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

 

INCREASED SUSCEPTIBILITY

 

INCREASED SUSCEPTIBILITY

 

EXPOSURE

 

EXPOSURE

 

PNEUMONIA

DIARRHOEA

 

PNEUMONIA

DIARRHOEA

ENVIRONMENTALWASH*, reduce overcrowding and Household air Pollution 

NUTRITIONBreast feeding promotion,Preventive vitamin A or zinc supplementation*

VACCINES Measles, haemophilus Influenzae type B, Pneumococcal infection, Rotavirus, cholera

TREATMENTOral rehydration solution, continued feeding after diarrhoea, zinc for diarrhoea treatment, probiotic use, antibiotics and oxygen therapy for pneumonia, antibiotics for dysentery

DELIVERY PLATFORMSCommunity based health & behavior change promotion

 Financial Incentives to promote care seeking

 Integrated Community Case Management

  Facility Based IMCI 

SURVIVALSURVIVAL DEATHDEATH

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

Methods

Interventions common to Diarrhoea and Pneumonia

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 AND THE RISK FOR MORBIDITY AND MORTALITY

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%

Risk reductions for diarrhoea

• 48% with hand washing with soap

• 17% with improved water quality

• 36% with excreta disposal

WATER, SANITATION, AND HYGIENE INTERVENTIONS

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)

PREVENTIVE ZINC SUPPLEMENTATION

Diarrhoea specific interventionsPreventive

• 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%)

ROTAVIRUS 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)

CHOLERA VACCINE

Diarrhoea specific interventionsTherapeutic

Reduction in:

• Diarrhoea mortality by 69% (95% CI 51–80%)

• Treatment failure by 0·2% (95% CI 0·1–0·2%)

ORS and recommended home fluids

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)

Therapeutic Zinc supplementation

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

Feeding strategies & improved dietary management of diarrhoea

Cryptosporidiosis:• Reduced clinical failure by 52% • Reduction in parasitological failure by 38% • Non-significant reduction in all-cause mortality

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%

Pneumonia specific interventionsPreventive

Hib Vaccine:

• Severe pneumonia by 6% (RR 0·94, 95% CI 0·89–0·99)

Vaccines

Measles Vaccine:

• 85% (95% CI 83–87%) effective in prevention of disease before age 1 year

Pneumococcal conjugate vaccine:

• 29% reduction in radiologically confirmed pneumonia• 11% reduction in severe pneumonia

Pneumonia specific interventionsTherapeutic

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)

Antibiotics for the treatment of neonatal pneumonia

• Pulse oximetry together with oxygen therapy reduced severe

• pneumonia mortality by 35% (RR 0·65, 95% CI 0·52–0·78)

Oxygen systems

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 outcomesfor 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)

Antibiotics for dysentery

Zinc - for treatment of diarrhea

Vitamin A supplementation

Hygienic disposal of children's stools

Rotavirus Vaccine

ORS

Improved sanitation

Hand washing with soap

Hib Vaccine

Zinc supplementation

Improved water source

Oral antibiotics : case management of pneumonia in children

Breastfeeding promotion

Case management of neonatal infections

Pneumococcal Vaccine

- 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.

• 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

Discussion

• 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

Key messages

THANKS