An insight into GAPPD; the management of pneumonia and diarrhoea; and GAPPD interventions

1. The Integrated Global Action Plan for
the Prevention and Control of
Pneumonia and Diarrhoea
By:
Mazi Ejeckam Chukwuebuka . C.
6th October 2017
Preston Healthcare Consulting

2. Outline:
 Understanding Pneumonia
 Background, Aetiology,
Transmission, Prevention &
Treatment
Understanding Diarrhoea
 Background, Aetiology ,
Transmission, Prevention &
Treatment
GAPP Basic Intervention
GAPPD- Fore runners
Sustainable Development Goal 3
GAPPD - Background

3. Outline –cont’d
 15 High Burden States
GAPPD- PPT Framework
GAPPD- Closing the Gap
GAPPD- Goals, Targets & Indicators
GAPPD – Country Level Actions
GAPPD: Scorecard Indicators
GAPPD- 2016 Assessment Highlights
Nigeria Highlights
Challenges & Opportunities
References

4. Tolstoy
Harrison
Tubman
Puskas
Pavorroti
Candido

5. Background
Pneumonia is a form of acute respiratory infection that affects the lungs, caused by a number of
infectious agents – bacteria, viruses and fungi.
Pneumonia is the single largest infectious cause of death, accounting for 16% of all deaths of
children under 5 in 2015.
Pneumonia is also a leading infectious cause of death in developed countries. Pneumonia is referred
as the ‘’ forgotten killer” because historically it has received little attention despite it’s importance.
Pneumonia is most prevalent in South-Asia and Sub-Saharan Africa, killing more children than
those from HIV/AIDs, malaria and measles combined.
Economic cost of pneumonia is estimated at around 109 million USD per year. This includes price of
antibiotics and diagnostics of pneumonia management
Pneumonia can be prevented using simple interventions, treated with low-cost, low- medication and
care.

6. Background : Nigeria
In 2010, an estimated 868,000 under five died in Nigeria via Pneumonia. Pneumonia is the
second leading cause of death killing more 140,000 children each year.
Nigeria is second only to India in the total number of childhood deaths via Pneumonia.
In 2012, Nigeria introduced the pentavalent vaccine which protects against Hib, Pneumonia
and meningitis, along with other four childhood diseases.
Though there are wide gaps, Nigeria has made appreciable gains with regards to immunization
coverage across all vaccine schedule. Between 2000-2010,DTP3 coverage more than doubled
from 29% to 69% (WHO).

7. Aetiologic Agents
Bacteria
•Streptococcus
Pneumoniae
•Haemophilus Influenza
type b(Hib)
Virus
•Respiratory Syncytial
Virus
•Inflluenza Virus
•Para-influenza Virus
Fungi
•Coccidioides
•Blastomyces
•Aspergillus
•Cryptococus
•Pneumocystis Jiroveci
Pneumonia

8. Transmission
The viruses and bacteria that are found in a child’s nose or throat can infect the lungs if inhaled.
Can also spread via air-borne droplets from cough or sneeze.
 Can also be spread or transmitted through blood, especially during and shortly after child birth
Risk Factors
Immuno- compromised children, whose natural defence lines are weakened, are at a higher risk of
developing Pneumonia ( Malnutrition or undernourishment especially in infants not exclusively breastfed).
Pre-existing infections, such as symptomatic HIV infections and measles, also increases a child risk of
contracting Pneumonia.
Environmental factors : Indoor air pollution caused by cooking and heating with biomass fuel ( wood &
dung), Living in crowded homes, etc.
Parental smoking also exposes an infant to the risk of developing Pneumonia.

9. Prevention
Preventing pneumonia in children is an essential component of the strategy to reduce child
mortality. Immunization against Hib,pneumococcus, measles and whooping cough (pertussis) is
the most effective way to prevent pneumonia.
Adequate nutrition is key to improving children’s natural defences, starting with exclusive
breastfeeding for the first 6 months of life. In addition to being effective in preventing
pneumonia, it also helps to reduce the length of the illness if a child does become ill.
Addressing environmental factors – provision of clean affordable indoor stoves and
encouraging good hygiene in crowded homes.
In children infected with HIV, cotrimoxazole is given daily to reduce risk of contracting
pneumonia.

11. Treatment
Amoxicillin dispersible tablet is the antibiotic
of choice for the treatment of pneumonia.
Most cases will require oral antibiotics which
are prescribed at health centres.
Hospitalization is recommended only for
severe cases of pneumonia.
In 2009, WHO & UNICEF released GAPP
showing that pneumonia deaths could be
reduced by 2/3 if existing interventions could
be scaled up to 90 percent of the world
children. There are 6 basic strategic
intervention to achieve the above target-

12. 6 Basic GAPP Intervention (WHO/UNICEF)
Reducing Indoor Air Pollution
Immunization with vaccines against Hib,
Pneumococcus, Measles and Pertusis
Effective Case management and treatment at
community level.
Exclusive Breastfeeding for the first 6 months and
providing zinc supplementation

13. Con’td
Preventing Mother-To-Child Transmission of
HIV
Promoting Regular Hand Washing

14. Diarrhoea
Diarrhoea – passage of unusually loose or watery stool at least 3 times in 24 hours. For infants
especially, stool consistency/integrity rather than frequency is most important.
Diarrhoea is the second leading cause of death in children <5, accounting for 9% of under five
mortality. Globally, there are 1.7 billion cases of childhood diarrhoea every year, resulting in about
525000 mortalities annually.
According to a 2016 UNICEF global WASH fact sheet, 2,200 children die every day as a result of
diarrhoea disease in low and middle income countries (LMIC).
Diarrhoea is usually a symptom of the infestation of the intestinal tract which can be caused by a
variety of bacteria, viral and parasitic organisms.
Diarrhoea infection is spread through contaminated food or drinking water, or from person-to-
person as a result of poor hygiene. 88% of death from diarrhoea are from unsafe drinking water,
inadequate availability of water for hygiene and lack of access to sanitation.
There are simple interventions to treat diarrhoea ranging from the provision of safe drinking water,
use of improved sanitation and hand washing using soap.

15. Clinical Presentation & Aetiology
Acute Watery Diarrhoea (
last for several hours or
days, includes chorela .
Common aetiologic
agents includes V.cholera,
E.coli and Rotavirus.
Acute Bloody Diarrhoea
(last for 3-6 weeks, also
termed dysentery with
mucus and/or blood in
stool. Common aetiologic
agent is Shigella bacteria.
Persistent Diarrhoea (last
14 days or longer with or
without blood loss).
Commonly affects
malnourished children
and those with illnesses
such as AIDs.

16. Transmission & Prevention
Transmission
Diarrhoea disease can spread from person-to-person aggravated by
poor personal hygiene.
Food prepared or stored in very unhygienic conditions. Fish and
seafood from polluted water may also contribute to the disease.
Unsafe domestic water storage and handling is also a critical risk
factors.
Prevention
 Access to safe drinking water
Use of improved sanitation
Exclusive breastfeeding for the first 6 months of life
Good personal and food hygiene
Health education about how infections spread
Rotavirus vaccination

17. Treatment
Rehydration – with Oral Rehydration Salt
(ORS). Rehydration with intravenous fluids in
case of severe dehydration or shock.
Zinc supplement- reduces episode by 25%
and associated with a 30% reduction in stool
volume.
Nutrient rich food-like breast milk during
episode and EBS for the first 6 months of life.
Consulting a health professional in particular
for management of persistent diarrhoea.

20. Treatment Con’td

21. GAPPD : Ending Two Major Preventable
Causes of Child Death – the fore runners
United Nations Global Strategy for Women’s and Children’s Health (2010) – calls for a continuum of
care approach, aiming to save 16 million lives. With Every Woman Every Child (EWEC), efforts have
continued.
Call to Action: Committing to Child Survival- A promise Renewed (2012) – Global community to
reduce child mortality to 20 or fewer deaths per 1000 live births by 2035
Global Vaccine Action Plan (GVAP, 2012)-strategy for preventing childhood diseases through
vaccination.
United Nations Sustainable Energy for All Initiative – a public –private commitment to universal
access to modern energy services by 2030
United Nations Commission on Life Saving Commodities (2012)– recommendations to strengthen
access to and use of saving commodities including treatment for diarrhoea and pneumonia
United Nations Commission on Information & Accountability – improved monitoring of programmes
to protect women and children’s health.

22. Global Vaccine Action Plan

23. Every Woman, Every Child ( EWEC):framework
of global strategy for women & children’s
health

24. Sustainable Development Goal
 Goal 3: Ensure Healthy Lives and Promote Wellbeing for All in All
Ages
Target 3.2: Reducing Death in Children under 5 years of age to at
least as low as 25 per 1000 live births.

25. Integrated Global Action Plan for Prevention of
Pneumonia & Diarrhoea (GAPPD) - Background
In 2009, W.H.O,UNICEF and partners published 2 separate strategies for control of pneumonia and diarrhoea-Global
Action Plan for Prevention and Control of Pneumonia (GAPPD) and a Diarrhoea Disease Prevention and Control Strategy-
Diarrhoea: Why Children are still dying and what can be done.
Since these strategies were launched, it’s been recognised that (1) Pneumonia & Diarrhoea are most effectively
addressed in a coordinated manner(2) Share same determinants as well as same control strategies and delivery system (
3) Both are caused by multiple pathogen and no single intervention will manage either problem (4) Many countries are
already addressing these diseases jointly through inter-sectoral working group, integrating protection, prevention and
treatment.
GAPPD, an integrated 2013 plan from W.H.O and UNICEF representing the first-ever simultaneous plan to address
childhood Pneumonia & Diarrhoea. Target is set for 2013 – 2025-2030.
Designed to inform national program and policies, providing a cohesive framework to PROTECT children, PREVENT
disease and TREAT children who do become sick using proven interventions that have already contributed to reductions
in child death.
Country level performances are assessed via a GAPPD intervention scorecard developed by IVAC (John Hopkins
Bloomberg School of public health) across 10 key GAPPD indicators using available coverage data.
The GAPPD scorecard assessment specifically focuses on the 15 most burdened states – Nine of which are in Africa & 6
in the Asian pacific both in 2014 and2016 –carries 72% of the global burden of pneumonia/diarrhoea child death even
though they are home to only 55% of the world > 5 population.

26. Most Burdened States ( 2014) Most Burdened States ( 2016)
India India
Nigeria Nigeria
Pakistan Pakistan
Democratic Republic of Congo Democratic Republic of Congo
Ethiopia Angola
Angola Ethiopia
China Indonesia
Afghanistan Chad
Indonesia Afghanistan
Kenya Niger
Sudan China
Bangladesh Sudan
Niger Bangladesh
Chad Somalia
Uganda Tanzania

27. GAPPD – PPT Framework

28. GAPPD: Complementarity of Pneumonia
& Diarrhoea Intervention

29. Closing the Gap: Inequalities in Health
Children who are poor, hungry and live in remote
areas are most likely to be affected by these ‘’
forgotten’’ killers.
Burden placed on families and health system
aggravate existing inequalities
Proven intervention exist- does not require major
advances in technology
Children are dying because services are received
piecemeal and those most at- risk are not being
reached, use of effective intervention remain low
and life –saving commodities are not being
provided to many.

30. GAPPD – Goals & Targets 2013-2030
GOAL 2025 TARGET 2030 TARGET
Reduce mortality by Pneumonia
and Diarrhoea in children less
than 5 years of age to 3 and 1
per 1000 live births respectively
90% full dose coverage of each
relevant vaccine ( with 80%
coverage in every district)
Universal access to basic drinking
water in health care facilities and
homes
Reduce Incidence of severe
pneumonia by 75% in children
less than 5 years of age compared
to 2010 level
90% access to appropriate
pneumonia and diarrhoea case
management ( with 80 %
coverage in every district)
Universal access to basic
adequate sanitation in healthcare
facilities by 2030 & homes by
2040
Reduce incidence of severe
diarrhoea by 75% in children less
than 5 years of age compared to
2010 level
At least 50% coverage of exclusive
breastfeeding during the first 6
months of life
Universal access to hand washing
facilities (water and soap) in
healthcare facilities and homes
Reduce by 40% the global
number of children who are
stunted compared to 2010 level
Virtual elimination of Paediatrics
HIV
Universal access to clean and safe
energy technologies in healthcare
facilities and homes

31. GAPPD Intervention Target (2025)

32. GAPPD/ Intervention specific coverage
indicators

33. GAPPD: Actions at Country Level
Develop a clear country-level strategy and work
plan, with key responsibilities assigned
Coordinate implementation of interventions
 Generate political will and prioritize
interventions
 Designate a national working group for
pneumonia and diarrhoea prevention and
control or review membership of an appropriate
existing group
 Develop/update a situation analysis for
pneumonia & diarrhoea
 Mobilize resources
 Identify areas of harmonization and
collaboration between programmes and sectors,
including the private sector, academia and civil
society
 Apply lessons from other integrated disease
prevention and control efforts
Use data to identify groups at greater risk or
missed by services and develop targeted
approaches to reach them and develop a set of
common indicators for tracking progress.
 Track execution and progress
 Develop/update a costed plan for accelerated
action
 Take and/or assign accountability for action

34. GAPPD: Actions at Country Level cont’d
Engage and embed critical partners in the overall
work plan/approach
Other actions
 involve other programmes and sectors  promote innovations, especially for overcoming
barriers to service delivery
Involve the private sector and non-
governmental organisations
 Generate demand and ensure supply
Engage the United Nations agencies and
development partners
 Focus on implementation research and identify
optimal modes of delivery of existing
interventions in order to reach those most in
needs.

35. 10 GAPPD Intervention Scorecard
Indicators
Coverage rates for third dose of pertussis
vaccine
Coverage rates for Measles containing
vaccine(MCV)
Coverage rates for third dose of Hib vaccine
Coverage rates for third dose of
Pneumococcal vaccine
Coverage rate for last dose of rotavirus
vaccine
Access to appropriate healthcare provider
Antibiotic treatment for children with
suspected Pneumonia
Treatment with Oral Rehydration Salt(ORT)
Zinc supplements for children with diarrhoea
Exclusive breastfeeding for a child in the first
six months of life

36. GAPPD – 2016 Assessment Scorecard
Highlights
Overall GAPPD scores varied widely from as low as 20% ( Somalia) to 74% (Tanzania)
The median score among the 15 high burden states was 48% - a point above the 2015 median
score of 47%
None of the 15 high burden states met the 86% target for overall GAPPD assessment score.
5 countries met atleast 50% -(minimal threshold target ) – Afghanistan,
Sudan,Bangladesh,Ethiopia and Tanzania
Countries with the highest under 5 pneumonia and diarrhoea deaths ( India, Pakistan, Nigeria
& DRC) have overall GAPPD score less than 50%
Ethiopia & Tanzania ( countries with the highest overall GAPPD score) are using all five vaccines
preventive against pneumonia & diarrhoea and are achieving relatively coverage with each
vaccine

37. Nigeria - Highlights
 Compared to 2015, Nigeria only made a moderate +3% increase in 2016.
In the 2014 report, GAPPD state level data ranges from 2% ( Sokoto & Kebbi) to 49% in Ekiti
State. 7 states had below 10%
Geographic patterns in GAPPD scores by states shows that southern states with higher scores
having lower under 5 mortalities when compared to northern states with low GAPPD scores ( a
pattern also noticed in India).
Urban – Rural disparities also existed in vaccine coverage ( 37% and 31%) for pentavelent and
measles respectively. This was also observed with regards to treatment although the
differences were relatively smaller .

38. Challenges & Opportunities

39. References
GAPPD: Pneumonia and Diarrhoea Progress Report (2014), IVAC/ John Hopkins Bloomberg
School of Public Health
GAPPD: Pneumonia and Diarrhoea Progress Report (2016), IVAC/ John Hopkins Bloomberg
School of Public Health
Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025 – the Integrated
Global Action Plan for Pneumonia & Diarrhoea
Nigeria: Diarrhoea Diseases – World Health Ranking, May 2014
Fight Pneumonia – Final Report of Small Grant Program In Nigeria, 2011

40. ‘’ Intervention to Prevent Pneumonia exist – the challenge is
delivering them to children who need them. Overcoming these
hurdles will save the lives of millions of children’’
Orin Levine, PhD (Executive Director, International Vaccine Access Centre)