Child Health: Overview

Dr E Malek, Principal SpecialistDepartment of Paediatrics, University

of Pretoria, Witbank Hospitalemalek@postino.up.ac.za

Acknowledgements• Dr Joy Lawn (Save the Children Fund)• DR Lesley Bamford (National DOH)• Dr Debbie Bradshaw (MRC NBD unit)• Prof T Duke (CICH, University of Melbourne)• Dr M Weber (WHO-CAH, Geneva)• Dr N McKerrow (PMB Hospital)• DR Macharia (UNICEF, Pretoria)• Dr N Rollins (UKZN)• DR C Sutton (MEDUNSA, Polokwane)

Outline• Global child health• Child Health in South Africa

Global Context (1)

• Child Health Inequity• Causes of global child mortality• Child disability and development• Neonatal Health• Adolescent Health• Children in complex emergencies • Effect of poor child health on communities

Global Context (2)

• Child Health in context of Maternal Health• International Conventions and child health• Evidence for effective intervention in

reducing child mortality• Pathways to & principles of global child

health

Source: Bryce J et al for the Child Health Epidemiology Reference Group. The Lancet, March 2005. As used in WHR 2005

Injuries3%

Pneumonia19%

Neonatal deaths

36%

Other10%

HIV/AIDS3%Measles

4%

Malaria8%

Diarrhoea17%

10 million child deaths – Why?

For these 4 causes, ~

53% of deaths are malnourished children

AIDS is much bigger proportion in Southern

Africa.

4 million newborn deaths – Why?

Source: Lawn JE, Cousens SN, Zupan J Lancet 2005. for 192 countries based on cause specific mortality data and multi cause modelled estimates. As used in World Health Report 2005

60 to 90% of neonatal deaths are in low birth weight babies, mostly preterm

Three causes account for 86% of all neonatal

deaths

Source: UNICEF, 2001

181

128

80

5853

45

175

100

64

4437 38

9 6

0

20

40

60

80

100

120

140

160

180

200

Sub-SaharanAfrica

South Asia Middle East &North Africa

East Asia andPacific

Latin America& Caribbean

CEE/CIS andBaltics

Industrializedcountries

U5M

R (d

eath

s pe

r 100

0 bi

rths)

19902000Least

reduction 3%

Greatest reduction

32%

Under five mortality rates: Trends from 1990-2000

Slide: Ngashi Ngongo

International Conventions

• Declaration of Alma Ata: “Health for All by the year 2000”

• UN Convention of the Rights of the Child (1990)

• UN Millenium Development Goals (MDGs)

Millennium Development Goals (MDGs)

1. Eradicate extreme poverty and hunger

2. Achieve universal primary education

3. Promote gender equality and empowerment of women

4. Reduce child mortality by two thirds

5. Reduce MMR by three quarters6. Combat HIV/AIDS,

malaria and other diseases

7. Ensure environmental sustainability

8. Develop global partnerships

for development

Integrated Management of Chilldhood Illness (IMCI)

Department of Child and Adolescent Health and Development

Finding Classification Treatment

Danger signs Severe disease Urgent referral

Cough or difficulty inbreathing

Severe disease Urgent referral

Diarrhoea

FeverDisease with specifictherapy

Specific medical treatment

Ear problem

Nutritional status/anaemia

Disease without specifictherapy

Symptomatic treatment

Vaccination status Complete/incomplete Vaccinate

Assess and classify

IMCI facility based usage in Bangladesh (Lancet, 2004)

WHO Initiatives to improve quality of care for children at

hospital level: state of the art and prospects

Martin Weber, Harry Campbell, Susanne Carai, Trevor Duke, Mike English, Giorgio Tamburlini

25th International Congress of Paediatrics, Athens, 25-30 August 2007

Standards of Hospital Care for Children: Hospital IMCI Evidence-Based Guidelines

Child Health in South Africa

• Child Health Inequity• Causes of Child Mortality• Neonatal Health• National interventions for improving child

health• Children’s Act (Amendment Bill: 2007)• Challenges

UNICEF remarks at opening of SA Child Health Priorities conference

(Dec 2007, Durban)

Distribution of Resources

Slide: Ngashi Ngongo

South Africa progressto MDG 4

Under 5 mortality is increasing, related to HIV (73 000 a year)Neonatal mortality is probably static and accounts for ~30% of

under five deaths (23,000 newborn deaths a year)

21

6754

200

50

100

150

1980 1985 1990 1995 2000 2005 2010 2015

Mor

talit

y pe

r 1,0

00 b

irths

.

Neonatal MortalityRateUnder 5 Mortality Rate

Infant Mortality Rate

MDG 4 Target

Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006

Causes of U5M

Low birth weight, 12%

Asphyxia, 3%

Infections, 3%

Others: 30%

PEM: 5%

Pneumonia: 6%

Diarrhoea: 11%

HIV/AIDS: 40%

Neonatal18%

Source: MRC 2003

Every Death Counts

Challenges: Health Service in South Africa

Child Mortality (1)• The National Burden of Disease study estimated

just over half a million deaths of which• 106 000 were of children under the age of 5

years • A further 7800 were children aged 5-14 years.• An estimated 4564 deaths are from protein-

energy malnutrition (Kwashiorkor)• In general, young babies are much more

vulnerable than older• The cause of death patterns in the different age

groups are very different.

Top twenty specific causes of death in childrenunder 5 years, South Africa 2000 (NBD)

0102030405060708090

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

EastWestNorth

Leading causes of death among infants under 1 year of age, South Africa 2000

Leading causes of death among infants under 1 year of age, South Africa 2000

Child Mortality (2)

• The NBD study estimates that by the year 2000, – the Infant Mortality Rate had risen to 60 per 1000 live

births and – the Under-5 mortality rate had risen to 95 per 1000.

• This deterioration in child health occurred despite the introduction of free health care and nutrition programmes and was attributable to paediatric AIDS, commensurate with the high prevalence of HIV observed among pregnant women.

Leading causes of death among children aged 1-4 years, South Africa 2000

Leading causes of death among children aged 1-4 years, South Africa 2000

Child Mortality (3)• As children get older, external causes of death

(eg. road traffic injuries and drowning) rise in importance.

• This is particularly noticeable among boys who die in greater numbers than girls. This pattern becomes particularly marked among the 10 -14 year age group, where road traffic accidents is the leading cause of death.

• Homicide and suicide feature in the top causes among the 10-14 year age group, homicide is the second leading cause of death.

* Source: WHO World health Statistics 2006 www.who.int

Child PIP (%) (1532 deaths)1 month to 5 years

WHO* (%)Zero to 5 years

HIV/AIDS - 57Pneumonia 22 1Septicaemia/meningitis 21 -Diarrhoea 20 1TB 5 -PCP 11 -Other 19 1Malaria - 0Measles - 0Injuries Included under “other” 5Neonatal (16% of all admissions but causes

tabulated for 1 month to 5 years) 35

Child deaths in RSA - Why?

HIV test ~ 54% tested26% +ve20% exposedOnly 8% tested -ve

HIV clinical stage~ 58% stagedof which half were Stages III & IV

88% HIV if exclude neonatal

Most deaths 1 month to 5 yrs

Child PIP in Mpumalanga:

ChPIP Data: Witbank Hospital had 2244 child admissions & 101 child deaths in 2006; overall case fatality rate 4.5;31% of all deaths within 1st 24 hours of admissionChPIP Sites:2004: Witbank

2006: Witbank & Barberton

2007: above plus 8 new sites

Causes of death of children in hospitals

(n = 1695)

33

1512

103

20

1216

7

13

0

5

10

15

20

25

30

35

%

2004 2005

ARI DD Sepsis AIDS TB PCP

Child Mortality: HIV/AIDS

• 1998 SADHS U5MR 61/1000 (1994-8)• 2003 SAHDS U5MR 58/1000 (1999-2003)?• Without PMTCT one third of babies born to HIV+

mothers will be infected: of these, 60% expected to die before 5 years of age

• 40% U5 hospital deaths due to AIDS • Child mortality in SA too high for middle-income

country, and increasing, despite children’s rights

Child mortality: HIV/AIDS

• Vertical transmission rate 20.8% (KZN)• <50% pregnant women being tested• 2/3 all HIV+ infants needing ART by 10

months of age – without access to ARV 1/3 of HIV+ children die in 1st year of life

• One in 6 qualifying children get ARV

Policy Brief: Child Mortality• The Medical Research Council published the

Initial Burden of Disease Estimates for South Africa, 2000 in March 2003.

• A major finding of the study was the quadruple burden of disease experienced in South Africa resulting from the combination of the pre-transitional causes related to underdevelopment, the emerging chronic diseases, the injury burden and HIV/AIDS.

Policy Implications (1)

• The mortality data indicates that many of the child deaths occurring in South Africa are preventable.

• We have identified three broad areas that will require differing approaches for intervention:

Policy Implications (2)

1. The prevention of mother-to-child transmission of HIV, even at its current efficacy, is the single most effective intervention to reduce mortality among under-5-year olds, eclipsing all other interventions for other causes of death combined.

Policy Implications (3)2. Although dominated by the rise of HIV/AIDS, the classic

infectious diseases such as diarrhoea, respiratory infections and malnutrition are still important causes of mortality. Environment and development initiatives such as access to sufficient quantities of safe water, sanitation, reductions in exposure to indoor smoke, improved personal and domestic hygiene as well as comprehensive primary health care will go a long way to preventing these diseases. Poverty reduction initiatives are also important in this regard.

Policy Implications (4)

3. Road traffic accidents and violence, which includes homicide and suicide is another group of high mortality conditions that will require dedicated interventions.

PMTCT (1)

• Most important intervention to reduce HIV infection in children

• Almost all ANC services provide PMTCT, but many barriers to testing and effective treatment.

• Cotrimoxazole prophylaxis from 6 weeks of age reduces HIV related child mortality by as much as 43%

PMTCT (2)

• Recommendation: Mandatory testing all children at 6 week immunisation visit & double testing of pregnant women

• Currently 300 000 HIV infected children – 50-60% expected to currently need ARV’s

• SA is one of only 9 countries world-wide where child mortality is increasing

PMTCT (3)

• Routine provider-initiated testing for all 6 week old infants is currently excluded from the NSP on HIV/AIDS

• Memorandum of concern: Maternal & Child survival (2007)

• TAC Media Statement: Call for finalisation of Revised PMTCT Guidelines (Jan 2008)

Key Child Survival Strategies

1. Infant and Young Child Feeding (including EBF)

2. Immunisation3. Treatment of common childhood illnesses4. Care of children with HIV-infection5. Provision of Vitamin A6. PMTCT

National Health Targets

Key MCH interventionsMATERNAL CARE

1. Focused ANC 2. PMTCT-Plus 3. Skilled

attendant deliveries

4. EMOC5. Family

planning

NEONATAL CAREBasic neonatal care1. Resuscitation2. LBW care3. Early EBF4. KMC5. PMTCT-Plus6. Infection

management

CHILD CARE1. Infant and

Young Child Feeding

2. HIV care3. IMCI (clinic)4. Hospital care5. EPI6. Vitamin A7. HIV testing,

cotrim, ARV

South Africa:Coverage along the

MNCH continuum of care

7%84%94% 93%

0%

25%

50%

75%

100%

Antenatal care(at least one

visit)

Skilledattendant

duringchildbirth

Postnatal care Excl. BF Immunisation(DPT3)

no data

Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006

The days of highest risk

have the lowest coverage of care

Infant and Young Child Feeding

• Exclusive breastfeeding (BFHI)• Provision of good quality complementary

feeds• Appropriate care of children with

malnutrition

Only 12% of infants EBF by 6 months

EBF at 6 months

Plain water only

Other liquids

Solid mushy food

Not BF

0

10

20

30

40

50

60

70

80

90

100

0-4 4-6 7-9 10-12

Source: Demographic Health Survey 2003 Slide: Ngashi Ngongo

Immunisation• Good coverage• Major reduction in number of children with measles• South Africa declared polio free• Need to ensure high coverage is maintained, and to use

every opportunity to immunise children• Community outreach programmes RED STRATEGY• Management issues e.g. cold chain, monitoring

coverage

• Not linked to HIV screening (6 week visit!)

Existing norms and standards

• Primary Health Care package• District Hospital package• Regional hospital package• Service Transformation Plan• Modernization of Tertiary Services

Existing norms and standards

• IMCI• Clinic supervisors manual• EDL• WHO pocketbook

Staffing norms

• No official staffing norms for the country• Various systems have been used

Service transformation plan

• PHC clinics: 1 for 10 000 people• CHC: 1 for 60 000 people• District hospital: 1 for 300 000 people• Regional (Level II) hospital:1 for 1.2 million• Tertiary (Level III) hospital:1 for 3-

3.5million people

Standard Treatment Guidelines & Essential Drug List

Care of children with HIV-infection

• Prevention is key• Early diagnosis and

preventive care• Staging and referral for

ART when appropriate• Psychosocial support

IMCI

IMCI: Bringing it all together

Maternal

Health

HOUSEHOLD AND COMMUNITY IMCI

EPI

Nutrition (Vitamin

A)

Care of HIV infected children

PMTCT Plus

Appropriate infant feeding

TEMBA

BARBERTON

PIET RETIEF

ERMELO

CAROLINA

STANDERTON

WITBANK

MIDDELBURG

TINTSWALO

EVANDER

ROB FERREIRA

Active Site

Future Site

Witbank NNMR 2000-2005 trend (=/> 1000 grams)

0

50

100

150

200

250

2000 2001 2002 2003 2005*

1000-1499g1500-1999g2000-2499g>2500g

NICU

nCPAP

References• SA IMCI chart booklet: UP Intranet (Block 10)• www.who.int/child-adolescent-health/publications/

CHILD_HEALTH/PB.htm

• www.who.int/child-adolescent-health/over.htm• www.ichrc.org• www.unhchr.ch/html/menu3/b/k2crc.htm• www.unicef.org/sowc02• www.developmentgoals.org/Child_Mortality.htm• www.doh.gov.za • www.thelancet.com

“There can be no keener revelation of a society’s soul than the way it treats its children”

Nelson Mandela, 1988