Excerpts from “Pneumonia & Diarrhea Progress Report: Reaching Goals Through Action and Innovation”, prepared and published annually by the International Vaccine Access Center (IVAC), at the Johns Hopkins Bloomberg School of Public Health, for World Pneumonia Day on November 12:
Between 2015 and 2016, 12 of the 15 countries with the greatest burden of child pneumonia and diarrhea deaths showed some improvements in their GAPPD scores. However, gains were minimal in some of the largest countries (Nigeria, Democratic Republic of the Congo (DRC), and Afghanistan) or remained unchanged, including in Pakistan and China. India increased its score by seven percentage points, although still remains with a score below 50.
Between 2015 and 2016, the ranking of the 15 countries accounting for the greatest number of pneumonia and diarrhea deaths remain unchanged. Progress in implementing GAPPD interventions in these countries over the past year has been mixed. Global Action Plan for Pneumonia and Diarrhea (GAPPD) scores improved for 12 countries: six countries realized an improvement of five or greater percentage points (India, Angola, Ethiopia, Indonesia, Niger, and Bangladesh), six countries had only a very modest change ranging from one to three percentage points (Nigeria, DRC, Afghanistan, Chad, Sudan, and Tanzania), three remained unchanged from 2015 (Pakistan, China, and Somalia).
Improved GAPPD scores were largely driven by new vaccine introductions and ongoing country rollouts. India, the country that leads the world in under-5 pneumonia and diarrhea deaths, increased their GAPPD score by seven percentage points by continuing to roll out Hib vaccine (pentavalent) and improving exclusive breastfeeding rates. India, however, still has a relatively low score, below 50 points. Small or no changes were observed in the GAPPD scores for Nigeria, the DRC and Pakistan, three countries that are consistently in the top four highest burden countries.
It is increasingly evident that without significant gains in GAPPD scores in countries with large birth cohorts, such as India, Nigeria, Pakistan, and DRC, reduction in global pneumonia and diarrhea mortality in children will not be achieved. The pace of progress must be accelerated to make a difference in reducing global totals, which will occur through both the increased use of recommended interventions and treatment innovations.
Overall GAPPD scores in 2016 varied widely from a low of 20% (Somalia) to a high of 74% (Tanzania), with all 15 countries falling below the 86% target for the overall GAPPD score. Over the past year, some large countries, including Nigeria, DRC, Afghanistan, Pakistan, and China had little to no improvement in their GAPPD scores, while others, including India, Angola, Niger, and Bangladesh have made substantial gains.
The top 15 countries contributing to the global burden of child pneumonia and diarrhea deaths were unchanged between 2015 and 2016. These 15 highest burden countries consist of (1) India, (2) Nigeria, (3) Pakistan, (4) DRC, (5) Angola, (6) Ethiopia, (7) Indonesia, (8) Chad, (9) Afghanistan, (10) Niger, (11) China, (12) Sudan, (13) Bangladesh, (14) Somalia, and (15) United Republic of Tanzania (listed in decreasing order of pneumonia and diarrhea child deaths).
In 2016, overall GAPPD scores varied widely from a low of 20% (Somalia) to a high of 74% (Tanzania). Tanzania achieved the highest GAPPD score reached by any of the 15 highest-burden countries since we began evaluating both pneumonia and diarrhea interventions in 2013, prompting an in-depth analysis on this count. The median score among the 15 countries was 48%. This represents a slight improvement over 2015 scores, which ranged from 20% (Somalia) to 72% (Tanzania), with a median score of 47%. However, in 2016, only five of the 15 countries had overall GAPPD scores of at least 50% (Afghanistan, Sudan, Bangladesh, Ethiopia and Tanzania), and none met the 86% target for the overall GAPPD score, which would be achieved if a country met the minimal coverage targets for each of the 10 GAPPD interventions evaluated in this report. India achieved an improvement of seven percentage points, but still remained below the threshold of 50%.
Of the 15 countries profiled in this report, the two countries with the highest GAPPD scores (Tanzania and Sudan) are using all five vaccines protective against pneumonia and diarrhea (pertussis, measles, Hib, PCV, and rotavirus vaccines) and are achieving relatively high coverage with each vaccine. In contrast, where PCV and rotavirus vaccine had not been introduced into the national immunization schedule of countries with large populations of children under-5 as of December 2015, including India, Indonesia, and China, the overall GAPPD scores stagnated.
The pattern noted in previous editions of the Progress Report persists in 2016: countries with the greatest absolute burden of child deaths from pneumonia and diarrhea have among the lowest GAPPD scores. Those countries with the largest number of under-5 pneumonia and diarrhea disease deaths, represented by the largest bubbles, are India, Nigeria, Pakistan, and the DRC. All of these countries have overall GAPPD scores below 50%.
It is important to recognize that the absolute burden of pneumonia and diarrhea deaths in children under-5 does not necessarily tell the complete story for a country. The death rate for pneumonia and diarrhea per 1000 live births provides a different representation of the child health environment than the absolute burden of disease. In countries with large birth cohorts, even relatively low pneumonia and diarrhea mortality rates can result in a high number of deaths.
For example, India has a pneumonia mortality rate of 7 and diarrhea mortality rate of 5 per 1000 live births, lower than 11 of the top 15 countries. However, since India’s under-5 population is the largest in the world, at 121.3 million, the absolute burden of pneumonia and diarrhea deaths is still very high and gains will be great if the problem can be addressed.
A single hospitalization for rotavirus diarrhea can be financially catastrophic for some families close to the poverty line. In India, for example, a hospitalization can cost the equivalent of more than three weeks’ salary. Some of the reasons we do not see growing momentum for introduction of rotavirus vaccine in Asia are related to competing priorities for small resources; limited political will to address such a chronic and common disease; a lack of knowledge about the true local burden of rotavirus disease;14 a misperception that traditional hygiene measures that prevent transmission of other diarrheal pathogens are sufficient to prevent rotavirus disease; lack of appreciation for the severe effects rotavirus disease can have on the vicious cycle of malnutrition; and, the logistical difficulties of adding new vaccines to the routine immunization system in a developing country.
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