Elsevier

The Lancet

Volume 381, Issue 9875, 20–26 April 2013, Pages 1417-1429
The Lancet

Series
Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost?

https://doi.org/10.1016/S0140-6736(13)60648-0Get rights and content

Summary

Global mortality in children younger than 5 years has fallen substantially in the past two decades from more than 12 million in 1990, to 6·9 million in 2011, but progress is inconsistent between countries. Pneumonia and diarrhoea are the two leading causes of death in this age group and have overlapping risk factors. Several interventions can effectively address these problems, but are not available to those in need. 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 on mortality when these interventions are applied. We estimate that if implemented at present annual rates of increase in each of the 75 Countdown countries, these interventions and packages of care could save 54% of diarrhoea and 51% of pneumonia deaths by 2025 at a cost of US$3·8 billion. However, if coverage of these key evidence-based interventions were scaled up to at least 80%, and that for immunisations to at least 90%, 95% of diarrhoea and 67% of pneumonia deaths in children younger than 5 years could be eliminated by 2025 at a cost of $6·715 billion. New delivery platforms could promote equitable access and community platforms are important catalysts in this respect. Furthermore, several of these interventions could reduce morbidity and overall burden of disease, with possible benefits for developmental outcomes.

Introduction

Although global mortality in children younger than 5 years has substantially reduced in the past two decades from more than 12 million deaths in 1990, to 6·9 million in 2011,1 improvements have been inconsistent worldwide. Whereas some countries and regions have reduced child mortality by more than half,2 progress in others has been much slower. Half of all deaths worldwide in children younger than 5 years are concentrated in only five countries: India, Nigeria, the Democratic Republic of the Congo, Pakistan, and China.1 In the past decade, the number of child deaths decreased by 2 million worldwide, with reductions in deaths due to pneumonia and diarrhoea contributing to 40% of the overall reduction.3 Notwithstanding this success, pneumonia diseases still account for 1·3 million deaths and diarrhoeal diseases for 0·7 million deaths, and both are major causes of post-neonatal child deaths.2, 3 Pneumonia is the largest cause of child deaths worldwide. Corresponding reductions in burden of disease and morbidity have been much slower than those for global child mortality. Incidence of diarrhoea has fallen from 3·4 episodes to 2·9 episodes per child-year, and that of pneumonia from 0·29 episodes to 0·23 episodes per child-year between 1990 and 2010.4 Despite such decreases, these disorders are two of the most common reasons for health service attendance and hospital admission, with an estimated 1731 (uncertainty range 1376–2033) million episodes of childhood diarrhoea (uncertainty range 26·6–42·4 million severe episodes) and 120 (60·83–277·03) million episodes of pneumonia (10·03–40·04 million severe episodes) in 2011.5, 6

Pneumonia and diarrhoea deaths are closely associated, with overlapping risk factors such as those related to poverty, undernutrition, poor hygiene, and deprived home environments making children more likely to develop these diseases. Improvements in socioeconomic development with corresponding increases in maternal education, falling fertility rates, and improved living conditions (with reduced crowding) are important contributors to reductions in child mortality.7 However, to reduce childhood pneumonia and diarrhoea, interventions are needed that directly lower disease transmission and severity, and promote access to life-saving treatment once a child becomes sick. Previous reviews8, 9, 10, 11 have shown that increases in coverage with present evidence-based interventions could greatly reduce child mortality and deaths from diarrhoea and pneumonia. However, little consensus exists about approaches to scale up coverage and about delivery strategies to reduce disparities and provide equitable access to marginalised populations.12

Key messages

  • Worldwide, pneumonia and diarrhoeal diseases are the two major killers of children younger than 5 years

  • Each year, 1·3 million children die from pneumonia and 700 000 from diarrhoea

  • Preventive and therapeutic interventions exist that could have a role in reducing the morbidity and mortality burden due to diarrhoea and pneumonia, especially in children younger than 5 years

  • Few interventions with wide range of outcomes have been assessed at a sufficient scale

  • Interventions with maximum effect include breastfeeding, oral rehydration solution, and community case management

  • Despite persistent burden, childhood diarrhoea and pneumonia deaths are avoidable and 15 interventions delivered at scale can prevent most of these avoidable deaths

  • Estimates modelled with the Lives Saved Tool show that 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 US$6·715 billion, only $2·9 billion more than present levels of spending; costs needed for lives saved calculated on the basis of estimates of projected spending based on historic trend

  • Scaling up of these interventions could also ensure equitable delivery of care

  • The cost-effectiveness of these interventions in national health systems needs urgent assessment

  • With an increasing number of countries deploying community health-worker programmes to reach unreached populations, real opportunities exist to scale-up community advocacy and education programmes and early case detection and management strategies

In this Series paper, we systematically review evidence for the effectiveness of various potential health interventions on morbidity and mortality due to diarrhoea and pneumonia in line with guidelines from the Child Health Epidemiology Reference Group.13 We used a standardised method with criteria from the Child Health and Nutrition Research Initiative (CHNRI) to identify priority areas for research and future interventions. We modelled the potential effect of delivery of these interventions to the 75 high-burden countries that are part of the Countdown to 2015 initiative and assessed the result of scaling-up of interventions on diarrhoea and pneumonia mortality across poverty quintiles in three countries (Bangladesh, Pakistan, and Ethiopia).

Section snippets

Interventions reviewed and the conceptual framework

We used a conceptual framework to assess preventive and case management interventions for diarrhoea and pneumonia, including preventive and therapeutic interventions common to both disorders (figure 1). We selected these interventions from several previous reports that identified their benefits and effects.9, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 We specifically reviewed the interventions to identify data for their effectiveness on diarrhoea or pneumonia, or both; incidence; and

Strategies to promote breastfeeding

Table 1 summarises the available evidence and effect estimates for interventions to prevent and manage diarrhoea and pneumonia. Breast milk provides various immunological, psychological, social, economic, and environmental benefits, and is therefore recommended as the best feeding option for newborn babies and young infants in developing countries, even in HIV-infected populations.31 Lamberti and colleagues27 reviewed 18 studies from developing countries reporting the effect of breastfeeding on

Preventive interventions

Table 2 summarises the evidence and effect estimates for interventions to prevent and manage diarrhoea. Rotavirus is the most common cause of severe dehydrating diarrhoea in infants worldwide.5 In their review of six studies assessing the effectiveness of new rotavirus vaccines, Munos and colleagues34 estimated that use of these vaccines was associated with a 74% reduction in very severe rotavirus infections, a 61% reduction in severe infections, and reduced rotavirus-related hospital admission

Preventive interventions

Table 3 summarises the evidence and effect estimates for interventions to prevent and manage pneumonia. Several effective vaccines are available for prevention of various causes of pneumonia. In regions where measles is a substantial cause of childhood morbidity and mortality, measles vaccination is an important intervention that can also affect risk of subsequent complications, including secondary bacterial infections and diarrhoea. Sudfeld and colleagues56 proposed that measles vaccination

Community-based promotion and case management

Although evidence shows the efficacy and effectiveness of many interventions, these interventions are not accessible to people in need; hence, focus on delivery strategies has increased. One of the main contributors to the delay in meeting the targets of Millennium Development Goal 4 is the paucity of trained human resource professionals in first-level health services, and the reduced awareness of and accessibility to services for those living in large socioeconomically, geographically

Research priorities to develop and deliver interventions

We undertook a systematic analysis of various emerging interventions for diarrhoea and pneumonia on the basis of priorities emerging from the global research priority review process.70, 71 Preventive interventions assessed were reductions in levels of household air pollution,72, 73 and vaccines for Shigella43, 74, 75, 76, 77 and enterotoxigenic Escherichia coli.43 Therapeutic interventions were probiotics for diarrhoea78 and antiemetics for gastroenteritis.79 The appendix summarises the

LiST modelling effects on mortality outcomes for 75 Countdown countries

We selected a set of interventions from those reviewed for modelling on the basis of their proven benefits and availability in public-health programmes. We used LiST to model the potential effect of introduction of these interventions with a standard sequential introduction in health systems of the 75 high-burden Countdown countries. LiST estimates the effect of increases in intervention coverage on deaths from one or more causes, or in reduction of the prevalence of a risk factor (appendix).

Cost analysis

Table 5 shows results of our cost analysis with LiST of interventions and packages in 2025 for the 75 Countdown countries. The costs are based on four components: personnel and labour, drugs and supplies, other direct costs, and indirect costs. We obtained assumptions about time needed for an intervention and costs for drugs and supplies from the One Health Model87 developed by the UN. Costs shown for daily zinc supplementation are for 6–36 months. For breastfeeding, there was difficulty in

Equitable delivery of interventions and effect

A major limitation in previous strategies used to establish outcomes has been relatively little emphasis on reducing of inequities and targeting. We assessed the effect of interventions across equity strata for three countries (Pakistan, Bangladesh, and Ethiopia). We estimated the potential effect and cost-effectiveness of targeting of the same set of interventions to address neonatal mortality and mortality in children younger than 5 years within wealth quintiles. We computed all inputs except

Discussion

Our findings are in line with those from previous reviews and studies, emphasising that effective interventions exist to address childhood diarrhoea and pneumonia, which are still major killers of children younger than 5 years worldwide. We refined and updated the evidence for a range of preventive, promotive, and therapeutic interventions, and by application of these estimates to the LiST model, reaffirmed that these interventions could potentially eliminate diarrhoea deaths and prevent almost

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