More proven interventions are available to prevent and treat diarrhea than any other major child killer

Jones G Bryce J. et al., Lancet CS series 2003

The Effectiveness of ORS

•Oral rehydration treatment reverses dehydration in more than 90% of patients •Since 1971, saved the lives of over 50 million children •When ICDDR,B began experiments with oral rehydration in the 1960s, fatalities among diarrhea patients dropped from 50% to zero.

Zinc for the Treatment of Diarrhea: Research Findings

• 25% reduction in duration of acute diarrhea • 29% reduction in duration of persistent diarrhea • 40% reduction in treatment failure or death in persistent diarrhea •WHO-issued recommendations about the use of zinc in treating diarrhea Zinc Investigators’ Collaborative Group.

Am J Clin Nutr 2000

Photo: PATH

Breastfeeding

•Non-breastfed infants aged 0 5 months have 7-fold increased risk of death from diarrhea •13% of the under-5 deaths could be prevented if infants were exclusively breastfed for 6 months.

•6% of under-5 deaths could be prevented with adequate and safe complementary feeding.

WHO, “Key strategies for promotion of breastfeeding”

Rotavirus vaccines

GSK Rotarix® - monovalent, human, live, attenuated, oral rotavirus vaccine

• Lyophilized vaccine reconstituted with CaCO 3 buffer • human G1P8 strain; cross-protective of multiple strains • high efficacy and safety • 2-dose schedule, given with DPT1,2 • WHO prequalification: Jan 2007

Merck RotaTeq® - pentavalent, human bovine reassortant, live, attenuated, oral, rotavirus vaccine

• Liquid vaccine, 5 human-bovine reassortant strains: • G serotypes - human G1, G2, G3 and G4; bovine G6; cross-protective of multiple strains • high efficacy and safety • 3-dose schedule, given with DPT1,2,3 • WHO prequalification: Oct 2008

Photo: PATH

June 2009: WHO recommends rotavirus vaccines be included in all country’s national immunization programs.

Diarrhea Still a Top Killer

Undernutrition is an underlying cause of 53% of deaths among children under 5 years of age

Source:

Bryce J. et al., Lancet 2005

Incidence of Diarrheal Disease Remains High

Incidences for Diarrheal Episodes per Child per Year from Three Reviews of Prospective Studies in Developing Areas, 1955-2000 6 5 4 3 1980-1990 1990-2000 2 1 0 0-5 months 6-11 months 1 year

Gerald T. Keusch,et al, "Diarrheal Diseases." 2006.

Disease Control Priorities in Developing Countries (2nd Edition),ed.

371-388. New York: Oxford University Press. DOI: 10.1596/978-0-821-36179-5/Chpt-19.

Decline in ORS use

Percentage of all cases of diarrhea in children <5 treated with oral rehydration salts or recommended home fluids

100 80 60 40 20 0 1986

Source: UNICEF. State of the World’s Children

1995 2007

Figure 1. Percent change in use of oral rehydration therapy during the two most recent DHS surveys, 1992-2005

Uptake of ORS: 1992-2005 In 23 countries 14 in Africa - use of ORS has declined

Ram et al, Bulletin of the WHO, March ‘08

100% 80% 60% 40% 20% 0% 6% 7% 7% 8% 8% 14% 18% 32% Among Global Health Priorities Health Priorities Diarrheal disease Neonatal causes Malnutrition ARIs/Pneumonia Measles Tuberculosis Malaria AIDS N = 33

•

Whenever policymakers talk about global health problems…

they leave out the big three of the neglected problems

– diarrheal disease, pneumonia, and malnutrition -Academic

•

Policymakers think of specific diseases, and I

don’t think diarrheal disease comes in the top ten

PATH, FSG Social Impact Advisors. Diarrheal disease advocacy: Findings from a scan of the global funding and policy landscape.

-Advocate

Interviewees Offer Reasons Why Awareness of Diarrheal Disease May be Low Lack of advocacy around diarrheal disease in the last decade

“Diarrhea has dropped out of the public health agenda – it has become totally invisible. This is

not only a problem with lay people, but public health specialists, too. People have forgotten about diarrheal disease”

Diarrheal disease does not have a well-known spokesperson from either the scientific or celebrity community

“We are really lacking a champion for diarrheal disease. You need two people – a celebrity... and someone from the scientific community to bring credibility” “There is no high profile person – we need a Bono. But who wants to be associated with

diarrhea

? …You can’t make diarrhea sexy”

PATH, FSG Social Impact Advisors. Diarrheal disease advocacy: Findings from a scan of the global funding and policy landscape.

Diarrheal Disease Has Failed to Capture the Attention of Donors & Policymakers

© PATH

The Potential of Integration

• No single solution is adequate • Successful at the policy level • One intervention – like rotavirus vaccines – can mobilize adoption of others • Allows flexibility to design a package appropriate for a country’s needs • Programmatic level?

• Combining interventions may offer efficiencies/cost savings • Opportunity to strengthen health systems

From Individual Interventions…

Rotavirus vaccines Zinc treatment Enhanced Diarrheal Disease Control Sanitation/ hygiene New-ORS/ORT/

…To An Integrated Approach

Jim Grant’s Vision

“The world community has now set itself the challenge to reach the goal of 80% ORT use by the end of 1995. I am convinced that the goal can be reached…” ”Celebrating 25 years of ORT” conference, 1994

Increasing Access to Data

When Asked What Motivates Donors and Policymakers, Interviewees Agreed On Actionable Solutions and Hard Data 100% 80% 74% 60% 40% 30% 30% 30% 19% 20% 11% 7% 0%

Credible data that highlights the potential impact of available interventions Pressure from key constituents Credible data that highlights specific needs Cost effectiveness Pressure from peer decision makers Need to support UN Millenium Development Goals Other

Key Factors Motivating Health Funders and Policymakers to Take on a Particular Issue or Disease

PATH, FSG Social Impact Advisors. Diarrheal disease advocacy: Findings from a scan of the global funding and policy landscape.

Increasing Access to Interventions

Percent Respondents Selecting Each Intervention as Integral to an Integrated DD Approach

Clean water and sanitation 93% ORS/ORT Breastfeeding Vaccines Zinc Nutrition Restorative feeding Diagnostics Anti-diarrheals 23% 20% 33% 63% 63% 83% 80% 93% N = 30 0% 20% 40% 60% 80% 100%

PATH, FSG Social Impact Advisors. Diarrheal disease advocacy: Findings from a scan of the global funding and policy landscape.

Perceptions Research: Increasing access to proven interventions is believed to be the most effective way to accelerate progress toward MDG 4

What Will It Take to Put Diarrheal Disease Back on the Public Health Stage?

Action Agenda:

• Pursue a research agenda around individual and integrated interventions for the prevention and treatment of diarrheal disease • Communicate the evidence and data to policy makers • Support integration of packages of interventions to prevent and treat diarrheal disease • Speak out to raise awareness of diarrheal disease