Problems and Interventions in Global Child Health

1. Problems and Interventions in Global Child Health

2. Learning Objectives Describe the scope of the problem of child mortality List the 7 leading direct causes of childhood mortality State the major underlying risk factor for childhood mortality Explain the prevention and treatment interventions that are currently recommended for preventing child mortality from pneumonia, diarrhea, and malaria State the approximate coverage rates for the most important interventions

3. Scope of the Problem ~7.6 million children under 5 years of age die each year Equivalent to a tsunami every few days

4. What are the leading causes of childhood mortality worldwide? Reproduced from UNICEF ChildInfo website: http://www.childinfo.org/mortality.html and based on Black R et al. Global, regional, and national causes of child mortality in 2008. Lancet. 2010;375:1969–1987.

5. Causes of Childhood Mortality do Vary

6. Undernutrition: Underlying Cause in >1/3 of Childhood Deaths Underweight, stunted, wasted Lack of exclusive breastfeeding Micronutrient Deficiencies

7. Diarrhea 7x risk death Pneumonia 5x risk death CG Victoria et al, Am J Epidemiol 1989 Impact of Breastfeeding on Childhood DiseaseRisk in not BF vs exclusively BF

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

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

10. 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)

11. The Vicious Cycle of Infectious Diarrhea, Malabsorption, and Undernutrition Infectious Diarrhea Growth Faltering, Weight Loss Micronutrient Deficiencies Lowered Immunity Increased Risk of Infectious Diseases Intestinal Injury and Enteropathy Leaky Intestines, Malabsorption of Nutrients, Decreased Uptake & Reduced Efficacy of Oral Medications and Vaccines Poverty and Food Insecurity HIV/AIDS

12. Prevention: WaSH • Clean Water • drinking, food preparation • Sanitation • Safe Feces Disposal • Hygiene • Especially hand washing

13. Access to Improved Water Sources Source:UN MDG Report. 2011

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

15. Access to Improved Sanitation Facilities http://www.childinfo.org/sanitation_status_trends.html

16. 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)

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

18. 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

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

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

22. 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 can we break the enteropathy-undernutrition cycle? How does water privatization impact access to water? Vaccines—rotavirus, cholera Elucidating etiologies of diarrhea/surveillance

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

24. Pneumonia: Prevention • Immunization(measles, pertussis) • “Newer” immunizations have slowly been incorporated into vaccine schedules (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 • Hand Hygiene

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

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

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

28. Pneumonia: Treatment 50 % world wide

29. 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

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

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

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

33. Malaria • 225 million cases of clinical malaria/yr • 781,000 deaths/year • 90% in sub-Saharan Africa • Majority in children • Past couple of decades -- upsurge • Environmental factors (climate, water development projects) • Areas of conflict (disruption in previous control programs)

34. ~50% of the worlds’ population live in malaria endemic areas Source: UNICEF childinfo.org

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

36. ITNs

37. ITNs: Household Ownership Percentage of households owning at least one ITN (among African countries with at least two data points, 2000-2010) 37 http://www.childinfo.org/malaria_progress.html

38. ITN use in sub-Saharan AfricaProportion of children sleeping under an ITN (among all African countries with 2 or more comparable points) http://www.childinfo.org/malaria_progress.html

39. ITN use in sub-Saharan AfricaProportion of pregnant women sleeping under an ITN (among all African countries with 2 or more comparable points) 39 http://www.childinfo.org/malaria_progress.html

40. 40 http://www.childinfo.org/malaria_progress.html

41. ITN Distribution in Ghana

42. Malaria: Treatment • Intermittent Preventative Treatment of malaria in pregnancy (IPTp) • Prompt treatment with appropriate antimalarials

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

44. Africa: > 50% of children receive antimalarials, but often with ineffective medicines http://www.childinfo.org/malaria_progress.html

45. Changes in Treatment Recommendations  Changes in Monitoring Treatment Indicators Among all children who received an antimalarial drug, the proportion of children receiving ACT, African countries, 2007–2010 http://www.childinfo.org/malaria_progress.html 45

46. Malaria: Future Interventions • Vaccine • Infant IPT

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

48. Causes of vaccine-preventable deaths among children <15 years, 2002 http://www.who.int/immunization_monitoring/diseases/en/

49. Basic Vaccine Schedule BCG=Bacillus Calmette-Guerin (against TB) DPT=Diphtheria, Tetanus, Pertussis OPV=Oral Polio Vaccine HepB=Hepatitis B Hib=Hemophilus influenza b

50. What is the Global Vaccine Coverage Rate?