Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...

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Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
& Diarrhea        Sustainable
                  Progress in the
Progress Report   Post-2015 Era

Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
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
Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
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) 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

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.
Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
Executive Summary | Global Burden of Pneumonia and Diarrhea in Children


IVAC at Johns Hopkins University
Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
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

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

2015, the mortality rate in children under     steady (15-16% for pneumonia and 9%
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
it was in 1990 (91 deaths per 1,000 live       In addition, pneumonia and diarrhea

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.
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
Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
Executive Summary | Evaluating
                    Global Burden
                                  of Pneumonia
                                        in the 15 and
                                                               in Children

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
Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
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

     Angola                                  Indonesia                                      Pakistan
     Ethiopia                                Niger                                          Chad
     Afghanistan                             China                                          Bangladesh

    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
Pneumonia & Diarrhea Progress Report 2015 - Johns Hopkins Bloomberg School of Public ...
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

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

of reducing 1990 under-five mortality            continue to focus on further reductions
by two-thirds by 2015. Pneumonia and             of pneumonia and diarrhea mortality,

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                                                                                              8
Executive Summary | Global Burden of Pneumonia and Diarrhea in Children

GAPPD sets forth
the following                                                              coverage for each
coverage                                                                   of the following

                                                                           vaccines: pertussis,
targets for its                                                            measles, Haemophilus

recommended                                                                influenzae type b
                                                                           (Hib), pneumococcal
interventions,                                                             conjugate, and rotavirus
which countries
should strive                                                              treatment coverage
to achieve:                                                                for children

                                                                     90%   with suspected
                                                                           including care by an
                                                                           appropriate health
                                                                           care provider and

                                                                           treatment coverage
                                                                           for children with

                                                                     90%   diarrhea, including
                                                                           treatment with oral
                                                                           rehydration salts
                                                                           (ORS) and zinc

                                                                           rate of exclusive

                                                                           breastfeeding for
                                                                           the child’s first six
                                                                           months of life

IVAC at Johns Hopkins University                                                                      9
Introduction | 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




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                                                                                                                                             10
Key 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
                                                                                               met the minimum coverage targets for
                                                                                               each of the ten GAPPD interventions
                                                                                               evaluated in this report.

Pneumonia & Diarrhea Progress Report 2015                                                                                                11
Table 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-
    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                                                 (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

         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

        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

        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.

  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 .

  WHO/UNICEF. WHO/UNICEF National Immunization Coverage Estimates. Data as of 10 Jul 2015. Retrieved from
  UNICEF. Global databases 2015 based on MICS, DHS and, other national household surveys. Retrieved from
  UNICEF. Global databases 2015 based on MICS, DHS and, other national household surveys. Retrieved from
  The DHS Program. (n.d.). Demographic and Health Surveys (DHS) Final Reports. Retrieved from
  UNICEF. (2014). Multiple Indicator Cluster Surveys / MICS5. Retrieved from
  UNICEF. Global databases, 2014, DHS, MICS, other national household surveys and UNICEF. Retrieved from
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%
                                                                                                                             as subnational areas that tend to
    Democratic Republic
                                                                                                                             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

IVAC at Johns Hopkins University                                                                                                                                        14
Key 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
                                                                                                                                                                            and vice versa. For example, Nigeria
    Democratic Republic
                                                                                                                                                                            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,
                                                       Tanzania                                                                                                             but lack them for diarrhea (or vice
  Overall GAPPD Scores (%), 2015

                                                                                                                                                                            versa), and therefore perform better in
                                      60      Angola                                                                                                                        certain areas than others. Even within

                                                                                                                                                                            countries, improvements in pneumonia
                                           Afghanistan                      Pakistan                                                                        India
                                                                                                                                                                            compared to diarrhea and the degree to
                                                                                                                                 China                                      which each were improved could vary
                                             Chad                                                                                                                           across states and districts, especially
                                      20                                Nigeria
                                                                                                                                                                            in large, heterogeneous countries with

                                      10                                                                                                                                    a decentralized government and health
                                                                                                                                                                            system. To devise a more tailored
                                                                                                         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

Pneumonia & Diarrhea Progress Report 2015                                                                                                                                                                              15
Key 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%
                    Nigeria                                21%
                  Pakistan                                             28%
      Democratic Republic                                                                                               61%
            of the Congo                                                     33%
                    Angola                                                                                 52%                                    GAPPD-Pneumonia
                                                                                                                 55%                                 Target Score
                   Ethiopia                                                               42%                                                           (84%)
                                                                                                     47%                               GAPPD-Diarrhea
                 Indonesia                                                   32%                                                        Target Score
                      Chad                                             30%
              Afghanistan                                                                                                   63%
                      Niger                                                   34%
                      China                                                              42%
                     Sudan                                                                                              59%
               Bangladesh                                                                            48%
                   Somalia                                       26%
          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                                                                                                                                           16
Key Findings:
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.

Key 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
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                                                                                               18
Key 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                                                                                                                  19
Key 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                                                                                              20

Executive Summary | Global Burden of Pneumonia and Diarrhea in Children

India                                            PROGRESS:
                                                   Strong political commitment to
                                                                                                 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                                                                                                        22

Executive Summary | Global Burden of Pneumonia and Diarrhea in Children

Indonesia                                        PROGRESS:
                                                   The Ministry of Health has called
                                                                                            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                                                                                          24

Executive Summary | Global Burden of Pneumonia and Diarrhea in Children

                                                 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                                                                                                          26
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