Interventions to address deaths from childhood Pneumonia and Diarrhoea equitably - PowerPoint Presentation

Slide1

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

Slide2

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

Slide3

Conceptual Framework

 

INCREASED SUSCEPTIBILITY

 

EXPOSURE

 

PNEUMONIA

DIARRHOEA

ENVIRONMENTAL

WASH*, reduce overcrowding and Household air Pollution

 

NUTRITION

Breast feeding promotion,

Preventive vitamin A or zinc supplementation*

VACCINES

Measles,

haemophilus

Influenzae

type B, Pneumococcal infection, Rotavirus, cholera

TREATMENT

Oral rehydration solution,

continued feeding after diarrhoea, zinc for diarrhoea treatment, probiotic use,

antibiotics and oxygen therapy for pneumonia, antibiotics for dysentery

DELIVERY PLATFORMS

Community based health & behavior change promotion

 

Financial Incentives to promote care seeking

 

Integrated Community Case Management

 

 

Facility Based IMCI

 

SURVIVAL

DEATH

Slide4

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

Slide5

Interventions common to

Diarrhoea

and Pneumonia

Slide6

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

Slide7

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%

Slide8

Risk reductions for diarrhoea

48% with hand washing with soap

17% with improved water quality

36% with excreta disposal

WATER, SANITATION, AND HYGIENE INTERVENTIONS

Slide9

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

Slide10

Diarrhoea specific interventions

Preventive

Slide11

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

Slide12

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

Slide13

Diarrhoea specific interventions

Therapeutic

Slide14

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

Slide15

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

Slide16

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

Slide17

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%

Slide18

Pneumonia specific interventions

Preventive

Slide19

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

Slide20

Pneumonia specific interventions

Therapeutic

Slide21

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

Slide22

Pulse

oximetry

together with oxygen therapy reduced severe

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

Oxygen systems

Slide23

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.

Slide24

LiST

modeling effects on mortality outcomes

for 75 Countdown countries

Slide25

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

Slide26

Coverage of Interventions in 75 Countdown Countries

Slide27

Additional effect of the ambitious scale-up approach on diarrhoea and pneumonia deaths averted for the 75 Countdown countries up to 2025 Specific Interventions

Slide28

Impact of individual interventions on deaths due to diarrhoea and pneumonia (Sequential)

Slide29

Equity Analysis

Slide30

Equity analysis for Bangladesh, Ethiopia and Pakistan

Slide31

Cost Analysis

Slide32

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

.

Slide33

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

Slide34

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

Slide35

THANKS