Problems and Interventions in Global Child Health

Donna M. Denno

Affiliate Assistant Professor, Dept of PediatricsClinical Assistant Professor, Dept of Global Health

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)

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Scope of the Problem

>9 million children under 5 years of age die each year.

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Trends in U5MR

• 1970—146 deaths/1000

• 2003– 79 deaths/1000

• However reductions in U5MR are slowing down– 1970-1990 U5MR 20%/decade– 1990-2000 U5MR 12%/decade

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Slowing trends in child mortality

Source: WHO Report 2005: Make Every Mother and Child Count

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Millennium Development Goal 4

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Millennium Development Goal 4

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

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Trends in U5MR: Regional differences

• Sub-Saharan Africa

– Started w/ highest levels – Saw smallest reductions (5%/decade)– Most marked slow down in progress

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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

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Trends in U5MR

In 21 developing countries:

• Overall U5MR • Gaps in U5MR between rich and poor

while

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)

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What are the leading causes of childhood mortality worldwide?

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What are the leading causes of childhood mortality worldwide?

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

Underweight

Lack of exclusivebreastfeeding

Micronutrient Deficiencies

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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

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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

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Underlying Causes of Disease and Malnutrition

Poverty

Inequity

Lack of maternal education

Lack of access to care

Conflict/War/Disaster

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)

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Disease Specifics

• Interventions = “biologic agent or action intended to reduce morbidity or mortality”

–Prevention

–Treatment

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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)

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Diarrhea: Prevention

– Clean Water• drinking, food

preparation

– Sanitation• Adequate supply of

water/hygiene • Safe Feces

Disposal

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82

100

81

73

69

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95

96

100

99

94

94

69

80

North America

Eastern Europe

LatinAmerica/ Caribbean

Western Asia

East Asia

South-Central Asia

Sub-Saharan Africa

Rural

Urban

In many parts of the world, rural populations still lack access to safe

drinking water

Source: Based on UNICEF, End-Decade Databases, January 2005.

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

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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)

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Diarrhea: Treatment

How much does a sachet of ORS cost?

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Diarrhea: TreatmentORT

– 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

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IMPACT OF ORT

• Saves 1 million lives per year• Diarrhea deaths HALVED from 1990-2000

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

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ORT coverage rates among children with diarrhea

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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, choleraElucidating etiologies of

diarrhea/surveillance

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Pneumonia

• >1.5 million deaths/year in < 5yo’s

• Bacteria (60-70%)– Pneumococcus

– Haemophilus influenzae type b (Hib)

– Staphylococcus aureus – Mycobacterium tuberculosis

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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

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Pneumonia: Treatment

• Case management--Prompt treatment with appropriate antibiotic (right doses, full course)

• The good news: 1st line oral antibiotics (amoxicillin, cotrimoxazole) are effective

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Pneumonia: Treatment

Case management can pneumonia associated childhood mortality by 40%

– S Sazawal, et al Lancet 2003

Pneumonia: Treatment Coverage

What % of children with pneumonia are taken to a health care provider?

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Pneumonia: Treatment

50 % world wide

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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

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Malaria

• Plasmodium parasites

• Anopheles mosquito – Pools of water—breeding ground

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Malaria• Clinical presentation:

– Asymptomatic– “Uncomplicated” malaria = fever, headache,

malaise (cough, diarrhea)– “Severe” or “Complicated” malaria = multi-

organ system involvement• Severe anemia• Jaundice• Cerebral malaria

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Malaria

• Morbidity– Major cause of anemia in endemic areas– Impact on growth and cognitive development

• Drains $2 billion from economies in sub-Saharan Africa

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

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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)

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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

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Household surveys

2006-2007, DHS, MICS, MIS

Household ITN ownership

Use by children <5 years of age

WHO World Malaria Report 2008

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ITNs

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Malaria: Treatment

• Intermittent Presumptive Treatment of malaria in pregnancy (IPTp)

• Prompt treatment with appropriate antimalarials

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Malaria: Treatment Resistance Artemisinin Combination Therapy (ACT)

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Malaria in children: Treatment Coverage

• 38% with fever any antimalarial

• 19% antimalarial on day 1 or 2 of onset of fever

• 3% ACT

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Malaria: Future Interventions

• Vaccine

• Infant IPT

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Vaccine Preventable Deaths

1.7 million annual deaths

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

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Basic Vaccine ScheduleBirth BCG

6weeks DPT 1, OPV 1, HepB1

10 weeks DPT 2, OPV2, HepB2

14 weeks DPT3, OPV3, HepB3

9 months Measles

BCG=Bacillus Calmette-Guerin (against TB)DPT=Diphtheria, Tetanus, PertussisOPV=Oral Polio VaccineHepB=Hepatitis B

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What is the Global Vaccine Coverage Rate?

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Vaccine Coverage

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Measles: Treatment

• Treatment with high dose vitamin A reduces mortality from measles by 25%

• Treatment of sequelae:– Pneumonia– Diarrhea– Tuberculosis

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)

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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)

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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

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Three Components of IMCI

• Improves health worker skills

• Improves health systems

• Improves family and community practices

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IMCI Addresses Most Causes of Death

• Pneumonia• Diarrhea• Measles• Malaria• Malnutrition

• Sepsis• Meningitis• Dehydration• Anemia• Ear infection• HIV/AIDS• Wheezing• Sore throat

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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

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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

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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

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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 servicesIMCI cannot impact child mortality.

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Improving Health Worker Skills,

Community Care, and Health Systems

Capacity, structureand functions ofhealth system

Knowledge,Beliefs and skills caretakers

ClinicalAssessmentand treatment by health workers

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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

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Treatment Issues: Need for community based treatment and

access to care

WHO Progress Against Malaria. 2007