How many child deaths can we prevent this year

To estimate the global illness and deaths caused by rotavirus disease, we reviewed studies published from 1986 to 2000 on deaths caused by diarrhea and on rotavirus infections in children. We assessed rotavirus-associated illness in three clinical settings (mild cases requiring home care alone, moderate cases requiring a clinic visit, and severe cases requiring hospitalization) and death rates in countries in different World Bank income groups. Each year, rotavirus causes approximately 111 million episodes of gastroenteritis requiring only home care, 25 million clinic visits, 2 million hospitalizations, and 352,000–592,000 deaths (median, 440,000 deaths) in children <5 years of age. By age 5, nearly every child will have an episode of rotavirus gastroenteritis, 1 in 5 will visit a clinic, 1 in 60 will be hospitalized, and approximately 1 in 293 will die. Children in the poorest countries account for 82% of rotavirus deaths. The tremendous incidence of rotavirus disease underscores the urgent need for interventions, such as vaccines, to prevent childhood deaths in developing nations.

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Global Illness and Deaths Caused by Rotavirus Disease in Children

Current estimates of the global burden of disease for diarrhoea are reported and compared with previous estimates made using data collected in 1954-79 and 1980-89. A structured literature review was used to identify studies that characterized morbidity rates by prospective surveillance of stable populations and studies that characterized mortality attributable to diarrhoea through active surveillance. For children under 5 years of age in developing areas and countries, there was a median of 3.2 episodes of diarrhoea per child-year. This indicated little change from previously described incidences. Estimates of mortality revealed that 4.9 children per 1000 per year in these areas and countries died as a result of diarrhoeal illness in the first 5 years of life, a decline from the previous estimates of 13.6 and 5.6 per 1000 per year. The decrease was most pronounced in children aged under 1 year. Despite improving trends in mortality rates, diarrhoea accounted for a median of 21% of all deaths of children aged under 5 years in these areas and countries, being responsible for 2.5 million deaths per year. There has not been a concurrent decrease in morbidity rates attributable to diarrhoea. As population growth is focused in the poorest areas, the total morbidity component of the disease burden is greater than previously.

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The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000

Studies published between 1986 and 1999 indicated that rotavirus causes ≈22% (range 17%–28%) of childhood diarrhea hospitalizations. From 2000 to 2004, this proportion increased to 39% (range 29%–45%). Application of this proportion to the recent World Health Organization estimates of diarrhea-related childhood deaths gave an estimated 611,000 (range 454,000–705,000) rotavirus-related deaths.

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Rotavirus and Severe Childhood Diarrhea

We set out to determine the impact of washing hands with soap on the risk of diarrhoeal diseases in the community with a systematic review with random effects meta-analysis Our data sources were studies linking handwashing with diarrhoeal diseases Seven intervention studies, six case-control, two cross-sectional, and two cohort studies were located from electronic databases, hand searching, and the authors' collections The pooled relative risk of diarrhoeal disease associated with not washing hands from the intervention trials was 188 (95% CI 131-268), implying that handwashing could reduce diarrhoea risk by 47% When all studies, when only those of high quality, and when only those studies specifically mentioning soap were pooled, risk reduction ranged from 42-44% The risks of severe intestinal infections and of shigellosis were associated with reductions of 48% and 59%, respectively In the absence of adequate mortality studies, we extrapolate the potential number of diarrhoea deaths that could be averted by handwashing at about a million (11 million, lower estimate 05 million, upper estimate 14 million) Results may be affected by the poor quality of many of the studies and may be inflated by publication bias On current evidence, washing hands with soap can reduce the risk of diarrhoeal diseases by 42-47% and interventions to promote handwashing might save a million lives More and better-designed trials are needed to measure the impact of washing hands on diarrhoea and acute respiratory infections in developing countries

Effect of washing hands with soap on diarrhoea risk in the community: a systematic review

In 1980, diarrhoea was the leading cause of child mortality, accounting for 4.6 million deaths annually. Efforts to control diarrhoea over the past decade have been based on multiple, potentially powerful interventions implemented more or less simultaneously. Oral rehydration therapy (ORT) was introduced in 1979 and rapidly became the cornerstone of programmes for the control of diarrhoeal diseases. We report on the strategy for controlling diarrhoea through case management, with special reference to ORT, and on the relationship between its implementation and reduced mortality. Population-based data on the coverage and quality of facility-based use of ORT are scarce, despite its potential importance in reducing mortality, especially for severe cases. ORT use rates during the 1980s are available for only a few countries. An improvement in the availability of data occurred in the mid-1990s. The study of time trends is hampered by the use of several different definitions of ORT. Nevertheless, the data show positive trends in diarrhoea management in most parts of the world. ORT is now given to the majority of children with diarrhoea. The annual number of deaths attributable to diarrhoea among children aged under 5 years fell from the estimated 4.6 million in 1980 to about 1.5 million today. Case studies in Brazil, Egypt, Mexico, and the Philippines confirm increases in the use of ORT which are concomitant with marked falls in mortality. In some countries, possible alternative explanations for the observed decline in mortality have been fairly confidently ruled out. Experience with ORT can provide useful guidance for child survival programmes. With adequate political will and financial support, cost-effective interventions other than that of immunization can be successfully delivered by national programmes. Furthermore, there are important lessons for evaluators. The population-based data needed to establish trends in health service delivery, outcomes and impact are not available in respect of diarrhoea, as is true for malaria, pneumonia and other major childhood conditions. Standard indicators and measurement methods should be established. Efforts to change existing global indicators should be firmly resisted. Support should be given for the continuing evaluation and documentation activities needed to guide future public health policies and programmes.

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Reducing deaths from diarrhoea through oral rehydration therapy

Introduction WHO recommends that all children receive one dose of bacille Calmette-Guerin vaccine (BCG), three doses of diphtheria--tetanus-pertussis vaccine (DTP), three doses of either oral polio vaccine (OPV) or inactivated polio vaccine (IPV), three doses of hepatitis B vaccine, and one dose of a measles virus-containing vaccine (MVCV), either anti-measles alone or in combination with other antigens (1-9) It also recommends three doses of vaccine against infection with Haemophilus influenzae type b (Hib) (10) To boost immunity at older ages, additional immunizations are recommended for healthcare workers, travellers, high-risk groups and people in areas where the risk of specific vaccine-preventable diseases is high (11) Immunization coverage levels and trends are used (i) to monitor the performance of immunization services locally, nationally and internationally; (ii) to guide strategies for the eradication, elimination and control of vaccine-preventable diseases; (12-14) (iii) to identify areas of immunization systems that may require additional resources and focused attention; (15,16) and (iv) to assess the need to introduce new vaccines into national and local immunization systems (17) Models of vaccine-preventable disease burden frequently include immunization coverage levels among their components (18-20) Coverage levels for measles vaccine and DTP are indicators of health system performance frequently considered by funding agencies when reviewing applications for financial and technical support (21-24) Measles immunization coverage is one of the indicators for tracking progress towards Millennium Development Goal 4, to reduce child mortality (25) Furthermore, trends in immunization coverage are used to establish the link between immunization service delivery and disease occurrence and to provide a framework for setting future coverage goals (26) Trends in immunization coverage While some countries had routine immunization systems in place before 1980, major national and international development of routine, universal infant immunization systems did not begin until the late 1970s In fact, it was not until the 1980s that dramatic improvements in immunization coverage were achieved, along with an increase in coverage with the third dose of DTP vaccine (DTP3) from 20% in 1980 to 75% coverage in 1990 While some countries reported significant declines in coverage after 1990, global coverage levels remained fairly constant and began rising slowly but steadily in 2000, until DTP3 coverage worldwide had reached 81% in 2006 In 1980, fewer than 10% of the world's children lived in 20 of the 167 countries with DTP3 coverage levels greater than 80%; 84% of the world's children lived in countries where coverage was less than 50% By 1990, 108 countries (43% of all children) had DTP3 coverage levels greater than 80%, and fewer than 10% of children lived in countries with under 50% coverage Although national coverage levels can "mask" sub-national geographical or sociological pockets where coverage is much lower, in 2006, 57% of children lived in countries with greater than 80% DTP3 coverage Still, that year approximately 263 million children who reached their first birthday did not receive DTP3, but 162 million (62%) of them lived in China, India, Indonesia or Nigeria At the time this report was prepared, there remained seven countries where fewer than half of the children were vaccinated with three doses of DTP3: Angola, Central African Republic, Chad, Equatorial Guinea, Gabon, Niger and Somalia" WHO and UNICEF publish annual estimates of national immunization coverage; (27-30) such estimates have been available by country since 1980 at http://wwwwhoint/immunization_monitoring/en/globalsummary/ wucoveragecountrylistcfm and http://wwwchildinfoorg/immunization_countryreportshtml Additional analyses can be found at http://wwwwhoint/immunization_monitoring/data/en/and http://www …

WHO and UNICEF Estimates of National Infant Immunization Coverage: Methods and processes/Estimations Par l'OMS et l'UNICEF Des Couvertures Vaccinales Des Nourrissons Par Pays : Methodes et procedures/Estimaciones De la OMS Y El UNICEF Sobre la Cobertura Nacional De Vacunacion De Los Lactantes: Metodos Y Procedimientos

En 1980, la diarrhee etait la principale cause de mortalite chez l’enfant avec 4,6 millions de deces par an. Au cours de la decennie qui vient de s’ecouler, les efforts de lutte contre les maladies diarrheiques ont repose sur plusieurs interventions potentiellement efficaces, mises en œuvre plus ou moins simultanement. La therapie par rehydratation orale (TRO) a ete introduite en 1979 et elle est rapidement devenue l’element essentiel des programmes de lutte contre les maladies diarrheiques. Nous rendons compte ici de la strategie de prise en charge des cas, en nous referant particulierement a la TRO, et de la relation entre son application et la baisse de la mortalite. Les donnees obtenues en population sur l’etendue et la qualite de l’utilisation de la TRO dans les services de sante sont rares, alors qu’il s’agit d’une intervention qui peut etre importante pour reduire la mortalite, surtout dans les cas graves. On ne dispose de donnees relatives a l’utilisation de la TRO pendant les annees 80 que pour quelques pays ; c’est au milieu des annees 90 que l’on a pu disposer de davantage de donnees. L’etude de l’evolution dans le temps est rendue difficile par l’utilisation de plusieurs definitions successives de la TRO. Neanmoins, dans la plupart des regions du monde, les donnees font apparaitre des tendances positives dans la prise en charge des maladies diarrheiques. La TRO est aujourd’hui administree a la plupart des enfants atteints de diarrhee. Le nombre de deces annuels imputables aux maladies diarrheiques chez les moins de 5 ans a chute, passant de 4,6 millions en 1980 a environ 1,5 million aujourd’hui. Les etudes de cas effectuees au Bresil, en Egypte, au Mexique et aux Philippines confirment un recours de plus en plus frequent a la TRO, qui s’accompagne d’une chute marquee de la mortalite. Dans quelques pays, on a recherche d’autres explications a ce phenomene sans en trouver. L’experience de la TRO peut fournir des indications utiles aux programmes axes sur la survie de l’enfant. Moyennant une volonte politique et un soutien financier suffisants, des interventions d’un bon rapport cout-efficacite autres que la vaccination peuvent dont etre mises en œuvre avec succes par les programmes nationaux. En outre, les responsables de l’evaluation peuvent en tirer des enseignements importants. On ne dispose pas des donnees obtenues en population necessaires pour fixer les orientations en matiere de fournitures de services de sante, de resultats et d’impact, qu’il s’agisse des maladies diarrheiques, du paludisme, de la pneumonie ou des autres grandes maladies de l’enfant. Il faut fixer des indicateurs et des methodes de mesure standard et resister fermement aux efforts visant a modifier les indicateurs mondiaux existants. Il faut egalement favoriser les activites d’evaluation et de documentation sur une base continue pour orienter les futures politiques et programmes de sante publique.

Roeland Monasch

Papers

Reducing deaths from diarrhoea through oral rehydration therapy

Maladies diarrheiques : reduire la mortalite ´ grac e ala therapie par rehydratation orale