Global burden of childhood pneumonia and diarrhoea

In the paper

“We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years.”

In the paper

“15 countries—namely, Afghanistan, Angola, Burkina Faso, China, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Kenya, Mali, Niger, Nigeria, Pakistan, Tanzania, and Uganda—account for 53% of total episodes of diarrhoea and 56% of severe episodes, and 65% of total episodes of pneumonia and 64% of severe episodes (appendix).”

In the paper

“Morbidity and mortality from childhood pneumonia and diarrhoea are falling, but action is needed globally and at country level to accelerate the reduction.”

In the paper

“15 countries—namely, Afghanistan, Angola, Burkina Faso, China, Democratic Republic of the Congo, Ethiopia, India, Indonesia, Kenya, Mali, Niger, Nigeria, Pakistan, Tanzania, and Uganda—account for 53% of total episodes of diarrhoea and 56% of severe episodes, and 65% of total episodes of pneumonia and 64% of severe episodes (appendix).”

In the paper

“Pneumonia incidence is more variable between regions than is diarrhoea incidence; adjusted for immunisation against H influenzae type b and S pneumoniae, it was lowest in the European region and highest in the African and southeast Asian regions.”

In the paper

“We estimated that, in 2011, 700 000 episodes of diarrhoea and 1·3 million of pneumonia led to death.”

In the paper

“In 2011, the number of deaths from the two diseases fell to 1·97 million (0·71 million associated with diarrhoea and 1·26 million with pneumonia).”

In the paper

“Rotavirus is the most common cause of vaccine-preventable severe diarrhoea (associated with 28% of cases), and Streptococcus pneumoniae (18·3%) of vaccine-preventable severe pneumonia.”

In the paper

“Rotavirus is the most common cause of vaccine-preventable severe diarrhoea (associated with 28% of cases), and Streptococcus pneumoniae (18·3%) of vaccine-preventable severe pneumonia.”

In the paper

“We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years.”

In the paper

“We estimated that, in 2011, 700 000 episodes of diarrhoea and 1·3 million of pneumonia led to death.”

In the paper

“We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years.”

In the paper

“Nearly three-quarters of diarrhoea mortality and pneumonia mortality are concentrated in 15 high-burden countries, yet data sources from these countries are scant”

In the paper

“Nearly a third of episodes of severe diarrhoea are preventable by vaccination (ie, against rotavirus and cholera), whereas vaccine-preventable pneumonias (ie, those caused by Streptococcus pneumoniae, Haemophilus influenzae type b, and the influenza virus) account for at least a third of severe episodes and two-thirds of deaths”

In the paper

“Diarrhoea incidence peaks at age 6–11 months and then decreases with age;8 proportionate mortality is highest from age 0–11 months, the ages at which the risk of disease and severe disease also peak.”

What the sources say

• Not checked yetcites [8] Fischer Walker, 2012, Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review, BMC Public Health source

In the paper

“The incidence of diarrhoea does not differ substantially between regions, but incidence and case-fatality ratios are much higher in low-income than in middle-income and high-income countries.”

In the paper

“We estimated that, in 2010, there were 1·731 billion episodes of diarrhoea (36 million of which progressed to severe episodes) and 120 million episodes of pneumonia (14 million of which progressed to severe episodes) in children younger than 5 years.”

In the paper

“We estimate that 2% of diarrhoea episodes and 12% of pneumonia episodes progress to severe disease.”

In the paper

“V cholerae causes roughly 1% of severe diarrhoea worldwide, but is endemic in south Asia and some countries in sub-Saharan Africa.”

In the paper

“A systematic review14 of pneumonia sequelae showed that the risk of at least one long-term major sequela was 5·5% (95% CI 2·8–8·3) in non-severe pneumonia and 13·6% (6·2–21·1) in severe pneumonia treated in hospital.”

What the sources say

• Not checked yetcites [14] Edmond, 2012, Long term sequelae from childhood pneumonia; systematic review and meta-analysis, PLoS One source

In the paper

“Most data from developing countries are reported from unrepresentative hospital-based studies, which have little relevance in home-birth settings (where most children are born in many countries).56, 57, 58, 59”

What the sources say

• Not checked yetcites [56] Zaidi, 2005, Hospital-acquired neonatal infections in developing countries, Lancet source
• Not checked yetcites [57] Zaidi, 2009, Pathogens associated with sepsis in newborns and young infants in developing countries, Pediatr Infect Dis J source
• Not checked yetcites [58] Jawad, 2012, Assessing available information on the burden of sepsis: global estimates of incidence, prevalence and mortality, J Global Health source

In the paper

“The link between childhood pneumonia and obstructive lung disease is not yet clear.14”

What the sources say

• Not checked yetcites [14] Edmond, 2012, Long term sequelae from childhood pneumonia; systematic review and meta-analysis, PLoS One source

In the paper

“Rates of mortality from diarrhoea and pneumonia are highly correlated, and changes in mortality with time are similar for both diseases within the same country (figure 2 ).”

In the paper

“Pathogen-specific incidences of diarrhoea vary by age, yet few data are available for generation of age-specific estimates by enteropathogen.”

In the paper

“The global estimate of cases of severe diarrhoea associated with V cholerae, which is based on available data from a global model, differs slightly from that based on regional estimates derived from a subset of regional data (table 2).”

In the paper

“Important vaccine-preventable causes of severe pneumonia are S pneumoniae (which causes at least 18% of severe episodes and 33% of deaths worldwide), the influenza virus (7% of severe episodes and 11% of deaths), and H influenzae type b (4% of severe episodes and 16% of deaths).”

In the paper

“The yearly rate of change varies substantially between countries, with China reaching 12% for both diseases, whereas other countries have rates that are much less than the fourth Millennium Development Goal target rate of 4·4%.”

In the paper

“Important vaccine-preventable causes of severe pneumonia are S pneumoniae (which causes at least 18% of severe episodes and 33% of deaths worldwide), the influenza virus (7% of severe episodes and 11% of deaths), and H influenzae type b (4% of severe episodes and 16% of deaths).”

In the paper

“Important vaccine-preventable causes of severe pneumonia are S pneumoniae (which causes at least 18% of severe episodes and 33% of deaths worldwide), the influenza virus (7% of severe episodes and 11% of deaths), and H influenzae type b (4% of severe episodes and 16% of deaths).”

In the paper

“Guillain-Barré syndrome, haemolytic uraemic syndrome, and reactive arthritis are rarely noted and are attributable only to selected pathogens (unpublished).15, 45”

What the sources say

• Not checked yetcites [15] Poropatich, 2010, Quantifying the association between Campylobacter infection and Guillain-Barré syndrome: a systematic review, J Health Popul Nutr source
• Not checked yetcites [45] Fischer Walker, 2012, Haemolytic-ureaemic syndrom as a sequela of diarrhoeal disease, J Health Popul Nutr

In the paper

“The most common cause of severe and fatal diarrhoea worldwide is rotavirus (associated with 28% of severe cases and 28% of fatal cases); the data analysed here are from before the rotavirus vaccine was available, and thus this proportion might be slightly lower in 2011 in the Americas and a few other countries where the vaccine is used (unpublished).”

In the paper

“In a randomised controlled trial75 in rural Guatemala, participants who were given wood stoves with chimneys had non-significant reductions in the incidence of pneumonia compared with those who continued to use open fires (RR 0·84, 95% CI 0·63–1·13); however, in an exposure–response analysis the reduction was significant (0·82, 0·70–0·98).”

What the sources say

• Not checked yetcites [75] Smith, 2011, Effect of reduction in household air pollution on childhood pneumonia in Guatemala (RESPIRE): a randomised controlled trial, Lancet source

In the paper

“Risk relations between specific water and sanitation risk factors (ie, unwashed hands and poor water quality) and diarrhoea morbidity and mortality have been shown, but for some outcomes, such as inappropriate excreta disposal, poor availability of evidence permits only rough estimates of risk.68, 69”

What the sources say

• Not checked yetcites [68] Esrey, 1991, Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma, Bull World Health Organ
• Not checked yetcites [69] Cairncross, 2010, Water, sanitation and hygiene for the prevention of diarrhoea, Int J Epidemiol source

In the paper

“Vitamin A deficiency increases the risk of severe diarrhoea and thus diarrhoea mortality (relative risk [RR] 1·5, 95% CI 1·3–1·8),66 but is not an important risk factor for the incidence of diarrhoea or pneumonia, or for pneumonia-related mortality.66”

What the sources say

• Not checked yetcites [66] Black, 2008, Maternal and child undernutrition: global and regional exposures and health consequences, Lancet source

In the paper

“Both diseases are associated with poverty, and child mortality from them is higher in low-income than in high-income countries and in populations in crisis situations (panel 2 ).”

In the paper

“Severe morbidity and mortality and yearly changes in mortality with time are strongly correlated for childhood diarrhoea and pneumonia.”

In the paper

“In neither country was the reverse relation—ie, pneumonia as a risk for diarrhoea—noted.”

In the paper

“In a small group of studies,74 exposure to indoor air pollution (various definitions of risk were used) was associated with increased risk of severe pneumonia and pneumonia mortality; additional studies are needed before a combined analysis can be done to produce a risk estimate.”

What the sources say

• Not checked yetcites [74] Dherani, 2008, Indoor air pollution from unprocessed solid fuel use and pneumonia risk in children aged under five years: a systematic review and meta-analysis, Bull World Health Organ source

In the paper

“Other factors, such as intrauterine growth restriction and prematurity, are risk factors for all-cause neonatal mortality, but cause-specific data are not available and thus risk relations cannot be quantified.67”

What the sources say

• Not checked yetcites [67] Fishman, 2004, Childhood and maternal underweight

In the paper

“Both diseases are associated with poverty, and child mortality from them is higher in low-income than in high-income countries and in populations in crisis situations (panel 2 ).”

In the paper

“Little information is available about the effect of HIV infection on neonatal pneumonia.”

In the paper

“Crowding and exposure to indoor air pollution increase pneumonia incidence, but are not associated with increased risk for diarrhoea morbidity or mortality.”

In the paper

“72% of deaths from diarrhoea and 81% of deaths from pneumonia occur within the first 2 years of life, which has clear implications for health policy.”

In the paper

“Rotavirus is the most important cause of diarrhoea mortality in children, whereas S pneumoniae, H influenzae, and influenza virus are three of the four main causes of pneumonia mortality.”

In the paper

“For some risk factors, such as inadequate water and sanitation, poor handwashing, indoor air pollution, and crowding, risk relations have been difficult to define, but addressing them will probably have benefits for disease reduction.”

In the paper

“Childhood pneumonia and diarrhoea were estimated to account for about 2 million child deaths in 2011 (28·5% of total mortality in children younger than 5 years), and are a high priority for child health programmes.”

In the paper

“For example, in Burkina Faso, the estimated rates of diarrhoea and pneumonia specific mortality fell from 2000 to 2010, yet the estimated number of deaths in children younger than 5 years increased (from 13 447 to 14 648 for diarrhoea and 17 389 to 21 763 for pneumonia); we note similar trends in Afghanistan, Cameroon, Chad, Democratic Republic of the Congo, and Mali.”

In the paper

“Mortality from both diarrhoea and pneumonia fell substantially between 2000 and 2011.”

In the paper

“In Cambodia, for example, diarrhoea mortality rates have been falling by 12% and pneumonia mortality rates by 8% each year from 2000 to 2010—findings which contrast with yearly decreases of 2·4% and 1·6% in Papua New Guinea.”

In the paper

“We made no adjustments for the effects of the HIV/AIDS pandemic, because the relation between HIV/AIDS and severe morbidity and mortality from pneumonia is not sufficiently understood.”

In the paper

“The epidemiology of childhood diarrhoea and that of pneumonia overlap, which might be partly because of shared risk factors, such as undernutrition, suboptimum breastfeeding, and zinc deficiency.”

In the paper

“Despite large reductions in child mortality between 2000 and 2010 (both all-cause mortality, and that specifically associated with diarrhoea and pneumonia), these diseases remain major causes of avoidable deaths and account for about 30% of all child deaths worldwide.1, 2”

What the sources say

• Not checked yetcites [1] Liu, 2012, Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000, Lancet source
• Not checked yetcites [2] 2012

In the paper

“We did a systematic review of published reviews of risk factors for childhood pneumonia and diarrhoea and retained risk factors that met the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria level 1 or 2 in favour of a definite effect.”

In the paper

“As children grow older, the causes of clinical pneumonia are mainly respiratory syncytial virus, influenza virus, Streptococcus pneumoniae, and Haemophilus influenzae.”

In the paper

“Stunting is an important sequela because it is indicative of long-term nutritional deficit and is associated with decreased cognitive function.43”

What the sources say

• Not checked yetcites [43] Walker, 2011, Inequality in early childhood: risk and protective factors for early child development, Lancet source

In the paper

“The HIV/AIDS pandemic has also changed the risk for both diseases and the range of causes in countries with high prevalences of HIV infection.”

In the paper

“G lamblia and E histolytica do not typically cause severe dehydrating diarrhoea, but Cryptosporidium spp can in some circumstances.”

In the paper

“Chronic diarrhoea is part of the clinical syndrome of AIDS; it occurs in roughly 50% of children younger than 5 years who have AIDS in high-income countries and nearly all of those in low-income and middle-income countries.”

In the paper

“In pathogen-endemic areas, infants receive passive protection from transplacental and breastmilk antibodies for the first 6 months of life.”

In the paper

“The most common cause of severe and fatal diarrhoea worldwide is rotavirus (associated with 28% of severe cases and 28% of fatal cases); the data analysed here are from before the rotavirus vaccine was available, and thus this proportion might be slightly lower in 2011 in the Americas and a few other countries where the vaccine is used (unpublished).”

In the paper

“Many other viruses (including norovirus, astrovirus, and adenovirus), bacteria (the most common of which are pathogenic Escherichia coli, Shigella, Campylobacter, and Salmonella) and parasites (including Giardia lamblia, Entamoeba histolytica, and Cryptosporidium) cause severe diarrhoea but cannot be prevented by vaccines.”

In the paper

“For an otherwise healthy child, a single episode of diarrhoea is typically self-limiting and has no long-term sequelae.”

In the paper

“Klebsiella pneumoniae, other Gram-negative rods (E coli, Pseudomonas spp, Acinetobacter spp), and S aureus are the major pathogens isolated from the bloodstream in hospital settings in the neonatal period, and about 70% of these blood isolates might be untreatable in low-income settings.56, 57, 58, 59”

What the sources say

• Not checked yetcites [56] Zaidi, 2005, Hospital-acquired neonatal infections in developing countries, Lancet source
• Not checked yetcites [57] Zaidi, 2009, Pathogens associated with sepsis in newborns and young infants in developing countries, Pediatr Infect Dis J source
• Not checked yetcites [58] Jawad, 2012, Assessing available information on the burden of sepsis: global estimates of incidence, prevalence and mortality, J Global Health source

In the paper

“Repeated episodes of diarrhoea can thus lead to cognitive deficits via stunting, but not independently as some researchers have postulated.44”

What the sources say

• Not checked yetcites [44] Fischer Walker, 2012, Does childhood diarrhea influence cognition beyond the diarrhea-stunting pathway, PLoS One source

In the paper

“The outbreak of cholera that began in October, 2010, in Haiti is not included in these estimates, which are for endemic disease only.51”

What the sources say

• Not checked yetcites [51] Cravioto

In the paper

“Additionally, as the immune system fails, generally when patients have fewer than 200 CD4 cells per μL, such individuals are also susceptible to many opportunistic pathogens, such as Mycobacterium tuberculosis, the Mycobacterium avium complex, cryptosporidium, microsporidia, and cytomegalovirus.”

In the paper

“Individuals who are infected with HIV and not yet immunodeficient are susceptible to the same microbial causes of diarrhoea as are HIV-negative individuals.”

In the paper

“After passive immunity wanes, the child's first exposure to a pathogen often results in severe disease; subsequent illnesses tend to be milder and less likely to result in severe dehydration, admission to hospital, and death.”

In the paper

“In the early neonatal period, any of these infections might be environmentally acquired because of unhygienic delivery practices in low-income settings rather than perinatally acquired, which might explain the predominance of Gram-negative infections in home-born infants.56, 57, 58, 59”

What the sources say

• Not checked yetcites [56] Zaidi, 2005, Hospital-acquired neonatal infections in developing countries, Lancet source
• Not checked yetcites [57] Zaidi, 2009, Pathogens associated with sepsis in newborns and young infants in developing countries, Pediatr Infect Dis J source
• Not checked yetcites [58] Jawad, 2012, Assessing available information on the burden of sepsis: global estimates of incidence, prevalence and mortality, J Global Health source

In the paper

“Additionally, exclusively breastfed infants are exposed less to many pathogens than are infants who are not breastfed or receive mixed feedings.”

In the paper

“These studies suggested that risk was highest in the first year of life, presumably because of damage to lung parenchyma and bronchioles in an early stage of lung development, which is postulated to impair lung growth and reduce vital capacity and forced expiratory volume.14”

What the sources say

• Not checked yetcites [14] Edmond, 2012, Long term sequelae from childhood pneumonia; systematic review and meta-analysis, PLoS One source

In the paper

“A vaccine against respiratory syncytial virus is in development.50”

What the sources say

• Not checked yetcites [50] Rudan I, O'Brien KL, Nair H, et al. Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causing pathogens for 192 countries. J Glob Health (in press).

In the paper

“Infection with Clostridium difficile is common in patients exposed to antimicrobials and hospital settings.”

In the paper

“As antiretroviral therapy and co-trimoxazole prophylaxis become more widely used and lead to improved survival of HIV-positive children, severe pneumonia and chronic lung disease can be expected to become more common in older children.”

In the paper

“In areas where tuberculosis is endemic, M tuberculosis is an important cause of pneumonia in HIV-positive children and can present as acute severe pneumonia.”

In the paper

“In 1983, Feachem and Koblinsky78 estimated that, with moderate coverage of the measles vaccine (45–90%) in infants, the incidence of diarrhoea could be reduced by 0·6–3·8%, and, more importantly, diarrhoea mortality could be reduced by 6–26% in children younger than 5 years.”

What the sources say

• Not checked yetcites [78] Feachem, 1983, Interventions for the control of diarrhoeal diseases among young children: measles immunization, Bull World Health Organ

In the paper

“Infections with more than one pathogen or antibiotic-resistant bacteria are more common in HIV-positive than in HIV-negative children, and lead to higher case-fatality ratios.62, 63”

What the sources say

• Not checked yetcites [62] Enarson, 2010, Impact of HIV on standard case management for severe pneumonia in children, Expert Rev Respir Med source
• Not checked yetcites [63] Graham, 2007, HIV-related pulmonary disorders: practice issues, Ann Trop Paediatr source

In the paper

“Infection typically causes acute secretory diarrhoea with so-called rice-water stools (as much as 1 L/h), and can result in hypotensive shock and high case-fatality rates in susceptible individuals.90”

What the sources say

• Not checked yetcites [90] Harris, 2012, Cholera, Lancet source

In the paper

“Epidemics occur in areas with poor water and sanitation facilities, little basic infrastructure, and high population densities.93”

What the sources say

• Not checked yetcites [93] Hartley, 2006, Hyperinfectivity: a critical element in the ability of V. cholerae to cause epidemics?, PLoS Med source

In the paper

“HIV can directly affect the intestinal mucosa, resulting in enteropathy with diarrhoea due to changed intestinal functions.60”

What the sources say

• Not checked yetcites [60] Wilcox, 2000, Etiology and evaluation of diarrhea in AIDS: a global perspective at the millennium, World J Gastroenterol

In the paper

“In epidemics when V cholerae infects a naive population, morbidity and mortality occur at all ages.92”

What the sources say

• Not checked yetcites [92] Feachem, 1982, Environmental aspects of cholera epidemiology. III. Transmission and control, Trop Dis Bull

In the paper

“Data from health information systems81 in these populations show that pneumonia (defined by WHO thresholds for fast breathing) accounted for 20% of all child deaths and 17% of illness episodes, whereas diarrhoea accounted for 7% of deaths and 10% of illness episodes.”

What the sources say

• Not checked yetcites [81] Hershey, 2011, Incidence and risk factors for malaria, pneumonia and diarrhea in children under 5 in UNHCR refugee camps: a retrospective study, Confl Health source

In the paper

“Pneumonia is the most common mode of death from measles, and is associated with 56–86% of measles deaths.79”

What the sources say

• Not checked yetcites [79] Duke, 2003, Measles: not just another viral exanthem, Lancet source

In the paper

“In endemic areas, incidence peaks in children younger than 5 years because at least partial immunity develops after illness.88, 91”

What the sources say

• Not checked yetcites [88] Glass, 1992, The epidemiology of cholera
• Not checked yetcites [91] Glass, 1982, Endemic cholera in rural Bangladesh, 1966–1980, Am J Epidemiol source

In the paper

“Cholera is one of the most devastating diarrhoeal diseases, and causes high rates of mortality and widespread social upheaval during epidemics.88”

What the sources say

• Not checked yetcites [88] Glass, 1992, The epidemiology of cholera

In the paper

“Chronic lung disease is common (although no accurate estimates are available) in HIV-positive children and is due to bacterial pneumonias responding poorly to treatment, tuberculosis, bronchiectasis, lymphoid interstitial pneumonia, or opportunistic fungal infections.61, 63, 64”

What the sources say

• Not checked yetcites [61] Madhi, 2000, Increased disease burden and antibiotic resistance of bacteria causing severe community-acquired lower respiratory tract infections in human immunodeficiency virus type 1-infected children, Clin Infect Dis source
• Not checked yetcites [63] Graham, 2007, HIV-related pulmonary disorders: practice issues, Ann Trop Paediatr source
• Not checked yetcites [64] Graham, 2005, Non-tuberculosis opportunistic infections and other lung diseases in HIV-infected infants and children, Int J Tuberc Lung Dis

In the paper

“because pneumonia is a major cause of death from pandemic influenza in young children.”

In the paper

“Of these pathogens, P jirovecii and cytomegalovirus pneumonia occur mainly in infants aged 2–6 months.”

In the paper

“It is caused by infection of the small intestine with the Gram-negative Vibrio cholerae.89”

What the sources say

• Not checked yetcites [89] Morris, 2003, Cholera and other types of vibriosis: a story of human pandemics and oysters on the half shell, Clin Infect Dis source

In the paper

“Pneumonia has also been postulated to be a climate-sensitive disease that is likely to be affected substantially by pronounced climate change.107”

What the sources say

• Not checked yetcites [107] Paynter, 2010, Childhood pneumonia: a neglected, climate-sensitive disease?, Lancet source

In the paper

“Referrals of severe disease to hospitals would be substantially reduced for both disorders, but management of the remaining cases would be more complicated and expensive, with increased health-service costs per case.”

In the paper

“For some risk factors, such as inadequate water and sanitation, poor handwashing, indoor air pollution, and crowding, risk relations have been difficult to define, but addressing them will probably have benefits for disease reduction.”

In the paper

“An effective health-service response to this burden of severe disease will necessitate not only development of hospital services and improved access to inpatient care, but also community approaches to management of illness before hospital care becomes necessary.”

In the paper

“Differences in immunisation rates, breastfeeding practices, and community case management of diarrhoea and pneumonia might be important factors in these discrepancies.”

In the paper

“Estimates of deaths from pneumonia and diarrhoea in children younger than 5 years are lower than are the WHO and UNICEF estimates we used, which is probably because of differences in the inclusion data, cause-of-death classification, and modelling approaches.”

In the paper

“Many of the available data are not nationally representative and do not come from the highest mortality stratum, and so they might underestimate the true national burden of disease,4, 5 and consequently our estimates have wide CIs.”

What the sources say

• Not checked yetcites [4] Rudan, 2007, Childhood pneumonia and diarrhoea: setting our priorities right, Lancet Infect Dis source
• Not checked yetcites [5] Rudan, 2005, Gaps in policy-relevant information on burden of disease in children: a systematic review, Lancet source

In the paper

“Checkley and colleagues106 reported increases in hospital admissions for diarrhoea in Peru associated with El Niño in 1997–98, suggesting that if ambient temperatures increase because of climate change, admissions associated with diarrhoea could be expected to rise.”

What the sources say

• Not checked yetcites [106] Checkley, 2000, Effect of El Niño and ambient temperature on hospital admissions for diarrhoeal diseases in Peruvian children, Lancet

In the paper

“Reports from WHO105 and the Intergovernmental Panel on Climate Change have identified changes in the incidence of diarrhoea as one of the most important future health effects of climate change.105”

What the sources say

• Not checked yetcites [105] 2009

In the paper

“Therefore, monitoring of disease trends with time or assessment of the effect of new interventions is difficult.”

In the paper

“A substantial change in the causative range for pneumonia would be expected with high coverage of these vaccines (both available vaccines and effective new vaccines), which could necessitate fundamental change to case management guidelines.”

In the paper

“Although improved access and expanded treatment is an important public health goal, the associated rise in antibiotic use can lead to increased antimicrobial resistance and more multidrug resistant pathogens.”

In the paper

“Prevention of some of these severe episodes is possible through routine and timely immunisation, especially of high-risk children, and timely community-based case management.99, 100”

What the sources say

• Not checked yetcites [99] Chowdhury, 2008, Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study, Lancet source
• Not checked yetcites [100] Soofi, 2012, Effectiveness of community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Matiari district, rural Pakistan: a cluster-randomised controlled trial, Lancet source

In the paper

“Incidence in many settings is strongly associated with rainfall, and thus the predicted increased intensity rainy seasons in Asia, Africa, the western Pacific region, and parts of South America in the future will probably be associated with a raised burden of childhood pneumonia.108”

What the sources say

• Not checked yetcites [108] Torti, 2012, Floods in southeast Asia: a health priority, J Glob Health source

In the paper

“Integrated Community Case Management103 of pneumonia, diarrhoea, and malaria improves access to care, and community health workers can safely and effectively treat such disorders.”

What the sources say

• Not checked yetcites [103] Young, 2012, World Health Organization/United Nations Children's Fund joint statement on integrated community case management: an equity-focused strategy to improve access to essential treatment services for children, Am J Trop Med Hyg source