India’s Deadly Diarrhea Problem

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A woman held her daughter who is undergoing treatment for diarrhea in Hyderabad, May 10, 2009.  

For many people, a case of diarrhea means a visit to the doctor, a course of medication or eating bland food for a few days. Yet diarrhea is still the second biggest killer of children globally, with more than 800,000 under-fives dying every year according to Unicef. A quarter of these deaths occur in India. Hundreds of thousands more children in the country are hospitalized and permanently stunted from the disease.

Two new studies were published Tuesday: one highlights the major viruses, parasites and bacteria that lead to the most severe types of diarrhea, while the other details promising results of an affordable Indian vaccine trial for the most important cause of childhood diarrhea.

In the largest international study ever conducted on diarrhea death, published in the Lancet today, the Global Enterics Multi-Center Study found that the top cause of moderate to severe diarrhea in India is rotavirus. In a world where cholera, typhoid and dysentery are well known as common diseases acquired through the gut, the greatest killer of them all doesn’t have name recognition amongst parents or policymakers.

The World Health Organization estimates that rotavirus leads to the death of 450,000 children worldwide every year. India is the worst affected, with an estimated 98,000 deaths a year. Even if children don’t die, the diarrheal illness due to rotavirus can be severe, resulting in rapid dehydration, metabolic disturbances and possible long-term consequences of malnutrition and a damaged gut.

Although most diarrheal diseases can be managed without a specific drug by making sure that hydration is maintained, rotavirus also causes vomiting, which results in additional fluid loss and makes it difficult to treat a child except by giving intravenous fluids.

The GEMS study looked at seven countries in Africa and Asia. Many children with the most severe diarrhea had a rotavirus infection. Facilities where very young children can be safely and effectively treated are severely limited and if parents cannot reach them in time, their children die. Even if they can get to the right place, managing illness in young children is not easy or cheap. And this is without counting the costs to parents having to travel to reach health care, pay for medicines and lose time at work, which cumulatively can push families into poverty.

So what can be done?

The results of the final part of a 25-year effort project to develop an indigenous vaccine against rotavirus were presented in New Delhi Tuesday. The vaccine, based on an Indian strain and developed and tested here, was found to be safe and effective in preventing rotavirus disease, according to the study supported by the Department of Biotechnology and Bharat Biotech.

At the projected price of $1 per dose, this vaccine is at least 60% cheaper per dose than other available rotavirus vaccines procured by Unicef for GAVI supported countries.

Critics might ask why there is a focus on a vaccine when we know that safer water and food prevents disease. Unfortunately, although a cleaner environment delays rotavirus infection, it doesn’t prevent it. Many children even in the most high-income countries get infected and sick with rotavirus; it just happens at a later age and children do not die, because they are older. They also have fewer underlying problems such as malnutrition and they can access healthcare more easily.

In the U.S., for example, all children are recommended rotavirus vaccines, even though none die of rotavirus disease and immunization costs $200 a child. Still, according to the New England Journal of Medicine, the U.S. healthcare system is estimated to have saved $270 million because of the number of hospital admissions the vaccines have prevented.

Preventing and treating diarrhea cannot be done through one vaccine alone. Available vaccines aren’t perfect and public health systems don’t reach every child. Water and sanitation must be improved, oral rehydration solutions need to be made more widely available, and zinc should be distributed to children with acute diarrhea. 

There is much to do, but that includes giving serious and urgent consideration to addressing rotavirus. Every year, we count the number of children’s lives we lose to preventable disease in developing countries. It is not up to the children to protect themselves; it is up to us to stop neglecting them.

Dr. Gagandeep Kang is a professor in the Department of Gastrointestinal Sciences at Christian Medical College in Vellore