Interventions in Global Child Health Donna M. Denno

GLOBAL CHILD HEALTH PROBLEMS Big Picture: What are they? How Many? Where? Disease Specific: Interventions for Prevention & Treatment Strategies for Intervention Delivery: Integrated Management of Childhood Illnesses (IMCI)

Scope of the Problem 10.6 million children under 5 years of age die each year.

Trends in U5MR 35 years of improvement Uneven Progress –Between and within countries –Disparities in wealth Recently some countries—stalled progress or reversal

Slowing trends in child mortality Source: WHO Report 2005: Make Every Mother and Child Count

Trends in U5MR 1970—146 deaths/ – 79 deaths/1000 However reductions in U5MR are slowing down – U5MR20%/decade – U5MR 12%/decade

Trends in U5MR: Regional differences Africa –Started w/ highest levels –Saw smallest reductions (5%/decade) –Most marked slow down in progress

Trends in U5MR: Regional differences Africa –43% of all child deaths SE Asia –28% of all child deaths

Bryce J, et al. “WHO estimates of the causes of death in children.” Lancet 2005.

Major Causes of Child Death (1998) EIP/WHO All other (18%) HIV/AIDS (3%)) Congenital (4%)) Injuries (6%) Malaria (7%) Measles (8%) Diarrhoeal diseases (17%) Respiratory diseases (17%) Perinatal (20%) Total deaths: 10.8 million Malnutrition is estimated to contribute to around 50% of all childhood deaths. 49% of child deaths

Malnutrition Underlying Cause/Contributor in 50% of Childhood Deaths

Nutrition: Underweight Breastfeeding Micronutrient Deficiencies

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

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

Underlying Causes of Disease and Malnutrition Poverty Inequality Lack of access to care Conflict/War/Disaster

Causes of Death Multifactorial/Comorbidites Currently not well elucidated

Co-morbidity/Underlying Cause Example WarDisruption Immunization Services Child with measles Diarrhea&Pneumonia DEATH

Disease Specifics Interventions = “biologic agent or action intended to reduce morbidity or mortality” –Prevention –Treatment

Acute Infectious Diarrhea 1.5 million child deaths/year (80% in < 2yo’s) Microbiologic Etiology –Regional/local variation: Rotavirus, Shigella, Enterotoxogenic E coli, Campylobacter Spread –water, food, utensils, hands, flies Deaths –dehydration (water loss) –electrolytes/salts loss (sodium, potassium, bicarbonate)

Diarrhea: Prevention –Clean Water drinking, food preparation –Sanitation Adequate supply of water/hygiene Safe Feces Disposal

In many parts of the world, rural populations still lack access to safe drinking water Source: Based on UNICEF, End-Decade Databases, January 2005.

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)

Diarrhea: Treatment ORT—Home based –Recognition of symptoms –Initiation and continuation of ORT –Knowledge ORT does not treat diarrhea Prevents and treats dehydration

Diarrhea: Treatment/Facility Based ORT –Recognition of dehydration Selective use of antibiotics –Dysentery Zinc supplementation –Given during acute diarrhea episode reduces duration and severity of episode –Given for days reduces incidence of diarrhea in following 2-3 months

IMPACT OF ORT--estimates Saves 1 million lives per year Diarrhea deaths HALVED from

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, cholera Elucidating etiologies of diarrhea/surveillance

Acute Respiratory Infection (ARI)/Pneumonia 2 million deaths/year in < 5yo’s Bacteria –Pneumococcus –Haemophilus influenzae type b (Hib) –Staphylococcus aureus –Mycobacterium tuberculosis

Pneumonia: Prevention Immunization (measles, pertussis) –“Newer” immunizations not readily available (pneumococcus, H influenzae b)--$$ Nutrition –Exclusive breastfeeding/complementary feeding –Vit A and Zinc supplementation Avoidance of indoor air pollution (ex 2 nd hand smoke)

Pneumonia: Treatment Recognizing symptoms of illness Case Management –Access to care –Quality of care Health worker classifies illness based on increased respiratory rate (pneumonia) and chest in drawing (severe pneumonia) Treat non severe pneumonia with appropriate antibiotic for full course Refer severe pneumonia

Pneumonia: Treatment Case management can pneumonia associated childhood mortality by 40% –S Sazawal, et al Lancet 2003

Pneumonia: Treatment 50 % world wide

Malaria Plasmodium parasites Anopheles mosquito –Pools of water—breeding ground

Malaria Clinical presentation: –Asymptomatic –“Uncomplicated” malaria = fever, headache, malaise (cough, diarrhea) –“Severe” or “Complicated” malaria = multi- organ system involvement Severe anemia Jaundice Cerebral malaria

Malaria Morbidity –Major cause of anemia in endemic areas –Impact on growth and cognitive development Drains $2 billion from economies in sub- Saharan Africa

41% of worlds’ population live in malaria endemic areas

Malaria million cases of clinical malaria/yr 1 million 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)

Malaria: Prevention Vector control –Spraying –Insecticide treated materials (ITMs) including insecticide treated bednets (ITNs) High ITN use  17% reduction in childhood mortality C Lengeler The Cochrane Library, Issue 4, 2001 PA Phillips-Howard PA. Am J Trop Med Hyg 2003

ITNs

Malaria: Prevention Vector control Intermittent Presumptive Treatment of malaria (IPT)

Malaria: Treatment Home based management Case management Prompt and appropriate treatment

Malaria: Treatment Resistance More effective drug combinations

Malaria: Future Interventions Immunization Infant IPT

Vaccine Preventable Deaths 1.7 million annual deaths

Causes of vaccine-preventable deaths among children <15 years, 2000

Basic Vaccine Schedule BirthBCG 6weeksDPT 1, OPV 1, HepB1 10 weeksDPT 2, OPV2, HepB2 14 weeksDPT3, OPV3, HepB3 9 monthsMeasles BCG=Bacillus Calmette-Guerin (against TB) DPT=Diphtheria, Tetanus, Pertussis OPV=Oral Polio Vaccine HepB=Hepatitis B *

Vaccine Coverage

Measles: Prevention 1 st dose at 9 months 2 nd ‘opportunity’ –Increases chance that all get 1 dose –2 nd dose increases protection against disease

Measles: Treatment Vit A supplementation reduces mortality from measles by 25% Treatment of sequelae: –Pneumonia –Diarrhea –Tuberculosis

Intervention Delivery Vertical Programs –Focus on control of one disease –Often separate implementation from existing health system Primary Health Care—comprehensive, intersectoral prevention and treatment services delivered at the community level Integrated Management of Childhood Illnesses (IMCI)

integrated approach aims to reduce death, illness and disability, and to promote improved growth and development includes both preventive and curative elements implemented by families, communities and health facilities

IMCI Addresses Most Causes of Death Pneumonia Diarrhea Measles Malaria Malnutrition Sepsis Meningitis Dehydration Anemia Ear infection HIV/AIDS Wheezing Sore throat

Three Components of IMCI Improves health worker skills Improves health systems Improves family and community practices

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

Improves Health Worker Skills Targets first level health facilities Addresses causes of at least 70% of deaths Case management guidelines Training Supervision Monitoring

Improves Health Systems Planning and Management Availability of drugs and supplies Organization of work Monitoring and supervision Referral pathways and systems Health information systems

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 services  IMCI cannot impact child mortality.

Improving Health Worker Skills, Community Care, and Health Systems Capacity, structure and functions of health system Knowledge, Beliefs and skills caretakers Clinical Assessment and treatment by health workers

Conclusion 7 in 10 of the 10.6 million annual deaths in children younger than 5 years are attributable to six causes Effective interventions exist Effective interventions need to be available to the poorest populations Need strong communities and health systems