1. Problems and Interventions in Global Child Health Donna M. Denno Affiliate Assistant Professor, Dept of Pediatrics Clinical Assistant Professor, Dept of Global Health

2. 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)

3. 3 Scope of the Problem >9 million children under 5 years of age die each year.

4. 4 Trends in U5MR 1970—146 deaths/1000 2003– 79 deaths/1000 However reductions in U5MR are slowing down –1970-1990 U5MR20%/decade –1990-2000 U5MR 12%/decade

5. 5 Slowing trends in child mortality Source: WHO Report 2005: Make Every Mother and Child Count

6. 6 Millennium Development Goal 4

7. 7 Reduce child mortality rates by 2/3 by the year 2015

8. 8 Trends in U5MR: Regional differences Sub-Saharan Africa –Started w/ highest levels –Saw smallest reductions (5%/decade) –Most marked slow down in progress

9. 9 Regional Distribution of Child Deaths 98% of childhood deaths occur in developing countries Africa –49% of all child deaths –43% in 1990 –30% in 2003 S Asia –33% of all child deaths Loaiza E et al. Child mortality 30 years after the Alma-Ata Declaration. Lancet Sept 2008

10. 10 Trends in U5MR In 21 developing countries: Overall U5MR Gaps in U5MR between rich and poor while

11. 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)

12. 12 What are the leading causes of childhood mortality worldwide?

13. 13 What are the leading causes of childhood mortality worldwide?

14. 14 Undernutrition: Underlying Cause in >1/3 of Childhood Deaths Underweight Lack of exclusive breastfeeding Micronutrient Deficiencies

15. 15 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

16. 16 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

17. 17 Underlying Causes of Disease and Malnutrition Poverty Inequity Lack of maternal education Lack of access to care Conflict/War/Disaster

18. 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)

19. 19 Disease Specifics Interventions = “biologic agent or action intended to reduce morbidity or mortality” –Prevention –Treatment

20. 20 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)

21. 21 Diarrhea: Prevention –Clean Water drinking, food preparation –Sanitation Adequate supply of water/hygiene Safe Feces Disposal

22. 22

23. 23 In many parts of the world, rural populations still lack access to safe drinking water Source: Based on UNICEF, End-Decade Databases, January 2005.

24. 24 http://www.childinfo.org/eddb/sani/trend.htm

25. 25 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)

26. 26 Diarrhea: Treatment How much does a sachet of ORS cost?

27. 27 Diarrhea: Treatment  ORT –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

28. 28 IMPACT OF ORT Saves 1 million lives per year Diarrhea deaths HALVED from 1990-2000

29. 29 What is the coverage rate of ORT among children with diarrhea?

30. 30 ORT coverage rates among children with diarrhea

31. 31 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

32. 32 Pneumonia >1.5 million deaths/year in < 5yo’s Bacteria (60-70%) –Pneumococcus –Haemophilus influenzae type b (Hib) –Staphylococcus aureus –Mycobacterium tuberculosis

33. 33 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

34. 34 Pneumonia: Treatment Case management--Prompt treatment with appropriate antibiotic (right doses, full course) The good news: 1 st line oral antibiotics (amoxicillin, cotrimoxazole) are effective

35. 35 Pneumonia: Treatment Case management can pneumonia associated childhood mortality by 40% –S Sazawal, et al Lancet 2003

36. Pneumonia: Treatment Coverage What % of children with pneumonia are taken to a health care provider?

37. 37 Pneumonia: Treatment 50 % world wide

38. 38 Pneumonia: Treatment What does it take? –Caretaker recognizing symptoms of illness, seeking prompt care, giving full course of antibiotics –Access to care –Community based care—community health workers can effectively identify and treat pneumonia with oral antibiotics

39. 39 Malaria Plasmodium parasites Anopheles mosquito –Pools of water—breeding ground

40. 40 Malaria Clinical presentation: –Asymptomatic –“Uncomplicated” malaria = fever, headache, malaise (cough, diarrhea) –“Severe” or “Complicated” malaria = multi- organ system involvement Severe anemia Jaundice Cerebral malaria

41. 41 Malaria Morbidity –Major cause of anemia in endemic areas –Impact on growth and cognitive development Drains $2 billion from economies in sub- Saharan Africa

42. 42 Almost half of the worlds’ population live in malaria endemic areas

43. 43 Malaria 300-500 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)

44. 44 Malaria: Prevention Vector control –Indoor Residual Spraying (IRS)  Insecticide Treated Nets (ITNs) High ITN use  17% reduction in childhood mortality C Lengeler The Cochrane Library, Issue 4, 2001

45. 45 Household surveys 2006-2007, DHS, MICS, MIS Household ITN ownership Use by children <5 years of age WHO World Malaria Report 2008

46. 46 ITNs

47. 47 Malaria: Treatment Intermittent Presumptive Treatment of malaria in pregnancy (IPTp) Prompt treatment with appropriate antimalarials

48. 48 Malaria: Treatment Resistance Artemisinin Combination Therapy (ACT)

49. 49 Malaria in children: Treatment Coverage 38% with fever  any antimalarial 19%  antimalarial on day 1 or 2 of onset of fever 3%  ACT

50. 50 Malaria: Future Interventions Vaccine Infant IPT

51. 51 Vaccine Preventable Deaths 1.7 million annual deaths

52. 52 Causes of vaccine-preventable deaths among children <15 years, 2000

53. 53 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

54. 54 What is the Global Vaccine Coverage Rate?

55. 55 Vaccine Coverage

56. 56 Measles: Treatment Treatment with high dose vitamin A reduces mortality from measles by 25% Treatment of sequelae: –Pneumonia –Diarrhea –Tuberculosis

57. 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)

58. 58 Intervention Delivery Approaches Vertical -- separate implementation from existing health system vs. Horizontal — implemented within existing health system Selective -Focus on control of one disease vs. Comprehensive — focus on multiple prevalent causes of morbidity and mortality Primary Health Care — comprehensive, intersectoral, prevention and treatment services delivered at the community level within health system Integrated care — viewing individual as a whole, comprehensive care of individuals Integrated Management of Childhood Illnesses (IMCI)

59. 59 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

60. 60 Three Components of IMCI Improves health worker skills Improves health systems Improves family and community practices

61. 61 IMCI Addresses Most Causes of Death Pneumonia Diarrhea Measles Malaria Malnutrition Sepsis Meningitis Dehydration Anemia Ear infection HIV/AIDS Wheezing Sore throat

62. 62 IMCI Component 1: 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

63. 63 IMCI Component 2: Improves Health Worker Skills Targets first level health facilities Addresses causes of at least 70% of deaths Case management guidelines Training Supervision Monitoring

64. 64 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

65. 65 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.

66. 66 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

67. 67

68. 68 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 strong communities and health systems

69. 69

70. 70 Treatment Issues: Need for community based treatment and access to care WHO Progress Against Malaria. 2007