2021 Pneumonia and Diarrhea Progress Report Finds Key Gains Despite Toll of the COVID-19 Pandemic

Introduction

Between 1990 and 2019, the number of children who died before their 5th birthday fell by more than half.1 However, sustaining this hard-won progress is at risk. The direct and indirect effects of the COVID-19 pandemic have threatened the health and well-being of the world’s children and although the full impact is still being assessed, the latest data highlight the need for immediate action to prevent catastrophic backsliding against progress in eliminating preventable child deaths.

In 2020, an estimated 1.23 million children under age 5 died from pneumonia and diarrhea2—diseases that are highly preventable and treatable with simple, known measures. While vaccines to prevent COVID-19 were developed with cutting-edge technology and distributed at record speeds, highly preventable and treatable infectious diseases like pneumonia and diarrhea continue to kill the equivalent of over 141 children per hour, or 3,400 deaths per day.

The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD) outlines a set of core interventions shown to successfully prevent, protect, and treat children who are at risk of serious illness or death due to these leading diseases.3 Vaccines that prevent pneumonia and diarrhea deaths are key components of GAPPD, but 22.7 million children in the world missed out on vaccination in 2020—3.7 million more than in 2019.4

Contents:

Report Indicators

In 2009 and 2013, the World Health Organization (WHO) and UNICEF published GAPPD, a bold call to action with the goal of achieving a global 75% reduction in incidence of severe pneumonia and diarrhea in children under 5 by 20253. GAPPD outlines a set of core interventions to successfully prevent, protect, and treat children who are at risk of serious illness or death due to these two diseases.

Key Results and Findings

Each year we calculate and compare GAPPD scores based upon 10 key indicators to track global progress toward GAPPD targets. Exclusive breastfeeding PROTECTS children by making them healthier and less vulnerable to pneumonia and diarrhea. Vaccination against pertussis, measles, Hib, pneumococcus, and rotavirus PREVENTS illness and death due to these pathogens that cause pneumonia and/or diarrhea, while access to appropriate health care providers, antibiotics, ORS, and zinc are key interventions to TREAT pneumonia and diarrhea.

N/A: Data is unavailable or not reported

Data in this table may differ from that reported in WHO, UNICEF, or national survey sources. Differences of 1-2 percentage points are often due to rounding differences across sources. Data used for this table came from the most recently available sources as of October 2021.

China has not yet introduced Hib, rotavirus, or pneumococcal vaccines into its national immunization program (NIP); as such, WUENIC estimates indicate 0% coverage for these three vaccines. Hib and rotavirus vaccines are available through the private market. While relatively high private market coverage for Hib vaccine and low coverage for rotavirus vaccine has been reported in some settings, vaccine coverage levels are not well-documented in the private sector. In past reports, because some evidence suggests that private market Hib3 coverage may exceed 50% in some parts of China even though the vaccine has not yet been introduced into the NIP—as opposed to private market coverage for other non-NIP vaccines, for which data is either unavailable or is limited and reflects low coverage—we classified Hib3 coverage as “missing” (noted in the data tables as “private market coverage”). We have applied the same approach this year. China’s Hib3 coverage is classified as “missing,” and therefore not included in the numerator or denominator for this year’s scores.

Progress Summary

Overall GAPPD Scores

  • All 15 countries failed to reach the overall GAPPD score target of 86%
  • The mean for overall GAPPD score across all 15 countries was 48%, the same as last year
  • For 2021, overall GAPPD scores ranged from 23% (Somalia) to 68% (Bangladesh)
  • This year, 4 countries experienced a decline in overall GAPPD scores of greater than 1% while 3 countries experienced an improvement in overall GAPPD score

GAPPD Pneumonia Scores

  • None of the countries met the GAPPD Pneumonia score target of 84%
  • The mean for the GAPPD Pneumonia score for all 15 countries was 56%—a decline from 57% last year
  • For 2021, scores ranged from 31% (Chad and Somalia) to 81% (Bangladesh)
  • Seven countries experienced a decrease of greater than 1 percentage point and 2 countries experienced an increase
  • The decline in GAPPD Pneumonia score was largely caused by declines in immunization coverage across countries in 2020. Improvements in GAPPD Pneumonia score were largely driven by new MICS and DHS data for treatment and prevention indicators.

GAPPD Diarrhea Scores

  • All countries also fell short of the GAPPD Diarrhea score target of 82%
  • The mean GAPPD Diarrhea score for all 15 countries was 41%—an increase from 40% last year
  • In 2020, scores ranged from 20% (Chad and Somalia) to 60% (India)
  • The improvement in diarrhea score was largely driven by substantial increases in rotavirus vaccine coverage from new introductions in 2019 and 2020

Country Progress Summary

From 2019 - 2020, 7 countries saw overall GAPPD score changes of more than two percentage points.

Chad +4

New data from the 2019 MICS reflects improvements in coverage in several indicators including coverage in breastfeeding (an increase of 16 percentage points) and zinc (1% improvement to 21%).

Democratic Republic of Congo (DRC) +3

DRC’s overall score improvement was entirely driven by the introduction of rotavirus vaccine in late 2019 (a change from 0% coverage to 33%). DRC is the first Gavi-supported country in Africa to introduce ROTASIIL®

India +2

Continued successful national rollouts of rotavirus (increase from 53% to 82%) and pneumococcal conjugate vaccines (increase from 15% to 21%) led to substantial gains in immunization coverage for these indicators.

United Republic of Tanzania -2

Declines across all immunization indicators ranging from 3 – 4 percentage points contributed to a small decrease in overall GAPPD score. However, with an overall score of 66%, Tanzania continues to lead target countries with the second highest overall score.

Mali -3

Mali experienced declines of 7 to 8 percentage points across most immunization indicators. However, rotavirus vaccine coverage improved from 63% to 68%.

Indonesia -3

Indonesia experienced declines of 8 to 12 percentage points across several vaccine indicators. The recent PCV roll-out led to an increase in coverage from 3% to 4%.

Angola -5

Angola experienced across-the-board decreases in immunization coverage ranging from 6 to 19 percentage points. Rotavirus vaccine coverage was the hardest hit, declining by 19 percentage points.

Conclusions and Recommendations

As impacts of the COVID-19 pandemic continue to be felt across the globe, careful consideration is needed to ensure efforts to reduce child mortality due to pneumonia and diarrhea remain a priority. Investments in these proven interventions to prevent, protect, and treat have dramatically reduced child mortality, but with over 1 million young children still dying of pneumonia and diarrhea every year, we cannot allow this progress to stall or backslide.

Deaths due to pneumonia and diarrhea among young children continue to be disproportionally concentrated in a subset of countries. We must continue to work in partnership with key stakeholders in these vulnerable settings to advance country-level and regional progress to reduce this unacceptably high burden of preventable child mortality.

The COVID-19 pandemic has highlighted health inequities that exist, threatens to widen existing gaps, and placed the most vulnerable children at even greater risk. We must commit greater levels of funding, secure strong political commitment, foster transparency and accountability, and ensure that the coordinated global effort prioritizes equity.

Equity: Target the Places of Greatest Need

The global burden of childhood pneumonia and diarrhea is a symptom of a broader problem. Health systems in low-resource settings are falling woefully short of ensuring sufficient access to prevention and treatment for the most vulnerable members. We need to prioritize reaching those underserved populations by first identifying the risk factors, understanding the determinants of inequity, and then developing evidence-based strategies to target those factors.

Data: Monitoring Gaps and Gains

Collecting high-quality data is needed to accurately monitor and assess progress. To address equity, efforts must include key indicators to understand subnational differences. Committed efforts will be needed to explore important subnational disparities so that approaches can be efficiently tailored to reach communities which are suffering the most due to prevailing health inequities.

Integration: Identifying Missed Opportunities

To tackle health equity challenges, we need a comprehensive, integrated strategy that considers social determinants of health influenced by factors such as poverty and gender equity and does not shy away from system-level changes to identify missed opportunities and leverage improvements in supply chains and product suitability.

Data and Methodology

Identifying the Highest Burden Countries

For this report, we analyze the progress of 10 GAPPD indicators in the 15 countries with the highest total number of pneumonia and diarrhea deaths among children under 5 years.

These 15 high-burden countries are identified based on the latest data on pneumonia and diarrhea deaths, sourced from the WHO Maternal and Child Epidemiology Estimation (MCEE) group estimates2. The most recent publicly available estimates were made available November 2018.

The list of the 15 high-burden countries can shift from year-to-year as new data is made available. Therefore, countries included in our list of high-burden countries may change either due to country progress that results in fewer under-5 pneumonia and diarrhea deaths or adjustments to the methodology used to estimate mortality.

GAPPD Indicators

The main sources for data for this report come from WHO and UNICEF data repositories on global child health. The most recent available data are used to compile the national coverage estimates for each of the 10 GAPPD indicators tracked in the report.

We used data collected within the last 10 years to compile national coverage estimates for each of the 10 indicators.

Three key target scores are calculated by averaging the GAPPD coverage target scores for these 10 indicators: a GAPPD Pneumonia score, GAPPD Diarrhea score, and an Overall GAPPD score that includes both pneumonia and diarrhea indicators. These scores can be used to track country progress towards achieving GAPPD coverage targets based upon this selection of proven pneumonia and diarrhea interventions.

Limitations

Data availability

Not all indicators are available for each country for each year. While the data for some indicators are updated annually, as with the WUENIC immunization coverage, other data sources may only be updated once every few years when new national surveys are published. In cases where a country has no available data for a particular indicator, that indicator is recorded as either “missing” or “0% coverage,” depending on the indicator.

While actual changes in the availability and provision of these key interventions may have occurred in a given year, estimates reflecting these changes may not yet be recorded or available. In the event that new data are not collected, the last reported data point within the last 10 years is used for calculations. Thus, GAPPD scores for countries where more data are available may better reflect trends toward GAPPD targets. This limitation underscores the importance of regularly collected, high-quality data that enables accurate monitoring of key GAPPD interventions

Antibiotics

Concerns have been raised about the validity of antibiotics for suspected pneumonia as an indicator and recommend excluding this indicator in analyses of pneumonia treatment coverage.

Learn more: “A prospective validation study in South-West Nigeria on caregiver report of childhood pneumonia and antibiotic treatment using Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) questions”

Oxygen

The availability of oxygen is not currently a standard health system indicator, despite oxygen’s classification as an essential medicine by the WHO. Indicators for tracking country-level progress for oxygen coverage have not been included this year but may be incorporated in the future.

Read more here: The Every Breath Counts Coalition Indicators Working Group describe the challenges of estimating real-world oxygen access in health facilities.

Additional Resources

Every Breath Counts

The Missing Piece: Why the global pandemic is an inflection point for pneumonia control

Utilizing several data sources including the Global Burden of Disease and updated OECD Official Development Assistance, this report makes the case for a total reboot of the way governments and global health agencies invest in pneumonia.

The ROTA Council

Rotavirus Disease and Immunization: Series of Briefs

Six rotavirus-focused briefs cover epidemiology and disease burden, available vaccine products, the impact of vaccination, economic costs of rotavirus disease and the value of vaccines, safety, and introduction and coverage status.

VIEW-hub

https://view-hub.org/

VIEW-hub is an online, interactive, map-based platform for visualizing data on vaccine use and impact. Find the most relevant and recent vaccine data, covering topics such as Vaccine Introduction & Use, Immunization Equity, Vaccine Preventable Disease Burden, and Immunization System Strength. It also includes country level summary data on the latest academic studies on Vaccine Impact, as well as the Economic Burden of Disease.

References

1. UNICEF. Pneumonia in Children. UNICEF Data. https://data.unicef.org/topic/child-health/pneumonia/

2. WHO-MCEE. Child Causes of Death, 2000-17. Published online 2018. https://www.who.int/healthinfo/global_burden_disease/childcod_estimates_2000_2017.xls?ua=1

3. WHO-UNICEF. End Preventable Deaths: Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea.; 2013. https://www.unicef.org/media/files/Final_GAPPD_main_Report-_EN-8_April_2013.pdf

4.  UNICEF. COVID-19 pandemic leads to major backsliding on childhood vaccinations, new WHO, UNICEF data shows. Published July 15, 2021. https://www.unicef.org/press-releases/covid-19-pandemic-leads-major-backsliding-childhood-vaccinations-new-who-unicef-data

Additional Data Sources

Bangladesh Bureau of Statistics (BBS) and UNICEF Bangladesh. Progotir Pathey, Bangladesh Multiple Indicator Cluster Survey 2019, Survey Findings Report. (2019). Dhaka, Bangladesh. https://mics-surveys-prod.s3.amazonaws.com/MICS6/South%20Asia/Bangladesh/2019/Survey%20findings/Bangladesh%202019%20MICS%20Survey%20Findings_English.pdf

Central Statistical Agency [Ethiopia] and ICF International. Ethiopia Demographic and Health Survey 2011. (2012). Addis Ababa, Ethiopia and Calverton, Maryland, USA. https:// dhsprogram.com/pubs/pdf/FR255/FR255.pdf

INSEED et UNICEF. 2020. MICS6-Tchad, 2019, Rapport final. N’Djamena, Tchad. https://mics-surveys-prod.s3.amazonaws.com/MICS6/West%20and%20Central%20Africa/Chad/2019/Survey%20findings/Chad%202019%20MICS%20Survey%20Findings%20Report_French.pdf

Institut National de la Statistique (INS) et ICF International. Enquête Démographique et de Santé et à Indicateurs Multiples du Niger 2012. (2013).  Calverton, Maryland, USA. https://dhsprogram.com/pubs/pdf/FR277/FR277.pdf

Institut National de la Statistique (INS). Enquête Par Grappes à Indicateurs Multiples, Côte d’Ivoire 2016, Rapport Des Résultats Clés. (2017). Abidjan, Côte d’Ivoire. https://mics-surveys-prod.s3.amazonaws.com/MICS5/West%20and%20Central%20Africa/C%C3%B4te%20d%27Ivoire/2016/Final/Cote%20d%27Ivoire%202016%20MICS_French.pdf

Institut national de la statistique (INSTAT). Enquête par grappes à indicateurs multiples au Mali (MICS-Mali), 2015, Rapport final. (2016). Bamako, Mali. https://microdata.worldbank.org/index.php/catalog/3421/download/46200

Instituto Nacional de Estatística (INE), Ministério da Saúde (MINSA), Ministério do Planeamento e do Desenvolvimento Territorial (MINPLAN), and ICF. Angola Inquérito de Indicadores Múltiplos e de Saúde (IIMS) 2015-2016. (2017). Luanda, Angola and Rockville, Maryland, USA. https://dhsprogram.com/publications/publication-FR327-DHS-Final-Reports.cfm

l’Institut National de la Statistique du Ministère du Plan de la RDC, UNICEF. Enquête Par Grappes à Indicateurs Multiples, 2017-2018, Rapport de Résultats de l’enquê. (2019). Kinshasa, République Démocratique du Congo. https://mics-surveys-prod.s3.amazonaws.com/MICS6/West%20and%20Central%20Africa/Congo%2C%20Democratic%20Republic%20of%20the/2017-2018/Survey%20findings/Congo%2C%20Democratic%20Republic%20of%20the%2C%202017-18%20MICS%20SFR_French.pdf

Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. (2016). Dar es Salaam, Tanzania and Rockville, Maryland, USA. https://dhsprogram.com/pubs/pdf/FR321/FR321.pdf

National Bureau of Statistics (NBS) and United Nations Children’s Fund (UNICEF). Nigeria: 2017 Multiple Indicator Cluster Survey 2016-17, Survey Findings Report. (2018). Abuja, Nigeria. https://www.unicef.org/nigeria/reports/multiple-indicator-cluster-survey-2016-17-mics

National Institute of Population Studies (NIPS) [Pakistan] and ICF. Pakistan Demographic and Health Survey 2017-18. (2019). Islamabad, Pakistan, and Rockville, Maryland, USA. https://dhsprogram.com/pubs/pdf/FR354/FR354.pdf

National Population and Family Planning Board (BKKBN), Statistics Indonesia (BPS), Ministry of Health (Kemenkes), and ICF. Indonesia Demographic and Health Survey 2017. (2018). Jakarta, Indonesia. https://dhsprogram.com/pubs/pdf/FR342/FR342.pdf