Problems and Interventions in Global Child Health

GLOBAL CHILD HEALTH PROBLEMS

Big Picture: How Many? Where? What?

Disease Specific:Interventions for Prevention & Treatment

Strategies for Intervention Delivery:Integrated Management of Childhood Illnesses (IMCI)

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Scope of the Problem

~8 million children under 5 years of age die each year

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Regional Distribution of Child Deaths

• 99% of childhood deaths occur in LMIC

• Africa – HALF of all child deaths– Up from 30% in 1990

43% in 2003

• S Asia– 33% of all child deaths

Source: Levels and trends in child mortality, 1990-2009. UNICEF. 2010

Regional Differences in Child Mortality: U5MRs in 6 countries

Carl Haub and Diana Cornelius, 2000 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2000)

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Regional differences in U5MRs

Region U5MR Risk of death

Globally 60 1 in 17

Developing 66 1 in 15

S. Asia 69 1 in 14

Sub-Saharan Africa 129 1 in 8

Developed 6 1 in 167

USA 8 1 in 125

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Regional differences in U5MRs

Sub-Saharan Africa

• Started w/ highest levels

• Saw smallest reductions (5%/decade)

• Most marked slow down in progress

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Trends in U5MR

• 1970—146 deaths/1000

• 1990— 90 deaths/1000

• 2009— 60 deaths/1000

• However reductions in U5MR—slowed– 1970-1990 U5MR 20%/decade– 1990-2000 U5MR 12%/decade

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Slowing trends in child mortality

Source: WHO Report 2005: Make Every Mother and Child Count

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Millennium Development Goal 4

Reduce child mortality rates by 2/3 by the year 2015

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Trends in Child Mortality: Not on Track to Meet MDG4

Based on data from the Interagency Group for Child Mortality Estimates

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Trends in U5MR

In 21 developing countries:

• Overall U5MR • Gaps in U5MR between rich and poor

while

GLOBAL CHILD HEALTH

Big Picture: How Many? Where? What?

Disease Specific:Interventions for Prevention & Treatment

Strategies for Intervention Delivery:Integrated Management of Childhood Illnesses (IMCI)

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What are the leading causes of childhood mortality worldwide?

Reproduced from UNICEF ChildInfo website: http://www.childinfo.org/mortality.html and based on Black R et al. Global, regional, and national causes of child mortality in 2008. Lancet. 2010;375:1969–1987.

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Undernutrition: Underlying Cause in >1/3 of Childhood Deaths

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Impact of Breastfeeding on Childhood Disease

Risk in not BF vs exclusively BF

Diarrhea

7x risk death

Pneumonia

5x risk death

CG Victoria et al, Am J Epidemiol 1989

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Micronutrients

Example

Vit A Deficiency

20-24% Risk of death from Diarrhea, Measles, (Malaria)

AL Rice et al In: Comparative quantification of health risks, 2004

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Underlying Determinants of Child MortalityPovertyInequityLack of maternal educationLack of access to careRural residence

Conflict/War/DisasterDebtStructural Adjustment Policies

Examples of Socio-political-economic policies and factors that impact health

GLOBAL CHILD HEALTH

Big Picture: How Many? Where? What?

Disease Specific:Interventions for Prevention & Treatment

Strategies for Intervention Delivery:Integrated Management of Childhood Illnesses (IMCI)

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Disease Specifics

• Interventions = “biologic agent or action intended to reduce morbidity or mortality”

–Prevention

–Treatment

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Acute Infectious Diarrhea

• 1.2 million child deaths/year (80% in < 2yo’s)• Microbiologic Etiology--multiple

– Regional/local variation – e.g. Rotavirus, Shigella, Enterotoxogenic E coli,

Campylobacter

• Spread– water, food, utensils, hands, flies

• Deaths– dehydration (water loss) – electrolytes/salts loss (sodium, potassium, bicarbonate)

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Diarrhea: Prevention

– Clean Water• drinking, food

preparation

– Sanitation• Safe Feces

Disposal

– Adequate supply of water

• hygiene

23Source: UNICEFhttp://www.childinfo.org/water_status_trends.html

Access to Improved Water Sources

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In many parts of the world, rural populations still lack access to safe

drinking water

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http://www.childinfo.org/sanitation_status_trends.html

Access to Improved Sanitation Facilities

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Diarrhea: Treatment

• Prevention and treatment of dehydration--Oral Rehydration Therapy (ORT)

– Increased fluids (IF)– Home-made sugar/salt/water solutions (SSS)– Oral Rehydration Salts (ORS)

– Continued feeding(/breastfeeding) (CF)

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Diarrhea: Treatment

How much does a sachet of ORS cost?

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Diarrhea: TreatmentORT

– Prevent and treat dehydration

Zinc supplementation– Given during acute diarrhea episode reduces duration

and severity of episode– Given for 10-14 days reduces incidence of diarrhea in

following 2-3 months

• Selective use of antibiotics– Dysentery

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IMPACT OF ORT

• Saves 1 million lives per year• Diarrhea deaths HALVED from 1990-2000

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What is the coverage rate of ORT among children with diarrhea?

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Diarrhea—Questions and Future Interventions

How to increase ORT utilization?individual, community, country

Will further increased ORT utilization have same dramatic impact on mortality?

How will water privatization impact clean water supplies?

Vaccines—rotavirus, choleraElucidating etiologies of

diarrhea/surveillance

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Pneumonia

• >1.4 million deaths/year in < 5yo’s

• Bacteria (60-70%)—especially – Pneumococcus

– Haemophilus influenzae type b (Hib)

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Pneumonia: Prevention

• Immunization (measles, pertussis)– “Newer” immunizations not readily available

(pneumococcus, H influenzae b)--$$

• Nutrition– Exclusive breastfeeding / appropriate complementary

feeding– Vit A and Zinc through diet / supplementation

• Avoidance of indoor air pollution – E.g., Unprocessed household solid fuels (wood, dung,

coal)1.8 increased risk of pneumonia

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Pneumonia: Treatment

• Case management--Prompt treatment with appropriate antibiotic (right doses, full course)

• The good news: 1st line oral antibiotics (amoxicillin, cotrimoxazole) are effective

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Pneumonia: Treatment

Case management can pneumonia associated childhood mortality by 40%

– S Sazawal, et al Lancet 2003

Pneumonia: Treatment Coverage

What % of children with pneumonia are taken to a health care provider?

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Pneumonia: Treatment

50 % world wide

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Pneumonia: Treatment

What does it take?

• Caretaker recognizing symptoms of illness, seeking prompt care, giving full course of antibiotics

• Access to care

• Community case management—community health workers can effectively identify and treat pneumonia with oral antibiotics

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Malaria

• Plasmodium parasites

• Anopheles mosquito – Pools of water—breeding ground

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Malaria• Clinical presentation:

– Asymptomatic– “Uncomplicated” malaria = fever, headache,

malaise (cough, diarrhea)– “Severe” or “Complicated” malaria = multi-

organ system involvement• Severe anemia• Jaundice• Cerebral malaria

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Malaria

• Morbidity– Major cause of anemia in endemic areas– Impact on growth and cognitive development

• Drains $2 billion from economies in sub-Saharan Africa

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Malaria• 300-500 million cases of clinical malaria/yr

• 650,000 deaths/year– 90% in sub-Saharan Africa– Majority in children

• Recent upsurge– Environmental factors (climate, water

development projects)– Areas of conflict (disruption in previous control

programs)

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Almost half of the worlds’ population live in malaria endemic areas

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Malaria: Prevention• Vector control

– Indoor Residual Spraying (IRS)– Environmental measures (e.g. reduction of

standing water)

Insecticide Treated Nets (ITNs)• High ITN use 17% reduction in childhood

mortality

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ITNs

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http://www.childinfo.org/malaria_progress.html

Progress in scaling up ITN use in sub-Saharan AfricaProportion of children sleeping under an ITN, all African countries with two or more comparable points

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http://www.childinfo.org/malaria_progress.html

What needs to happen to increase ITN use?

African countries have received enough ITNs during

2004-2009 to cover >50% of at risk population

Global production of ITNs (in millions)

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Malaria: Treatment

• Intermittent Presumptive Treatment of malaria in pregnancy (IPTp)

• Prompt treatment with appropriate antimalarials

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Malaria: Treatment Resistance Artemisinin Combination Therapy (ACT)

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Africa: > 50% of children receive antimalarials, but often with ineffective

medicines

http://www.childinfo.org/malaria_progress.html

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Malaria: Future Interventions

• Vaccine

• Infant IPT

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Vaccine Preventable Deaths

1.4 million annual child deaths14% of child deaths are due to vaccine preventable causes.

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Causes of vaccine-preventable deaths among children <15 years, 2002

http://www.who.int/immunization_monitoring/diseases/en/

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Basic Vaccine ScheduleBirth BCG

6weeks DPT1, OPV1, HepB1, Hib1

10 weeks DPT2, OPV2, HepB2, Hib2

14 weeks DPT3, OPV3, HepB3, Hib3

9 months Measles

BCG=Bacillus Calmette-Guerin (against TB)DPT=Diphtheria, Tetanus, Pertussis OPV=Oral Polio VaccineHepB=Hepatitis B Hib=Hemophilus influenza b

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What is the Global Vaccine Coverage Rate?

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Vaccine Coverage

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Childhood Injuries• Burns, pedestrian injuries, drowning, falls

• 250,000 deaths of children <5 years

• Most injuries are preventable

• Requires an multi-sector approach to prevent injuries

• Simple protocols can reduce fatality and disability

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Summary: Interventions to Reduce Child Mortality

2/3 of child deaths could be averted with interventions that are already available and recommended for universal coverage!

however

Little progress in expanding treatment coverage in case management of major childhood illnesses

                                                                                             

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Intervention Delivery

• How do we actually get life saving interventions delivered to those who need them the most?

• What strategies or approaches work?

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Intervention Delivery Approaches aka how do you get the prevention and treatment interventions actually

delivered?Horizontal

vs.

Vertic

al ComprehensiveComprehensive vs. SelectiveSelective Approaches

Approaches

Facility vs. community based approach

Tackle direct vs. indirect causes of ill health

Social marketing?

Reduced cost?

Give away?

PHC approach?Integrated approach?Target universal population?Target the poor?

GLOBAL CHILD HEALTH

Big Picture: How Many? Where? What?

Disease Specific:Interventions for Prevention & Treatment

Strategies for Intervention Delivery:Integrated Management of Childhood Illnesses (IMCI)

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Trends in Intervention Delivery in Child Health

• Mass campaigns—small pox eradication

• Primary Health Care (PHC)—comprehensive, intersectoral, prevention and treatment services, district hospital at the hub, community participation

• Selective PHC (SPHC)—focus on a few problems--GOBI

• HIV, malaria, TB

• Integrated Management of Childhood Illnesses (IMCI)– Integrated care — viewing individual as a whole,

comprehensive care of individuals

1950’s

1990’s

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Integrated Management of Childhood Illnesses (IMCI)

• integrated approach

• to reduce death, illness and disability, and to promote growth and development

• preventive and curative elements

• implemented by families, communities and health facilities

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Three Components of IMCI

• Improves health worker skills

• Improves health systems

• Improves family and community practices

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IMCI Component 1: Improves Health Worker Skills

• Targets first level health facilities• Addresses causes of at least 70% of

deaths • Case management guidelines• Training• Supervision• Monitoring

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IMCI Addresses Most Causes of Death

• Pneumonia• Diarrhea• Measles• Malaria• Malnutrition

• Sepsis• Meningitis• Dehydration• Anemia• Ear infection• HIV/AIDS• Wheezing

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IMCI Component 2: Improves Family and Community Practices

• Community participation

• Preventive care– Immunization– Breast-feeding and other nutritional counseling

• Home care of sick children

• Recognition of severe illness

• Care-seeking behavior

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IMCI Component 3: Improves Health Systems

• Planning and Management

• Availability of drugs and supplies

• Organization of work

• Monitoring and supervision

• Referral pathways and systems

• Health information systems

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IMCI Multicountry Evaluation• Training health workers improved

performance

• Difficult to maintain & expand existing IMCI sites

• District and national health systems lack sufficient management structure, funding, coordination, supervision, and manpower

• Low utilization rates of health servicesIMCI cannot impact child mortality.

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Improving Health Worker Skills,

Community Care, and Health Systems

Capacity, structureand functions ofhealth system

Knowledge,Beliefs and skills caretakers

ClinicalAssessmentand treatment by health workers

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Conclusion

• 7 in 10 childhood deaths are attributable to six causes

• Effective interventions exist that are cost effective, feasible and recommended for implementation and can eliminate 2/3 of childhood deaths

• Effective interventions need to be available to the poorest populations

• Need involved communities and strong health systems