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
and Household air Pollution
INCREASED
SUSCEPTIBILITY
NUTRITION
Breast feeding promotion,
Preventive vitamin A or zinc
supplementation*
VACCINES
Measles, haemophilus Influenzae
type B, Pneumococcal infection,
Rotavirus, cholera
TREATMENT
Oral rehydration solution,
continued feeding after
diarrhoea, zinc for diarrhoea
treatment, probiotic use,
antibiotics and oxygen therapy
for pneumonia, antibiotics for
dysentery
SURVIVAL
DELIVERY PLATFORMS
Community based health &
behavior change promotion
Financial Incentives to promote
care seeking
EXPOSURE
Integrated Community Case
Management
Facility Based IMCI
PNEUMONIA
DIARRHOEA
DEATH
Methods
Review evidence base for key diarrhea and pneumonia prevention and treatment
interventions
Goal: To estimate the effect of selected interventions on diarrhea and pneumonia
morbidity and mortality in children less than 5 years of age
Methods:
• 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 MORTALITY
Not 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
• 43% at 1 day
• 30% at 0–1
months
• 90% at 1–6
months
Decreased no
breastfeeding
• 32% at 1 day,
• 30% at 0–1 month
• 18% for 1–6 months
• Predominant
and partial
breastfeeding
were not
significant
• After 6 months
increase rates of
partial
breastfeeding
by 19%
WATER, SANITATION, AND HYGIENE INTERVENTIONS
Risk reductions for diarrhoea
• 48% with hand washing with soap
• 17% with improved water quality
• 36% with excreta disposal
PREVENTIVE ZINC SUPPLEMENTATION
Non-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 interventions
Preventive
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 interventions
Therapeutic
ORS and recommended home fluids
Reduction in:
• Diarrhoea mortality by 69% (95% CI 51–80%)
• Treatment failure by 0·2% (95% CI 0·1–0·2%)
Therapeutic Zinc supplementation
Significant 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 interventions
Preventive
Vaccines
Measles Vaccine:
• 85% (95% CI 83–87%) effective in prevention of disease before
age 1 year
Hib 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 interventions
Therapeutic
Antibiotics for the treatment of neonatal pneumonia
Oral 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 Platforms
Community-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% of
pneumonia deaths in children younger than 5 years
can be averted
Ambitious Scale up- Eliminate almost all diarrhoea
deaths, but only two-thirds of pneumonia deaths
Coverage of Interventions in 75 Countdown Countries
Additional effect of the ambitious scale-up approach on diarrhoea and
pneumonia deaths averted for the 75 Countdown countries up to 2025
Specific Interventions
Impact of individual interventions on deaths due to
diarrhoea 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 children's 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