A solution to Uttar Pradesh’s ‘silent emergency’

When India’s living legend Amitabh Bachchan exhorts Indians towards a cleaner India, it’s the figures that he quotes that should make us sit up and pay attention.

Thirteen children die from diarrhoea every hour in India. India contributes to 10 per cent of all global diarrhoeal deaths in children below the age of five years.

Bachchan also emphasizes the case that India has the highest number of stunted children in the world.  

Pneumonia and diarrhoea together accounts for 29 per cent of all child deaths globally, resulting in the deaths of more than two million children each year. Countries most affected can end this staggering and unnecessary death toll.

Reducing Pneumonia and Diarrhoea deaths through an integrated approach

In 2013, the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) sought to reduce deaths from pneumonia to fewer than three children per 1000 live births, and from diarrhoea to less than one in 1000 by 2025, by fighting the two diseases together in an integrated approach.

The report suggested ways to combat both diseases with proven measures: exclusive breastfeeding for up to six months, vaccines, handwashing, safe drinking water, and appropriate treatments, among other solutions. However, we are painfully aware that Uttar Pradesh, still has a long way to go to universal access to hygiene and sanitation. Thus, too often children most at risk – in poor settings or hard-to-reach communities – don’t even have even these basic facilities. 

The vicious cycle of weakening immunity and malnutrition

The mention of stunting is important. India continues to have the highest number of low birth babies. These precious lives are immediately vulnerable to diarrhoea and pneumonia. It’s important to understand the link between episodes of diarrhoea and malnourishment. Vulnerable low-birth weight babies, who experience multiple episodes of diarrhoea get trapped in a vicious cycle of weakening immunity and malnutrition.

Later in life, the impact begins to show, when children are not able to cope up with their studies and later on in their adult lives. Several studies have long established observations that are consistent with the hypothesis that a higher cumulative burden of diarrhoea increases the risk of stunting.

The environment in Uttar Pradesh

Given the environment in large parts of Uttar Pradesh, both urban and rural, integrated approaches for diarrhoea prevention and management underscoring the importance of good sanitation, exclusive breastfeeding, clean drinking water, Vitamin A supplementation, oral rehydration solution, zinc and continued feeding are still not in place. This is because of various reasons.

How diarrhoea thrives even where there is good sanitation   

However, diarrhoea thrives even where there is good hygiene and sanitation and relatively better infant care. Rotavirus is the most common cause of severe diarrheal diseases in children worldwide. In 2013, a study determined that 37 per cent of the 578,000 childhood diarrheal deaths were due to rotavirus, for a total of 215,000 rotavirus deaths globally. More than 90 per cent of these deaths occurred in developing countries. Rotavirus disease cannot be treated with antibiotics or other drugs, and most children are at risk of infection regardless of hygiene practices or access to clean water. Hence, vaccination is the best way to protect children from rotavirus and the deadly dehydration caused by it.

WHO recommendation: Expansion of Rotavirus vaccines in Jharkhand, UP

In fact, in 2009, the World Health Organisation recommended that all countries should include rotavirus vaccines in their national immunisation programmes. In India, rotavirus diarrhoea amounts to 8,72, 000 hospitalisation, 32,70,000 outpatient visits and 78, 000 deaths annually. 

It is thus significant that of the States of Rajasthan, Madhya Pradesh, Bihar and Uttar Pradesh that bear the highest burden of under five deaths due to pneumonia and diarrhoea, Rajasthan and Madhya Pradesh have introduced the rotavirus vaccine in the Universal Immunisation Programme. This year, the Government of India is supporting the expansion of this vaccine in Jharkhand and Uttar Pradesh.

Introduction of Rotavirus in India

Since 2017, the Government of India has introduced the rotavirus vaccine in phases. In the first phase it was introduced in Andhra Pradesh, Haryana, Himachal Pradesh, Odisha, followed by Assam, Rajasthan and Madhya Pradesh, Tamil Nadu and Tripura in the second phase. 

There is no doubt that the introduction of the vaccine will help these states bring down fatal incidents of diarrhoea. Learning from other countries that have introduced the rotavirus vaccine show that Mexico reported nearly 50 per cent drop in diarrhoea-related deaths in children under five after the introduction of the vaccine in 2007, while Brazil recorded a 22 per cent drop in deaths.    

Keeping the Swachh Bharat focus on diarrhoea

Going back to the GAPPD report, India is recognising that prevention and control of pneumonia and diarrhoea can only be tackled through integrated programmes. That will reduce the numbers of children falling ill and dying, but also bring more efficient and effective use of often scarce health resources. An infant that experiences fewer episodes of diarrhoea has a greater chance of reaching his or her fifth birthday. This child then has a better chance of doing well in school and having a more complete and full life. 

Former UNICEF Executive Director James Grant (1980–1995) rightly called diarrhoea a ‘global silent emergency’. By keeping the Swachh Bharat focus on diarrhoea, Amitabh Bachchan is raising his voice on behalf of those thousands of children who could potentially lose their lives from what is now a vaccine-preventable disease!  

(The writer is national vice-president, Central Zone, Indian Academy of Pediatrics and immediate task president, Uttar Pradesh)