Child Health in Kerala

1. Child Health in Kerala Rajeev Sadanandan Additional Chief Secretary, Government of Kerala

2. Kerala has been an outlier among Indian states in health indicators • This is the result of enlightened by decisions by governments in Kerala since 19th Century • It was also influenced by other social indicators such as education, empowerment of all classes and castes and public action. • As indicators improve new strategies are needed to maintain the momentum: Improvement becomes progressively more difficult as the indicators get better

3. Statistics _ Mortality

4. We conducted a study in partnership with IAP to find out why our children die. The studyrevealedthat Prematurity, Sepsis, Birth Asphyxia and Congenital Anomalies are the leading causes. It also showed the areas we could intervene to reduce infant mortality. We also realised the importance of ANC and Obstetric interventions CAUSES OF INFANT MORTALITY IN KERALA • IAP study 2013

5. Sustainable Development Goal No. 3. Health and Well being: Ensure healthy lives and promote well being for all at all ages: • In 2016 the New Government decided to commit to clear, quantifiable targets to be achieved by 2020 and 2030. The targets were to be aligned to the UN Sustainable Development Goals framework. • 18 Expert Groups were constituted to identify targets to be achieved by Kerala by 2020 and 2030. • The groups recommended the targets and appropriate strategies to achieve them. • They also listed the activities and indicators to measure them. • The targets were announced in August 2016

6. SDG no. 3: Targets Set by Kerala • MMR: To reduce the Kerala Maternal Mortality Rate from 61 (based on SRS) to 30 per 100,000 live births by 2020 and to 20 by 2030. • Infant, Neo-natal and Under 5 Mortality Rates: • To reduce • IMR from 12 per 1000 live births to 8 per 1000 live births by 2020 and to 6 by 2030. • NMR from 7 to 5 by 2020 and to 3 by 2030 • Under 5 mortality from 14 to 9 per 1000 live births and to 7 by 2030.

7. Key interventions to achieve the goals _ I • Reducing deaths from Pneumonia • Development infrastructure and capacity for CCUs • Pneumococcal vaccination: Pneumonia and meningitis which accounts for 30% of morbidity & 6% of mortality • Standard case management : Standard Treatment Guidelines, appropriate referrals and ensuring availability of drugs. • Handling comorbidity: CHD to be early detected and corrected through tie up with Private institutions. • Correcting underlying PEM: Nutritional interventions

8. Key interventions _ II • Reduction of deaths from Congenital Anomalies • Primary prevention by folic acid • Targeted anomaly screening during antenatal period and screening for birth defects at birth • Congenital birth defect registry • Detection of CHD by Pulse oxymetry, metabolic screening • Pediatric surgical interventions in partnership with private institutions

9. Key interventions _ III • Prevention of deaths from Malnutrition : • Nutrition education as part of school curriculum • Coordinated efforts with ICDS, Food security, Agriculture, Education departments • Periodic deworming, nutritional surveillance & monitoring • Healthy eating practices, Link with school meal program • MicronutrientsupplementationIFA supplementation, Vit A, Zinc, Iodine

10. Key interventions _ III • Vaccine Preventable Deaths • Remove current apprehensions about immunization • Mandatory immunization at school entry • Modifying immunization policy:Td/ pneumococcus/MMR • Miscellaneous conditions: childhood malignancy, Thalassemia, sickle cell anemia. • Separate strategies have been developed for management of child hood cancers, haemoglobinopathies • Both focus on training of pediatricians for early detection and specialised case management. • For Mendelian disorders focus on children of families with the condition.

11. MILE STONES.. Hearing (OAE) Screening Metabolic Screening Pulse Oximetry Screening ROP Screening for High Risk Preterm VBD screening as part of RBSK OAE Screening program started with the support of KSSM. Presently, extended to all Delivery points with more than 50 deliveries per month Started as a special initiative in selected delivery points Started in selected 54 delivery points (with more than 100 delivery per month) for early detection of cCHD Screening for Retinopathy of Prematurity started in 7 Tertiary Care Special NewbornCare Units As part of rolling out RBSK, documenting Newborn Birth defect screening in delivery points were initiated 2014 2018 2016 2018 2012

12. COURSE OF SCREENING VBD Screening Pulse Oximetry OAE Screening Metabolic Screening Within 24 Hours 24-48 Hours Near 48 Hours After 48 Hours Newborn Screened by Delivery point Staff Nurse or RBSK Nurse & seen by Pediatrician. Being documented using the Jatakseva android app Blood sample collected by heel pricking and on blotting paper, dried samples transported to PH and RPH Labs. Reports captured in JatakSeva online from the Labs. Pulse Oximetry is recorded for Newborn using specific PO machine with in-built Software which record, interpret & transmit the readings Hearing Screening is done by trained Nurses at around 48 hours post partum using OAE machine. Referred cases are followed up at DEICs or NPCD leve 2 centres.

13. Interventions presented here • Birth Defects • Interventions for hearing disability including Cochlear implantation • ROP Screening • Congenital Heart Disease • Screening and management of errors of metabolism • Interventions to deal with Prematurity, Low Birth Weight and Birth Asphyxia Not presented: • Surgeries to remove club foot • Other pediatric surgeries • Management of Childhood Cance • Prevention of Mother to Child Transmission of HIV.

14. Results of screening

15. Challenges • Monitoring Infant and Under 5 Mortality to determine cause of mortality and near miss in government and private sector. • Critical Care of high risk Newborn like LBW/Extreme Premature is an area that needs to improve. Capacity in infrastructure and skills for critical care of Newborn needs to go up. • Ensuring protocol based management and referral of new born with different levels managing upto their capacity and referring only need-to-refer cases. • Management of discharged cases in the community

16. What do we dream of…. • An Electronic Health Record for every child to track life course changes in health status • With improvements in Genomic screening the ability to screen every pregnancy for known genetic disorders, with high sensitivity and specificity, so that parents can take informed decisions. • Early and adequate interventions in nutrition, health care and cognitive development, to ensure that every child is able to reach his/her full potential.

17. Thank you