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Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably :

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

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Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably :

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  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. INCREASED SUSCEPTIBILITY ENVIRONMENTAL WASH*, reduce overcrowding and Household air Pollution DELIVERY PLATFORMS Community based health & behavior change promotion Financial Incentives to promote care seeking Integrated Community Case Management Facility Based IMCI NUTRITION Breast feeding promotion, Preventive vitamin A or zinc supplementation* EXPOSURE VACCINES Measles, haemophilusInfluenzae type B, Pneumococcal infection, Rotavirus, cholera Conceptual Framework TREATMENT Oral rehydration solution, continued feeding after diarrhoea, zinc for diarrhoea treatment, probiotic use, antibiotics and oxygen therapy for pneumonia, antibiotics for dysentery PNEUMONIA DIARRHOEA DEATH SURVIVAL

  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

  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. 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. Delivery Platforms • 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)

  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

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