Seasonal variation and etiologic inferences of childhood pneumonia and diarrhea mortality in India

  1. Daniel S Farrar
  2. Shally Awasthi
  3. Shaza A Fadel
  4. Rajesh Kumar
  5. Anju Sinha
  6. Sze Hang Fu
  7. Brian Wahl
  8. Shaun K Morris
  9. Prabhat Jha  Is a corresponding author
  1. St Michael's Hospital, Canada
  2. King George's Medical University, India
  3. Postgraduate Institute of Medical Education and Research, India
  4. Indian Council of Medical Research, India
  5. Johns Hopkins Bloomberg School of Public Health, United States
  6. Hospital for Sick Children, Canada

Abstract

Future 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 in 2015 with prevalence surveys, we estimate 40,600 pneumonia deaths from Streptococcus pneumoniae, 20,700 from RSV, 12,600 from influenza, and 7,200 from Haemophilus influenzae type b and 24,700 diarrheal deaths from rotavirus. Careful mortality studies can elucidate etiologies and inform vaccine introduction.

Data availability

Data from the Million Death Study cannot be redistributed outside of the Centre for Global Health Research due to legal agreements with the Registrar General of India. Access to MDS data can be granted via data transfer agreements, upon request to the Office of the Registrar General, RK Puram, New Delhi, India (rgoffice.rgi@nic.in). The public census reports can be found at http://www.censusindia.gov.in/vital_statistics/SRS_Statistical_Report.html. Source data files have been provided for Figure 3, Figure 3 - figure supplement 1, Figure 3 - figure supplement 2, Figure 4, Figure 4 - figure supplement 1, Figure 6, Figure 6 - figure supplement 1, and Figure 8. Meta-analyses include only previously published data, and all data sources have been listed in supplemental reference lists within the article file.

Article and author information

Author details

  1. Daniel S Farrar

    Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
    Competing interests
    No competing interests declared.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0002-7823-1912
  2. Shally Awasthi

    Department of Pediatrics, King George's Medical University, Lucknow, India
    Competing interests
    No competing interests declared.
  3. Shaza A Fadel

    Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
    Competing interests
    No competing interests declared.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0002-2336-6254
  4. Rajesh Kumar

    School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
    Competing interests
    No competing interests declared.
  5. Anju Sinha

    Division of Reproductive Biology, Maternal and Child Health, Indian Council of Medical Research, New Dehli, India
    Competing interests
    No competing interests declared.
  6. Sze Hang Fu

    Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
    Competing interests
    No competing interests declared.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0003-4890-9339
  7. Brian Wahl

    International Vaccine Access Centre, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States
    Competing interests
    No competing interests declared.
  8. Shaun K Morris

    Centre for Global Child Health, Division of Infectious Diseases, Hospital for Sick Children, Toronto, Canada
    Competing interests
    No competing interests declared.
  9. Prabhat Jha

    Center for Global Health Research, St Michael's Hospital, Toronto, Canada
    For correspondence
    jhap@smh.ca
    Competing interests
    Prabhat Jha, Reviewing editor, eLife.
    ORCID icon "This ORCID iD identifies the author of this article:" 0000-0001-7067-8341

Funding

Canadian Institutes of Health Research (FDN154277)

  • Prabhat Jha

Bill and Melinda Gates Foundation

  • Prabhat Jha

National Institutes of Health (R01TW05991-01)

  • Prabhat Jha

The funders had no role in study design, data collection, analysis or interpretation, preparation of the manuscript or the decision to submit the work for publication.

Reviewing Editor

  1. Mark Jit, London School of Hygiene & Tropical Medicine, and Public Health England, United Kingdom

Version history

  1. Received: February 19, 2019
  2. Accepted: August 21, 2019
  3. Accepted Manuscript published: August 27, 2019 (version 1)
  4. Version of Record published: September 24, 2019 (version 2)

Copyright

© 2019, Farrar et al.

This article is distributed under the terms of the Creative Commons Attribution License permitting unrestricted use and redistribution provided that the original author and source are credited.

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  1. Daniel S Farrar
  2. Shally Awasthi
  3. Shaza A Fadel
  4. Rajesh Kumar
  5. Anju Sinha
  6. Sze Hang Fu
  7. Brian Wahl
  8. Shaun K Morris
  9. Prabhat Jha
(2019)
Seasonal variation and etiologic inferences of childhood pneumonia and diarrhea mortality in India
eLife 8:e46202.
https://doi.org/10.7554/eLife.46202

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https://doi.org/10.7554/eLife.46202

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