Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably: What works and at what cost? - Prof. Zulfiqar A Bhutta
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Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably: What works and at what cost? - Prof. Zulfiqar A Bhutta

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Prof. Zulfiqar A Bhutta: Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably: what works and at what cost? ...

Prof. Zulfiqar A Bhutta: Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably: what works and at what cost?
Professor & Founding Chair,
The Aga Khan University

As presented at Launch of The Lancet Series on Childhood Pneumonia and Diarrhoea, at the Royal College of Pediatrics and Child Health - 12 April 2013

In support of the UNICEF & WHO Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea

View the film accompanying the presentation at:

www.wateraid.org/news/news/global-action-plan-for-pneumonia-and-diarrhoea

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    Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably: What works and at what cost? - Prof. Zulfiqar A Bhutta Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably: What works and at what cost? - Prof. Zulfiqar A Bhutta Presentation Transcript

    • Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably: what works and at what cost?Zulfiqar A Bhutta, Jai K Das, Neff Walker, Arjumand Rizvi, Harry Campbell, Igor Rudan, Robert E Black, for The Lancet Diarrhoea and Pneumonia Interventions Study Group April 12, 2013 Lancet Launch London
    • In Paper 2 of this series• We systematically reviewed evidence showing the effectiveness of various potential preventive and therapeutic interventions against childhood diarrhoea and pneumonia, and relevant delivery strategies• We used the Lives Saved Tool model to assess the effect of scaling up 15 proven interventions on mortality due to diarrhoea and pneumonia and lives saved in 75 Countdown countries
    • Conceptual Framework ENVIRONMENTAL WASH*, reduce overcrowding INCREASED and Household air Pollution DELIVERY PLATFORMS SUSCEPTIBILITY Community based health & behavior change promotion NUTRITION Breast feeding promotion, Preventive vitamin A or zinc supplementation* Financial Incentives to promote care seeking VACCINES EXPOSURE Measles, haemophilus Influenzae Integrated Community Case type B, Pneumococcal Management infection, Rotavirus, cholera TREATMENT Facility Based IMCI Oral rehydration solution, continued feeding after PNEUMONIA diarrhoea, zinc for diarrhoea treatment, probiotic use, DIARRHOEA antibiotics and oxygen therapy for pneumonia, antibiotics for dysentery SURVIVAL DEATH
    • Methods Review evidence base for key diarrhea and pneumonia prevention and treatment interventionsGoal: To estimate the effect of selected interventions on diarrhea and pneumoniamorbidity and mortality in children less than 5 years of ageMethods: • Conducted systematic literature review of all outcomes • If data on 0-5 years was scarce, we included older children • Abstracted data • Applied standard methods for risk of bias assessment • Applied standard set of LiST rules for estimating effect on morbidity and mortality given evidence available
    • Interventions common to Diarrhoea and Pneumonia
    • BREASTFEEDING AND THE RISK FOR MORBIDITY AND MORTALITYNot breast feeding was associated with• 165% (RR 2·65, 95% CI 1·72–4·07) increase in diarrhoea (0–5 months)• 32% (1·32, 95% CI 1·06–1·63) increase in diarrhoea (6–11 months)• 32% (1·32, 95% CI 1·06–1·63) increase in diarrhoea (12-23 months)• 47% (1·47, 95% CI 0·67–3·25) increase in diarrhoea mortality (6–11 months)• 157% (2·57, 95% CI 1·10–6·01) increase in 12–23 months
    • BREASTFEEDING EDUCATION AND EFFECTS ON BREASTFEEDING RATES Increased EBF Decreased no • Predominant • 43% at 1 day breastfeeding and partial • 30% at 0–1 • 32% at 1 day, breastfeeding months • 30% at 0–1 month were not • 90% at 1–6 • 18% for 1–6 months significant months • After 6 months increase rates of partial breastfeeding by 19%
    • WATER, SANITATION, AND HYGIENE INTERVENTIONSRisk reductions for diarrhoea• 48% with hand washing with soap• 17% with improved water quality• 36% with excreta disposal
    • PREVENTIVE ZINC SUPPLEMENTATIONNon-significant reduction in• Diarrhoea-related mortality: 18% (0·82, 95% CI 0·64–1·05)• All-cause mortality: 9% (0·91, 0·82–1·01)• ALRI-related mortality: 15% (0·85, 0·65–1·11)
    • Diarrhoea specific interventionsPreventive
    • ROTAVIRUS VACCINE• Effectiveness against very severe rotavirus infection: 74% (95% CI 35–90%)• Effectiveness against severe rotavirus infection: 61% (95% CI 38–75%)• Effectiveness against hospital admission for rotavirus: 47% (95% CI 22–64%)
    • CHOLERA VACCINE• Effectiveness against cholera infection: 52% (RR 0·48, 95% CI 0·35–0·64)• Increase in Vibriocidal antibodies by124% (RR 2·24, 95% CI 1·32– 3·80)• Increase in risk of adverse events by 42% (RR 1·42, 95% 1·06– 1·89)
    • Diarrhoea specific interventionsTherapeutic
    • ORS and recommended home fluidsReduction in:• Diarrhoea mortality by 69% (95% CI 51–80%)• Treatment failure by 0·2% (95% CI 0·1–0·2%)
    • Therapeutic Zinc supplementationSignificant reduction in:• All-cause mortality by 46% (RR 0.54, 95% CI 0·32–0·88)• Hospital admission by 23% (RR 0·77, 95% CI 0·69–0·85)Non-significant reduction in:• Diarrhoea mortality by 66% (RR 0·34, 95% CI 0·04–1·37)• Diarrhoea prevalence by 19% (RR 0·81, 95% CI 0·53–1·04)
    • Feeding strategies & improved dietary management of diarrhoea In acute diarrhoea lactose –free diet significantly reduced: • Duration of diarrhoea: SMD –0·36, 95% CI –0·62 to –0·10 • Treatment failure: RR 0·53, 95% CI 0·40–0·70 • Weight gain did not have any significant effect
    • Antibiotics for Shigella, Cholera and Cryptosporidiosis Shigella: • Reduced clinical failure by 82% • Reduced bacteriological failure by 96% Cholera: • Reduced clinical failure by 63% • Reduced bacteriological failure by 75% Cryptosporidiosis: • Reduced clinical failure by 52% • Reduction in parasitological failure by 38% • Non-significant reduction in all-cause mortality
    • Pneumonia specific interventionsPreventive
    • VaccinesMeasles Vaccine:• 85% (95% CI 83–87%) effective in prevention of disease before age 1 yearHib Vaccine:• Severe pneumonia by 6% (RR 0·94, 95% CI 0·89–0·99)Pneumococcal conjugate vaccine:• 29% reduction in radiologically confirmed pneumonia• 11% reduction in severe pneumonia
    • Pneumonia specific interventionsTherapeutic
    • Antibiotics for the treatment of neonatal pneumoniaOral or injectable antibiotics reduced:• All-cause neonatal mortality by 25% (RR 0·75, 95% CI 0·64–0·89)• Neonatal pneumonia mortality by 42% (0·58, 95% CI 0·41–0·82)
    • Oxygen systems• Pulse oximetry together with oxygen therapy reduced severe• pneumonia mortality by 35% (RR 0·65, 95% CI 0·52–0·78)
    • Delivery PlatformsCommunity-based promotion and case management:• 160% significant increase in use of oral rehydration solution• 80% increase in use of zinc in diarrhoea• 13% increase in care-seeking for pneumonia• 9% increase in care-seeking for diarrhoea.• 75% significant decline in inappropriate use of antibiotics for diarrhoea• 40% reduction in rates of treatment failure for pneumonia.Reduction of financial barriers• Promote increased coverage of child health interventions• Pronounced effects achieved by those that directly removed user fees for access to health services.
    • LiST modeling effects on mortality outcomes for 75 Countdown countries
    • Historic Trends Scale up- 54% of diarrhoea and 51% ofpneumonia deaths in children younger than 5 yearscan be avertedAmbitious Scale up- Eliminate almost all diarrhoeadeaths, but only two-thirds of pneumonia deaths
    • Coverage of Interventions in 75 Countdown Countries
    • Additional effect of the ambitious scale-up approach on diarrhoea andpneumonia deaths averted for the 75 Countdown countries up to 2025Specific Interventions
    • Impact of individual interventions on deaths due todiarrhoea and pneumonia (Sequential) Pneumococcal Vaccine Case management of neonatal infections Breastfeeding promotion Oral antibiotics : case management of pneumonia in children Improved water source Zinc supplementation Hib Vaccine Hand washing with soap Improved sanitation ORS Rotavirus Vaccine Hygienic disposal of childrens stools Vitamin A supplementation Zinc - for treatment of diarrhea Antibiotics for dysentery - 50,000 100,000 150,000 200,000 250,000 300,000 350,000
    • Equity Analysis
    • Equity analysis for Bangladesh, Ethiopia and Pakistan
    • Cost Analysis
    • The costs are based on four components:• Personnel and labour• Drugs and supplies• Other direct costs• Indirect costs• Historic Trend- USD3·8 billion dollars to avert 882,274 deaths• Ambitious Scale-up - USD6·715 billion dollars to avert 1,439,437 deaths• An extra USD2·914 billion to save an additional 557,163 lives.
    • Discussion• Most the interventions exist within present health systems, although their coverage and availability to poor and marginalised populations varies greatly• Delivery strategies receive relative less focus• Structural changes are needed to reduce environmental pollution and provide safe water and sanitation• The forthcoming decade of vaccines initiative offers a unique possibility• Community delivery of these interventions could also ensure equitable delivery
    • Key messages• Interventions with maximum effect include breastfeeding, oral rehydration solution, and community case management• 15 interventions delivered at scale can prevent most of diarrhea and pneumonia deaths• If the interventions are scaled up by 80% in the 75 Countdown countries, they could save 95% of diarrhoeal and 67% of pneumonia deaths in children younger than 5 years by 2025• Scaling up of diarrhoea and pneumonia interventions would cost USD6·715 billion, only USD2·9 billion more than present levels of spending• The cost-effectiveness of these interventions in national health systems needs urgent assessment
    • THANKS