Global deaths from diarrhoea, malaria, AIDS declining, study predicts

Under-five child mortality from diarrhoeal diseases, which was 1.7 million in 2005, is expected to fall to just over half a million by 2030 and around 130,000 in 2060, a new study [1] predicts.

The study notes that headway is being made in fighting communicable diseases such as diarrhoea, malaria and AIDS. At the global level disease burdens are shifting from communicable diseases to chronic ones such as cancer, diabetes and heart disease.

Gates Foundation awards $10.9 million to study impacts of sanitation on diseases

Researchers at the University of California, Berkeley, have received a five-year, $10.9 million grant from the Bill & Melinda Gates Foundation to evaluate several interventions to combat diarrheal disease in developing countries.

Dr. Jack Colford

Dr. Jack Colford, professor of epidemiology at UC Berkeley’s School of Public Health, will coordinate the project, working with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and Innovations for Poverty Action (IPA).

An estimated 2.2 million children under the age of 5 die from diarrhoeal diseases each year, according to the World Health Organization. Most of these diseases are thought to be preventable with improvements in sanitation, water quality and hygiene.

Due to the high cost of developing and maintaining large infrastructure projects, such as networked water, there is now a movement toward simpler, alternative methods to improve health in rural areas. However, there is almost no evidence that allows direct comparison of the health benefits or cost effectiveness of these simpler interventions, such as improved latrines, household water treatment and hand washing with soap.

The goal of the new project is to determine how sanitation interventions, delivered alone or as part of combined intervention packages, impact child health and well-being. In addition to improved sanitation, the intervention packages will include drinking water improvements and hand washing solutions. The results have the potential to influence how billions of dollars are directed towards long-term improvements in health and economic outcomes for millions of children each year, said Colford.

“Increasingly, foundations, governments, the World Bank and development agencies such as the MCC (Millennium Challenge Corporation) are demanding evidence of effectiveness when awarding development funds,” said Colford. “Right now, it is unknown whether single interventions are as cost effective as combinations of these interventions. This grant will fund the first large-scale, randomized impact evaluation designed to gather rigorous evidence about this question.”

The study will test the impact of these sanitation, water and hygiene interventions using a large-scale, randomized impact evaluation in Bangladesh and Kenya. These two countries are representative of the two regions that account for the majority of the world’s gastrointestinal disease burden: Southeast Asia and sub-Saharan Africa. The researchers expect to enroll a total of 23,000 children in the trials, which will be monitored by several institutional review boards.

Of the $10.9 million, about $7.9 million will be subcontracted out to the two field sites. Dr. Stephen Luby, head of the Programme on Infectious Diseases and Vaccine Sciences with ICDDR,B, and Michael Kremer, Ph.D., a research affiliate with IPA, will lead the trials in Bangladesh and Kenya, respectively. They will be joined by a team of experts from various disciplines, including public health, economics, behavioral change, nutrition, cognitive development and tropical enteropathy.

Source: Linda Anderberg, UC Berkely News, 05 Nov 2009

Diarrhoea kills over a million over-fives each year

Diarrhoea kills three times more over-five-year-olds in Africa and South-East Asia than previously thought, new research finds.

Some 1.15 million over-fives — thought to be mostly adolescents and the elderly — are dying in these regions each year from diarrhoeal diseases, according to the research, commissioned by the WHO. Until now the death toll estimate for these regions came to 380,000.

Preliminary results from the study — which has yet to be published — were presented at this week’s meeting of the Foodborne Disease Burden Epidemiology Reference Group (FERG) (29 October) in Switzerland.

“These estimates highlight the significant burden of diarrhoeal diseases in adolescents and adults in the developing world,” said Martyn Kirk, chair of the FERG Enteric Diseases Task Force, who presented the results.

For the study, Christa Fischer-Walker and Robert Black from Johns Hopkins School of Public Health in the US searched 25,000 journal articles for information on diarrhoea in the over-fives. Only six of the articles contained reliable figures on diarrhoeal deaths in developing countries for this age group (compared to hundreds for younger children) — and there was no data for China, Latin America, the Middle East or South Asia.

The new estimate is on a par with the global annual death toll for malaria. It is also equivalent to nearly one-third of all HIV deaths and to almost half the number of global deaths from tuberculosis, says Claudia Stein, medical officer of the WHO’s Department of Food Safety and Zoonoses.

“What makes the tragedy even greater is that many of these diseases are clearly preventable,” said Jørgen Schlundt, director of FOS. Schlundt calls for policymakers to be alerted to cheap strategies known to prevent diarrhoea.

Improvements in food safety, sanitation and hygiene are critical, says Kirk. He told the meeting that nearly half (48.9 per cent) of diarrhoeal deaths in the developing world are caused by the bacteria Enterotoxigenic Escherichia coli and Vibrio cholerae, both of which are associated with poor sanitation and are common in resource-poor countries.

Stein says major gaps remain in scientists’ understanding of diarrhoeal deaths. Research focusing on older people attracts little funding, as a result of which the problem has never been thoroughly assessed in this group.

But it is expected that some of these gaps will be filled next year, when results emerge from studies in China and India. The FERG is also planning country-level studies across the world, the results of which should begin to emerge in 2010.

Source: Sian Lewis, SciDev.net, 30 Oct 2009

Tackling global health risks prevents premature deaths

Global life expectancy could be increased by nearly five years by addressing five factors affecting health – childhood underweight, unsafe sex, alcohol use, lack of safe water, sanitation and hygiene, and high blood pressure, according to a new WHO report.

These are responsible for one-quarter of the 60 million deaths estimated to occur annually.

Global health risks describes 24 factors affecting health. These are mixture of environmental, behavioural and physiological factors, such as air pollution, tobacco use and poor nutrition.

The report also draws attention to the combined effect of multiple risk factors. Many deaths and diseases are caused by more than one risk factor and may be prevented by reducing any of the risk factors responsible for them.

Read the full press release: WHO, 27 Oct 2009

Read the full report

The report mentions that unsafe water, sanitation and hygiene is one of the the leading global risks for burden of disease, accounting for 4% of disability-adjusted life years (DALYs), The others are childhood underweight (6% of global DALYs), unsafe sex (5%) and alcohol use (5%) [see fig. 7].

In developing countries, unsafe water, sanitation and hygiene comes second behind childhood underweight as the highest risk for burden of disease [see tab 2.].

In the annexes of the report there are more detailed tables on health risk factors by WHO region (Africa, Southeast Asia, the Americas, Eastern Mediterranean, Europe and Western Pacific).

Source: WHO, 2009. Global health risks

Source: WHO, 2009, Global health risks

UNICEF/WHO – Diarrhoea: Why children are still dying and what can be done

Despite the existence of inexpensive and efficient means of treatment, diarrhoea kills more children than AIDS, malaria and measles combined, according to a report issued today by UNICEF and the World Health Organization (WHO).

The report, titled Diarrhoea: Why Children Are Still Dying and What Can Be Done (PDF),  includes information on the causes of diarrhoea, data on access to means of prevention and treatment, and a seven-point plan to reduce diarrhoea deaths.  “It is a tragedy that diarrhoea, which is little more than an inconvenience in the developed world, kills an estimated 1.5 million children each year,” said UNICEF Executive Director, Ann M. Veneman.

“Inexpensive and effective treatments for diarrhoea exist, but in developing countries only 39 per cent of children with diarrhoea receive the recommended treatment.” Dr Margaret Chan, Director-General of WHO, said:  “We know where children are dying of diarrhoea. We know what must be done to prevent those deaths.  We must work with governments and partners to put this seven-point plan into action.”  Diarrhoea is a common symptom of gastrointestinal infection, which can have a variety of sources.

However just a handful of organisms are responsible for most acute cases of diarrhoea and one,  Rotavirus, is responsible for more than 40 per cent of all diarrhoea-related hospital admissions of children under five. A new vaccine for Rotavirus has been found to be safe and effective but is still largely unavailable in most developing countries. Though most episodes of childhood diarrhoea are mild, acute cases can lead to significant fluid loss and dehydration. This dehydration can lead to death unless fluids are quickly replaced. Oral rehydration therapy is the cornerstone of fluid replacement and the new low-osmolarity formula of oral rehydration salts (ORS) is a simple, inexpensive and life-saving remedy that prevents dehydration in children suffering diarrhoea.

Some 88 percent of diarrhoeal deaths worldwide are attributable to unsafe water, inadequate sanitation and poor hygiene. As of 2006, an estimated 2.5 billion people around the world were not using adequate sanitation facilities, and about 1 in 4 people in developing countries practiced open defecation.  Access to clean water and good hygiene practices are extremely effective in preventing childhood diarrhoea.  Hand washing with soap has been shown to reduce the incidence of diarrhoeal disease by over 40 per cent, making it one of the most cost-effective interventions for reducing child deaths caused by this neglected killer.

October 15 is annual Global Handwashing Day when millions of children and adults in over 80 countries will take part in activities to highlight this key intervention.  The overall health and nutrition of children is also critical to their susceptibility to diarrhoea and the damage it can cause.  Undernourished children are at higher risk of suffering more frequent, severe and prolonged episodes of diarrhoea, and repeated bouts of diarrhoea also place children at greater risk of worsening nutritional status.

The seven point plan to save the lives of children stricken by diarrhoea includes two treatment and five prevention elements.

The two treatment elements are:

1. fluid replacement to prevent dehydration; and
2. zinc treatments, which decrease the severity and duration of the attack.

The five prevention elements are:

1. immunization against rotavirus and measles;
2. early and exclusive breastfeeding and vitamin A supplementation;
3. handwashing with soap;
4. improved water supply quantity and quality; and
5. promoting community-wide sanitation.

Campaigns targeting childhood diarrhoea in the 1970s and 1980s achieved success by educating caregivers and scaling up oral rehydration therapy to prevent dehydration. The campaigns delivered promising results but following that success, focus shifted to other health problems. There is now an urgent need to shift attention and resources back to treating and preventing diarrhoea.

Johansson, E.M. … [et al.] (2009). Diarrhoea : why children are still dying and what can be done. New York, NY, USA, UNICEF and Geneva, Switzerland, World Health Organization. v, 58 p. ISBN 978-92-806-4462-3 (UNICEF). ISBN 978-92-4-159841-5 (WHO). Full report

There is also an online version of the report on 7pointplan.org

Related web sites:

• WHO – Diarrhoea
• Rehydration Project

UNICEF TV Video: Diarrhoea is the second leading killer of children

Source: UNICEF, 14 Oct 2009

Climate change: high adaptation costs for water sector, World Bank study says

“Water supply and flood management, ranks as one of the top three climate adaptation costs in both the wetter and drier scenario, with Sub-Saharan Africa footing by far the highest costs” says a new World Bank report.

The draft global report of the Economics of Adaptation to Climate Change Study (EACC) calculates the cost between 2010 and 2050 of adapting to an approximately 2°C warmer world by 2050. A second report due in March 2010 will consist of seven country case studies (Bangladesh, Bolivia, Ethiopia, Ghana, Mozambique, Samoa, and Viet Nam).

The EACC study estimates that over the next 40 years, global net annual adapation costs for municipal and industrial water supply will be between US$ 10.0 billion (wetter scenario) and US$ 11.1 billion (dry scenario). In both scenarios, nearly two-thirds of these costs (US$ 5.9 billion and US$ 7.3 billion, respectively) are for Sub-Saharan Africa [tab. 13, p. 54].

“Costs of adaptation are defined as the cost of providing enough raw water to restore future industrial and municipal water demand to the levels that would have existed without climate change. Such demand is assumed to be met by increasing the capacity of surface reservoir storage, except when that would raise withdrawals to more than 80 percent of river runoff and when the cost of supplying water from reservoir yield is more than $0.30 a cubic meter. In these cases, supply is assumed to be met through alternative measures, such as recycling, rainwater harvesting, and desalination, at a cost of $0.30 a cubic meter” [p. 53].

The adaptation cost for water supply and flood management in the EACC study is higher than previously calculated by United Nations Framework Convention on Climate Change (UNFCC) in 2007. The World Bank says this is because it has tried to include a number of costs that UNFCC overlooked, such as the costs of maintaining water quality standards and operating costs [p. 82-83].

“As do most sectoral studies of global adaptation costs, [EACC] study focuses on hard adaptation measures, which are easier to cost than behavioral measures. There is no implication that these are the best measures for adaptation. Ideally, adaptation options to ensure water supply during average and drought conditions should integrate strategies on both demand and supply sides. While demand-side adaptations are not explicitly costed in this study (demand projections already account for some increase in efficiencies over time, so this could lead to double counting), there is wide scope for economizing on water consumption” [p. 55].

Global adapation costs for water supply and sanitation infrastructure were estimated to be US$ 700 million per year [tab. 8, p. 44].

Average annual adaptation costs in the health sector for diarrhoea and malaria prevention and treatment lie in a narrow range of US$ 1.3–1.6 billion a year over the 40-year period 2010–50, according to the EACC study. These estimates for malaria and diarrhea are lower than the prior estimates of US$ 4–12 billion, because they take into account the effects of development and the resulting decline in under-five mortality [p. 66-68].

Though adaptation is costly, costs can be reduced, says the World Bank. “The clearest opportunities to reduce the costs of adaptation are in the water supply and flood protection sector. [...] A large share of the costs of adaptation in the water supply and flood protection sector could be avoided by adopting better management [and water tariff] policies” [p. 94-95].

One important lesson that the report mentions is that “development is the most powerful form of adaptation”. It suggests too that the costs of adaptation may also be dramatically reduced by a combination of technical change and private initiative.

SODIS under fire: study pours cold water on solar disinfection

“Doubt has been cast on a much-lauded method of disinfecting water using only sunlight, after a study found that it doesn’t reduce diarrhoea among children in families using the technique” SciDev.net reports.

“Solar Water Disinfection (SODIS), a low-cost water purification method that uses only sunlight to disinfect water, is currently used by about three million people in 30 countries, according to the SODIS Reference Centre [at SANDEC] in Switzerland”.

“Laboratory and community studies have shown that the method is effective. But a PLoS Medicine study published [on 18 August 2009] on 22 rural communities in Cochabamba, Bolivia, found no significant reduction in diarrhoea among children aged five and under in families using SODIS”.

“The authors suggest that more research is needed into how the laboratory results can be replicated on the ground and until this is done they say that campaigners should be careful about advocating SODIS”.

“Mercedes Iriarte, co-author of the study and a researcher at the Water and Environmental Sanitation Centre of San Simón University, in Bolivia, told SciDev.Net that in the laboratory there is better control of all factors”.

“Iriarte says that in the laboratory, clean, clear, pH-neutral water is contaminated with known microorganisms to evaluate the method but that in the field researchers should consider other factors such as cloudiness of the water”.

“Margot Franken, a researcher with the environmental quality unit at San Andrés University in Bolivia, told SciDev.Net that low efficacy of the method could also result from inadequate exposure to sunlight”.

Compliance was also low, with only a third of families routinely treating their water in the recommended manner despite 80 per cent claiming to use SODIS at the beginning and end of the study and an intensive promotion campaign.

Link to full article in PLoS Medicine.

See a video about the study on SciVee.

Source: Cristina Pabón, SciDev.net, 31 Aug 2009

Earlier in 2009 Wolf-Peter Schmidt and Sandy Cairncross concluded that the widespread promotion of household water treatment (HWT) is premature given the available evidence. This is echoed by the latest review of impact evaluations examining effectiveness of water, sanitation and hygiene (WSH) interventions by the International Initiative for Impact Evaluation (3ie).

In a comment about the study on its website, the SODIS Reference Centre says that “numerous studies have reported health benefits of SODIS when it is correctly and consistently used”. They cite the example of a study where “the incidence of cholera during an epidemic in Kenya was 88% lower among SODIS than non-users”.

“A well-known weakness of the SODIS process is that it is often not used consistently or is used to treat only a fraction of the drinking water consumed”, the statement continues. “Beneficial health impacts associated with the use of SODIS may also be compromised by poor sanitation and hygiene. Nonetheless, we feel that people should not be discouraged from continuing to use SODIS or from adopting it unless an alternate supply of safe drinking water is available”.

The SODIS Reference Centre/Sandec has also had to respond to “allegations circulating in a number of print media in developing countries on the carcinogenic risk of (re-)using PET bottles”. These “unfounded media reports” are drawn from research that show that antimony and phthalic acid and phthalate esters can leach from PET bottles. Sandec conducts its own study, together with Empa (Swiss Federal Laboratories for Materials Testing and Research) on “the migration of organic compounds – with special focus on plasticisers – into the water contained in PET bottles bottles under typical SODIS conditions”. “According to the results of this study, the risk of negative health effects caused by reused PET bottles for SODIS treatment is negligible”. SANDEC plans to repeat the study in India “to confirm the harmless nature of the technology in a country where media reports on the dangers of PET bottles are particularly widespread”.

Source: Samuel Luzi, Reuse of PET Bottles for SODIS – Blessing or Curse?, Sandec News, no. 10, July 2009

But SODIS is not off the hook yet, as a new danger is looming. In April 2009, scientists at Goethe University found that PET plastics may contain hormone-disrupting chemicals that leach into the water, Discovery News reported. According to researchers, it now appears that some as-yet-unidentified chemicals in PET plastics have the potential to interfere with estrogen and other reproductive hormones in the same manner that bisphenol A (BPA) and phthalates are suspected of doing.

Google Brings Water Data to Life

Google Labs [has] launched Fusion Tables, a powerful new online research and data organizing tool that makes it much easier to share and navigate the world’s digital science and technical archives. Fusion Tables, which was developed by Google engineers using sample research data about the global fresh water crisis provided by the Pacific Institute and Circle of Blue, is specifically designed to unlock a treasure trove of facts, trends, and scientific findings that until now have been sequestered in databases and spreadsheets not easily shared.

The new Google technology provides users a rare opportunity to share critical data, probe them, organize pertinent information and generate design elements — charts and graphs — that translate complex information into much more digestible trends. The intent is to enable online collaborators to study and understand in new dimensions the world’s complex problems — the fresh water crisis among them — discern the salient details and organize those scientifically confirmed facts. They can be used to tell stories, offer insights, and propose solutions that heretofore were largely the purview of scholars and scientific experts.

[...] Journalists from Circle of Blue wanted to understand the influence of per capita income and the availability of tap water on the incidence of child mortality worldwide from diarrhea. Circle of Blue merged Pacific Institute data in the Fusion Table Gallery with data sets from the Internet. Fusion Tables created a scatter plot that revealed a noticeable and predictable correlation of death by water-related illness, wealth and safe drinking water availability. As the gross domestic product per capita increased, the percentage of a country’s population connected to tap water increased, and child deaths related to diarrhea decreased.

Source: Aubrey Parker, Circle of Blue, 16 Jun 2009

Rotavirus vaccination: WHO move boosts fight against fatal diarrhoea

The World Health Organization has paved the way for children in Africa and Asia to be vaccinated against a diarrhoea-causing virus that kills some 500,000 children annually worldwide – 85 percent of them in African and Asian developing countries. WHO has recommended that the vaccine for rotavirus – the leading cause of severe and often fatal diarrhoea and dehydration in under-five children – be included in national immunization programmes worldwide.

As of 2007 the organization had said more research was needed on the vaccine’s efficacy in developing countries with high child mortality; new data from clinical trials has led WHO to recommend global use of the vaccine, according to a 5 June communiqué. The decision means poor countries in Asia and Africa can now apply for funding to include rotavirus vaccines in their national immunization programmes.

“This [vaccine] will significantly reduce mortality and morbidity of rotavirus disease,” Samba Ousmane Sow, associate professor of medicine at University of Maryland and coordinator of the Centre for Vaccine Development in Mali, told IRIN. “For rotavirus, as with many infectious diseases, mortality is often a question of geography,” he said. “For the many people in rural Africa who cannot easily access medical care, the best and most practical solution [against this lethal illness] is to bring the vaccine to them.”

A child with rotavirus disease – which causes fever, vomiting and diarrhoea – can rapidly become dehydrated. Death from rotavirus is most common where there is no quick access to medical care, so vaccination is the most effective way to prevent severe cases and deaths, experts say.

Transmitted primarily by the faecal-oral route, the virus affects the vast majority of children globally before age three, according to WHO. The virus attacks the villi – tiny projections on the wall of the small intestine. Destruction of the affected cells reduces digestion and absorption of nutrients, resulting in diarrhoea with a loss of fluids.

The virus is resilient and traditional hygiene measures that might prevent other sanitation-related illnesses are not sufficient to limit its impact, according to PATH, an international health non-profit and one of the organizations conducting vaccine trials with WHO and the Global Alliance for Vaccines and Immunization (GAVI). But given that there are many causes of diarrhoeal disease, the rotavirus vaccine must be part of a comprehensive control strategy, including improving water quality, hygiene and sanitation and providing oral rehydration solution and zinc supplements, WHO says in its communiqué.

[N]ow governments will have to prepare an investment plan for including rotavirus vaccine in their immunization programmes. The GAVI Alliance uses a co-financing approach, in which countries procure some vaccines with non-GAVI funds; the intention is for countries to gradually increase their share of vaccines’ cost, making immunization programmes sustainable. The GAVI Alliance board is expected to decide at its November 2009 meeting whether all 72 GAVI-eligible countries will now become eligible to apply for funding to include the rotavirus vaccine in their immunization programmes, GAVI’s Ariane Leroy told IRIN.

Clinical trials of the vaccine are ongoing in Asia and sub-Saharan Africa, but WHO’s Strategic Advisory Group of Experts has recommended the vaccine for all populations given available evidence, WHO says.

Source: IRIN, 09 Jun 2009

See also: WHO backs anti-diarrhoea vaccine, BBC, 05 Jun 2009

Donors urged to tackle leading killer of under-fives – reports by WaterAid and PATH

Two major aid agency reports published this week say millions of children’s lives are being put at risk because governments and the international aid community are not responding appropriately to diseases such as diarrhoea.

“Diarrhoea kills more children than HIV/AIDS, malaria and TB combined, yet compared to these diseases receives little financing and is not prioritised by governments in donor and developing country governments alike,” said Oliver Cumming, co-author of a report by Water Aid, “Fatal neglect: How health systems are failing to comprehensively address child mortality” [Read the WaterAid press release , 12 May 2009, here]‘.

The report shows that between 2004 and 2006 only $1.5 billion was spent globally on improving sanitation. In the same period, $10.8 billion was spent on interventions for HIV/AIDS – responsible for 315,000 child deaths in that period, and $3.5 billion on interventions for malaria – responsible for 840,000 child deaths.

A health worker in the only government-run clinic in Kibera said diarrhoea was a major problem in the slum, which is home to over one million of Kenya’s poor. [...] “There are a lot of cases of children dying of diarrhoea because the health service in a slum setting such as this is not so well distributed,” added the health worker who asked to remain anonymous.

[...] Another report “Diarrheal Disease: Solutions to Defeat a Global Killer” by health advocacy group PATH, speculates that in the 1970s and 1980s awareness-raising and fund-raising for tackling the problem were so successful that the mortality rate fell by almost 50 percent. It says many donors, governments and aid agencies may have considered the problem solved.

But the issue is far from solved. Water Aid says that when taking into account adult deaths, funding for HIV/AIDS is balanced, but when considering child deaths, the large resources for fighting the disease are disproportionate.

Both reports highlight that relatively cheap fixes can be effective – for example educating people to wash their hands, using water purifiers and disinfectants and taking rehydration salts for diarrhoea. But the aid community is not devoting sufficient funds or attention to the problem, the reports say.

The Kenyan government is working with aid groups to educate the public on good hygiene, improve water chlorination and provide communities with water purifiers and disinfectants. But the financial burden is high, says Kenya’s Health Minister Shahnaaz Sharif. “A lot of donor agencies are not concentrating on diarrhoea and then it is left up to the individual governments to handle those programmes and most governments cannot cope,” Sharif told AlertNet.

The Kibera health worker said she believed some funding for HIV, TB and malaria would do more good if it was diverted to treating diarrhoeal diseases in young children. “If I was offered a wish list, I would say we channel a lot of funds (to) healthcare for children under five with an emphasis on diarrhoea and malnutrition,” she added.

Source: Natasha Elkington, Reuters AlertNet, 14 May 2009

 

From WaterAid report "Fatal Neglect".