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Progress for child survival: Pneumonia and diarrhoea

Listen to Dr Shunmay Yeung describe the progress made in reducing child deaths from pneumonia and diarrhoea.
SHUNMAY YEUNG: So with pneumonia, we’ve had a lot of progress with the reduction of about 5% per year since 2000. Similarly with diarrhoea there’s been the reductions of over 6% on average per year since 2000. And it’s also worth noting the reduction in measles, which is almost double, and it’s important because it’s an important cause mainly of pneumonia but also diarrhoea. So all in all, these three causes have been responsible for about half of the reduction in deaths since 2000. But it’s worth remembering this pie chart that we saw earlier and looking at how many deaths are due to pneumonia and diarrhoea altogether.
So if we look at pneumonia, that’s about almost a million deaths a year or 2,500 deaths a day due to pneumonia and from diarrhoea about 600,000 a year or 1,500 a day. So they’re still really, really important causes of child mortality. So now we’re going to look at some of the preventative and treatment interventions, which may have been partly responsible for the reductions and also instruct us on how we might go forward in trying to reduce child deaths in the future. So starting with prevention and looking at the disease specific interventions, the main one has really been vaccines. In pneumonia one of the big advances has been measles where coverage is now globally over 80%.
More recently we’ve had the introduction of the vaccination against Haemophilus influenzae type B, or otherwise known as Hib, which is an important cause of pneumonia and is now reaching good levels of coverage were very variable. And much more recently we have pneumococcus vaccination, which is now available in over 100 countries and is gradually being rolled out. For diarrhoea there hasn’t been a vaccination for many years but now rotavirus, which is the most common cause of diarrhoea in children, we do have a vaccine against and that’s gradually being rolled out currently available in about just over 50 of the countries in the world. So in terms of non-disease specific preventions there’s some commonality.
So vitamin A is protective both against pneumonia and also diarrhoea. And the aim is in high child mortality countries that children under the age of five should be having two doses per year up until the age of 5. And the coverage rates of vitamin A have increased since the year 2000. Breastfeeding is a really important intervention, which again protects against both diseases, and again, very variable coverage rates but gradually improving as well. Really importantly are non-health specific measures and improvements in social and environmental conditions, particularly the availability of clean water and sanitation. So moving on from prevention, treatment. Now, like HIV and malaria, the progresses made with coverage of case management strategies has probably been less successful.
And that’s probably because it’s a little bit more difficult and requires a comprehensive approach to child health. With diarrhoea we’ve done a little bit better. Diarrhoea, there are many different causes. Most of them are viral, which means that you don’t need antibiotics. But the treatment is the same, and it’s mainly oral re-hydration solution, otherwise known as ORS, and zinc. And coverage with that is improving, again very patchy with countries like Bangladesh, which have done very well, but overall the coverage of about 50%. Case management of pneumonia is more difficult partly because there’s a lot of different causes.
Many pneumonias are actually caused by viruses, which don’t require antibiotics. But those that are due to bacteria require treatment with antibiotics, otherwise they lead to severe pneumonia and potential death. And we do have effective antibiotics like amoxicillin, which we need to five for three days. But diagnosis, as a rule, is really difficult. There is no easy test like there is for a rapid diagnostic test for malaria. So big challenge, big challenge there. So how about other challenges. So kind of looking back what have been the challenges and where are we going in the future.
So looking back, in comparison to malaria and HIV, there’s been limited investment for diarrhoea and pneumonia, apart from vaccines where there’s been a huge amount of development and research and progress.
Investment in pneumonia and diarrhoea has also been– it’s been quite fragmented and really we need to have a more holistic approach to the child. If you think about it, when the child gets sick and the parent takes them to a health provider, the child is presenting as a febrile child, maybe off eating, maybe vomiting a bit, a bit of diarrhoea. They’re not coming with a label of malaria or pneumonia. And really we need to have an integrated approach to the child. But this requires a much kind of health systems rather than a vertical approach. And as with malaria and the others we’ve heard about, there is an issue about delivery.
So we’ve got effective tools, but actually how to we get them out to the periphery where the most vulnerable children are and ensure that there’s equity in terms of access.
Finally, and it’s something that we’ll go on to talk a little bit later, there are other problems underpinning both pneumonia, diarrhoea, and other childhood diseases. And that is one of the most important things is under-nutrition. And there’s a complex interaction between infections such as diarrhoea and pneumonia and under-nutrition. But I’m not going to talk about that more, as you’ll hear about that later. So in summary, there’s lots of potential. We have tools that work, both for prevention and treatment. We have made quite a bit of progress, but we could do a lot better if we were able to scale up the interventions that we have.
And we do require some innovation and a lot of thought on actually how to get these interventions out to the most vulnerable children and provide a comprehensive health service to kids.

Dr Shunmay Yeung now highlights our third and final examples of rapidly-reducing but major causes of child mortality: pneumonia and diarrhoea. Despite gains these two conditions remain the biggest childhood killers, accounting for 25% of all deaths of children under-five, or around 1.5 million per year.

Along with measles, which is closely linked to both pneumonia and diarrhoea, these three causes are responsible for almost half the total reduction of child deaths. This has been achieved through:

  • Prevention via vaccines, provision of vitamin A, promotion of breastfeeding practices and clean water and sanitation
  • Treatment with oral rehydration solutions (ORS) and antibiotics.

Until recently both have been relatively neglected compared to HIV and malaria, but there is huge potential to make further, even more significant reductions in the number of deaths with a more integrated approach. How do the approaches to prevention and treatment differ from HIV and malaria? What about the challenges?

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