Mumbai: In 2016, almost 261,000 Indian children died before their fifth birthday due to diarrhoea or pneumonia, both preventable diseases. This is the highest toll taken anywhere in the world by the two disease--a fifth of their global burden--according to the 2018 Pneumonia & diarrhoea Progress Report, released on November 12, 2018, which was World Pneumonia Day.

This means that about 735 Indian children died everyday of either disease in 2016--one child every two minutes. Globally, pneumonia and diarrhoea cause a quarter of deaths in children under five and fighting them together can drastically reduce child mortality across the world.

India has had mixed success in the prevention, control and treatment of diarrhoea and pneumonia in the year to 2016: Immunisation coverage improved but there was a decline in treatment indicators, said the report by the International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health.

This report analyses how effectively countries are delivering 10 key interventions to prevent and treat pneumonia and diarrhoea--breastfeeding, vaccination, access to care, use of antibiotics, oral rehydration solution (ORS) and zinc supplementation.

Since 2015, the coverage of haemophilus influenzae type b (Hib) vaccine that prevents pneumonia has increased by 8 percentage points in India, as per the report. The number of children covered by rotavirus vaccines that protects against severe diarrhoea and introduced mid-2016 has moved up by 9 percentage points since last year’s report.

In contrast, India’s other treatment indicators decreased: ORS coverage (13 percentage points), exclusive breastfeeding (10 percentage points), and access to pneumonia care (4 percentage points).

Meanwhile, there has been a steady decline in diarrhoea and pneumonia deaths in children below the age of five--almost 7.2% every year for diarrhoea and 6.8% for pneumonia--as per data. From 2000 to 2018, diarrhoea deaths fell by 69.7%--from 339,937 to 102,813--and pneumonia deaths reduced by 67%--from 485,094 to 158,176.

India prevented 1 million deaths among children under five years of age between 2005 and 2015 with interventions such as timely treatment in the case of diarrhoea, vaccinations for tetanus and measles, and increased hospital births, IndiaSpend reported in October 2017.

“India has made tremendous improvements but it needs to do much more,” said Mathu Santosham, professor, department of international health and paediatrics, Johns Hopkins University. “Currently only 20% of children with diarrhoea receive zinc supplements, rotavirus vaccine is still not available across the country and PCV [pneumococcal conjugate vaccine] is rolled out only in six states.”

India’s uptake of pneumococcal conjugate vaccine (PCV) vaccine--against pneumococcal infections that can cause pneumonia--initiated since May 2017--has also been slow, it has been included only in six states to date and no child has yet received the third dose of the vaccine, said the report.

Treatment In Countries With Most Under-Five Pneumonia & Diarrhoea Deaths
% of children under 5 with suspected pneumonia % of children under 5 with suspected diarrhea
Global rank Country Taken to an appropriate health care provider Receiving antibiotics Receiving ORS Receiving zinc supplements
Target: 90%
1 India 73 N/A 21 20
2 Nigeria 24 23 37 33
3 Pakistan 64 42 38 1
4 DRC 42 40 39 2
5 Ethiopia 31 7 30 33

Source: 2018 Pneumonia & Diarrhoea Progress Report

Preventive and treatment interventions could help India achieve the UN’s Sustainable Development Goal target of reducing under-five mortality to 25 per 1,000 live births by 2030. India’s current under-five mortality rate is 39 per 1,000 live births and there has been 30% reduction in number of deaths since 2012, from 1.4 million to 989,000 as IndiaSpend reported in September 2018.

Neighbouring Bangladesh, along with Tanzania, experienced the largest positive change in a composite indicator of multiple interventions for control of pneumonia and diarrhoea, said the report.

Immunisation up but treatment is often wrong

India’s performance on the Global Action Plan for the Prevention and Control of Pneumonia and diarrhoea (GAPPD) intervention score--a composite score based on the earlier mentioned 10 indicators--has improved by one percentage point since last year to 50%. But this is a long way from the target score of 86% which none of the 15 countries listed in the action plan have achieved. The listed nations had the highest number of diarrhoea and pneumonia deaths in 2016.

India performed better on pneumonia control and prevention than diarrhoea: As against the target score of 84% for pneumonia, India scored 65%; in the case of diarrhoea it was 39% against the target of 82%.

Countries With Most Under-Five Pneumonia & diarrhoea Deaths: Performance On Global Action Plan For Prevention & Control
Global rank Country 2018 GAPPD
Overall Target 86% Pneumonia* Target 84% Diarrhoea* Target 82%
1 India 50 65 39
2 Nigeria 30 33 27
3 Pakistan 50 63 33
4 DRC 49 64 34
5 Ethiopia 52 53 53
Median across 15 high-burden countries 50 59 36

Source: 2018 Pneumonia & Diarrhoea Progress Report

This can be attributed to the fact that only 20% children under five with diarrhoea received ORS salt and 21% received zinc--two life-saving interventions to treat diarrhoea, according to the report.

Also, more than 90% of treatments for childhood diarrhoea are incorrect, as IndiaSpend reported on February 18, 2015. Unqualified medical practitioners, unfamiliar with relatively simple life-saving medications, often prescribe antibiotics and other potentially harmful drugs, the report said.

ORS is a mixture of clean water, salt and sugar which is absorbed in the small intestine and replaces the water and electrolytes lost through faeces. Zinc supplements reduce the duration of a diarrhoea episode by 25%, and are associated with a 30% reduction in stool volume, according to the World Health Organization.

“Overall it is observed that immunisation coverage is increasing but in the long term ultimately it is not about focussing on either vaccines or treatment, we need both to reduce deaths due to diarrhoea and pneumonia,” said Santosham.

India ranked third best among 15 nations on the percentage of children (77%) who were taken to healthcare providers to treat pneumonia. There were no data on how many Indian children received antibiotics to treat pneumonia though.

Inequalities impact coverage: Girls from poor homes most neglected

The report also analysed data by gender, wealth, maternal education and residence to understand how socio-demographic factors in national data cause disparities in immunisation coverage.

This analysis revealed inequities--across India, lower vaccine coverage was seen among female children in rural areas and in poor urban areas. For example, in low-income areas of Delhi, 78 females were fully immunised for every 100 males, according to a study.

“We need to find the children who are not getting vaccinated or getting treated because they are the ones who are the poorest and most likely to die [of infections],” said Santosham.

However, there are initiatives that are working in India. For example, the annual immunisation week (April 24-30) is improving coverage in remote rural areas. Also there have been successful communications interventions under the National Health Mission (NHM), India’s flagship health programme, including initiatives to develop groups of community health workers and activists--to deal with the gender gap--and reimburse travel to health facilities.

“This approach successfully closed the gender gap from a baseline of nearly 6% higher full immunisation coverage in boys to an almost indistinguishable difference between boys and girls,” said the report, citing a 2016 study that measured the impact on gender and social inequalities of the rural health mission in Haryana.

(Yadavar is a principal correspondent with IndiaSpend.)

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