Children and Infectious Diseases: Vaccine Preventable Diseases and Maternal Health Yvonne Maldonado, MD Departments of Pediatrics and Health Research and Policy Stanford University School of Medicine

Ten Great Public Health Achievements United States, 1900 - 1999 Vaccination Motor-vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease Safer and healthier foods Healthier mothers and babies Family planning Fluoridation of drinking water Recognition of tobacco use as a health hazard Source: Center for Disease Control and Prevention, 1999

Decreased Mortality in the US from Infectious Diseases in the 1900s Sharp drop in infant and child mortality In 1900 30.4% of all deaths among children <5; by 1997 only 1.4% Leading causes of death pneumonia, tuberculosis, diarrhea, and diphtheria 29.2 year increase in life expectancy

Vaccine Successes and Failures Pediatric vaccinations have had the most profound impact of any intervention on increasing global child survival, accounting for 3 million children’s lives saved annually. Even in the 21st century, however, vaccine-preventable infectious diseases, including tetanus, measles and pertussis, cause disease and death in many parts of the world.

Global Burden of Disease – Where do vaccine preventable diseases fit in? World Health Organization assessment of global scope and cause of death Many sources of information to assess mortality throughout the world Categories: infectious, non-infectious, trauma

Leading Global Causes of Death - 1990

Global Burden of Infections One death in three of the ~54 million deaths worldwide is from an infectious cause Virtually all of these deaths are in developing areas of the world – mainly India and sub-Saharan Africa Disproportionately affect children Many of the developing world deaths are due to preventable causes Pneumonia and Diarrhea – account for 40% of these deaths Tuberculosis Measles Malaria

Limitations of GBD Index In most developing areas, this is just an estimate of death Does not account for incapacitating illness Acute and chronic illness may have long term effects on family and social structure Individuals in marginal circumstances, even in developed settings, are at higher risk

The Global Infectious Disease Threat Infectious diseases are a leading cause of death worldwide Spread due to two major causes Changes in human behavior--including lifestyles and land use patterns, increased trade and travel, inappropriate use of antibiotics Microbial factors – mutations, antibiotic resistance

The Global Infectious Disease Threat and Its Implications for the United States Of the seven biggest killers worldwide, TB, malaria, hepatitis, and, in particular, HIV/AIDS continue to surge HIV/AIDS and TB likely to account for the overwhelming majority of deaths from infectious diseases in developing countries by 2020 Acute lower respiratory infections, diarrheal diseases and measles appear to have peaked at high incidence levels

The Global Infectious Disease Threat and Its Implications for the United States

Global Burden of Vaccine Preventable Deaths ~2.5M deaths/year

What is the global status of immunization? Each year 130 million children are born, 91 million of them (70%) in developing countries. Almost 30 million children have no access to immunization. Due to immunization, and in particular to the global Expanded Programme on Immunization (EPI), launched by the World Health Assembly in 1974, almost 3 million lives have been saved each year, and 750 000 children are saved from disability.

Global Impact of Immunization on Vaccine-Preventable Diseases # of Preventable Cases Hepatitis B 900,000 Measles 888,000 Haemophilus influenzae type b (Hib) 400,000 Pertussis (Whooping cough) 346,000 Neonatal Tetanus 215,000 Tetanus 195,000 Yellow Fever 30,000 Diphtheria 5,000 Poliomyelitis 720 TOTAL 2,979,720

What is the global status of immunization? In 1990, worldwide average vaccination coverage of children under five was 80% but by 1999 fell to 74%. One in four children in the world remains without immunization against the six diseases initially covered by EPI (measles, polio, pertussis, diphtheria, tetanus and tuberculosis).

Access to immunization varies greatly across the world A child in a developing country is ten times more likely to die of a vaccine-preventable disease than a child from an industrialized one. In some countries, up to 70% of children do not receive the full set of vaccines; the lowest coverage is found in sub-Saharan Africa. In Africa as a whole, over 40% of children are not immunized against measles, a major cause of infant mortality that kills one child every minute.

Access to immunization varies greatly across the world WHO has been recommending vaccination against Hepatitis B since 1993, yet it kills approximately one million people each year. Recommendations have also been made for yellow fever, yet 30 000 deaths occur each year.

What is the global status of immunization? There is no equality of access to vaccines for children in industrialized and developing countries, and there is a lack of equality between rural and urban areas within countries. It is estimated that a child in an industrialized country receives eleven vaccines on average, while a child from a developing country is lucky to receive half that number.

What is the global status of immunization? There is a lack of investment in research and development for new vaccines or to disseminate existing vaccines to combat the diseases that are prevalent in developing countries: Diarrhoeal diseases (Rotavirus, E. coli, Salmonella, Shigella, Cholera) Malaria Tuberculosis Pneumonia (Pneumococcus, H. influenzae type B, RSV) HIV/AIDS.

Progress in Eradication of Global Infections Eradication of Smallpox in 1977 Elimination of Poliomyelitis from the Western Hemisphere in 1994 Potential elimination of global poliomyelitis in the next 5 to 10 years Potential elimination of measles in the next 10 to 20 years Vaccines in development for prevention of diarrheal diseases, cervical cancer (HPV)

New Modes of Vaccination Administration of vaccines is a major area of research Many antigens given in the first year of life so combination vaccines available and in development “Needle-less” injections a global priority for compliance and safety reasons (decrease spread of HIV and HBV through reuse of needles) Development of edible vaccines (bananas, potatoes) Nasal or other mucosal routes

Impact of Infectious Diseases in the Next 20 years Three variables will affect the immediate future Relationship between increasing microbial resistance and scientific efforts to develop new antibiotics and vaccines Trajectory of developing and transitional economies, especially concerning the basic quality of life of the poorest groups in these countries Degree of success of global and national efforts to create effective systems of surveillance and response The interplay of these drivers will determine the overall outlook

Why Global Eradication of Infectious Diseases? Immunization is one of the most cost effective health interventions in existence. If polio is eradicated by 2005, $ 1.5 billion per annum will be saved on immunization costs alone. Similarly, eradication of smallpox in 1979 led to direct savings of $ 275 million per annum. Immunization reduces the social and financial costs of treating diseases, offering opportunities for poverty reduction and greater social and economic development.

Why Global Eradication of Infectious Diseases? Improved survival generally result in improved standard of living for all Benefits to society when most members are healthy and productive Overall global stability

Maternal and Neonatal Health Maternal-Perinatal Morbidity & Mortality Infections Inadequate Perinatal Care Premature Births Obstructed Labor Fistulas Genital Mutilation Cancer

Maternal and Neonatal Health Women and their babies suffer at the hands of Poverty Poor nutrition Infection Lack of effectively trained health workers and medical staff Natural disasters

Maternal and Neonatal Health 529,000 pregnant women die per annum, 1 per minute, and 5.7 million newborns die, almost all in the developing countries of the world In addition, for every woman who dies in childbirth, 20 more suffer injury, infection and disease– 10 million women a year. A woman living in sub-Saharan Africa has a 1 in 16 chance of dying on pregnancy or childbirth, compared with a 1 in 2,800 risk for a woman in a developed country.

Maternal and Neonatal Health 70% of maternal deaths are due to hemorrhage, obstructed labor, eclampsia, sepsis, and unsafe abortion. Of the 529,000 maternal deaths, 527,000 are from the developing world. 2.7 million newborns are born dead each year and 3 million will not survive the first week of life– the astonishing total of 5.7 million!

Maternal and Neonatal Health The WHO Department of Making Pregnancy Safer (MPS) “every birth should be attended by a skilled health worker if the terrible toll of maternal deaths is to be reduced… many of the deaths could be avoided if all women had the assistance of a skilled health care worker before, during and after pregnancy, including access to emergency medical care if complications should arise.”

Maternal and Neonatal Health Goals UN Goal is to reduce by three-quarters the rate that women die by childbirth by 2015 WHO Goal is to dramatically increase the number, training and availability of trained health care workers in areas where there is unmet need.

Pediatric Preventable Infections – Immigrant Populations Immunizations are key Lack of a sustained medical home Poor tracking by immunizations registries Tuberculosis rates are high among immigrant populations in the US Exposure to infected adults Disease most severe in infants and young children Maternal prenatal care important for good perianatal outcomes Lack of consistent prenatal care in immigrant women