RotaFlash, April 2016
Together, pneumonia and diarrhea kill more children under the age of five each year than any other infectious disease. Luckily, a number of prevention and treatment solutions (like vaccine delivery systems, handwashing/sanitation, antibiotics, and exclusive breastfeeding) can be applied to both, warranting an approach that leverages common resources to fight them in an integrated way. The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea is the roadmap for doing just that. This post originally appeared on the PATH blog. Photo credit: PATH/Doune Porter.
Fifteen years ago, roughly two million children under age five died from pneumonia annually. Today, that number is down by more than half thanks to improved prevention and treatment interventions and their growing presence in traditionally underserved countries.
Despite this progress, pneumonia still kills more children than any other infectious disease, especially in the developing world. Why? Because it is a complex disease with many causes and the tools to fight it are still not equitably accessible. To finish the job, we must harness an integrated array of solutions (vaccines, treatments, clean air, nutrition, and diagnostics) that can hit pneumonia from multiple angles.
Here’s my list of five particularly exciting solutions that are vital for enhancing the fight against pneumonia and overcoming systemic barriers that inhibit children from getting the prevention and care they need.
There are vaccines on the horizon that hold great promise to protect against all pneumococcal strains. Photo: PATH/Heng Chivoan.
1. Vaccines to provide broad protection
Vaccines against the leading cause of severe childhood pneumonia—pneumococcus—are effective against a number of the bacterium’s many varieties, but not all. They are also too expensive for many countries to afford without substantial donor assistance. By design, they’re doing their job, but what if a vaccine could provide affordable protection against all pneumococcal strains? The good news is vaccines designed to do just this are on the horizon. Public-private partnerships are advancing the development of vaccines that hold the promise to potentially change the pneumococcal prevention game.
Dr. Amy Ginsburg demonstrates a user-friendly application for mobile phones and tablets called mPneumonia that aims to help health care providers detect and manage pneumonia. Photo: PATH/Patrick McKern.
2. Technologies to diagnose and treat low oxygen levels
By afflicting the lungs, pneumonia can result in fatal oxygen deficiency. A pulse oximeter is the gold standard for non-invasively diagnosing this deficiency; easily and painlessly clips on a finger or other extremity to measure blood oxygen levels; and can inform the best use of lifesaving oxygen treatments. In low-income countries, however, supply, policy, training, and cost hurdles make pulse oximetry and oxygen scarce resources, particularly for children. Investing in creative ways to address the challenges (like mobile phone applications or alternative energy for pulse oximetry) is critical for expanding use.
Fast-dissolving tablets are an easy and cost-effective way to administer antibiotics to children. Photos: PATH/Patrick McKern.
3. Child-friendly antibiotics ideal for low-resource settings
The recommended first-line treatment for childhood pneumonia is the antibiotic amoxicillin. In its traditional forms, it’s difficult to use in the harsh conditions of many low-resource countries because of factors like heat and light sensitivity and the need for precise measurement. In these settings, amoxicillin dispersible tablets are a better option, particularly for children who can’t swallow pills. They have a longer shelf-life, are cost-effective, don’t need refrigeration, and are easy to administer because the tablets quickly disperse in clean water or breastmilk. Their lack of availability in countries where most needed, however, underscores the urgency of resolving barriers to access so these tablets can be put to work.
Cleaner-burning fuels can reduce indoor air pollution, which causes 4.3 million deaths—of which 12 percent are children with respiratory infections like pneumonia. Photo: PATH/Heng Chivoan.
4. Clean household fuels to clear the air
Nearly three billion people use coal, wood, and crop residue for cooking, but the smoke these fuels produce can cause serious illness. Indoor air pollution causes 4.3 million deaths of which 12 percent are children with respiratory infections like pneumonia. Clean-burning fuel like liquid-petroleum gas is a potential solution, but is often too costly for poor, rural communities. However, there are interventions streamlining supply chains, providing consumer financing, and using direct marketing to bring clean fuel into more households, but further investment is needed to maximize reach.
Thanks to a thriving human milk bank, an infant receives donor breastmilk in the neonatal intensive care unit at Mahila Chikitsalaya Government Hospital in Jaipur, India. Photo: PATH/Tom Furtwangler.
5. Human milk banking to protect vulnerable infants
Exclusive breastfeeding provides infants with the nutrients and hydration they need; prevents exposure to contaminated food and water that cause deadly illnesses like diarrhea; and confers protective antibodies against many illnesses, including pneumonia (a particularly dangerous infection for newborns). When infants don’t have access to their own mother’s milk, donor breastmilk is the next best thing. Human milk banks are an innovative solution that gives otherwise deprived infants access to safe donated breastmilk—and a chance to thrive.Read more
Health workers transport pneumonia and rotavirus vaccines across Tanzania. Photo credit: PATH/Doune Porter.
Two years ago, Dr. Namala Mkopi, pediatrician and Shot@Life Global Immunization Fellow, celebrated Tanzania’s dual introduction of pneumonia and rotavirus vaccines with a blog here on DefeatDD. We were lucky to catch him in during a visit in DC just ahead of World Pneumonia Day 2015 to hear about the changes he’s seen first-hand since the nationwide vaccine introduction.
Before we focus on the past couple years in Tanzania, let’s go back a bit further. What first inspired you to go into the medical field?
I always said I wanted to treat kids before I even knew what it took! I never really liked biology, to be truthful – I liked math and physics – but at the end of the day that was the path I had to take to practice medicine and help children.
I’ve spent my whole education and medical career in Tanzania, and I find that in working with children for such a long time you find yourself driven to do so many things. Especially when you realize that no matter what you do for treatment, there’s only so much one person can do. You find yourself being an advocate and trying to train and mentor as many people as you can. Eventually, when you hear there is a vaccine that is effective – that is really something. There are many entry points to prevent pneumonia, but in my experience, one of the best and easiest to deal with is vaccination.
Your day-to-day experiences as a pediatrician in Tanzania certainly underscore the importance of pneumonia and diarrhea prevention. What is a typical day like in the clinic?
I work at the National Hospital in Dar es salaam, Tanzania. We have more specialized equipment because we are in an urban setting, and I deal with critically ill children who have been transferred from municipal hospitals because their cases are life-threatening. Everything moves so quickly, especially when several children arrive at once needing oxygen or a blood transfusion, and there are only two or three medical staff with varying degrees of experience. I need to make several major decisions at one time. I scan patients for prompt issues. Divide and deal. Children have died simply because they are waiting for blood or oxygen to be available.
I also mentor medical staff in districts and hard-to-reach areas so that they learn how to evaluate and assess children well. This is the place where there is opportunity to make a difference. If kids are getting interventions early, they have a better chance.
Because of poverty, parents delay bringing kids to the hospital. The health of one child is important, but they may have other kids, too. For many who cultivate farms, today’s meal will be determined by what they do on that particular day. If they go to the hospital, what will they eat? Where will they leave the other kids?
I can’t change the health statistics of my country, even if I see kids 24 hours a day. But if we give children vaccines, I can at least go sleep at home!
You blogged for DefeatDD after Tanzania’s dual introduction of pneumonia and rotavirus vaccines in 2013. What changes have you seen since then?
I was so excited that the advocacy efforts were paying off. Back then, we had some hope because of success stories we’d heard from other countries, but now we are living that hope. It is no longer a told story.
I used to see so much pneumonia that we had to swap oxygen cylinders from one child to another because there were not enough to go around. We do not struggle that way anymore. In the diarrhea ward, there are days when I see only one child, and my colleagues can’t believe it; they say, “Are you sure?!” Yes, there have been other health interventions that have made an impact, but why this big of a change within two years? It tells me that the pneumonia and rotavirus vaccines are doing what they’re supposed to be doing.
People need to hear these stories so we can implement this model in other countries.
I am amazed by Tanzania’s extraordinary vaccination coverage rates. How do you account for it?
The secret of Tanzania’s 90% plus vaccine coverage rate is in public-private partnerships and, from region to region, a solid cold chain infrastructure and health system. This means that parents, regardless of region or type of hospital, can access vaccines for their children.
The other thing that motivates parents is that they’ve seen the changes since they started vaccinating their children. They become local ambassadors because they’ve seen the changes with their own eyes. And now they are even becoming more curious, asking, “Is my child getting all the necessary vaccines?” Even the third dose of the pneumonia vaccine, where participation tends to drop off, still has a high coverage rate of over 90%, which speaks volumes about the commitment of parents.
The role of media – tools like radio – has been important as well.
At the briefing “The Fight Against Pneumonia: From Global Immunization Partnerships to Local Impact,” you mentioned that you want to help start a grassroots advocacy movement for vaccines in Tanzania. Why is this a priority for you?
I think of advocacy as operating on a macroscopic and microscopic level. I work on the macroscopic level: talking on the radio, teaching medical students.
But I am only one voice. Grassroots advocacy is like a wildfire spreading underground – by the time you see it, it has covered everything. Like looking through a microscope, just because an organism is tiny doesn’t mean it’s not there. Engaging youth in grassroots advocacy is important because parents might hear me on the radio and get bored and turn the station, but they will listen to their children. Our youth need to be equipped to become good ambassadors – and good future parents.
Youth also have leverage with policymakers. More than 60% of the people who voted in the last election were under 30 years old. Politicians care about votes, and if the youth are demanding something, they will have nowhere to run!Read more
I’m grateful to Chelsea Clinton for her admission that she is “obsessed with diarrhea,” and her total lack of embarrassment in bringing it up repeatedly. In an interview with Fast Company, it was the first thing she wanted to talk about.
I’m grateful to her because she is, as far as I know, the only well-known public figure to champion the prevention and treatment of diarrhea, the world’s second biggest killer of children under five years old, even though we have cheap and effective ways of dealing with it.
“It’s completely unacceptable that more than 750,000 children die every year because of severe dehydration due to diarrhea,” said Clinton last year. “I just think that’s unconscionable.”
We need more champions of the diarrhea issue.
Four years ago, I wrote a blog bemoaning the fact that oral rehydration therapy (ORT) seemed to be on life support, even though The Lancet once called it “the most important medical advance of the 20th century.” ORT and its practical application, oral rehydration solution (ORS), have long been found to be both effective and cost-effective in treating the dehydration caused by diarrhea.
Bangladesh is perhaps the best example of a country that has made stellar progress in fighting diarrhea through ORS. The treatment of diarrhea increased from 58% in 1993 to 81% in 2011. Productive collaborations between the government, the private sector and organizations like the Social Marketing Company, which used social marketing revenues to build Bangladesh’s first ORS factory in 2004, have led to tremendous improvements in diarrheal disease management.
Starting in the 1970s, ORS has saved an estimated 50 million lives, costing less than $0.30 per sachet, according to the WHO. In 1978, the World Health Organization (WHO) established the Control of Diarrheal Diseases Program, and by the early 1980s, most developing countries had their own dedicated national programs.
But even though ORS was cheap and effective, the global health community moved on to other diseases, like AIDS and malaria. In the 1990s, these diarrheal disease programs were merged into broader child health programming, and lost their dedicated funding, staff, and systems. A 2008 analysis that looked at changes in ORS use in children under three found declines in 23 countries and increases in only 11.
A 2009 research study conducted by PATH, a leading NGO working to fight diarrhea, to evaluate the funding and policy landscape found that “diarrheal disease ranked last among a list of other global health issues.”
After years of neglect, diarrhea is back on the global health map. Diarrhea deaths among children under five are down from 700,000 per year in 2011 to around 531,000 in 2015, according to PATH, a drop of 24% in four years. The bad news is that ORS use has stagnated, says PATH, at around 35% over the last 10-15 years.
Why has diarrhea death dropped even though ORS has stagnated?
“It’s been because of increasing access to a set of protection, prevention and treatment interventions,” said Ashley Latimer, senior policy and advocacy officer at PATH. “More children are being vaccinated against rotavirus (a leading cause of diarrhea). Understanding the importance of hand-washing and clean drinking water is improving. Improved nutrition and exclusive breastfeeding probably plays a small role.”
In 2013, the WHO and UNICEF published “Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025,” the first-ever global plan to tackle the two diseases that take the lives of 2 million children every year, which was supported by more than 100 nongovernmental organizations.
There are several efforts underway to fight diarrhea more effectively.
For example, PATH is working to improve the formulation of ORS to make its benefits more apparent to caregivers.
“Reimagining global health” recently highlighted “30 high-impact innovations to save lives.” One of them (see Page 17) included several new treatments to reduce the burden of severe diarrhea, such as DiaResQ, which supplements the use of ORS and provides nutrients for intestinal repair.
An already established innovation is to create “comprehensive diarrhea treatment” by combining zinc with ORS. Zinc is a vital micronutrient that helps the body absorb water and electrolytes, reduces the duration and severity of diarrhea and prevents subsequent infections in the two to three months following treatment. Diarrhea mortality is reduced by 23% when zinc is administered with ORS. Unfortunately, use of zinc is even worse than ORS – only 5% as compared to 35% for ORS.
Diarrheal disease research and development funding is increasing modestly. In 2013, it was $200 million, up from $170 million in 2012. As in previous years, the top three funders accounted for almost three-quarters of total funding – the Bill & Melinda Gates Foundation (25% of funding), the U.S. National Institutes of Health (23%) and industry (22%).
“With the introduction of rotavirus vaccines and advances in WASH interventions, these are exciting times,” said Deborah Kidd, senior communications officer at PATH. “However, what is often overlooked is the burden of diarrhea morbidity among children in the developing world. Chronic, repeated infections, resulting malnutrition and stunted development, and the persistent economic burden on the family all contribute to a destructive cycle that keeps families in poverty. So it’s great news that deaths are declining, but that the problem of childhood diarrhea and its long-term consequences are far from solved.”
UNICEF reports that improvements in drinking water, sanitation and hygiene are reducing diarrheal disease (90% of the world’s population use improved drinking water sources and two-thirds use improve sanitation facilities).
However, the decline in diarrhea deaths should be no cause for complacency: UNICEF also reports that when children do fall ill with diarrhea, only two in five children receive appropriate treatment, including ORS.
Unlike many diseases, for which no cure exists, the cure for diarrhea has been around for decades and is cheap and available. We just have to find the financial, technical and social means to get it to people who need it, and help them use it to protect the health of their families.
This infographic shows the status of the war against pneumonia and diarrhea in the world’s poorest children.
Photo credit: PATH/Tony Karumba.Read more
Water, sanitation and hygiene (WASH) interventions are key to preventing diarrheal diseases. Handwashing is an easy way to prevent diarrhea, but is not always practiced. How can we improve the practices of people in countries where diarrheal diseases remain prevalent? To get some answers, we spoke with Dr. Emily Gurley, an infectious disease epidemiologist who is currently acting as the director of icddr,b’s Centre for Communicable Diseases.
Why is icddr,b’s WASH work significant in the context of Bangladesh? And globally?
The burden in Bangladesh from diseases and conditions that can be prevented by WASH interventions is considerable—everything from diarrhea to respiratory illness could be prevented through more sanitary and clean environments. While diarrhea may be a minor inconvenience in some places, in many countries it kills. Bangladesh is infamous for its high burden of diarrheal disease.
icddr,b’s WASH research is committed to finding and testing interventions such as handwashing and other good hygiene practices that can drastically improve health outcomes in Bangladesh and beyond, by creating evidence that WASH interventions work, and how they can be brought to scale in setting where people don’t always have access to safe water. Even at the global level, the evidence generated by our research could help identify key interventions to improve global health outcomes. This is particularly relevant in the new Sustainable Development Framework where one of the Global Goals is dedicated to ensuring access to water and sanitation for all.
Research doesn’t always prove the success of an intervention: we also have conducted research which proves that interventions in WASH aren’t always as effective as initially thought. This does, however, not mean that the intervention was a failure! There are valuable lessons learned that we can take home from this type of research, and that helps us develop interventions which are more effective and scalable.
What makes handwashing so important?
According to the WHO, each year there are an estimated 1.7 billion cases of childhood diarrhea worldwide. Handwashing with soap before preparing and eating a meal is the best way to keep families safe and healthy. Our studies on handwashing practices in Bangladesh have shown that the presence of water in close proximity to the home doubles the probability of handwashing. We know that washing your hands – even briefly – with water before handling, preparing and eating food can significantly reduce the incidence of diarrhea. Incidence is even further reduced when there is also soap available: almost 50% according to some estimates! In addition, handwashing can also prevent the spread of other diseases, if done properly.
Given its effectiveness, why is handwashing still not common practice in many rural areas?
We have a study going on right now in an urban area north of Dhaka – our experiences there build upon the evidence that, while there is knowledge about the importance of handwashing, it is still far from becoming a habit. The point of the study is to look at how households cope with water scarcity, and how their access to water is related to hygiene-related behavior, not just hand washing, but also bathing, washing clothes and dishes, cleaning households etc. If you have a ready access in at least one part of
your house to a tap that always has clean running water, and you can afford a bar of soap, why wouldn’t you clean your house every time it is dirty? If you have to bring water by bucket into your house to use for everything, you probably want to use that water for handwashing less often because it is so precious.
How can we use that knowledge to change behavior?
Education of the persons preparing and providing the food – in particular mothers, is very important. By demonstrating good hygiene practices, they will also teach their children and other people in the household to practice handwashing and other good hygiene habits. However, there is still the question of access to water and soap. Despite there being broad knowledge of the benefits of hand-washing, it is still not widely practiced if access to water and soap is limited. Our studies show that the best indicator for frequent handwashing is if they actually have a place in their house that has clean water and soap.
What are some key hygiene and sanitation messages you would like to share with our readers to encourage handwashing interventions?
WASH interventions are particularly important in those areas where environmental factors make it difficult to maintain a high standard of sanitation. At the same time, they are an essential component of an improved quality of life where, as countries progress from low-income to middle-income societies, the sanitation and hygiene conditions improve—as with Bangladesh over the years.
There is also a strong need for promoting the measurement of effectiveness of WASH interventions. By generating evidence of the benefits of WASH in combination with other interventions such as in nutrition, we hope that we can encourage policy and decision makers as well as implementers to adopt integrated policies and programs to maximize health outcomes.
All humans need fresh, clean water - reduced access to it leads to disease, forced migration, loss of crops and food security. It is just so central to everything that a society needs to thrive.Read more
Outbreak and emergency situations often raise the specter of cholera and the very real danger it poses. But many communities throughout the world also face the silent, but no less deadly, burden of endemic cholera. Earlier this year, results from a groundbreaking study showed the promise and potential of using cholera vaccines for prevention in endemic settings. DefeatDD talked with Dr. John Clemens, Executive Director of icddr,b, which conducted this large scale study in Dhaka, Bangladesh.
This study was unique in its focus on preventing endemic disease, as opposed to halting the outbreaks we commonly associate with cholera. Tell us about the vaccine and the study findings.
The vaccine we studied, Shancol, was developed by the International Vaccine Institute in Korea, Vabiotech in Vietnam, and Shantha Biotech in India, where it has been licensed since 2009. It was created with the intent of affordability, with a low cost-of-goods, and logistic adaptability to the challenging conditions that often occur in cholera epidemics. It is now prequalified by the World Health Organization and is the basis for a stockpile of oral cholera vaccines.
The predominant use of the stockpile has been for outbreaks, yet over 90 percent of the global cholera burden is endemic disease. As is the very nature of endemicity, endemic cholera has a tendency to become perceived as a part of daily life, and does not attract the international attention that outbreaks attract. Shanchol has been very useful in outbreak settings, very feasibly administered and impactful. So we evaluated the vaccine to determine if it is also feasible and impactful when deployed against endemic cholera in an urban, endemic setting.
The endemic cholera burden in an urban, highly populated area like Dhaka must be quite significant.
It is a tremendous burden in Bangladesh. Even though many of the modern approaches to the treatment of diarrhea and cholera were developed here, there are several hundred thousand cases of clinically significant cholera per year, and deaths in the thousands. And in urban areas, cholera burden is growing. Rural populations are moving to the city in great numbers and creating urban squatter settlements that are densely populated, with living conditions that allow diseases like cholera to thrive.
With endemic disease throughout the population, who is the vaccine's target populaton?
Endemic cholera affects all age groups, although it occurs with higher incidence in children. The current thinking is that to immunize pre-emptively against predictable endemic cholera, programs might focus on children under the age of 15 or even an entire population, depending on the strategy that provides the needed level of protection for the population. We are planning to undertake a project with this same vaccine in urban Bangladesh to determine which is the most high-impact, cost-effective, and feasible strategy.
The vaccine is given in two doses, and re-immunization would be required three or up to five years later, depending on the age group. Young children probably will require three-year boosters. Older people seem to be protected longer, to at least five years.
What is the timeline for potentially using this vaccine for pre-emptive protection in endemic communities?
Our project aims to provide the evidence the Government of Bangladesh needs to move forward in deciding whether to incorporate cholera vaccination against endemic disease. The project is two years in duration, and we hope that by its end, we would see decisions about vaccine introduction to be made soon thereafter.
This is very exciting. People have been talking about using oral cholera vaccine in Bangladesh for many years. 30 years ago, icddr,b conducted the world’s first field trial of the efficacy of an oral cholera vaccine against endemic chollera, and there has always been hope that such a vaccine could transition into programs to control the endemic problem, especially among the poor.
So why the gap? What happened in those 30 years that we are only now coming closer to this strategy?
The vaccine that was licensed based on the 1980s field trial was safe and effective, but proved too costly for developing-country programs. Also, because it had to be given with a liquid buffer, it was challenging to administer in some settings. As well, there has been a historical tension between those favoring vaccine strategies and those focusing on controlling cholera through traditional means like improved water and hygiene and improved treatment. Of course in an outbreak, treatment is priority number one.
We have come to realize that, clearly, improved water and sanitation are the ultimate solution to preventing cholera. And vaccines are just one tool to be considered in concert with other approaches. But achievement of the levels of improvement in WASH per se that would be necessary to control cholera is probably not a near-term goal. Urbanization, for example, creates even more challenges for delivering clean water, providing good sanitation, and changing hygienic behaviors. So now there is widespread agreement that we ought to be thinking about using every tool in our toolbox to prevent cholera. In fact, there are good theoretical reasons to believe that even provision of WASH at a level that is not sufficient to control cholera may enhance the performance of oral cholera vaccine. There's inherent synergy between these two approaches.
This study was quite large, with 250,000 subjects. Is it typical for icddr,b to conduct studies at this scale? What are the keys to success?
icddrb has a history of conducting very large studies, but this is the largest vaccine study that we have ever undertaken. Proper training, supervision, and quality control are always important. But an essential component is having trusting relationships with the community. Community trust is absolutely essential. And that has been a hallmark of icddrb's work, being able to develop these relationships over the long term.
You've worked in diarrhea research, in Bangladesh, and with iccddr,b for quite a long time. What do the results of this study mean for you?
The results of this study indicate clearly that the evidence base for moving ahead in vaccinating against endemic cholera is now nearly complete. It's a very important step forward.
Photo credit: M.Dorgabekova.Read more