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

1. 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

2. 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

3. 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

4. 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

5. Interventions common to Diarrhoea and Pneumonia

6. 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

7. 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%

8. WATER, SANITATION, AND HYGIENE INTERVENTIONS
Risk reductions for diarrhoea
• 48% with hand washing with soap
• 17% with improved water quality
• 36% with excreta disposal

9. 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)

10. Diarrhoea specific interventions
Preventive

11. 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%)

12. 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)

13. Diarrhoea specific interventions
Therapeutic

14. 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%)

15. 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)

16. 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

17. 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

18. Pneumonia specific interventions
Preventive

19. 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

20. Pneumonia specific interventions
Therapeutic

21. 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)

22. Oxygen systems
• Pulse oximetry together with oxygen therapy reduced severe
• pneumonia mortality by 35% (RR 0·65, 95% CI 0·52–0·78)

23. 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.

24. LiST modeling effects on mortality outcomes
for 75 Countdown countries

25. 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

26. Coverage of Interventions in 75 Countdown Countries

27. Additional effect of the ambitious scale-up approach on diarrhoea and
pneumonia deaths averted for the 75 Countdown countries up to 2025
Specific Interventions

28. 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

29. Equity Analysis

30. Equity analysis for Bangladesh, Ethiopia and Pakistan

31. Cost Analysis

32. 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.

33. 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

34. 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

35. THANKS