RotaFlash, April 2016
An infant being immunized at a child welfare clinic at the Elmina Urban Health Center in the Central Region of Ghana. Photo by: UNICEF.Read more
Children need a nutritious diet to grow healthy and strong. If children don’t get key nutrients during these critical early years, the impact can be far-reaching.
Malnutrition and diarrheal disease feed off each other in a relentless loop to keep children sick and vulnerable to infections. But if we assume the effects wear off when the symptoms disappear, we’re missing a huge part of the story: Chronic diarrhea and malnutrition can stunt physical growth and impact cognitive development, keeping children and their communities from reaching their fullest potential.
Researchers are beginning to uncover the implications of malnutrition on cognitive development, and study findings reinforce that an integrated approach to prevent and treat diarrheal disease (WASH, vaccines, exclusive breastfeeding, nutrition, and ORS/zinc) is the only way to comprehensively address the vicious cycle of diarrhea and malnutrition and the long-term damage it can cause.
We asked a few experts to weigh in:
“The leaky, chronically inflamed and poorly functioning gut of children exposed to unsanitary living conditions and repeated bouts of infection, including diarrheal disease, has been called ‘environmental enteropathy’ or EE . . . EE is associated with malnutrition, failure of the polio and rotavirus vaccines, and poor language and cognitive development . . . Understanding the problem is the first step to a solution.”
- William A. Petri, Jr., MD, PhD, Chief, Division of Infectious Diseases & International Health; University of Virginia. Learn more here.
"A child’s organ systems are trying to develop and get to their maximum potential, and that happens very, very quickly. The competition for nutrition is very high. Unfortunately, this is the time children in the developing world get afflicted with diarrhea and other infectious diseases. With a bout of diarrhea, it’s very easy for a child to tip off into malnutrition. When their brains are supposed to be developing, when their organs are supposed to be developing, they are completely depleted of these nutrients that they need. Once a child developmentally misses an opportunity to grow, you can never fix that."
- Dr. Roma Chilengi, Chief Medical Officer, Centre for Infectious Disease Research, Zambia.
“The link between malnutrition and cognitive development is powerful and far-reaching. Its effects span not only the lifespan of the individual affected, but also cross generations and can affect the earning potential of individuals and populations. For example, a baby born small for its age is less likely to achieve his or her academic and intellectual potential at school, and in their 50’s, 60’s, and 70’s has a higher risk of developing problems such as high blood pressure, diabetes, and high cholesterol.
Malnourished children often become malnourished parents and the vicious cycle is repeated. Now more than ever before, as the entire global community extends its survival focus to include to include thriving, we all need to work harder and closer together to ensure that every baby, every child, every woman and every man eats a well-balanced meal and is optimally nourished.”
- Dr. Cyril Engmann, Director of Maternal, Newborn and Child Health and Nutrition, PATH. Click here to learn more.
Photo credit: PATH.Read more
A mother in Uganda gives her 3 year old daughter, Naume, ORS and zinc for her diarrhea and she recovers quickly. She is well again and loves playing with her two older sisters. Photo credit: Melinda Stanley, Clinton Health Access Initiative, Inc.
In 2004, UNICEF and WHO updated their guidance for the treatment of acute diarrhea by recommending a combination of zinc supplementation and oral rehydration salts (ORS). Where have we come since then?
Significant global and political attention has raised the profile of this simple, highly-effective, and affordable solution and its potential to save the lives of children. For example, the UN Commission on Life-Saving Commodities for Women and Children named zinc and ORS as two of 13 essential commodities. The Integrated Global Action Plan for Pneumonia and Diarrhea (GAPPD), accompanied by a Lancet Series, updated and provided the evidence-base for an integrated framework of interventions for pneumonia and diarrhea, including zinc and ORS. Partner networks representing the NGO, donor, academic, and private sectors—including the Zinc Task Force and the Diarrhea & Pneumonia Working Group, among others—have come together to address global and regional barriers to access.
Most importantly, governments and local partners have demonstrated unprecedented leadership and commitment to reducing child mortality in their countries by increasing access to and use of zinc and ORS. A review of progress across the 10 focal countries of the Diarrhea & Pneumonia Working Group have shown notable improvements in treatment coverage, national policies, and care-seeking behavior compared to other countries. In spite of this progress, there is much work that remains in order to further reduce child deaths.
So, what can we learn from the high-performing countries?
Progress over a Decade of Zinc and ORS Scale-up: Best Practices and Lessons Learned, a new report published by the members of the Diarrhea & Pneumonia Working Group chaired by the Clinton Health Access Initiative, Inc. (CHAI) and UNICEF, attempts to answer this question, drawing from the past decade of experiences from a range of countries, child health partners, and other experts involved in large-scale efforts. Four key success factors were established (see figure below):
1. Securing a strong enabling environment: A national scale-up plan—in line with GAPPD and other global frameworks—helps to align government and partners around a common framework and a government-led national coordinating mechanism can drive its implementation. Achieving over-the-counter status for zinc is also needed to ensure the products can be widely distributed and marketed to consumers.
2. Improving availability of supply: The local market for high-quality, affordable, and optimal zinc and ORS products has improved dramatically, particularly in sub-Saharan Africa, with the introduction of new suppliers. In the public sector, robust forecasting, procurement, supply chain, and distribution practices help to ensure a consistent supply for health facilities and community health workers. In the private sector, partnerships with actors along the supply chain expand the reach of products to rural areas where most children die from diarrhea.
3. Generating demand among caregivers: A strategy informed by the latest market evidence and tailored to address local barriers has the greatest potential for improving awareness and usage of recommended products. Updating product packaging and presentations also has a strong influence on consumer appeal and adherence.
4. Improving knowledge and skills of providers: Frontline workers (both public and private sector) —often the first and only point of care for child diarrhea in remote areas—should be adequately equipped with the knowledge, skills, and motivation needed to manage and treat diarrhea.
Bangladesh has demonstrated that this ‘four-pronged approach’ works. Today, an increased number of children with diarrhea are receiving the correct treatment, with 77% receiving ORS and 44% receiving zinc.
Each year, over 500,000 children still die unnecessarily from diarrhea and governments, donors, and partners have invested significant time and resources to tackling this problem since 2004. More is needed to achieve high coverage levels. We have a responsibility to focus our next investments on what works (and learning from what doesn’t work) to continue to drive large-scale change and ensure children with diarrhea receive the correct treatment.Read more
Vaccines against diarrheal disease still have an enormous amount of untapped potential for Africa—for children’s lives, their ability to flourish, their families’ livelihoods, and their countries’ economies.
The Ministerial Conference on Immunization in Africa is currently underway. Leaders from across the continent have gathered in Addis Ababa, Ethiopia, to discuss how to achieve universal immunization coverage in all African countries and, in doing so, avert vaccine-preventable deaths and disabling diseases from limiting the potential of African children.
To help country decision-makers determine the best use of limited resources, Atherly’s team at PATH evaluates the costs and public health impacts of vaccines.
As with all public health decisions, the cost of immunization programs is an important consideration. Public officials have an important responsibility to spend public funds in a way that benefits the highest number of people. We already know that vaccines in general are one of the best buysin global health, and vaccines against diarrheal disease, which is responsible for 12 percent of deaths of African children under five years old, are no exception.
The financial burden of diarrhea
Diarrhea imposes a large public health burden—not just in terms of death and illness, but also in terms of finances. When a young child in a developing country gets sick with diarrhea, his or her parents usually have to pay for the care, which can amount to a significant portion of the family’s income. Additionally, because the parents have to stay home and take care of their child, or take him or her to a hospital, they lose wages that they would have otherwise made at their jobs. And then—on top of all that—often when one child gets sick, the infection is passed on to other children in the family. Having multiple sick children in the same household can be financially devastating for a family.
But what we also have to understand about diarrhea is that, when a child has multiple episodes of diarrhea, he or she is left more vulnerable to other infections, malnutrition, and stunting, which can have a lifelong toll on that child’s ability to grow, thrive, and contribute to society.
That is why we have to prioritize vaccines against diarrheal disease.
The promise of vaccines
Vaccines against rotavirus, the leading cause of severe and deadly diarrhea among children under five years of age, have now been introduced in 33 countries in Africa—27 of which are Gavi-eligible—and have a wealth of evidence on both their projected and real-world impact.
In 2012, I published an article on the projected health and economic impact of rotavirus vaccines in 72 countries eligible for support from Gavi, the Vaccine Alliance. Our model told us that, indeed, rotavirus vaccination would be considered very cost-effective in all of these Gavi-eligible countries—especially those in Africa, the region with the highest burden of diarrheal disease. Four years later, we are starting to see our projections come to life. In Rwanda, a recent study just revealed a 50 percent decline of all-cause childhood diarrheal hospitalizations following the introduction of rotavirus vaccines. And in Malawi, hospital admissions for diarrhea declined by 43 percent after the rotavirus vaccine rollout.
Additionally, vaccines against two of the other leading causes of severe diarrhea—enterotoxigenic E. coli (ETEC) and Shigella bacteria—are currently under development. While a lot more research will be needed before they can be introduced in countries, early estimates indicate the vaccines would be highly cost-effective in low-resource settings. We hope this evidence will help decision-makers as they consider and potentially plan for ETEC and Shigella vaccine introduction in years to come.
Saving lives, saving costs
We cannot afford to let any more children miss out on the protection of lifesaving, life-improving, and highly cost-effective vaccines against diarrheal disease. Diarrhea caused by rotavirus alone costs the lives, livelihoods, hopes, dreams, and futures of hundreds of thousands of children across Africa every year. For their families, the impact of rotavirus vaccination programs means more than just economics.
As countries with rotavirus vaccination programs have already shown, it means that more children can live past their fifth birthday. It means more children who are able to live to the full extent of their potential, not held back by disability, stunting, long-term illness and expensive hospital visits, or early death caused by rotavirus diarrhea. It means more parents are better able to take care of their children, work productively, and contribute to growing economies.
The cost of not introducing vaccines against diarrheal disease is just too high. By prioritizing vaccines against diarrheal disease, leaders across Africa can help ensure that African children and their families not only survive, but thrive—both physically and financially.
Photo credit: PATH/Gabe Bienczycki.Read more
Let’s face it, after more than eight years leading PATH’s work on developing vaccines against Shigella and enterotoxigenic Escherichia coli (ETEC) and more than three decades of working on enteric diseases, you might assume that I’ve heard it all when it comes to diarrhea. Not in the least!
There have been some amazing advances in the enteric vaccine field over the last few years, and I’m sure there are lots more that I don’t even know about. That’s why I’m so excited to announce PATH’s first international Vaccines Against Shigella and ETEC (VASE) Conference. We’re launching this new biennial conference series in Washington, DC on June 28 to 30, 2016, and we want you to be there.
I know what you’re thinking – why should I come to yet another dry scientific meeting? Well, this is where we’re hoping that VASE will break the mold. We’re taking a unique approach to the typical vaccine conference. We want to bring together a diverse group of scientists, public health professionals, immunization leaders, vaccine industry representatives, international donors, and other experts to engage in collaborative discussions focused on making Shigella and ETEC vaccines a reality for children in the developing world.
Truly making these vaccines a reality for these kids is the key. Although we expect to include plenty of updates on vaccine research, burden of disease, and other typical scientific topics, we’re aiming for every presentation, session, and discussion to include a link back to this important end-goal. (If you have a presentation idea, I urge you to submit an abstract – deadline for submission is March 1, 2016.)
We’re also reaching far and wide to bring together a diverse group of participants from across the globe. We aren’t charging a registration fee to make it easier for anyone to attend (registration opened on February 15 – sign up now!), and we’re offering the opportunity to apply for a travel grant (deadline for applications is May 1, 2016) if you need help getting here. We really want to get voices from the front lines of the war against diarrhea in the room for these discussions, since they’re the ones who can best help us figure out how to get these new vaccines to the kids who need them most.
Finally, we’re designing a conference program that has lots of opportunity for interactive discussion, including some focused small-group workshops to really zero-in the challenges and potential solutions to making new enteric vaccines a reality.
One last point: while the primary focus of the conference is on Shigella and ETEC, we recognize that there are many other neglected enteric diseases emerging as important causes of illness and death among infants and children in the developing world. For this reason, we are also hoping to include broader work on these and other pathogens in the conference program.
I hope to see you at VASE 2016!
Photo credit: PATH/Richard Walker.Read more