Pneumonia and diarrhoea Tackling the deadliest diseasesfor the worlds poorest children

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United Nations Childrens Fund (UNICEF) June 2012

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ISBN: 978-92-806-4643-6

Photo credits: cover, UNICEF/NYHQ2010-2803crop/Olivier Asselin; page vi, UNICEF/NYHQ2004-1392/Shehzad Noorani; page 6, UNICEF/INDA2012-00023/Enrico Fabian; page 12, UNICEF/NYHQ2011-0796/Marco Dormino; page 19, UNICEF/UGDA01253/Chulho Hyun; page 23, UNICEF/SRLA2011-0199/Olivier Asselin; page 25, UNICEF/MLIA2010-00637/Olivier Asselin; page 29, UNICEF/NYHQ2006-0949/Shehzad Noorani; page 31, UNICEF/NYHQ2010-1593/Pierre Holtz; page 34, UNICEF/INDA2010-00170/Graham Crouch; page 36, UNICEF/INDA2010-00190/Graham Crouch; page 37, UNICEF/NYHQ2010-3046/Giacomo Pirozzi; page 40, UNICEF/NYHQ2012-0156/Nyani Quaryme.

Pneumonia and diarrhoea Tackling the deadliest diseasesfor the worlds poorest children

This report was prepared at UNICEF Headquar-ters/Statistics and Monitoring Section by Emily White Johansson, Liliana Carvajal, Holly Newby and Mark Young, under the direction of Tessa Wardlaw.

This report is one of UNICEFs contributions to the multistakeholder global initiative that has been established to develop an integrated global action plan for prevention and control of pneu-monia and diarrhoea. We thank Zulfiqar Bhutta for his feedback on the report and for his guid-ance around the forthcoming global action plan.

The authors acknowledge with gratitude the con-tributions of the many individuals who reviewed this report and provided important feedback. Special thanks to Elizabeth Mason, Cynthia Bos-chi-Pinto, Olivier Fontaine, Shamim Qazi and Lulu Muhe of the World Health Organization. The report also benefited from the insights of Zulfiqar Bhutta (Agha Khan University), Robert Black (Johns Hopkins University), Kim Mulhol-land (London School of Hygiene and Tropical Medicine), Richard Rheingans (University of Florida), and Jon E Rohde (Management Sci-ences for Health).

Overall guidance and important inputs were provided by numerous UNICEF staff: David Anthony, Francisco Blanco, David Brown, Danielle Burke, Xiaodong Cai, Theresa Diaz, Therese Dooley, Ed Hoekstra, Elizabeth Horn-Phathanothai, Priscilla Idele, Rouslan Karimov, Chewe Luo, Rolf Luyendijk, Nune Mangasaryan,

Osman Mansoor, Colleen Murray, Thomas OConnell, Khin Wityee Oo, Heather Papowitz, Christiane Rudert, Jos Vandelaer, Renee Van de Weerdt and Danzhen You.

The authors would like to extend their grati-tude to Neff Walker, Ingrid Friberg and Yvonne Tam (Johns Hopkins University) for produc-ing the LiST modelling work under a tight timeline. Thanks also go to Robert Black and Li Liu (Johns Hopkins University) for providing the cause of death estimates, Richard Rhein-gans (University of Florida) for equity analy-sis on vaccinations, as well as Nigel Bruce and Heather Adair-Rohani (World Health Organi-zation) for text and data related to household air pollution.

Further thanks to Robert Jenkins, Mickey Cho-pra, Werner Schultink, Sanjay Wijesekera ( UNICEF), and Jennifer Bryce (Johns Hopkins University) for their guidance and support.

Special thanks to Anthony Lake, UNICEFs Exec-utive Director, for his vision in promoting the equity agenda, which served as the inspiration for this report.

While this report benefited greatly from the feed-back provided by the individuals named above, final responsibility for the content rests with the authors.

Communications Development Incorporated pro-vided overall design direction, editing and layout.

Acknowledgements

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Executive summary 1

1 Pneumonia and diarrhoea disproportionatelyaffect the poorest 7

2 We know what works 11

3 Prevention coverage 13Vaccination 13Clean home environment: water, sanitation,

hygieneandother home factors 15Nutrition 20Co-morbidities 22

4 Treatment coverage 24Community case management 24Treatment for suspected pneumonia 25Diarrhoea treatment 30

5 Estimated childrens lives saved by scaling upkey interventions in an equitable way 38

6 Pneumonia and diarrhoea: a call to action tonarrow the gap inchild survival 41

Annex 1 Action plans for pneumonia and diarrhoeacontrol 43

Annex 2 Technical background 45

Notes 49

References 50

Statistical tables1 Demographics, immunization and nutrition 542 Preventative measures and determinants of

pneumonia and diarrhoea 603 Pneumonia treatment, by background

characteristic 664 Diarrhoea treatment, by background

characteristic 72

Boxes1.1 Cholera, on the rise, affects the most

vulnerablepeople 92.1 The importance of evidence-based

communication strategies for child survival 123.1 Disparities in vulnerability and access reduce

theimpact of new vaccines 143.2 The importance of improved breastfeeding

practices for child survival 214.1 The importance of integrated community case

management strategies 244.2 Diarrhoea treatment recommendations 325.1 Focus on the poorest children the example

ofBangladesh 396.1 Global action plan for pneumonia and diarrhoea 41

Figures1.1 Pneumonia and diarrhoea are among the

leadingkillers of children worldwide 71.2 Nearly 90per cent of child deaths due to

pneumonia and diarrhoea occur in sub-Saharan Africa and South Asia 8

1.3 Different patterns of child deaths in high- and low-mortality countries: Ethiopia and Germany 10

2.1 Many prevention and treatment strategies for diarrhoea and pneumonia are identical 11

3.1 Progress in introducing PCV globally, particularlyinthe poorest countries, but a rich-poor gap remains 13

3.2 Closing the rich-poor gap in the introduction ofHib vaccine in recent years 14

3.3 Few countries use the rotavirus vaccine, which islargely unavailable in the poorest countries 15

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3.4 Substantial wealth gap in measles vaccine coverage in every region 15

3.5 Most children not immunized against pertussis livein just 10 mostly poor and populous countries 15

3.6 Water, sanitation and hygiene interventions are highly effective in reducing diarrhoea morbidity among children under age 5 16

3.7 Use of an improved drinkingwatersource is widespread, but the pooresthouseholds oftenmiss out 16

3.8 Most people without an improved water sourceorsanitation facility live in rural areas 17

3.9 Worldwide, 1.1 billion people still practice open defecationmore than half live in India 17

3.10 The poorest households in South Asia have barelybenefited from improvements in sanitation 17

3.11 Child faeces are often disposed of in an unsafe manner, further increasing the risk of diarrhoea inrural areas 18

3.12 New data available on households with a designated place with soap and water to washhands 18

3.13 Young infants who are not breastfed are at greaterrisk of dying due to pneumonia or diarrhoea 21

3.14 Too few infants in developing countries are exclusively breastfed 22

3.15 The incidence of low-birthweight newborns isconcentrated in the poorest regions and countries 22

3.16 Least developed countries lead the way in coverage of vitamin A supplementation 23

4.1 Most African countries have a community case management policy, but fewer implement programmes on a scale to reach the children mostin need 25

4.2 Many African countries with a government community case management programme reportintegrateddelivery for malaria, pneumoniaand diarrhoea 26

4.3 Fewer than half of caregivers report fast ordifficultbreathing as signs to seek immediatecare 26

4.4 Most children with suspected pneumonia in developing countries are taken to an appropriatehealthcare provider or facility 27

4.5 Boys and girls with suspected pneumonia are taken to an appropriate healthcare provider or facility at similar rates 27

4.6 Gaps in appropriate careseeking forsuspected childhood pneumonia exist between rural and urban areas... 28

4.7 ...and across household wealth quintiles 284.8 Every region has shown progress in appropriate

careseeking for suspected childhood pneumonia over the past decade 29

4.9 Narrowing the rural-urban gap in careseeking forsuspected childhood pneumonia over the pastdecade 29

4.10 Across developing countries fewer than athirdofchildren with suspected pneumonia receive antibiotics 30

4.11 Children in rural areas are less likely to receiveantibiotics for suspected pneumonia... 30

4.12 ...as are the poorest children 314.13 The lowest recommended treatment coverage

forchildhood diarrhoea is in Middle East and NorthAfrica and sub-Saharan Africa 32

4.14 Modest improvementin recommended treatmentfordiarrhoea in sub-Saharan Africa overthe past decade 33

4.15 UNICEF has procured some 600 million ORS packets since 2000 33

4.16 Only a third of children with diarrhoea indeveloping countries receive ORS 33

4.17 Low use of ORS in both urbanand rural areas of every region 34

4.18 The poorest children often do not receive ORS to treatdiarrhoea 35

4.19 Use of ORS totreat childhood