rural population (figure 8). Yet appropriate 50 per cent of the under-five population in each region. Data coverage was insufficient to calculate the regional average for CEE/CIS, Latin America andcareseeking for suspected childhood pneumo- the Caribbean, and industrialized countries. Source: UNICEF global databases 2012, based on Multiple Indicator Clusternia remains too low across developing countries, Surveys, Demographic and Health Surveys and other national surveys.and less than a third of children with suspected 5
  13. 13. Pneumonia and diarrhoea: accelerating It is time to refocus our efforts on these two child survival by tackling the deadliest leading killers. This report is a call to action diseases for the world’s poorest children to reduce child deaths due to pneumonia and This report once again shows what has long been diarrhoea. Doing so would not only reduce the known: coverage of key pneumonia and diar- survival gap between poorest and better-off chil- rhoea prevention and treatment interventions is dren, but would also accelerate progress towards much lower in the poorest countries and among eliminating preventable child deaths. This tre- the most-deprived children within these coun- mendous opportunity to narrow the child sur- tries – children who often bear a larger share vival gap both across and within countries cannot of child deaths. Child survival impact is thus be missed. Greater commitment, attention and reduced when key interventions miss these vul- concerted global action are needed now on nerable children at greatest risk of dying from behalf the most vulnerable children. pneumonia or diarrhoea.6
  14. 14. 1 Pneumonia and diarrhoea disproportionately affect the poorestThe world has made substantial gains in child mortality rate has declined since 1990, the sur-survival over the past two decades, but progress vival gap between the poorest and better-off chil-has been uneven both across and within coun- dren has widened in many cases.2tries.1 Since 1990 child mortality has becomeincreasingly concentrated in the world’s poor- Pneumonia and diarrhoea are among theest regions: sub-Saharan Africa and South Asia. leading causes of child deaths globally (fig-Within most countries the poorest and most- ure 1.1)­– ­ nd are perhaps the starkest exam- adeprived children are more likely to die before ples of the child survival gap. Together, thesetheir fifth birthday. Limited data suggest that diseases cause 29 per cent of child deaths,even in countries where the national child more than 2 million a year. Nearly as many Figure   Pneumonia and diarrhoea are among the leading killers of children worldwide 1.1 Global distribution of deaths among children under age 5, by cause, 2010 Pneumonia (postneonatal) 14% Other 18% Pneumonia Pneumonia (neonatal) 4% 18% Measles 1% Meningitis 2% Other postneonatal Other neonatal 35% AIDS 2% Diarrhoea Diarrhoea (postneonatal) 10% Injuries 5% 11% Diarrhoea (neonatal) 1% Malaria 7% Other postneonatal Other neonatal 35% Other 2% Preterm birth Tetanus 1% complications 14% Congenital abnormalities 4% Sepsis and meningitis 5% Intrapartum-related events 9% Note: Undernutrition contributes to more than a third of deaths among children under age 5. Values may not sum to 100 per cent because of rounding. Source: Adapted from Liu and others 2012; Black and others 2008. 7
  15. 15. Figure   Nearly 90 per cent of child deaths due This staggering toll, however, is not evenly felt 1.2 to pneumonia and diarrhoea occur in across the world but instead is highly concen- sub-Saharan Africa and South Asia trated in the poorest settings. The vast major- ity of deaths due to pneumonia and diarrhoea Deaths among children under age 5 due to pneumonia and diarrhoea, by region, 2010 occur in the poorest regions­– nearly 90 per cent ­ of them in sub-Saharan Africa and South Asia (figure 1.2 and table 1.1). About half the world’s Other regions deaths due to pneumonia and diarrhoea occur 268,000 in just five mostly poor and populous coun- tries: India, Nigeria, Democratic Republic of the Congo, Pakistan and Ethiopia (table 1.2). Chol- era, too, is on the rise in many areas and dispro- Sub-Saharan Africa portionately affects vulnerable groups living in 1,078,000 fragile settings (box 1.1). South Asia 851,000 Within countries the child survival gap in deaths due to pneumonia and diarrhoea is likely sub- stantial, but much less is known about the causes of child deaths within most high-mortality coun- tries. It is known that the poorest and most vul- nerable children within countries are more often Source: Adapted from Liu and others 2012. exposed to pathogens that cause pneumonia and diarrhoea (for example, through poor sanita- tion or inadequate water supplies) and are more children died from pneumonia and diarrhoea likely to develop severe illness (for example, from in 2010 as from all other causes after the new- undernutrition or co-morbidities).3 Coverage of born period­– ­ n other words, nearly as much i key prevention measures should be higher among as from malaria, injuries, AIDS, meningitis, these children, but too often the opposite occurs. measles and all other postneonatal conditions These sicker children are then in greater need of combined. effective treatment (such as antibiotics for bacterial Table   Child deaths due to pneumonia and diarrhoea are concentrated in the poorest regions . . . 1.1 Deaths among children Deaths among children Deaths among children under age 5 due to pneumonia under age 5 due to under age 5 due to and diarrhoea, 2010 pneumonia, 2010 diarrhoea, 2010 Per cent Per cent Per cent UNICEF regions Number of total Number of total Number of total Sub-Saharan Africa 1,078,000 49 648,000 46 430,000 54 South Asia 851,000 39 550,000 39 300,000 37 East Asia and Pacific 145,000 7 111,000 8 34,000 4 Middle East and North Africa 103,000 5 68,000 5 36,000 4 Latin America and Caribbean 38,000 2 26,000 2 12,000 1 Central and Eastern Europe and the Commonwealth of Independent States 25,000 1 18,000 1 6,000 1 Least developed countries 894,000 41 545,000 39 350,000 44 Developing countries 2,191,000 99 1,390,000 99 801,000 99 Industrialized countries 2,000 1 2,000 1 1,000 1 World 2,197,000 100 1,396,000 100 801,000 100 Note: Due to rounding, regional values may not sum to the world total, percentages may not sum to 100 and data in columns 3 and 5 may not sum to the values in column 1. Source: Adapted from Liu and others 2012.8
  16. 16. Table  . . . and in mostly poor and populous countries in these regions 1.2 Deaths among children under age 5 due to pneumoniaRank Country and diarrhoea, 2010 1 India 609,000 2 Nigeria 241,000 Half of all child deaths 3 Democratic Republic of the Congo 147,000 due to pneumonia and diarrhoea worldwide 4 Pakistan 126,000 5 Ethiopia 96,000 6 Afghanistan 79,000 7 China 64,000 Three-quarters of all child 8 Sudana 44,000 deaths due to pneumonia and diarrhoea worldwide 9 Mali 42,000 10 Angola 39,000 11 Uganda 38,000 12 Burkina Faso 36,000 12 Niger 36,000 14 Kenya 32,000 15 United Republic of Tanzania 31,000 Rest of the world 537,000 Total 2,197,000a. Estimates refer to pre-cession Sudan.Source: Adapted from Liu and others 2012.Box   Cholera, on the rise, affects the most vulnerable people1.1An estimated 1.4 billion people are at risk of cholera in are emerging.2 Cholera affects the most marginalizedendemic countries, with approximately 3 million cases populations­– ­ hose who have the lowest access to es- tand about 100,000 deaths per year worldwide. Chil- sential services such as adequate water, sanitation anddren under age 5 account for about half the cases and healthcare and who already suffer from poor nutrition.deaths.1 Large, protracted outbreaks with high case-­fatality ratios are becoming more frequent, reflecting Cholera is a diarrhoeal disease that can lead to rapida lack of adequate preparedness, early detection, pre- death if not detected and treated early with solutionsvention and timely access to healthcare. These explo- made of oral rehydration salts. Key interventions tosive and deadly outbreaks affect the whole of society, prevent and treat cholera are similar to those for diar-can disrupt essential services and often require sub- rhoea outlined in this report and should be scaled up.stantial resources, including emergency response In addition, reducing transmission and death from out-operations. breaks requires specific preparedness and response activities such as strong national multisector co­Although large cholera outbreaks gain attention, en- ordination and control structures, comprehensive riskdemic cholera routinely accounts for a substantial assessments, enhanced surveillance and early warn-share of the global disease burden and is often under- ing systems, mobilization of communities and policy-detected and underreported. Cholera has become en- makers, and readily available resources and supplies.trenched in more countries in Africa and has recentlyreturned to the Americas, with ongoing transmission Notesin the Dominican Republic and Haiti. And new, more 1. Ali and others 2012.virulent and drug-resistant strains of Vibrio cholera 2. Ad Hoc Cholera Vaccine Working Group 2009. 9
  17. 17. pneumonia and oral rehydration solutions for diar- and diarrhoea, are the main contributors to the rhoea), but are generally less likely to receive it.4 child survival gap between Ethiopia and Ger- many and between the poorest and richest coun- The child survival gap between the richest and tries more generally. Narrowing this gap will take poorest countries is due largely to a handful of focused action on these ‘diseases of poverty’­– infections, notably pneumonia and diarrhoea. p ­ articularly pneumonia and diarrhoea­– and on ­ Compare, for example, Ethiopia and Germany­– other infections that disproportionately afflict t ­ wo countries with among the highest and lowest the most-deprived children. child mortality rates in 2010. In Ethiopia 271,000 children under age 5 died in 2010 (106 deaths The data presented in this chapter are based on per 1,000 live births); pneumonia and diarrhoea modelled estimates of childhood pneumonia and caused more than a third of these deaths, and a diarrhoea mortality for all countries. Robust data large proportion of the remaining deaths were on the distribution of cases and deaths within caused by other preventable and treatable infec- high-mortality countries are largely unavailable. tions (figure 1.3). In Germany approximately There is an urgent need to strengthen health 3,000 children under age 5 died in 2010 (4 deaths information and vital registration systems in per 1,000 live births), and the vast majority of order to identify the populations at greatest risk these deaths were caused by noncommunicable of suffering and dying from pneumonia and diseases and conditions. diarrhoea within countries. This information is critical for control programmes in their drive Childhood infections left untreated or not to better target high-impact interventions to the treated appropriately, particularly pneumonia children most in need within countries. Figure   Different patterns of child deaths in high- and low-mortality countries: Ethiopia and Germany 1.3 Distribution of deaths among children under age 5, by cause, 2010 Ethiopia Germany Pneumonia 2% Diarrhoea Pneumonia 1% Other 17% (postneonatal) 18% Preterm birth complications 22% Pneumonia Other Malaria 2% Pneumonia 36% 21% AIDS 2% Other (neonatal) 3% postneonatal Other Measles 4% 37% postneonatal Other 44% Diarrhoea Diarrhoea neonatal Meningitis 6% 14% 55% (postneonatal) 13% Congenital Other anomalies Injury 6% neonatal Diarrhoea 16% 30% (neonatal) 1% Other 1% Meningitis 1% Congenital abnormalities 2% Preterm birth Injury 6% Intrapartum- Sepsis and complications 12% related events 5% meningitis 6% Intrapartum- Other 10% Sepsis and related events 9% meningitis 2% Total deaths among children under age 5: 277,000 Total deaths among children under age 5: 2,900 Under-five mortality rate: 106 deaths per 1,000 live births Under-five mortality rate: 4 deaths per 1,000 live births Note: Country selection was based on high- and low-mortality countries that are not in conflict and with a population greater than 40 million to improve data reliability and reduce uncertainty around the estimates. The distribution of deaths among children under age 5 by cause in these two countries is comparable to other high- and low-mortality countries. Source: Adapted from Liu and others 2012.10
  18. 18. 2 We know what worksUNICEF, WHO and partners have published and diarrhoea morbidity and mortality (figureaction plans for pneumonia and diarrhoea con- 2.1). These interventions require communica-trol (see annex 1). Many well known child sur- tion strategies that inform and motivate healthyvival interventions from across different sectors actions and create demand for services essentialhave a proven impact on reducing pneumonia to pneumonia and diarrhoea control (box 2.1). Figure  Many prevention and treatment strategies for diarrhoea and pneumonia are identical 2.1 Diarrhoea Pneumonia P r e v e n t i o n Vaccination: Adequate nutrition for Vaccination: rotavirus, cholera, mothers and children PCVa, Hibb, pertussis   typhoid  Breastfeeding promotion and support Reduced household air Safe water and improved pollution sanitation Measles vaccination   Micronutrient supplementation (such as zinc, vitamin A) Hand washing with soap Prevention and treatment of co-morbidities (such as HIV)   Tr e a t m e n t Low-osmolarity ORS, zinc Improved care-seeking behaviour Antibiotics for pneumonia and continued feeding Improved case management Oxygen therapy Antibiotics for dysentery  at both the community (where indicated) and health facility levels Note: A complete list of Child Health Epidemiology Reference Group review papers on the effects of pneumonia and diarrhoea interventions on child survival is available at www.cherg.org/publications.html. Effectiveness of pneumonia interventions was also recently reviewed by Niessen and others (2009). a. Pneumococcal conjugate. b. Haemophilus influenzae type b. Source: Adapted from the Global Action Plan for Prevention and Control of Pneumonia and presentations in WHO regional workshops in 2011. 11
  19. 19. Box   The importance of evidence-based communication strategies for child survival 2.1 Communication strategies to inform and motivate in- these vaccines, but also to prevent unrealistic com- dividual, community and social change (behaviour munity expectations that could damage immunization change communication) are vital for child survival pro- programmes. grammes. To this end, UNICEF and its partners re- cently developed the Communication Framework for This communication framework stresses a structured New Vaccines and Child Survival to support the in- approach to guide the design, implementation and troduction of new vaccines for pneumonia and diar- evaluation of a national communication plan for child rhoea as part of a comprehensive package to also survival. Communication is challenging, and there is strengthen complementary ‘healthy actions’ for pneu- more than one way to do it correctly. But it must be monia and diarrhoea control, such as early and ex- based on the information needs of the intended target clusive breastfeeding, hand washing with soap, audience, crafted to both inform and motivate, linked vaccinations and appropriate care seeking for illness to programme goals, based on sound analysis and re- symptoms, among others (see figure 2.1 in the text). search, and structured to include rigorous monitoring New vaccines prevent many but not all cases of pneu- and evaluation. monia and diarrhoea and thus require new commu- nication strategies not only to promote uptake of Source: UNICEF 2011a.12
  20. 20. 3 Prevention coverageKey prevention measures include vaccinations, highly effective vaccine. By the end of the 1990sclean home environments (such as those with around two-thirds of high-income countries withsafe drinking water and improved sanitation) data had added the vaccine to their immuniza-and adequate nutrition for mothers and children tion schedule, but low-income countries, where(such as through optimal breastfeeding practices the burden is often highest, have been slower toand micronutrient supplementation). do so. In 2006 WHO recommended introducing the Hib vaccine into all national immunizationVaccination programmes, and since then the gap in vac-Several vaccines­– ­ oth new and old­– ­ ould save b c cine introduction between low- and high-incomecountless children from dying due to pneumonia countries has nearly closed (figure 3.2).or diarrhoea every year. These include vaccinesagainst leading pneumonia-causing pathogens Rotavirus vaccine(Streptococcus pneumoniae and Haemophilus influen- Rotavirus is the leading cause of severe child-zae type b [Hib]) and rotavirus vaccine for diar- hood diarrhoea and is responsible for an esti-rhoea, as well as vaccines that prevent infections mated 40 per cent of all hospital admissions duethat lead to pneumonia or diarrhoea as a compli- to diarrhoea among children under age 5 world-cation (such as pertussis for pneumonia and mea- wide.1 Rotavirus caused some 420,000–494,000sles for both pneumonia and diarrhoea). child deaths in 2008, a large share of them in sub-Saharan Africa and South Asia, where thePneumococcal conjugate vaccine (PCV)Streptococcus pneumoniae (or pneumococcus) is a Figure  Progress in introducing PCV globally,leading cause of bacterial pneumonia, menin- 3.1 particularly in the poorest countries,gitis and sepsis in children. In 2007 WHO rec- but a ‘rich-poor’ gap remainsommended introducing PCV into all national Share of countries that have introduced PCV into the entire country, byimmunization programmes, particularly in coun- income group (per cent)tries with high child mortality. 100 In 2007 WHO recommended introducing the pneumococcal conjugate vaccine in all nationalProgress is being made in introducing PCV glob- immunization programmesally, and use has been increasing in the poorestcountries (figure 3.1). By 2011, 13 of 35 low- 75 High incomeincome countries with data had introduced PCV, (49 countries with data)covering 41 per cent of surviving infants (about25 million) in low-income countries. More low- 50income countries, particularly those with high Upper middle incomepneumonia burdens, urgently need to introduce (52 countries with data)PCV into routine immunization programmes. Low incomeBut introducing a vaccine does not necessarily 25 Lower (35 countries with data)translate into high and equitable coverage within middle income (54 countriescountries, and inequities in uptake greatly reduce with data)the impact of vaccines (box 3.1). 0 1980s 1990s 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Hib vaccine Note: Income groups are based on the World Bank July 2011 classificationHib is a leading cause of childhood meningitis and are applied for the entire time series (see http://data.worldbank.org/and a major cause of bacterial pneumonia in chil- about/country-classifications/country-and-lending-groups#Low_income). Source: WHO Department of Immunization, Vaccines and Biologicals 2011.dren. Fortunately, Hib is preventable thanks to a 13
  21. 21. Box   Disparities in vulnerability and access reduce the impact of new vaccines 3.1 New vaccines, such as that for rotavirus, could sub- many high-mortality countries have a substantial gap in stantially reduce child mortality. But to do so, they coverage between the richest and poorest. must reach the children most in need. In many low- income countries poor children have several risk fac- Achieving equitable coverage in these countries (de- tors for mortality due to pneumonia or diarrhoea, such fined here as all quintiles having the same coverage as poor nutritional status and less access to timely as the richest) resulted in an 89 per cent increase in treatment. These children are often much less likely benefits (reduced child mortality from rotavirus) in the to be reached by routine vaccination in high-mortality poorest quintile and a 38 per cent increase in benefits countries. overall. The pattern is particularly notable in the high- est mortality countries of India and Nigeria. In India A study of 25 low-income countries using data from equitable coverage would double the benefits for the the most recent Demographic and Health Survey in poorest children and increase the benefits 40 per cent each country found that the impact (deaths averted per at the national level. In Nigeria equitable coverage 1,000 children vaccinated) of introducing rotavirus vac- would increase health benefits 400 per cent for the cination was up to five times greater for the poorest poorest children and double them at the national level.  wealth quintile than for the richest, due to higher esti- mated risks of rotavirus mortality, and that cost effec- While new vaccines hold great promise for reduc- tiveness was most favourable for the poorest wealth ing child mortality, closing disparities in access within quintile, due to its greater burden of rotavirus disease. high-mortality countries is essential. However, while some countries have achieved fairly equitable vaccination coverage across wealth quintiles, Source: Rheingans, Anderson and Atherly 2012. rotavirus vaccine remains largely unavailable.2 In 2009 WHO recommended introducing rota- Figure   Closing the ‘rich-poor’ gap in the introduction virus vaccine into all national immunization 3.2 of Hib vaccine in recent years programmes, and in September 2011 the GAVI Share of countries that have introduced the Haemophilus influenzae type b Alliance approved funding to support rollout vaccine into the entire country, by income group (per cent) of the rotavirus vaccine in 16 developing coun- 100 High income tries (figure 3.3). By 2015 the GAVI Alliance and (49 countries with data) its partners plan to support more than 40 of the world’s poorest countries in rolling out the rota- 75 virus vaccine.3 Upper middle income (52 countries Lower Measles and pertussis vaccines with data) middle income (54 countries Pneumonia is a serious complication of both 50 with data) measles and pertussis (or whooping cough) and is the most common cause of death associated with these illnesses. An effective vaccine against 25 measles and pertussis (DTP3) has been available In 2006 WHO recommended for decades and has been included in national introducing the Haemophilus Low income influenzae type b vaccine in immunization programmes worldwide since the (35 countries all national immunization with data) programmes 1980s. 0 1980s 1990s 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 There has been substantial progress in reduc- Note: Income groups are based on the World Bank July 2011 classification ing mortality due to measles and pertussis over and are applied for the entire time series (see http://data.worldbank.org/ about/country-classifications/country-and-lending-groups#Low_income). the past few decades. Worldwide mortality due Source: WHO Department of Immunization, Vaccines and Biologicals 2011. to measles declined from an estimated 535,300 deaths in 2000 to 139,300 in 2010­– a reduc- ­ tion of 74 per cent.4 Pertussis remains endemic14
  22. 22. Figure   Few countries use the rotavirus vaccine, which Figure   Substantial ‘wealth gap’ in measles vaccine 3.3 is largely unavailable in the poorest countries 3.4 coverage in every region Share of countries that have introduced the rotavirus vaccine into the entire Share of children under one year of age who received a vaccine against country, by income group (per cent) measles, by household wealth quintile and region, 2000–2008 (per cent) 100 100 In 2009 WHO recommended Richest 20% introducing the rotavirus vaccine in all national Poorest 20% immunization programmes 75 75 In 2011 the GAVI Alliance approved grants for 16 countries to roll out the rotavirus vaccine 50 50 Upper middle income (52 countries with data) High income 25 25 (49 countries with data) Low income (35 countries Lower middle income with data) (54 countries with data) 0 0 South Sub-Saharan East Asia Developing 1980s 1990s 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Asia Africa and Pacifica countriesa Note: Income groups are based on the World Bank July 2011 classification a. Excludes China. and are applied for the entire time series (see http://data.worldbank.org/ Source: UNICEF 2010, based on 74 of the latest available Multiple Indicator about/country-classifications/country-and-lending-groups#Low_income). Cluster Surveys and Demographic and Health Surveys conducted between Source: WHO Department of Immunization, Vaccines and Biologicals 2011. 2000 and 2008.worldwide. An estimated 50 million pertussiscases occur each year, most of them in develop- Figure   Most children not immunized againsting countries. In 2008 pertussis caused approxi- 3.5 pertussis live in just 10 mostly poor andmately 200,000 deaths among children under populous countriesage 5, mostly among infants.5 Children not immunized against pertussis, by country, 2010 (millions)Although coverage of measles and DTP3 vaccinesis high globally (85 per cent for both in 2010),it varies across and within countries­– ­ ith the wpoorest and most vulnerable children most oftenleft unvaccinated (figures 3.4 and 3.5). Rest of the world 6.0 India 7.2Clean home environment: water, 15% of childrensanitation, hygiene and other home worldwide are not immunizedfactors against pertussisA clean home environment is critical for reduc-ing transmission of pathogens that cause pneu- Ethiopia 0.3monia or diarrhoea. Access to safe water and to South Africa 0.4adequate sanitation is necessary to prevent diar- Iraq 0.4 Nigeriarhoea. Improving home and personal hygiene Afghanistan 0.4 1.8 Pakistan 0.5helps prevent both pneumonia and diarrhoea. Uganda 0.6Other home environment factors, such as house- Indonesia 0.7 Dem. Rep. of the Congo 0.9hold air pollution and overcrowding, also raise Note: Data are based on children who receive three doses of diphtheria andthe risk of childhood pneumonia. tetanus toxoid with pertussis (DTP3) vaccine. Source: WHO and UNICEF joint estimates of national immunization coverage (www.childinfo.org) as of 15 July 2011.Water, sanitation and hygieneNearly 90 per cent of deaths due to ­ iarrhoea dworldwide have been attributed to unsafe water, 15

×