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Keyword: gappd

The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD) was launched last month. Now this week we’ve learned that a new rotavirus vaccine from India, Bharat Biotech‘s ROTAVAC, looks promising, and The Lancet featured results from the Global Enteric Multi-Center Study or GEMS, which offers a comprehensive look at the causes of diarrhea in children, such as rotavirus. In light of this recent news and its impact on efforts to prevent and treat diarrheal disease, especially rotavirus, we sat down with Mathu Santosham, MD, MPH. Dr. Santosham co-chairs the ROTA Council and also chaired the Data Safety and Monitoring Board for the ROTAVAC trial established to protect the participating infants’ rights and needs during the trial.

Why is all of this recent news important for children?

Santosham

Mathu Santosham, MD, MPH

We know that pneumonia and diarrhea are the leading killers of children under 5 worldwide, and we know that we need an integrated approach that uses all proven tools to tackle these two illnesses and prevent unnecessary suffering and death. GAPPD is important because it provides a framework, designed to inform global and national programs and policies, for integrating efforts against these two child killers. It sets ambitious but achievable goals including reducing under-five pneumonia and diarrhea deaths to 3 per 1,000 live births and 1 per 1,000 live births, respectively. A big part of the strategy for tackling both illnesses is vaccination.

For diarrhea, we know rotavirus – a pathogen for which there is a vaccine – is the leading cause of severe diarrhea among infants and children. In fact, the active surveillance results announced from the seven sites in GEMS reaffirmed this understanding, and offered important insights that will help better target interventions to the pathogens like rotavirus that are causing the most diarrhea. We also know that rotavirus contributes significantly to child mortality. According to the most recent estimates, more than 450,000 children died from rotavirus diarrhea in 2008. Rotavirus vaccine is critical to protecting children from rotavirus and preventing illness and death.

There are currently two licensed rotavirus vaccines, and they are saving lives and improving health today in the countries where they are in use. Having an additional vaccine from an Indian manufacturer will expand the market, which will offer more options to protect children in India and around the world. If licensed, Bharat has committed to offering the initial frozen formulation at $1 per dose, which will increase market competition for countries and organizations procuring vaccine. Also, it is especially encouraging to see India making so much progress toward a vaccine because nearly one-quarter of rotavirus deaths occur in India.

Why is rotavirus such a large concern?

Rotavirus is highly contagious and can last for long periods of times on hands and surfaces. It is not adequately prevented by proper hygiene or improvements in water and sanitation, like other pathogens that cause diarrhea. So even children in developed countries are susceptible to contracting rotavirus. In fact, nearly every child will be infected at least once by the age of 5. Once infected, a child often experiences symptoms that include fever, vomiting, and diarrhea. In developed countries where access to care is more reliable, children are unlikely to die from this infection, but in developing countries, children are less likely to have quick access to oral rehydration, making them at risk to suffer severe dehydration. This can lead to hospitalization and even death. In addition, children who suffer from malnutrition are more vulnerable to diarrhea, and diarrhea in turn worsens their malnutrition, resulting in a vicious cycle. For these reasons, rotavirus is a concern worldwide, but especially in developing countries.

What can we do about rotavirus?

Rotavirus cannot be treated with antibiotics or other drugs. However, its symptoms can be alleviated by prompt use of oral rehydration therapy (ORT), which includes home available fluids, oral rehydration salts (ORS), and, in cases of severe dehydration, IV fluids. ORT can effectively treat most rotavirus infections, but when the treatment is received too late, rotavirus can be deadly. In India, only about 4 in 10 children receive ORT when they have diarrhea. Vaccination, on the other hand, can actually prevent rotavirus diarrhea from happening in the first place. The two currently licensed vaccines, Rotarix and RotaTeq, have been demonstrated to be safe and effective and have been introduced in more than 45 countries. When combined with ORT, zinc supplementation, breastfeeding, and improvements in nutrition, hygiene, and water quality, vaccines contribute to the comprehensive approach required to effectively prevent severe illness and deaths caused by rotavirus diarrhea. 

What is ROTA Council doing about this problem?

ROTA_Council_2012

Dr. Santosham with other members of the ROTA Council at the International Rotavirus Symposium in Bangkok, September 2012.

The ROTA Council, which I co-chair with Dr. Ciro de Quadros of Sabin Vaccine Institute, is a dedicated team of technical experts with the mission of saving children’s lives by accelerating the introduction of rotavirus vaccines. We work at the global and country level to ensure that policy makers have the latest evidence-based information to inform their decisions about introducing and scaling up rotavirus vaccines as part of broader diarrhea control efforts. At the same time, many of our Council members are on the frontlines of research, conducting the studies needed to demonstrate vaccine efficacy, safety, and impact. We are pleased to see that more than 45 countries have introduced rotavirus vaccines, but many more are still leaving their children unprotected, particularly in Asia, where countries have been slow to introduce the vaccine.

Why should India and other low- and middle-income countries introduce rotavirus vaccine?

Rotavirus diarrhea is a ubiquitous problem that can have some very serious consequences. In India, and other countries where access to care can be quite unequal, prevention becomes even more critical. If left untreated, rotavirus infection can lead to unnecessary illness, hospitalization, and even death, which is not only concerning from a health standpoint, but also takes a very serious toll from a social and economic standpoint. Hospitalization for one child with rotavirus costs nearly the entire amount of an average Indian household’s spending in a month. Diarrhea related healthcare needs are also costly for the country and stretch its already burdened state healthcare system. Beyond direct costs, vaccination could avoid productivity losses and help children grow into healthy, educated, productive adults.

The vaccine has the potential to make a big difference in the lives of families around the developing world. In India alone, we could prevent tens of thousands of deaths, not to mention nearly 300,000 hospitalizations and more than 300,000 doctor visits, which amounts to savings of over US$20 million in medical costs.

Based on your experiences, what is your hope for India and the rotavirus vaccination?

As a medical student in India in the 60s I saw children dying of diarrhea every day. Over the years, we were fortunate enough to develop powerful treatments like ORT, which helped to reduce the number of diarrheal deaths per year from 5 million in 1980 to less than a million now. However, more than 700,000 children continue to die from diarrhea annually because they don’t get the necessary treatment on time. Rotavirus is the leading cause of these diarrheal deaths, and it is a tragedy to see a child die from rotavirus when we have such a powerful weapon to combat this disease. It is my sincere hope that every child in India will soon have access to this life-saving vaccine.

 

Mathuram Santosham, MD, MPH, is Co-Chair of the ROTA Council and Professor of Pediatrics and International Health at Johns Hopkins University. He also serves as Director of the Center for American Indian Health, Director of the International Center for Maternal and Neonatal Health, and a Senior Advisor at IVAC.  

By Dr. Kate O’Brien

This week scientists came together to declare that we will eradicate polio in 5 years. It’s an achievable goal, and admittedly an aspirational one. But, if we as a global community leverage proven strategies and follow through on commitments made, it will be met. It is amazing to think that this goal, which just two decades ago seemed impossible to many, is now firmly in our sights. It also gives me confidence that we can reach other goals, such as reducing preventable childhood deaths to a degree that any such death is seen as a shocking, rare event rather than predictable and intractable. This challenge, which the global health community laid out in last year’s Promise Renewed initiative may seem daunting, given that despite recent declines, 6.9 million children died in 2011. However, when you consider that worldwide polio cases have dropped by 99% since the Global Polio Eradication Initiative began in 1988, it is clear these problems are surmountable. Like polio eradication, we need a concrete approach to tackling the leading child killers, and we made a big step forward with today’s launch of the Integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD). Released by WHO and UNICEF, GAPPD clearly outlines the steps we must take to eliminate the two leading killers of young children in 20 years.

GAPPD cover

The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD)

Most of my professional life has been spent assessing and applying interventions to reduce pneumonia and diarrhea, both in the United States among American Indian communities and around the world in the communities where most child deaths still occur. I’ve seen the burden of these diseases in the numbers we calculate and on the faces of the patients I’ve treated. I’ve also seen that we have the tools we need to stop children from dying or suffering from severe pneumonia and diarrhea. When I worked in Haiti, the ward was full of children, over a third of whom would die in those beds. Nearly all of the illnesses these children had were fully preventable, mostly through the use of vaccines but also through other simple, sensible interventions. The interventions we have work, and the task we have is to figure out how to use them most effectively, to know if what we are doing is working, and to make adjustments in optimizing their impact. This feedback loop can only be put in place when we can measure the impact of what we’re doing. We may not be able to measure with absolute precision, but with enough precision to know if our time and treasure is being wisely spent.

We know what we need to do to tackle pneumonia and diarrhea, and establishing clear evidence on the burden of disease and on interventions that work creates the platform from which we can prioritize our efforts. A new series published in the Lancet today in conjunction with GAPPD provides updated evidence on this front. One of the papers, led by faculty in our Department of International Health at Johns Hopkins provides updated mortality estimates for pneumonia and diarrhea – together responsible for more than 2 million child deaths in 2011.

We also have a clear understanding of which interventions work, and we know that many of them overlap. As my colleague Bob Black pointed out in the Lancet series launch, while diarrhea and pneumonia have very different symptoms and causes, several risk factors for the two diseases are the same, including under-nutrition, suboptimal breastfeeding, and zinc deficiency, meaning that they can be effectively prevented and treated as part of a coordinated program. We also know that vaccination campaigns will play an important role. A second paper in the Lancet evaluated 15 key interventions using the Lives Saved Tool. It found that nearly one third of severe diarrhea episodes could be prevented by widespread vaccination against rotavirus and cholera, while up to two thirds of pneumonia deaths could be prevented by implementation of pneumococcal and Haemophilus influenzae type b vaccines. With ambitious scale-up – 80% coverage or more – the authors estimated all 15 interventions could effectively eliminate (95% prevented) diarrheal deaths and prevent around two-thirds of pneumonia deaths by 2025. All this at a total cost of just USD6.7 billion.

GAPPD and the Lancet series reflect years of work toward a consensus among all stakeholders that we must target our efforts on proven interventions, and we must work together in an integrated way. Many of the interventions for childhood diseases overlap, and can be delivered more efficiently if all parties work together. This integration will not only result in better care for each child, it is also crucial in resource-poor settings, where countries simply cannot afford to maintain siloed efforts and where partnering countries and organizations are increasingly demanding more impact for their investments.

We have the evidence, and our marching orders are clear. With polio eradication beckoning our efforts, it is the time to leverage this energy, know-how, and confidence by fulfilling our promises and advocating for all stakeholders – donors, governments, civil society, and other leaders – to fulfill theirs. We can all take inspiration and insight from polio eradication efforts and make the end of preventable pneumonia and diarrhea deaths a reality.

 

Kate O’Brien, MD, MPH is Acting Executive Director of IVAC. A pediatric infectious disease physician, epidemiologist, and vaccinologist, she previously served as Deputy Director of IVAC. She also serves as Associate Director of the Center for American Indian Health.

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