Problems and Interventions in Global Child Health

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

4. 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

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

6. Millennium Development Goal 4

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

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

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

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

15. 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

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

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

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

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

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

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

30. ORT coverage rates 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

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

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 based care—community health workers can effectively identify and treat pneumonia with oral antibiotics

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

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

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

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

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

46. ITNs

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

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

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. Malaria: Future Interventions • Vaccine • Infant IPT