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Pneumonia
& Diarrhea Sustainable
Progress in the
Progress Report Post-2015 Era
2015
Executive Summary 4
Global Burden of Pneumonia and Diarrhea in Children 5
Evaluating Progress in the 15 Highest Burden Countries 6
Key Progress Updates 7
Introduction 8
Contents Pneumonia and Diarrhea – Major Threats to Child Health and Survival 8
Measuring and Evaluating Country Progress 8
GAPPD Intervention Scoring 10
Key Findings: GAPPD Package Coverage 11
Key Findings: Prevention through Vaccination 17
DTP3 Coverage 18
Measles Coverage 18
Hib Vaccine Coverage 18
PCV Coverage 19
Rotavirus Vaccine Coverage 19
Striving to Achieve and Maintain High, Equitable Vaccine Coverage 20
Country Highlights 21
India 22
Indonesia 23
Nigeria 25
Key Findings: Protection 27
Exclusive Breastfeeding 28
Key Findings: Treatment 29
Pneumonia Treatment: Care by Appropriate Health Care Provider and Antibiotics 30
Diarrhea Treatment: Oral Rehydration Salts (ORS) and Zinc 31
Sustainable Progress in the Post-2015 Era 32
Vaccine Financing 34
Impact of Changing Levels of Gavi Support 35
Immunization Systems, Supply Chains, and Decision Making Capacity 36
Capacity to Scale Up Interventions and Sustain Progress 38
Acknowledgements This 2015 edition of the Pneumonia and Diarrhea Progress Report is the sixth annual progress report prepared and published by the International Vaccine Access Center (IVAC) www.jhsph.edu/ivac at the Johns Hopkins Bloomberg School of Public Health for World Pneumonia Day. 7th Annual World Pneumonia Day 2015 (November 12, 2015) Report Team Lead Author Thuy-Linh Nguyen Contributors (IVAC) Katherine L. O’Brien Lois Privor-Dumm Maria Knoll Elizabeth Chan Molly Sauer Margaret Miller Chizoba Wonodi Chisom Obi Expert Reviewers Mathuram Santosham Robert Black Li Liu Design and Layout John Welker, Pixels+Points Photos Adrian Brooks Oscar Seykens Suggested Citation International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. (2015). Pneumonia and Diarrhea Progress Report 2015: Sustainable Progress in the Post-2015 Era. Retrieved from www.jhsph. edu/research/centers-and-institutes/ivac/ resources/IVAC-2015-Pneumonia-Diarrhea- Progress-Report.pdf
Executive Summary | Global Burden of Pneumonia and Diarrhea in Children
Executive
Summary
IVAC at Johns Hopkins University
Executive Summary | Global Burden of Pneumonia and Diarrhea in Children
Executive Summary
Global Burden of Pneumonia and Diarrhea in Children
Every minute, six children die from pneumonia or diarrhea. Together, these diseases
claimed the lives of nearly 1.5 million children under the age of five in 2015.
This year, 2015, marks the end of the age of five in a single year. The lives of
Millennium Development Goals (MDGs), six children are lost with each passing
5.9m
and an opportunity to reflect on the minute. Although the number of child
drastic improvements in child health deaths in 2015 decreased compared
and survival that have been achieved to 2013 (6.4 million), the overall
over the past decades along with the contribution of pneumonia and diarrhea
need for sustained improvement. In to those deaths has remained rather
9%
2015, the mortality rate in children under steady (15-16% for pneumonia and 9%
deaths
the age of five years is less than half for diarrhea) over those two years.1
(43 deaths per 1,000 live births) of what
diarrhea
it was in 1990 (91 deaths per 1,000 live In addition, pneumonia and diarrhea
16%
births). However, this still falls short of mortality in young children continues
the MDG4 target of reducing under-five to be disproportionately concentrated
mortality by two-thirds between 1990 in a few countries, year after year.
pneumonia
and 2015. This reality serves as a stark Seventy-two percent of the global
reminder of the work that remains to be burden of pneumonia and diarrhea child
done and the continued investments deaths occur in just 15 countries, even
that are required to accelerate the pace though they are home to only 55% of the
of progress in the post-2015 era. world’s under-five population.
Of these 5.9 million
In 2015, a projected 5.9 million children deaths, pneumonia
around the world will die before reaching was responsible for
their fifth birthday.1 Of these 5.9 million 16% and diarrhea was
deaths, pneumonia was responsible
responsible for 9%,
for 16% and diarrhea was responsible
for 9%, making them two of the leading making them two of
killers of children worldwide. Together, the leading killers of
these diseases claimed the lives of children worldwide.
nearly 1.5 million children under the
IVAC at Johns Hopkins University 5
Executive Summary | Evaluating
Global Burden
Progress
of Pneumonia
in the 15 and
Highest
Diarrhea
Burden
in Children
Countries
Evaluating Progress in the 15 Highest Burden Countries
This 2015 Pneumonia and Diarrhea Progress Report
evaluates the progress of the 15 countries with the
greatest burden of under-five pneumonia and diarrhea
deaths in implementing high-impact interventions
outlined in the Global Action Plan for the Prevention
and Control of Pneumonia and Diarrhea (GAPPD)3,
where data are available, and evaluates the need to
accelerate the implementation of select interventions Collectively, these ten interventions
and assure sustainability of that progress. are evaluated and summarized into an
overall GAPPD score, developed by the
International Vaccine Access Center
(IVAC) at the Johns Hopkins Bloomberg
School of Public Health. These GAPPD
scores are used to assess and compare
The coverage targets for interventions included
progress over time in the highest-burden
in this report are:
countries with the greatest number
of pneumonia and diarrhea deaths in
90% for vaccinations
children under the age of five years.
Pertussis vaccine
GAPPD scores are a calculated average
Measles vaccine of countries’ coverage levels for the
ten GAPPD indicators, using the most
Haemophilus influenzae type b (Hib) vaccine
recent data available.
Pneumococcal conjugate vaccine
Rotavirus vaccine
90% for pneumonia and diarrhea treatments
Treatment of children with suspected pneumonia by a
health care provider
Antibiotic use in children with suspected pneumonia
Oral rehydration salts (ORS) for children with diarrhea
Zinc supplements for children with diarrhea
50% for exclusive breastfeeding
Exclusive breastfeeding for the first 6 months of life
Pneumonia & Diarrhea Progress Report 2015 6
Executive Summary | Key Progress Updates
Key Progress Updates
Between 2014 and 2015, 7 of the 15 countries with the greatest burden of child
pneumonia and diarrhea deaths showed improvements in their GAPPD scores.
However, gains were minimal in large countries, such as India and Nigeria.
Between 2014 and 2015, the 15 countries with the greatest number of pneumonia and diarrhea child deaths have remained
largely unchanged, with two exceptions. Uganda and Kenya dropped from the list in 2015, and were replaced by Somalia and
Tanzania. For the remaining countries on the list in both 2014 and 2015, mixed progress was observed. GAPPD scores improved
modestly for some countries (Democratic Republic of the Congo, Angola, Ethiopia, Afghanistan, and Sudan); remained
unchanged for Indonesia, Niger, and China; and decreased for others (Pakistan, Chad, and Bangladesh). Furthermore, India and
Nigeria, the two countries that consistently have the greatest number of pneumonia and diarrhea deaths under-five, improved
their GAPPD scores by only two percentage points.
GAPPD Score Change from 2014-2015
DRC
Angola Indonesia Pakistan
Ethiopia Niger Chad
Afghanistan China Bangladesh
Sudan
Reflecting on the rate of progress over the past few years, it has become increasingly
evident that without significant gains in countries with large birth cohorts, such as India,
Nigeria, China, and Indonesia, reduction in global pneumonia and diarrhea mortality in
children will continue to stall, as has been the case in recent years.
The rate of uptake and scale-up of child mortality relative to its 1990 rate Low GAPPD scores in this report may be
evidence-based interventions that and thus met the MDG4 target, they still due to a number of factors, including but
protect against, prevent, and treat bear a significant burden of pneumonia not limited to a lack of implementation
pneumonia and diarrhea have not kept and diarrhea child deaths worldwide. of GAPPD interventions (e.g., no
up with the pace required for countries Particularly in large countries or introduction of the vaccines that
to meet the MDG4 target of reducing countries that once had extremely can impact pneumonia and diarrhea
under-five mortality by two-thirds by high child mortality rates, the absolute mortality), slow rollout of vaccines that
2015. In fact, more than half of the number of child deaths (all-cause or have been introduced (which is often
countries evaluated in this report have pneumonia and diarrhea only) in 2015 the case for phased introductions in
missed the target.1 Although Ethiopia, can still be high relative to those of large countries), and challenges in
Indonesia, Niger, China, Bangladesh, other countries, despite a large relative changing health behaviors, specifically
and Tanzania successfully achieved reduction in their mortality rates with regard to adopting protective and
at least a two-thirds reduction in their over time. treatment measures.
IVAC at Johns Hopkins University 7
Introduction |
Introduction
Pneumonia and Diarrhea – though these countries only account pneumonia and diarrhea interventions
for 55% of the world’s under-five as recommended by the World Health
Major Threats to Child Health Organization (WHO) and the United
population.5 Of these 15 countries with
and Survival the greatest number of pneumonia Nations Children’s Fund (UNICEF) in the
and diarrhea child deaths, 6 (Angola, Global Action Plan for the Prevention
Over the past 25 years, the rate of Chad, Somalia, Nigeria, Democratic and Control of Pneumonia and
mortality in children under the age of Republic of Congo (DRC), and Niger) Diarrhea (GAPPD). Additionally, actual
five years has been cut by more than are also among the 10 countries with coverage levels for each intervention
half worldwide (from 91 deaths per 1,000 the highest under-five mortality rates are compared to coverage targets set
live births in 1990 to 43 deaths per 1,000 and 9 (India, Nigeria, Pakistan, DRC, forth in GAPPD to assess how close or
live births in 2015).1 Still, reaching a fifth Angola, Chad, Afghanistan, Sudan, and far countries are from meeting global
birthday is a life milestone that many Somalia) have missed the MDG4 target standards for pneumonia and diarrhea
children will never reach, especially in for the reduction of child mortality.1 prevention and treatment.
the poorest areas of the world. In 2015, The remainder (Ethiopia, Indonesia,
the number of childhood deaths is Niger, China, Bangladesh, and Tanzania)
expected to reach 5.9 million. Despite have achieved their MDG4 targets, but
significant gains in overall child health remain in the top 15 countries due to
Protect.
achieved across the globe, the world the high absolute burden of pneumonia
has still fallen short of reaching its goal and diarrhea, and therefore should
Prevent.
of reducing 1990 under-five mortality continue to focus on further reductions
by two-thirds by 2015. Pneumonia and of pneumonia and diarrhea mortality,
Treat.
diarrhea’s contribution to under-five particularly amongst their most
child deaths, in particular, have remained vulnerable populations.
stubbornly high.1,2 In 2015, these two
diseases together were responsible Measuring and Evaluating
GAPPD provides an integrated strategy
for one in four deaths that occurred in Country Progress for ending preventable pneumonia
children under five years of age.4 The
majority of the total burden of pneumonia and diarrhea deaths through the use
This report evaluates the progress of the
and diarrhea child deaths globally (1.5 of proven measures that protect child
15 countries with the greatest number
million) is also disproportionately borne health, prevent children from becoming
of deaths from pneumonia and diarrhea
by 15 countries. Of the children who lost ill with pneumonia and diarrhea, and
in children under the age of five years,
their lives to pneumonia and diarrhea treat affected children.
using the most up-to-date information
before the age of five, 72% are from on countries’ use of high-impact
these 15 high-burden countries,4 even
Pneumonia & Diarrhea Progress Report 2015 8Executive Summary | Global Burden of Pneumonia and Diarrhea in Children
GAPPD sets forth
the following coverage for each
coverage of the following
90%
vaccines: pertussis,
targets for its measles, Haemophilus
recommended influenzae type b
(Hib), pneumococcal
interventions, conjugate, and rotavirus
vaccines
which countries
should strive treatment coverage
to achieve: for children
90% with suspected
pneumonia,
including care by an
appropriate health
care provider and
antibiotics
treatment coverage
for children with
90% diarrhea, including
treatment with oral
rehydration salts
(ORS) and zinc
supplements
rate of exclusive
50%
breastfeeding for
the child’s first six
months of life
IVAC at Johns Hopkins University 9Introduction | GAPPD Intervention Scoring
GAPPD Intervention Scoring
GAPPD scores are composite scores dose of measles-containing vaccine countries in terms of providing children
that are calculated from countries’ (MCV1), third dose of Hib vaccine (Hib3), coverage of high-impact interventions
most recent coverage, expressed as a third dose of pneumococcal conjugate that protect against, prevent, and treat
proportion, for key GAPPD interventions, vaccine (PCV3), and the last dose pneumonia and diarrhea, integrating
for which data are available. There of rotavirus vaccine (RV); exclusive strategies that impact either pneumonia
are ten indicators that factor into the breastfeeding for the first six months or diarrhea, as well as those that impact
GAPPD score, which represents a of a child’s life; care by an appropriate both. For a closer look at countries’
summary of coverage and is calculated health care provider and antibiotic progress with respect to pneumonia and
as the average coverage across treatment for children with suspected diarrhea interventions separately, GAPPD-
interventions based on available data. pneumonia; and treatment with ORS Pneumonia and GAPPD-Diarrhea scores,
These intervention measures include and zinc for children with diarrhea. which respectively take into account only
coverage rates for the third dose of The overall GAPPD scores provide pneumonia-specific and diarrhea-specific
pertussis (as measured by DTP3), first an overview of the progress made in interventions, are also reported.
The coverage indicators that are included in each score are outlined below:
Pneumonia Treatments Diarrhea Treatments
RV Exclusive
Score DTP3 MCV1 Hib3 PCV3 (last Care by an breastfeeding
dose) appropriate Zinc in first 6
Antibiotics ORS supplements
health care months
provider
Overall
GAPPD
score
GAPPD-
Pneumonia
score
GAPPD-
Diarrhea
score
GAPPD scores reflect countries’ progress on ten key GAPPD interventions for which coverage data are publicly available; they
are not intended to represent the full portfolio of interventions that are effective in reducing pneumonia and diarrhea morbidity
and mortality in children. Therefore, non-inclusion of interventions in the GAPPD score calculations does not imply their lack of
importance in the prevention and treatment of childhood pneumonia and diarrhea.
Considerations for Interpreting GAPPD Scores: Recent data (within the last 10 years) are not available for certain GAPPD indicators and are thus excluded from the
calculation of GAPPD scores. As a result, countries with several missing values may have scores that either overestimate or underestimate the true progress being made
in the country. Additionally, progress may appear stalled in countries where coverage estimates for GAPPD indicators are not updated annually, even if the country has
made improvements in recent years. This underscores the importance of ongoing monitoring and availability of high quality data on key GAPPD interventions, which will
not only enhance the quality of programs delivering these interventions, but also allow an accurate and up-to-date assessment of countries’ progress.
In addition, immunization coverage rates calculated in the GAPPD scores are from the WHO/UNICEF Estimates of National Immunization Coverage (WUENIC), which are
updated on an annual basis for the most recent year, as well as for all previous years, taking into account any new survey data that were made available since the last
WUENIC data were released. Any changes in estimated coverage rates of previous years do not imply increases or decreases in actual coverage in that given year; rather,
they reflect an adjustment of coverage estimates based on the latest available survey data. Therefore, changes between the 2013 vaccine coverage rates reported in
the 2014 Pneumonia & Diarrhea Progress Report and the 2014 rates reported in this year’s Progress Report can be due to WHO/UNICEF’s adjustments of 2013 coverage
rates in its latest (2015) release or a true increase or decrease in coverage levels from 2013 to 2014. In this 2015 Progress Report, when assessing trends across years,
coverage rates from the latest WUENIC data are used, not the 2013 WUENIC coverage rates issued in 2014 and reported in the 2014 Progress Report.
IVAC at Johns Hopkins University 10Key Findings | GAPPD Package Coverage
Key Findings
GAPPD Package Coverage
Overall GAPPD scores in 2015 varied widely from a
low of 20% (Somalia) to a high of 72% (Tanzania), with
all 15 focus countries falling below the 86% target for
the overall GAPPD score. Large countries, such as
India, Nigeria, Indonesia, and China had little to no
improvement in their GAPPD scores since last year.
These large countries with low coverage of lifesaving
interventions that protect against, prevent, and treat
pneumonia and diarrhea represent critical opportunities
to bend the curve on child mortality.
In 2015, the 15 countries that contributed (10) Niger, (11) China, (12) Sudan, (13) (Uganda, Kenya, Somalia, and Tanzania),
most to the global burden of child Bangladesh, (14) Somalia, and (15) the combined burden of child mortality
pneumonia and diarrhea deaths were United Republic of Tanzania (listed in from pneumonia and diarrhea did
largely the same as those in 2014, with decreasing order of pneumonia and decrease between 2013 and 2015.4
two exceptions. Between 2014 and diarrhea child deaths).6 This shuffling
2015, Uganda and Kenya dropped from of countries on and off the list of the This year, overall GAPPD scores varied
the list of the 15 countries with the top 15 highest burden countries is due widely from a low of 20% (Somalia) to
greatest number of under-five deaths to several factors, including reductions a high of 72% (Tanzania), the highest
from pneumonia and diarrhea, and were in the total number of child pneumonia GAPPD score reached by any of the
replaced by Somalia and Tanzania. and diarrhea deaths and an adjustment 15 highest-burden countries since
These 15 highest burden countries of 2013 pneumonia and diarrhea burden we began evaluating pneumonia and
now consist of (1) India, (2) Nigeria, (3) estimates in the latest update of the diarrhea interventions together in 2013
Pakistan, (4) DRC, (5) Angola, (6) Ethiopia, global burden of disease estimates (See Fig. 1 and 2 and Table 1). The
(7) Indonesia, (8) Chad, (9) Afghanistan, released in 2015.4 In all 4 cases median score among the 15 countries
was 46%. This represents a slight
Figure 1: Overall GAPPD scores for the 15 countries with the greatest absolute improvement from 2014 scores, which
number of pneumonia and diarrhea deaths in children under 5 years of age, 2015 ranged from 23% (Chad) to 63% (Sudan),
and with a median score of 44%.6
However, only 4 of the 15 countries had
overall GAPPD scores of at least 50% in
2015 (Angola, Sudan, Bangladesh, and
Overall GAPPD Scores, 2015 Tanzania), and all 15 fell short of the
20-35 86% target for the overall GAPPD score,
36-50 which would be achieved if a country
51-60
met the minimum coverage targets for
61-72
each of the ten GAPPD interventions
evaluated in this report.
Pneumonia & Diarrhea Progress Report 2015 11Table 1: Current levels of coverage for pneumonia and diarrhea interventions in the 15 countries with the most absolute child pneumonia and diarrhea deaths
% of Children Under 5 % of Children Under 5
Global rank Pneumonia Vaccine Coverage (%)
with Suspected Pneumonia with Diarrhea
order of total & Diarrhea % Exclusive 2015 2015
2015 Overall
pneumonia Deaths in Breastfeeding GAPPD- GAPPD-
GAPPD
and diarrhea Country Children in first 6 Pneumonia Diarrhea
Hib3 Taken to an Intervention
deaths in Under 5 PCV3 months7 Intervention Intervention
Pertussis 20142 appropriate Receiving Receiving Receiving zinc Score
children Years Measles 20142& Rota 20142 (2005-2014) Score Score
(DTP3) & Vaccine health care Antibiotics3 ORS 4 supplements5,6
under 5 20151 20142 Vaccine Use & Vaccine Use Status
20142 Use provider 3 (2005-2014) (2005-2014) (2005-2014)
Status
Status (2005-2014)
1 India 297,114 83 83 20 0 0 69 12.5 26 0.3 46 34 45 31
No decision Non-Gavi planning intro
0 0
2 Nigeria 210,557 66 51 66 (Dec 2014) Gavi plan to apply 34.5 34.9 34 2.3 17 31 39 21
3 Pakistan 103,760 73 63 73 68 0 64.4 41.5 38 1.5 38 46 60 28
Gavi plan to apply
Democratic 0
4 Republic of 78,422 80 77 80 61 No decision 41.6 39.6 39 2.4 48 47 61 33
the Congo
5 Angola 54,548 80 85 80 61 18 - - - - - 65 77 52
6 Ethiopia 46,888 77 70 77 76 63 27 6.8 26 0.0 52 48 55 42
0 0
7 Indonesia 33,737 78 77 21 Non-Gavi Non-Gavi planning intro 75.3 38.9 39 1.1 42 37 47 32
planning intro
0 0
8 Chad 30,641 46 54 46 No decision No decision 26.1 31.4 13 0.2 3 22 30 14
0
9 Afghanistan 30,419 75 66 75 40 Gavi plan to apply 60.5 63.9 53 5.3 - 49 63 31
10 Niger 28,164 68 72 68 13 19 53.1 10.7 44 10.3 23 38 44 34
Private 0 0
11 China 27,114 99 99 Market No decision No decision - - - - 28 45 56 42
Coverage
12 Sudan 24,903 94 86 94 97 86 48.3 59 22 - 41 70 74 59
0 0
13 Bangladesh 24,571 95 89 95 Introduced Gavi plan to apply 42 34.2 77 11.8 60 50 59 48
Mar 2015
0 0
14 Somalia* 23,426 42 46 42 No decision No decision 13 32 13 0.9 9 20 26 14
Tanzania,
15 United 22,394 97 99 97 93 97 70.6 - 44 4.7 50 72 84 59
Republic of*
*Not profiled in the 2014 Pneumonia & Diarrhea Progress Report; was not among the top 15 countries with the highest number of child pneumonia and diarrhea deaths in the previous year.
Sources:
1
Liu, L., Oza, S., Hogan, D., Chu, Y., Perin, J., Zhu, J., Lawn, J., Cousens, S., Mathers, C., Black, R. E. (2015). National, regional and global causes of child mortality in 2000-2015 – reflecting on the MDG 4 and embarking on the SDG 3.2. Under preparation .
2
WHO/UNICEF. WHO/UNICEF National Immunization Coverage Estimates. Data as of 10 Jul 2015. Retrieved from http://www.who.int/immunization/monitoring_surveillance/data/en/
3
UNICEF. Global databases 2015 based on MICS, DHS and, other national household surveys. Retrieved from http://data.unicef.org/child-health/pneumonia.html
4
UNICEF. Global databases 2015 based on MICS, DHS and, other national household surveys. Retrieved from http://data.unicef.org/child-health/diarrhoeal-disease.html
5
The DHS Program. (n.d.). Demographic and Health Surveys (DHS) Final Reports. Retrieved from http://dhsprogram.com/publications/publication-search.cfm?type=5
6
UNICEF. (2014). Multiple Indicator Cluster Surveys / MICS5. Retrieved from http://www.childinfo.org/mics5_surveys.html
7
UNICEF. Global databases, 2014, DHS, MICS, other national household surveys and UNICEF. Retrieved from http://data.unicef.org/nutrition/iycf.html.Key Findings | GAPPD Package Coverage
Compared to 2014 scores, 7 of the PCV, and rotavirus vaccines) and are
15 countries had improvements in achieving relatively high coverage
their 2015 scores (Fig. 3), with the with each. By contrast, in countries
largest increases seen in Angola with large populations of children
(+15%), Ethiopia (+10%), and DRC (+8%). under the age of five years, such as
Afghanistan and Sudan, respectively, India, Nigeria, China and Indonesia,
also saw increases in their overall PCV and rotavirus vaccine have not
GAPPD scores (+5 and +7, respectively) yet been introduced into the national
and India and Nigeria raised their score immunization schedule, which
slightly (+2%). It is quite notable that contributes to stagnation of their
India has the lowest GAPPD score overall GAPPD scores.
among the Asian countries evaluated
in this report, despite its resources. Moving the needle in large countries
Indonesia, Niger, and China had no where a large portion of the world’s
improvements in their overall score. under-five population lives has
Overall GAPPD scores decreased in proven difficult and slow. As evident
three countries: Pakistan and Chad in Figure 4, India and Nigeria, which
decreased only slightly (-1%), but bear the greatest burden of child
Bangladesh’s score declined by 8%. deaths from pneumonia and diarrhea,
Bangladesh’s lower GAPPD score was have overall GAPPD scores that
largely attributable to its decreasing remain well below 50%, revealing
rate of antibiotic treatment for children the substantial opportunities for
with suspected pneumonia (from 71% to reduction of this burden of mortality.
Without significant and
34%) and zinc coverage in children with This pattern is true for other countries
accelerated progress in these
diarrhea (from 41% to 12%). with large under-five populations as
large countries, reduction Of the 15 countries profiled in this well, including China, Indonesia, and
of preventable pneumonia report, the 3 countries with the highest Pakistan, who also have scores less
and diarrhea deaths in young GAPPD scores (Tanzania, Sudan, than 50%.
children globally will continue and Angola) are using all 5 vaccines
to stall. protective against pneumonia and This progress will need to not only
diarrhea (pertussis, measles, Hib, include introduction of the vaccines,
but equitable rollout to ensure
Figure 2: 2015 Overall GAPPD intervention scores for countries shown from top to maximum impact. In large countries,
bottom in decreasing order of absolute child pneumonia and diarrhea deaths the phased approach for introduction
of vaccines, often because of weaker
Overall GAPPD
Target Score
systems can inadvertently result
India 34% (86%) in lower than desired progress,
Nigeria 31%
Pakistan
as subnational areas that tend to
46%
Democratic Republic
47%
introduce last are also areas where
of the Congo
Angola 65%
disease burden is highest. A deliberate
Ethiopia 48% effort to introduce interventions in
Indonesia 37% highest burden areas in parallel with
Chad 22%
Afghanistan 49%
system strengthening is needed to
Niger 38% achieve the greatest impact.
China 45%
Sudan 70%
Bangladesh 50%
Somalia 20% No missing data values
Tanzania, United 72% 1 missing data value
Republic of
4+ missing data values
0% 10 20 30 40 50 60 70 80 90 100%
Source: World Health Organization (WHO). (2015). WHO vaccine-preventable diseases: monitoring system. 2015 global summary.
Last updated 8 Sep 2015. Retrieved from http://apps.who.int/immunization_monitoring/globalsummary/indicators
IVAC at Johns Hopkins University 14Key Findings | GAPPD Package Coverage
When evaluating pneumonia and
diarrhea interventions separately,
Countries consistently scored higher on their GAPPD-Pneumonia
GAPPD-Pneumonia scores
scores than their GAPPD-Diarrhea scores. Tanzania was the only
were consistently higher than
country of the 15 highest burden countries to meet the GAPPD- GAPPD-Diarrhea scores across all 15
Pneumonia target score of 84%, while no country achieved the countries, ranging from 26-84% and
target 82% GAPPD-Diarrhea score. 14-59%, respectively (Fig. 5). India,
DRC, Ethiopia, Angola, and Sudan made
improvements to both their GAPPD-
Figure 3: Change in overall GAPPD scores between 2014 and 2015 shown from top Pneumonia and GAPPD-Diarrhea scores.
to bottom in decreasing order of absolute child pneumonia and diarrhea mortality In other countries, there was mixed
progress, with some countries making
Overall GAPPD Intervention Scores, 2015
gains on pneumonia interventions, while
India 2 losing ground on diarrhea interventions,
Nigeria 2
Pakistan
and vice versa. For example, Nigeria
-1
Democratic Republic
8
increased its GAPPD-Pneumonia score
of the Congo
Angola 8 15
by two percentage points, but lost the
Ethiopia equivalent in its GAPPD-Diarrhea score.
Indonesia 0 10 Similarly, Afghanistan’s GAPPD-
Chad -1
Afghanistan 5
Pneumonia score improved by
Niger 0 six percentage points, while its
China 0 GAPPD-Diarrhea score dropped by two
Sudan 7
Bangladesh -8
percentage points. Niger, on the other
Somalia* hand, gained five percentage points in
Tanzania, United
Republic of*
its GAPPD-Diarrhea score and lost four
-10 -5 0 5 10 15 in its GAPPD-Pneumonia score. Two
countries (Bangladesh and Chad) had
*Not profiled in the 2014 Pneumonia & Diarrhea Progress Report; was not among the top 15 countries with the highest number of
child pneumonia and diarrhea deaths in the previous year.
decreases in both their GAPPD-Pneumo-
nia and -Diarrhea scores.
Figure 4: Absolute number of pneumonia and diarrhea deaths in under-five children This shows that progress on the child
and overall GAPPD scores in the 15 highest burden countries, relative to their pneumonia and diarrhea fronts could
under-five population size differ by country and that barriers
to each should be addressed on the
individual country level. Some countries
90 could have strong champions or
funding for pneumonia interventions,
80
Sudan
Tanzania but lack them for diarrhea (or vice
Overall GAPPD Scores (%), 2015
70
versa), and therefore perform better in
60 Angola certain areas than others. Even within
Bangladesh
50
Ethiopia
countries, improvements in pneumonia
Afghanistan Pakistan India
compared to diarrhea and the degree to
40
Niger
DRC
China which each were improved could vary
Indonesia
30
Chad across states and districts, especially
20 Nigeria
in large, heterogeneous countries with
Somalia
10 a decentralized government and health
system. To devise a more tailored
0
60 120 140
solution, it is important to recognize
20 40 80 100
these potential differences across
Under-5 Child Population in Each Country, 2015 (in millions) geographic areas and between the
various interventions.
Note: The size of each bubble represents the absolute number of under-five child deaths from pneumonia and diarrhea in each
country.
Pneumonia & Diarrhea Progress Report 2015 15Key Findings | GAPPD Package Coverage
Figure 5: 2015 GAPPD-Pneumonia and GAPPD-Diarrhea intervention scores for countries shown
from top to bottom in decreasing order of total child pneumonia and diarrhea deaths
India 45%
31%
Nigeria 21%
39%
60%
Pakistan 28%
Democratic Republic 61%
of the Congo 33%
77%
Angola 52% GAPPD-Pneumonia
55% Target Score
Ethiopia 42% (84%)
47% GAPPD-Diarrhea
Indonesia 32% Target Score
(82%)
Chad 30%
14%
Afghanistan 63%
31%
44%
Niger 34%
56%
China 42%
74%
Sudan 59%
59%
Bangladesh 48%
Somalia 26%
14%
Tanzania, United 84%
Republic of 59%
0% 10 20 30 40 50 60 70 80 90 100%
GAPPD Scores (%)
GAPPD-Pneumonia Intervention Score
GAPPD-Diarrhea Intervention Score
Although none of the 15 countries minimum score achieved if a country children who need them most. Only
met the 86% target for their overall were to meet the minimum standards 5 of the 15 countries met one or
GAPPD score, Tanzania did meet all the for all the diarrhea-specific GAPPD more GAPPD coverage targets, with
minimum targets for the pneumonia- interventions). The sluggish pace of Tanzania hitting targets for the most (6)
specific GAPPD interventions, thereby progress with diarrhea interventions indicators, followed by Sudan, who met
achieving the 84% target for its GAPPD- highlights the urgent need to accelerate 4 coverage targets. In total, 10 of the 15
Pneumonia score. However, no country the rate of implementation and scale countries failed to reach even one of the
was even close to reaching the 82% up of diarrhea and treatment measures 10 GAPPD coverage targets.
target for its GAPPD-Diarrhea score (the so that these interventions can reach
IVAC at Johns Hopkins University 16Key Findings:
Prevention
through
Vaccination
Both accelerated vaccine introductions and scale ups are needed
to promptly raise coverage levels and prevent child deaths from
pneumonia and diarrhea. In countries with phased vaccine
introductions, slow rollout of the vaccine to all areas of the
country has contributed to persistently low coverage.
17Key Findings | Prevention through Vaccination
Vaccines have long been recognized as a cornerstone to child health and survival. However, the introduction of new
vaccines in developing countries has generally lagged behind use in developed countries, even though poorer countries
bear a disproportionate burden of disease.
For pneumonia and diarrhea, there are several vaccines that are safe and effective in preventing these diseases, such as
pertussis, measles, Hib, pneumococcal, and rotavirus vaccines.
concern. As we see with recent measles which is indicative of what their Hib
DTP3 Coverage outbreaks in the U.S., a country that coverage rates will likely be once they
had previously eliminated measles complete the transition from DTP to
According to the latest WHO/UNICEF over a decade ago,10 it is important Hib-containing pentavalent vaccine in all
Estimates of National Immunization for countries to recognize that their states. Somalia and Chad, on the other
Coverage (WUENIC) released in 2015, population will remain vulnerable to hand, have similarly low coverage rates
DTP3 rates rose in 7 of the 15 countries, outbreaks if coverage levels are not for both DTP and Hib (42% for Somalia
decreased in 3 of the countries, and were high and do not stay high. For measles and 46% for Chad), which suggests that
unchanged in the remaining 5 countries particularly, declining coverage levels they still have very weak immunization
between 2013 and 2014. In some pose a real and substantial threat to the systems and thus require strengthening
countries, such as Chad and Somalia, sustainability of previous successes of their routine immunization programs.
DTP3 coverage levels are unacceptably achieved in measles prevention.
low (less than 50%), indicating
serious issues with delivering routine
immunizations in those countries. For Hib Vaccine Coverage Hib Vaccination Coverage Target
many countries with remarkably low
DTP3 coverage, including Somalia, Hib vaccine, another vital vaccine
political conflict has played a major for the prevention of pneumonia, is
role in disrupting basic immunization widely used across the globe in every Met or Sudan
services. In these areas affected by country, except for China and Thailand. Exceeded Bangladesh
conflict, enhanced efforts to strengthen Children in China have access to Hib 90% Target Tanzania
immunization systems are especially vaccine in the private market, but its
critical, as more and more children coverage levels in the private sector are
become displaced and even harder to not well documented.7 Currently, 3 of
reach for preventive services.9 the 15 countries (Sudan, Bangladesh, Pakistan
and Tanzania) have met or exceeded DRC
the 90% GAPPD coverage target for Close to Reaching Angola
Measles Coverage Hib vaccination and several countries 90% GAPPD Target Ethiopia
are relatively close to reaching the (70-89%) Afghanistan
For measles vaccine, coverage rates target, including Pakistan (73%), DRC
increased in 3 countries, decreased in (80%), Angola, (80%), Ethiopia (77%),
6, and were unchanged for the other and Afghanistan (75%). Still, many
6 countries.8 Ten of the 15 countries countries continue to have extremely India
had measles vaccine coverage at or low coverage, such as India (20%), Extremely
Indonesia
above 70%, with 2 (China and Tanzania) Indonesia (21%), Somalia (42%), and Low Coverage Somalia
reaching nearly universal coverage Chad (46%). For India and Indonesia, low (Less than 70%) Nigeria
(99%). Nevertheless, the fact that coverage of Hib vaccine is a result of
measles vaccine coverage is not where incomplete introduction of the vaccine
it should be for 13 of the 15 countries, throughout all states and districts in
and that only 3 countries are on an the country. India and Indonesia’s DTP3
upward trajectory, should be a cause for coverage rates are much higher though,
Pneumonia & Diarrhea Progress Report 2015 18Key Findings | Prevention through Vaccination
are using the vaccine. On the global recommendation of LLR (for children
PCV Coverage
scale, uptake of rotavirus vaccine is 2-35 months of age) and its high price
especially delayed in South Asia and (costing roughly 10% of the average
Although the lag in use of PCV and Southeast Asia, falling substantially Chinese monthly salary for 2 doses),
rotavirus vaccines in developing behind the pace of introductions in private market coverage of rotavirus
countries compared with developed Africa. Compared to the 29 (55%) vaccine in Guangzhou was expectedly
countries has been significantly less countries in Africa using rotavirus low.13 For the 5 countries profiled in this
than that of Hib vaccine,7 the pace of vaccine in national immunization report that are using rotavirus vaccine,
introduction of these vaccines in the programs, Asia pales in comparison, coverage ranged from 18% (in Angola)
highest burden countries has been with only 11 countries (24%) routinely to 97% (in Tanzania). India, Nigeria,
remarkably slow, especially in large using the vaccine.11 Furthermore, the Pakistan, Indonesia, Afghanistan, and
countries that have the potential to make Asian countries that have not introduced Bangladesh are planning to introduce
great impact. Fifteen years after PCV’s rotavirus vaccine are also countries rotavirus vaccine, but not until 2016
first introduction in 2000, five of the with large birth cohorts, such as India, or 2017.11 In India, the country with the
highest pneumonia burden countries Indonesia, and China. highest absolute number of diarrheal
(India, Indonesia, Chad, China, and deaths, the vaccine is planned for
Somalia) are still not using the vaccine in Although rotavirus vaccine is introduction into 4 states, initially. DRC,
their routine immunization programs.11 not included in China’s national Chad, China, and Somalia have not yet
India, Chad, China, and Somalia have immunization schedule, there is a made decisions regarding rotavirus
not made official decisions to introduce licensed monovalent rotavirus vaccine vaccine introduction.11
the vaccine, and Indonesia is expected (LLR) available on the private market in
to introduce PCV no earlier than 2017, the country.12 However, based on a 2013 Despite an overall decline in diarrhea
and only in a limited area.11 Among the study of rotavirus vaccine coverage in and pneumonia mortality over time,
8 countries that have introduced PCV, Guangzhou, one of the largest cities countries must resist becoming
coverage varied widely from a low of 13% in China, only about 1 in 4 children complacent as long as preventable
(in Niger) to a high of 97% (in Sudan). In between the ages of 2 and 59 months disease and mortality in children still
all cases, the goal of vaccine introduction received 1 dose of LLR, and even remain, especially in hard-to-reach
should be to scale up access to fewer (0.5%) received 2 or more doses. areas where disease burden is high and
include all children, with policy makers Given the vague and broad schedule access to care is low.
prioritizing accelerated rollouts to the
highest burden populations that are most
Global rotavirus vaccine introductions
vulnerable and most in need.
Rotavirus Vaccine Coverage
Compared to PCV, rollout of rotavirus
vaccine in these 15 countries has been
even more limited. Nine years into
rotavirus vaccine’s introduction in the
global market, only 5 of the 15 highest
mortality burden countries (Angola,
Ethiopia, Niger, Sudan, and Tanzania)
Introduced – Universal (76 countries) Introduced – Subnational (4 countries)
IVAC at Johns Hopkins University 19Key Findings | Prevention through Vaccination
Striving to Achieve and began in August 2013.11 This again which translated to time savings for
Maintain High, Equitable underscores the importance of health workers and increased overall
Vaccine Coverage strengthening immunization programs efficiency of planning efforts.14
at the national, state, and district levels; Concurrent vaccine introductions
building awareness and political will for also allowed for combined advocacy
Beyond the political will needed to introduction; and assuring that systems and communications efforts,
introduce these vaccines, achieving at all levels have the capacity to roll out including development of key
high levels of coverage among children new vaccines at an accelerated pace, messages and materials.14 These
remains a major challenge for many especially in high-burden states where lessons, gleaned from Tanzania’s
of these countries. Of the 15 countries delivery might be particularly difficult. concurrent launch of PCV and
evaluated in this report, only 2 (Sudan rotavirus vaccine, provide valuable
and Tanzania) met the 90% GAPPD It is often the case that when countries insights into what is essential for a
coverage target for PCV and only 1 have multiple new vaccine introductions successful dual launch. They also
(Tanzania) met the same target for planned, they stagger the introductions bring to the forefront the benefits
rotavirus vaccine coverage. While some so as not to overburden the system. of dual, as opposed to separate and
countries improved vaccination coverage Even though it is wise to make sure that staggered, vaccine introductions.
for all vaccines already introduced (of immunization programs and systems These lessons can also be taken up
the five included in this report), such are well prepared to accommodate the by other countries contemplating
as DRC, Ethiopia, Afghanistan, Sudan, new vaccines, delaying introduction the introduction of multiple vaccines
and Tanzania; Chad’s vaccination rates means that children continue to be that target children within the same
dropped for all the vaccines evaluated in at risk of infection and death each age group.
this report. In Angola’s case, coverage day that the vaccines are not being
rates declined for DTP, measles, and given. Meanwhile, other countries have
Hib vaccine, but increased for PCV decided not to wait, opting for dual
and rotavirus vaccine. India showed introductions.
improvements in its DTP and measles
vaccine coverage; however, in 2014, three This was the case for Tanzania, the
years after Hib vaccine’s first rollout in country with the highest overall GAPPD
Indian states, only 20% of children in intervention score and also one of the
the country are receiving the vaccine.11 few countries among the 15 highest
Likewise, Indonesia, opting to wait for burden countries that is using both
an indigenously produced vaccine, was PCV and rotavirus vaccine. Tanzania
slow to adopt Hib vaccine and only experienced success with their dual
introduced the vaccine thirteen years PCV and rotavirus vaccine introduction
after Gavi support became available for a number of reasons. First, they
and over 10 years after a vaccine probe conducted cold chain assessments to
study demonstrated the high burden of proactively identify and address any
Hib disease. Additionally, Indonesia’s capacity or storage issues months in
decentralized system has contributed to advance of the introduction. Second,
a slow rollout of Hib vaccine, reaching because they were preparing two
only 21% coverage, well below DTP3 vaccine introductions at once, they
coverage rates after more than two were able to consolidate working
years since its phased introduction groups and health worker trainings,
Pneumonia & Diarrhea Progress Report 2015 20Country
Highlights:
India
21Executive Summary | Global Burden of Pneumonia and Diarrhea in Children
India PROGRESS:
Strong political commitment to
CHALLENGES:
Slow rollout of pentavalent vaccine
immunize all children in the next in high-burden states and low Hib
Global rank in number of pneumonia five years vaccine coverage nationally
& diarrhea child deaths: 1
Increased efforts to monitor data Lagged decision making on PCV
and progress at the district levels introduction
2015 GAPPD score: 34
Launch of Mission Indradhanush, Low levels of access to appropriate
aiming to expand immunization pneumonia and diarrhea treatments
coverage in high-priority districts with
large populations of unvaccinated
and undervaccinated children
In their addresses to the Global Call to zinc, antibiotics; human resources and the renewed commitment of India’s
Action Summit in New Delhi in August vacancies; where the activists are; and leadership to improve child survival.
2015, Prime Minister Narendra Modi and more. This in-depth monitoring has While the introduction and rollout of
Union Health Minister JP Nadda renewed contributed to some of the progress rotavirus and pentavalent vaccines are
the government’s commitment to ending that India is making in implementing an in motion in India, further supported
preventable maternal and child deaths integrated approach to fight pneumonia by the licensure of an indigenous
in India and highlighted the strides and diarrhea. rotavirus vaccine, PCV is not yet used
made to date. Heralding achievements in the UIP. In support of India’s push
in neonatal health, including India’s In 2014, the Government of India toward full immunization and prevention
successful elimination of maternal and announced the introduction of four new of diarrhea and pneumonia among
neonatal tetanus, Prime Minister Modi vaccines, including rotavirus vaccines, children, a symposium (“Pneumococcal
also called for accelerated immunization into the Universal Immunization Conjugate Vaccines in India: A Roadmap
of all children in India, pledging to reach Programme (UIP) and as of November for Introduction”) will be hosted in
full immunization in the next five years 2015, 20 states and Union Territories New Delhi in November 2015. The
to ensure that no child in India dies of a have rolled out pentavalent vaccine, symposium will bring together experts
vaccine-preventable disease. With one which includes DTP and Hib vaccines. and partners from across India and
in every five global child deaths from the world to discuss the experience of
diarrhea or pneumonia occurring in India, Working to ensure that the currently PCV introduction in other countries and
the need for an equitable, comprehensive available vaccines are reached potential steps for introduction and
approach to preventing and treating by the children who need them rollout of PCV in India. A country-led
these diseases is critical, including most, the Ministry of Health and committee will discuss evidence-based
expanding exclusive breastfeeding Family Welfare launched Mission policy options for state selection and
and access to antibiotics, along with Indradhanush (“Rainbow” Mission). develop a proposed PCV rollout strategy
increases in vaccine introduction Launched in December 2014, the for the Ministry’s consideration.
and use. aim of Mission Indradhanush was to
expand immunization coverage in 201
District Level Task Forces in India high-focus districts comprising 50% of
monitor data regarding progress on a unvaccinated or partially vaccinated
variety of indicators, including those on children in phase I, and add nearly 300
pneumonia and diarrhea. The District more districts to the program in phase
Magistrates have shown detailed II. The efforts to strengthen political
knowledge of various basic indicators of commitment and mobilize communities
program strength, including stock levels to scale up efforts that target the
of commodities, such as vaccines, ORS, hardest-to-reach communities signal
The government of India’s continued commitment to child health is inspiring. Each great
stride helps save more lives and prevent illness. It’s important to continue to demand the
same level of momentum for the fight against vaccine-preventable diseases.
IVAC at Johns Hopkins University 22Country
Highlights:
Indonesia
23Executive Summary | Global Burden of Pneumonia and Diarrhea in Children
Indonesia PROGRESS:
The Ministry of Health has called
CHALLENGES:
Indonesia’s decentralized health
for a phased introduction of PCV in system makes access to prevention
Global rank in number of pneumonia 2017 and 2018 in Central Lombok. and treatment services for
pneumonia and diarrhea difficult,
& diarrhea child deaths: 7
A limited introduction of rotavirus especially for hard-to-reach
vaccine is also planned within a populations.
2015 GAPPD score: 37 similar timeframe.
Local preference for a Halal vaccine
A new law which sets forth may complicate decision making if
minimum healthcare standards an indigenous trypsin-free vaccine
will help strengthen the healthcare does not become available soon.
delivery system and improve
accountability. To achieve universal vaccine
coverage, plans for expanded rollout
of PCV and rotavirus vaccine in all
regions of Indonesia are needed.
Indonesia has made impressive progress introduction of rotavirus vaccine is rollout, particularly on islands where
in reducing childhood mortality and planned in a similar timeframe as the immunization system is not strong.
reaching MDG4 goals. Despite this well, with an indigenous porcine-free Thus, raising awareness and advocating
progress, the country ranks seventh rotavirus vaccine. On the treatment for vaccines must be a priority at both
in absolute number of pneumonia and side, a new law in Indonesia calling national and local levels to ensure the
diarrhea child deaths. The decentralized for minimum standards in healthcare needed changes are implemented.
health system covering over 17,000 may facilitate the strengthening of Additionally, plans for timely and
islands makes access to care a the healthcare system and improve widespread rollout of pneumococcal
challenge and often leaves hard-to-reach accountability. and rotavirus vaccines introduction
populations without adequate will need to be expanded to additional
pneumonia and diarrhea prevention This news, while a positive signal provinces in order to achieve universal
and care. The country is taking steps to for children in the country, is still access and coverage.
address the burden of pneumonia and complicated by several factors.
diarrhea, however. With Indonesia graduating from Beyond the logistical issues, there may
Gavi support, it will be increasingly be other unique challenges that could
Indonesia plans to introduce both important to advocate for dedicated hinder the introduction of vaccines
pneumococcal conjugate and rotavirus funding to ensure that PCV rolls out in as planned at the national level. For
vaccine in the next several years. a timely and equitable manner. Given example, demand for a Halal vaccine
The Ministry of Health has called its decentralized system, buy-in from and perceptions about whether current
for introduction of pneumococcal both districts and provinces will be vaccines are haram (prohibited)
conjugate vaccine in 2017 in Central especially crucial; they will need to complicate decision making, should an
Lombok, following a recommendation understand the value of the vaccine and indigenous porcine trypsin-free vaccine
by The Komite Pensihat Ahli Imunisasi prioritize strengthening of systems to not be available within a reasonable
Nasional or Indonesia Technical Advisory enable smooth and impactful vaccine time period. This challenge could be
Group on Immunization (ITAGI) and the delivery. Declining DTP3 coverage reasonably managed with strengthened
vaccine’s inclusion in the multi-year rates (currently at 78% for 2014), even advocacy, engagement of Muslim
plan. This phased introduction will though the Indonesian government has community leaders, and contingency
continue in additional provinces and if strengthened immunization activities planning efforts for other acceptable
the indigenous whole-cell pneumococcal during the last five years, also strike alternatives to help ensure sustained
vaccine (now in clinical trials) is licensed, a note of concern about the certainty progress against diarrhea as well as
a switch will likely be made. A limited of achieving the goal of universal pneumonia is made.
Indonesia has made significant investments in the immunization program over the past
five years, but faces many challenges to ensure both equity and sustainability of their
program as they transition out of Gavi support.
Pneumonia & Diarrhea Progress Report 2015 24Country
Highlights:
Nigeria
25Executive Summary | Global Burden of Pneumonia and Diarrhea in Children
Nigeria
PROGRESS: CHALLENGES:
Delisting from polio-endemic Funding gaps for immunization and
countries by WHO other GAPDD interventions
Global rank in number of pneumonia Weak central coordination across
& diarrhea child deaths: 2 Successful roll out of pentavalent
GAPPD strategies and interventions
vaccine across the nation
No central point of accountability for
2015 GAPPD score: 31
Phased introduction of PCV the rollout of comprehensive GAPPD
interventions and continuing progress
Plans to apply for Rotavirus in 2016
Inadequate access to effective
and introduce by 2018 prevention and treatment of pneumonia
and diarrheal cases
Despite missing the MDG 4 target, strategy is to employ performance environmental conditions. Nigeria has
Nigeria has reason for cautious management to drive accountability made good progress on immunization
optimism; under-five mortality dropped and action to achieve targets on with three new vaccines (pentavalent,
49% between 1990 and 2015. But 750,000 coverage of interventions and number pneumococcal conjugate vaccine,
Nigerian children still die every year of lives saved. In 2015, the World Bank and IPV) in four years, being delisted
from largely preventable causes. Thus boosted the program with 500 million from WHO’s polio-endemic countries,
the country is still far from fulfilling USD to “pay” state governments for and making modest increases in
the “Promise Renewed” of ending results on targets. While the SOML immunization coverage. However,
preventable child deaths. program is an opportunity to increase the rising vaccine program costs and
access to the multi-pronged GAPPD looming transition out of Gavi support
Pneumonia and diarrhea are top killers interventions that “protect, prevent, and are real challenges.
of children in Nigeria. Unfortunately, treat”, national coordination along the
progress on pneumonia control is slow. GAPDD strategies remains weak and The “treat” strategy also has gaps.
From the year 2000 to 2013, the number implementation of the interventions There is limited access to diagnostic
of under-five deaths from pneumonia variable. technologies, (X-ray machines and
remains unchanged. In contrast, deaths pulse-oximeters) and to oxygen for
from malaria and measles declined Under “protect”, there has been no high- treatment. Even low-tech strategies
by 34% and 97% respectively. The visibility effort to promote breastfeeding such as integrated community case
country’s low GAPPD intervention score since the Baby Friendly Initiative (BFI) of management and referrals have not
of 31% reflects the poor coverage of key the 1990s. It is not surprising therefore been optimized. As a result, only
interventions and explains the lack of that only 17% of Nigerian children are 35% of children with symptoms of
progress. exclusively breastfed for the first six acute respiratory infections receive
months of life, as against the GAPPD antibiotics for their illness. Nigeria has
The Nigerian government has taken target of 50%.To move the breastfeeding begun local production of dispersible
concrete steps to address the high child agenda forward, a partnership for amoxicillin tablets and the distribution
mortality. In 2012, the then President, nutrition advocacy has begun working of ORS and zinc supplementation, while
Goodluck Jonathan, launched the to raise awareness, including the Future enhancing integrated community case
flagship Saving One Million Lives Assured Initiative of the Wife of the management to improve treatment
Initiative (SOML). This Initiative aimed President of Nigeria, Mrs. Aisha Buhari. access. Ending preventable child deaths
to rapidly increase access to proven by 2030 will require financing, advocacy,
interventions across six maternal Programs to “prevent” pneumonia and and strong systems to scale up GAPPD
newborn and child health program areas. diarrhea include vaccination; prevention interventions.
The SOML focuses on health outcomes of vertical transmission of HIV; and
rather than outputs or inputs. The core improving water, sanitation, and
Nigeria’s success with polio eradication is a demonstration of her strong commitment to
the health of her children. The same commitment should inspire the scale up of GAPPD
interventions, to battle and defeat two of the biggest killers of Nigerian children.
IVAC at Johns Hopkins University 26You can also read
