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      Estimating the distribution of morbidity and mortality of childhood diarrhea, measles, and pneumonia by wealth group in low- and middle-income countries


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          Equitable access to vaccines has been suggested as a priority for low- and middle-income countries (LMICs). However, it is unclear whether providing equitable access is enough to ensure health equity. Furthermore, disaggregated data on health outcomes and benefits gained across population subgroups are often unavailable. This paper develops a model to estimate the distribution of childhood disease cases and deaths across socioeconomic groups, and the potential benefits of three vaccine programs in LMICs.


          For each country and for three diseases (diarrhea, measles, pneumonia), we estimated the distributions of cases and deaths that would occur across wealth quintiles in the absence of any immunization or treatment programs, using both the prevalence and relative risk of a set of risk and prognostic factors. Building on these baseline estimates, we examined what might be the impact of three vaccines (first dose of measles, pneumococcal conjugate, and rotavirus vaccines), under five scenarios based on different sets of quintile-specific immunization coverage and disease treatment utilization rates.


          Due to higher prevalence of risk factors among the poor, disproportionately more disease cases and deaths would occur among the two lowest wealth quintiles for all three diseases when vaccines or treatment are unavailable. Country-specific context, including how the baseline risks, immunization coverage, and treatment utilization are currently distributed across quintiles, affects how different policies translate into changes in cases and deaths distribution.


          Our study highlights several factors that would substantially contribute to the unequal distribution of childhood diseases, and finds that merely ensuring equal access to vaccines will not reduce the health outcomes gap across wealth quintiles. Such information can inform policies and planning of programs that aim to improve equitable delivery of healthcare services.

          Electronic supplementary material

          The online version of this article (10.1186/s12916-018-1074-y) contains supplementary material, which is available to authorized users.

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          Most cited references18

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          Epidemiology and etiology of childhood pneumonia.

          Childhood pneumonia is the leading single cause of mortality in children aged less than 5 years. The incidence in this age group is estimated to be 0.29 episodes per child-year in developing and 0.05 episodes per child-year in developed countries. This translates into about 156 million new episodes each year worldwide, of which 151 million episodes are in the developing world. Most cases occur in India (43 million), China (21 million) and Pakistan (10 million), with additional high numbers in Bangladesh, Indonesia and Nigeria (6 million each). Of all community cases, 7-13% are severe enough to be life-threatening and require hospitalization. Substantial evidence revealed that the leading risk factors contributing to pneumonia incidence are lack of exclusive breastfeeding, undernutrition, indoor air pollution, low birth weight, crowding and lack of measles immunization. Pneumonia is responsible for about 19% of all deaths in children aged less than 5 years, of which more than 70% take place in sub-Saharan Africa and south-east Asia. Although based on limited available evidence, recent studies have identified Streptococcus pneumoniae, Haemophilus influenzae and respiratory syncytial virus as the main pathogens associated with childhood pneumonia.
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            The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality

            Background Most diarrhoeal deaths can be prevented through the prevention and treatment of dehydration. Oral rehydration solution (ORS) and recommended home fluids (RHFs) have been recommended since 1970s and 1980s to prevent and treat diarrhoeal dehydration. We sought to estimate the effects of these interventions on diarrhoea mortality in children aged <5 years. Methods We conducted a systematic review to identify studies evaluating the efficacy and effectiveness of ORS and RHFs and abstracted study characteristics and outcome measures into standardized tables. We categorized the evidence by intervention and outcome, conducted meta-analyses for all outcomes with two or more data points and graded the quality of the evidence supporting each outcome. The CHERG Rules for Evidence Review were used to estimate the effectiveness of ORS and RHFs against diarrhoea mortality. Results We identified 205 papers for abstraction, of which 157 were included in the meta-analyses of ORS outcomes and 12 were included in the meta-analyses of RHF outcomes. We estimated that ORS may prevent 93% of diarrhoea deaths. Conclusions ORS is effective against diarrhoea mortality in home, community and facility settings; however, there is insufficient evidence to estimate the effectiveness of RHFs against diarrhoea mortality.
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              Estimates of measles case fatality ratios: a comprehensive review of community-based studies.

              Global deaths from measles have decreased notably in past decades, due to both increases in immunization rates and decreases in measles case fatality ratios (CFRs). While some aspects of the reduction in measles mortality can be monitored through increases in immunization coverage, estimating the level of measles deaths (in absolute terms) is problematic, particularly since incidence-based methods of estimation rely on accurate measures of measles CFRs. These ratios vary widely by geographic and epidemiologic context and even within the same community from year-to-year. To understand better the variations in CFRs, we reviewed community-based studies published between 1980 and 2008 reporting age-specific measles CFRs. The results of the search consistently document that measles CFRs are highest in unvaccinated children under age 5 years; in outbreaks; the lowest CFRs occur in vaccinated children regardless of setting. The broad range of case and death definitions, study populations and geography highlight the complexities in extrapolating results for global public health planning. Values for measles CFRs remain imprecise, resulting in continued uncertainty about the actual toll measles exacts.

                Author and article information

                BMC Med
                BMC Med
                BMC Medicine
                BioMed Central (London )
                4 July 2018
                4 July 2018
                : 16
                : 102
                [1 ]ISNI 000000041936754X, GRID grid.38142.3c, Department of Global Health and Population, , Harvard T.H. Chan School of Public Health, ; Boston, MA USA
                [2 ]ISNI 0000000122986657, GRID grid.34477.33, Institute for Health Metrics and Evaluation, , University of Washington, ; Seattle, WA USA
                [3 ]ISNI 0000000092621349, GRID grid.6906.9, Erasmus School of Economics, , Erasmus University of Rotterdam, ; Rotterdam, The Netherlands
                [4 ]ISNI 0000000419368956, GRID grid.168010.e, Department of Medicine, , Stanford University School of Medicine, ; Stanford, CA USA
                [5 ]ISNI 000000041936754X, GRID grid.38142.3c, Center for Health Decision Science, , Harvard T.H. Chan School of Public Health, ; Boston, MA USA
                [6 ]ISNI 0000 0000 8990 8592, GRID grid.418309.7, Bill & Melinda Gates Foundation, ; Seattle, WA USA
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                : 26 June 2017
                : 14 May 2018
                Funded by: FundRef http://data.crossref.org/fundingdata/funder/10.13039/100000865, Bill & Melinda Gates Foundation;
                Award ID: OPP1137904
                Research Article
                Custom metadata
                © The Author(s) 2018

                distributional benefits,vaccines,equity,risk factors,measles vaccine,pneumococcal conjugate vaccine,rotavirus vaccine


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