Abstract
Control of pneumonia and diarrhea mortality in India requires understanding of their etiologies. We combined time series analysis of seasonality, climate region, and clinical syndromes from 243,000 verbal autopsies in the nationally representative Million Death Study. Pneumonia mortality at 1 month-14 years was greatest in January (Rate ratio (RR) 1.66, 99% CI 1.51-1.82; versus the April minimum). Higher RRs at 1-11 months suggested respiratory syncytial virus (RSV) etiology. India's humid subtropical region experienced a unique summer pneumonia mortality. Diarrhea mortality peaked in July (RR 1.66, 1.48-1.85) and January (RR 1.37, 1.23-1.48), while deaths with fever and bloody diarrhea (indicating enteroinvasive bacterial etiology) showed little seasonality. Combining mortality at ages 1-59 months with prevalence surveys, we estimate 40,600 pneumonia deaths from Streptococcus pneumoniae, 20,700 from RSV, 12,600 from influenza, and 7200 from Haemophilus influenzae type b and 24,700 diarrheal deaths from rotavirus occurred in 2015. Careful mortality studies can elucidate etiologies and inform vaccine introduction.
Highlights
Despite substantial declines in the last decade, pneumonia and diarrhea remain the leading causes of mortality in India among children, causing about 190,000 deaths at ages 1–59 months in 2015 (Fadel et al, 2017)
About 57% of pneumonia deaths occurred at ages 1–11 months, while diarrhea deaths occurred more evenly at ages 1–11 months (39%) and ages 1–4 years (43%)
Blinded physicians agreed upon a diagnosis of pneumonia or diarrhea in 77% and 86% of cases upon initial double review, respectively
Summary
Despite substantial declines in the last decade, pneumonia and diarrhea remain the leading causes of mortality in India among children, causing about 190,000 deaths at ages 1–59 months in 2015 (Fadel et al, 2017). The declines in pneumonia and diarrhea mortality during the last decade or so have mostly been driven by expanding treatment, improved nutrition, and vaccination against measles and standard childhood antigens (Bhutta et al, 2013; Wong et al, 2019). Newer vaccines such as rotavirus and pneumococcal conjugate vaccines have been only recently added to India’s Universal Immunization Program (Arora and Swaminathan, 2016; Sachdeva, 2017). Assessing the impact of these newer vaccines requires understanding the baseline mortality and distribution of specific microbiologic etiologies
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