1. Adina Ekwerike, MPH Health Program Manager Philadelphia Interdisciplinary Mortality Review Thursday, May 18, 2006 Understanding and Preventing Infant Deaths in Philadelphia Local Practice

2. Infant Mortality United States, 1925-2003 Rate per 1,000 live births Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2002 2003 preliminary rate - 6.85

3. Philadelphias Demographics 5 th largest US city Population estimate – 1.49M (7/2000) Infant Mortality Rate 10.7, in 2003 Source: Philadelphia Department of Public Health, Vital Statistics Report

4. Philadelphia - 2003 21,313 births21,313 births –50% African American or Black –30% White –20% Other 228 infant deaths228 infant deaths –62% African American –32% White –6% Other Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003

5. 2003 Causes of Death among Infants Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003

6. Philadelphia Infant Mortality by Race 1990-2003 Source: Philadelphia Department of Public Health, Vital Statistics Report, 1990 - 2003

7. Trends in Infant Mortality in Philadelphia, 1992 through 2003 All Races Black or African American Source: The Philadelphia Department of Public Health, Vital Statistics Report, 1992 - 2003

8. Infant Mortality in Philadelphia Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003

9. Response to Local Public Health Concern 2003 MEO began death scene investigations 2004 A Bed of Tragedies, Philadelphia Daily News (City alerted to 43 deaths in 17 months while sleeping with others) City-wide Safe Sleeping Press conference (The Philadelphia Department of Public Health and the Department of Human Services)

10. Infant Deaths from Sudden Unexplained Infant Death (SUID) and Hypoxia and Pending Deaths in Philadelphia, 71 Infant Deaths 48 in Co-sleeping Environment 8 Overlay Deaths Location of Death Sofas/couches (5) In a crib w/ sibling (2) Adult bed (1) 23 not in Co-sleeping Environment Source: Philadelphia Department of Public Health, April 1, 2003 – October 11, 2004

11. Collaboration with Community and Stakeholders Educate community and stakeholders about complex issues of infant safe-sleeping and bed sharing: - safe sleeping initiative (e.g., cribs for Kids) - Sudden Unexplained Infant Death - back-to sleep - bed sharing - exposure to environmental tobacco smoke

12. Philadelphia Interdisciplinary Mortality Review (PIMR) Division of Maternal, Child & Family Health

13. PIMRs Teams Rapid Review Infant Death Team Fetal and Infant Mortality Review Homicide Review Non-Homicide Review Non-Homicide Review

14. Role of PIMR The PIMR program is a multidisciplinary, and multi-agency process that reviews cases of deaths. The team coordinates, collect and review data from law enforcement, court systems, child protective services, medical examiner, health and social services providers.

15. Philadelphias Rapid Review Infant Death Team

16. Infant Deaths Receiving Rapid Review 111 deaths111 deaths –27 in 03 –46 in 04 –38 from 01/05 – 09/05 (preliminary data) –All reviewed by the same forensic investigator –All expired while sleeping Source: Philadelphia Department of Public Health, 2003 - 2005

17. Racial Disparities 03 – 09/30/05 % Source: Philadelphia Department of Public Health, 2003 - 2005

18. Gender Disparities 03 – 09/30/05 % Source: Philadelphia Department of Public Health, 2003 - 2005

19. Risk Factors Present 03 – 04 ETSNot on back Co-sleeping 2.9%10.3% 0.0% 20.6% 35.3% 14.7% 7.4% 8.8% had no risk factors Source: Philadelphia Department of Public Health, 2003 - 2005 n=68, 5 missing

20. Comparing 03/04 through 09/04 to 03/05 through 09/05 # of Deaths # of Co-sleeping Deaths 03/04 – 09/0403/05 – 09/05 1925 1415 p > 0.05 Notes: City-wide safe sleeping press conference and subsequent safe sleeping initiatives (e.g., Cribs for Kids) initiated in October 04. Time periods selected to control for seasonal differences. Source: Philadelphia Department of Public Health, 2004 - 2005

21. Co-Sleeping and Overlay 52 Rapid Review Cases Co-sleeping: 62% (32 of 52 cases)Co-sleeping: 62% (32 of 52 cases) Overlay: 16% (5 of 32 cases)Overlay: 16% (5 of 32 cases) Crib present, not used: 74% (17 of 23 cases)Crib present, not used: 74% (17 of 23 cases) –9 cases had no data on cribs Source: Philadelphia Department of Public Health, 2003 - 2005

22. Prematurity 52 Rapid Review Cases Premature: 17% (9 cases of 52)Premature: 17% (9 cases of 52) Source: Philadelphia Department of Public Health, 2003 - 2005

23. Funding Source Citys public funds Healthy Start federal grant Title V Block Grant

24. Proposed Recommendations Provide education and training on SIDS/SUID risk factors with emphasis on exposure to environmental tobacco smoke (ETS) to the Department of Human Services (DHS) workers and community-wide providers. Develop a specific focus on ETS prevention and education Collaborate with the Fetal and Infant Mortality Review (FIMR) Community Action Team to create literature on ETS and infant health for childbirth and parenting classes Source: Philadelphia Department of Public Health, Philadelphia Interdisciplinary Mortality Review Policy Committee

25. Proposed Recommendations Collaborate with the FIMR Community Action Team and DHS to develop a community education campaign/media strategy regarding ETS Conduct a cross training between fire department staff and health department Plan educational campaign for block captains Source: Philadelphia Department of Public Health, Philadelphia Interdisciplinary Mortality Review Policy Committee

26. PIMRs Plans Conduct timely death reviews Facilitate PDPHs access to medical records Link PIMR findings to MCFH, PDPH, DHS, state, federal other citywide initiatives Link PIMR findings to community and policymakers initiatives Maintain collaborate relationship with states and national death reviews