Over the past decade and a half since 2000, significant gains have been made in the reduction of pneumonia and diarrhea mortality in children worldwide. Between 2000 and 2013, the global health community succeeded in decreasing the number of deaths due to pneumonia and diarrhea in children under the age of five years by 44% and 54%, respectively.However, reductions in annual child mortality rates for pneumonia and diarrhea, the leading killers of children under five, have continued to be only modest. According to the latest child mortality estimates (published in 2014 for the year 2013), pneumonia and diarrhea caused over 1.5 million under-five child deaths, respectively accounting for 15% and 9% of the 6.3 million under-five deaths that occurred globally in 2013, compared to 1.6 million deaths in 2012. This means that every 20 seconds, a mother and father lose their young child to one of these deadly, but preventable diseases.
As in previous years, the burden of child pneumonia and diarrhea mortality continues to be most heavily concentrated in just a few countries. The 15 countries with the greatest number of under-five child deaths from pneumonia and diarrhea in 2013 bore 71% of the global burden of child deaths from these two diseases in spite of accounting for only 56% of the world’s under five year old population. This Pneumonia and Diarrhea Progress Report evaluates the progress of these 15 highest-burden countries in implementing high-impact interventions outlined in the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD) relative to GAPPD coverage targets, where data are available. The coverage targets for indicators included in this report are 90% for vaccinations; 90% for access to pneumonia and diarrhea treatments, which include treatment by a health care provider, antibiotics, oral rehydration salts (ORS), and zinc supplements; and 50% for exclusive breastfeeding during a child’s first six months of life.
Each year, progress of the 15 highest-burden countries are assessed through GAPPD scores, developed by the International Vaccine Access Center (IVAC) of the Johns Hopkins Bloomberg School of Public Health. GAPPD scores are derived from an average of countries’ coverage levels across 10 key GAPPD indicators for which data are available. This year’s GAPPD scoring includes all the indicators from 2013, with the addition of supplemental zinc coverage in under-five children with diarrhea. Based on the latest available data, very limited progress was made between 2013 and 2014 in the use of proven pneumonia and diarrhea interventions in the 15 countries with the highest-burden of child mortality from those diseases (India, Nigeria, Pakistan, the Democratic Republic of the Congo, Ethiopia, Angola, China, Afghanistan, Indonesia, Kenya, Sudan, Bangladesh, Niger, Chad, and Uganda). Because zinc coverage in the 15 countries was generally very low, the addition of this indicator to the GAPPD scoring in 2014 reduced countries' overall GAPPD scores and GAPPD-Diarrhea scores, complicating comparisons with 2013 scores. Nevertheless, overall GAPPD scores improved no more than 7% for any single country in 2014. India and Nigeria, the two countries with the greatest number of child pneumonia and diarrhea deaths, continue to have low GAPPD scores (32% and 29%, respectively), although Nigeria achieved a 7% gain from the previous year, even with the inclusion of zinc coverage in the score.
Low GAPPD scores among the 15 countries can be attributed to a combination of factors, including delayed or lack of introduction of pneumococcal conjugate vaccine (PCV) and rotavirus vaccine and poor coverage of pneumonia and diarrhea treatment interventions. Even in countries that have introduced Haemophilus influenzae type B (Hib) vaccine, PCV, and/or rotavirus vaccine in recent years, scale-up of these vaccination programs has been quite slow and a sizeable proportion of the under-five population living in these countries still lacks access to these lifesaving vaccines.
There are still limitations in data that potentially mask critical gaps in access to prevention and treatment or, on the contrary, underrepresent the progress that countries have truly made simply because there are no data to quantify such improvements. However, countries are beginning to take steps to measure their own progress. India, for example, has initiated plans to fill information gaps and evaluate available data at the district and block levels in high-burden states, which will guide actions that can drive forward real progress. In addition to coverage estimates of interventions, India is also looking at important process indicators to measure how well the system that delivers these interventions is performing. Nigeria, as well, is moving to implement score card measurements of system indicators at the subnational level. It will be important for other countries to follow a similar path, implementing monitoring at local levels to ensure that progress is being made. Particularly in countries with great subnational disparities, local monitoring is essential to identifying areas and populations of high risk for morbidity and mortality and matching targeted interventions to those high-risk groups. As the world nears the 2015 deadline for the Millennium Development Goal (MDG) 4 of reducing child mortality by two-thirds since 1990,4 it is absolutely crucial that stakeholders and advocates at all levels continue the global push for equitable access to vital interventions for every child and dedicate the necessary resources to ensure that no child dies of preventable pneumonia and diarrhea.