1. Problems and Interventions in Global Child 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. ~8 million children under 5 years of age die each year
Scope of the Problem
~8 million children under 5 years of age die each year

4. 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
>80% of childhood deaths occur in S Asia and Africa. 90% of deaths occur in 42 countries (from 2008 data reported in 2009). 99% of childhood deaths occur in LMIC
S Asia—Afghan, Bangl, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka
Source: Levels and trends in child mortality, UNICEF. 2010

5. 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)

6. Regional differences in U5MRs
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

7. Regional differences in U5MRs
Sub-Saharan Africa
Started w/ highest levels
Saw smallest reductions (5%/decade)
Most marked slow down in progress

8. Trends in U5MR 1970—146 deaths/1000 1990— 90 deaths/1000
However reductions in U5MR—slowed
U5MR 20%/decade
U5MR 12%/decade

9. Slowing trends in child mortality
Economic recession, increase oil prices, delinking of currency to gold, debt, SAPs, conflict
More recently some countries—stalled progress or reversal
What is MDG 4??
Uneven Progress
Between and within countries
Disparities in wealth
1960 U5MR Africa SE Asia around World Americas The fortunes of the world’s children are mixed. For ex, overall children today are better nourished: b/t 1990 and 2000 the global prevalence of stunting and underweight declined by 20 and 18% respectively. But in Southern and central Asia children continue to suffer very high levels of malnutrition and throughout sub-Saharan Africa the numbers of children who are stunted and underweight increased in this period. Source: WHO Report 2005 but actually de Onis M and Blossner M. The WHO Global Database on child growth and malnutrition: methodology and applications. Int J of Epi, 2003, 32:
Source: WHO Report 2005: Make Every Mother and Child Count

10. Millennium Development Goal 4
Reduce child mortality rates by 2/3 by the year 2015

11. Trends in Child Mortality: Not on Track to Meet MDG4
Based on data from the Interagency Group for Child Mortality Estimates

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

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

14. What are the leading causes of childhood mortality worldwide?
Diseases of poverty
Reproduced from UNICEF ChildInfo website: and based on Black R et al. Global, regional, and national causes of child mortality in Lancet. 2010;375:1969–1987.

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

16. CG Victoria et al, Am J Epidemiol 1989
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

17. Micronutrients Vit A Deficiency
Example
Vit A Deficiency
20-24% Risk of death from Diarrhea, Measles, (Malaria)
AL Rice et al In: Comparative quantification of health risks, 2004

18. Underlying Determinants of Child Mortality
Poverty
Inequity
Lack of maternal education
Lack of access to care
Rural residence
Conflict/War/Disaster
Debt
Structural Adjustment Policies
Examples of Socio-political-economic policies and factors that impact health

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

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

21. 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)
4 billion cases per year
Plethora of microbiologic causes_varies by locale_except for a few places etiologies are not well studied.

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

23. Access to Improved Water Sources
87% of world has access to improved water sources for drinking. Up from 77% in 1990.
Improved: Piped water into dwelling, plot or yard; Piped water into neighbor’s plot; Public tap/standpipe; Tubewell/borehole; Protected dug well; Protected spring; Rainwater
Unimproved: Unprotected dug well, Unprotected spring, Small cart with tank/drum, Tanker truck, Surface water (river, dam, lake, pond, stream, channel, irrigation channel), Bottled water
MICS household survey “What is the main source of drinking water for members of your household?”
Source: UNICEF

24. In many parts of the world, rural populations still lack access to safe drinking water

25. Access to Improved Sanitation Facilities
Unfortunately we have not made such great progress in sanitation facility coverage--62% of the world has access to improved sanitation facilities and another 8% has access to such facilities that are shared between multiple HHs. There has only been an 8% decrease in the # of people w/o access to improved sanitation facilities since the 1990s.
MICS What kind of toilet facility do members of your household usually use?
If “flush” or “pour flush”, probe:
Where does it flush to?

26. 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)

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

28. Diarrhea: Treatment ORT Zinc supplementation
Prevent and treat dehydration
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
Selective use of antibiotics
Dysentery

29. IMPACT OF ORT Saves 1 million lives per year
Diarrhea deaths HALVED from

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

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
“all diarrhea is local” but we don’t have a clear understanding of the causes of diarrhea in most developing country settings

32. Pneumonia >1.4 million deaths/year in < 5yo’s
Bacteria (60-70%)—especially
Pneumococcus
Haemophilus influenzae type b (Hib)

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

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. Pneumonia: Treatment
50 % world wide

38. 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

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

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. 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. 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)

43. Almost half of the worlds’ population live in malaria endemic areas
~half, symbols show falcip malaria endemicity—cause of severe malaria and most malaria assoc deaths
tropical and subtropical regions of Africa, Asia and the Americas.

44. Malaria: Prevention Vector control Insecticide Treated Nets (ITNs)
Indoor Residual Spraying (IRS)
Environmental measures (e.g. reduction of standing water)
Insecticide Treated Nets (ITNs)
High ITN use 17% reduction in childhood mortality

45. ITNs
This picture is a little anachronistic. What is wrong with the picture, what’s different about ITNs today compared to when this photo was taken in 1999?

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

47. Global production of ITNs (in millions)
What needs to happen to increase ITN use?
African countries have received enough ITNs during to cover >50% of at risk population
Global production of ITNs (in millions)

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

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

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

51. Malaria: Future Interventions
Vaccine
Infant IPT

52. Vaccine Preventable Deaths
1.4 million annual child deaths
14% of child deaths are due to vaccine preventable causes.

53. Causes of vaccine-preventable deaths among children <15 years, 2002
This chart doesn’t include pneumooccal vaccine to prevent pneumonia and other pneumococcus-related infections nor does it include rotavirus vaccine which protects against that leading cause of diarrheal illness. You can consider deaths caused by pneumococcus and rotavirus to be the leading causes of vaccine preventable deaths.

54. Basic Vaccine Schedule
Birth
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 Vaccine
HepB=Hepatitis B Hib=Hemophilus influenza b

55. What is the Global Vaccine Coverage Rate?

56. Vaccine Coverage

57. 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

58. 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
                                                                                             
c/w MDG4

59. Intervention Delivery
How do we actually get life saving interventions delivered to those who need them the most?
What strategies or approaches work?
Operations research

60. Intervention Delivery Approaches aka how do you get the prevention and treatment interventions actually delivered?
Horizontal
vs.
Comprehensive vs. Selective Approaches
Vertical
Social marketing?
Reduced cost?
Give away?
Facility vs. community based approach
Approaches
PHC approach?
Integrated approach?
Tackle direct vs. indirect causes of ill health
Target universal population?
Target the poor?

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

62. 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

63. 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

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

65. 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

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

67. 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

68. 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

69. 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.
Preliminary Data from 5 countries that where an evaluation of IMCI is taking place are encouraging in regards to training of health workers but the health systems component of IMCI was just not strong enough to deliver an effective total IMCI package. Access to care presents another significant impediment to IMCI effectiveness.

70. Improving Health Worker Skills, Community Care, and Health Systems
Clinical
Assessment
and treatment by health workers
Knowledge,
Beliefs
and skills
caretakers
Capacity, structure
and functions of
health system
If caretakers do not or cannot access care and health systems are not strengthened then just training health workers results in a incomplete delivery mechanism for the IMCI package

71. 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