International Health- The State of Our World’s Children

1. International Health- The State of Our World’s Children Barbara Oettgen, MD

2. Introduction • Present and discuss the statistics of Infant and Child mortality • Compare and contrast child mortality in developed vs. developing countries • Discuss some of the most common causes of child mortality in developing countries and what is being done to decrease mortality • Discuss status of progress towards mitigation or eradication of causes of mortality

3. Why talk about Global Health of Children? “A society in which human rights are promoted and protected and in which human dignity is respected is a healthy society; that is, a society in which people can best achieve physical, mental and social well-being.” Jonathan Mann, “Human Rights and the New Public Health” 1995

4. Why talk about Global Health of Children? • There is a stark contrast between developed and developing countries in terms of morbidity and mortality • 88% of the world’s children live in developing countries (Population Reference Bureau) • Through immigration, we will see children from developing countries; we must have an understanding of what medical issues for which to screen to care for these children and protect the health of the public

5. Infant MortalityUS(2000)=6.9 Least developed (2000)=102

6. Infant Mortality by World region

7. Infant Mortality in Selected Developed Countries (2000)* Singapore 2.9 Belgium 5.2 Hong Kong 3.0 UK 5.6 Finland 3.8 New Zealand 6.1 France 4.4 Cuba 6.2 Germany 4.4 USA 6.9 Switzerland 4.9 Canada 5.3 *Pediatrics, Dec. 2003

8. Percent of GDP spent on Health Care (2000)* Finland 6.7 UK 7.3 France 9.3 New Zealand 7.9 Germany 10.6 US 13 Switzerland 10.4 Canada 8.9 Belgium 8.8 * From Org. for Economic Cooperation and Development

9. Child (Under 5) Mortality RateUS(2001)=8 Least developed (2001)= 157

10. Child (Under 5) Mortality rate by Region

11. Major Causes of Mortality • Currently, epidemiologic work is being done to try to accurately measure causes of death • Difficult to get completely accurate numbers that can be tracked over time • Many deaths are due to a combination of reasons such as diarrhea and measles • At least 60% of deaths are thought to be associated with malnutrition • The breakdown of causes of death varies by country and region • Lack of public health infrastucture to accurately collect data

12. Major Global Causes of Mortality for Children under 5, in 2002 *WHO

13. Major Causes of Mortality for children < 5, SS Africa- 2002

14. Major Causes of Infant (< age 1) deaths in the US, 2000 *Pediatrics 12/03

15. Major Causes of Childhood Death in the US (ages 1-4), 2000 *Pediatrics 12/03

16. Causes of death • Use data to formulate a public health approach to reducing mortality • What are the challenges for each major morbidity? • How can we affect the most change? • What are the goals? (World Summit for Children) • Are we making progress?

17. Acute Respiratory Tract Infection (ARI) • Killed ~ 2 million Children in 2000 • Estimated that ~60% of deaths could be prevented with selective antibiotics • WHO recommends using many types of caregivers to evaluate children and provide Abx if necessary including village health workers; children should seek care outside the home

18. Acute Respiratory Tract Infection (ARI) How can the situation change? • Improve care-seeking behavior- get the word out to families and communities about having their children evaluated if sick • IMCI (Integrated Management of Childhood Illness) Initiative • Work on case management skills of health workers

19. Acute Respiratory Tract Infection (ARI) Progress • So far little- in nearly half of 81 developing countries with available data, < 50% if children with ARI were taken to an appropriate provider but there is wide inter-country variability • Biggest problem area is sub-Saharan Africa • Access is a big issue: urban vs. rural; also availability of meds

20. Diarrhea • In early 1990’s was the #1 killer; still important • Tactics so far have included ORT, breastfeeding promotion, measles immunization, safer water supply, and safe feces disposal • Between 1990-2000 diarrheal related deaths decreased by 50%

21. Diarrhea • Most of success attributed to ORT • Evolution of ORT • Early 1980’s ORT= ORS (Oral Rehydration Salts) • Since 1993- ORT=increased fluids and continued feeding (IF/CF)

22. Diarrhea • Different countries use different versions of ORT so a little difficult to compare data but overall there is wide use of ORT and either increasing or stable trends in use • Still lots of work needed to reach families • Still need to work on infrastructure to establish safe water and sewage disposal

23. HIV/AIDS • Actuality of epidemic (in its 3rd decade) is far worse than predictions in early 1990’s • As of 12/04, 40 mil infected (2.2 mil children <15) • Newly infected in 2003= 5 mil; deaths=3 mil (600,000 children)- 8,000 people every day • 95% of those infected live in low and middle income countries • Largest numbers are in sub-Saharan Africa • Epidemics emerging in Eastern Europe, Central Asia, and Asia/Pacific region (China/India)

24. HIV/AIDS in Africa- end 2003 • 25 million Africans with HIV • 19 million have already died • 80% of world’s children who are orphaned due to HIV live in Africa • 60% of world’s young people (15-24) with HIV live in Africa (10 million) • Half of all new infections occur in the 15-24 age range (women are 2.5 times as likely to be infected in this age group)

25. HIV/AIDS Problems • Lack of education- >50% don’t know about AIDS or how it is transmitted in the 20 of 22 countries for which there is information • Young people do not go for education even if its available because of lack of privacy, threatening environment, insensitive staff • Drug Abuse, Risky sexual behavior

29. Life-time risk for HIV/AIDS

31. HIV/AIDS Other issues • Maternal-Child transmission- U5MR could increase by 100% in most affected areas by 2010 • In 2003, 630,000 newly infected children <15 (mostly all perinatal) • Only 8% of infected pregnant women have access to meds (In SS Africa, <5%) • Orphaned children due to HIV • Already 14 million

32. HIV/AIDS • Need to be educating children, even before they reach the 15-24 age group on the disease, its severity, and prevention. • World HIV conference • HIV Vaccine

33. Antiretroviral Treatment; the “3 by 5” initiative

34. Malnutrition • In 1990, 1/3 of children <5 were malnourished (174 million) • Malnutrition contributes to >50% of all child deaths • Poverty, low status of women, poor care during pregnancy, high population densities, poor access to health care and feeding practices contribute

35. Malnutrition- Progress • Since 1990, the percent of underweight children has decreased from 32 to 28% (150 million). (The WSC goal was to reduce it by half). • Greatest decline has been in East Asia (especially China) from 24-16%. • South Asia remains the most affected area- with a small decline since 1990 from 55% to 48% where half of undernourished children live • Problem is 1.5 times greater in rural areas

36. Malnutrition

37. Malaria • Problem areas are sub-Saharan Africa, India, northern South America • Prevention: treated bednets- if every child slept under a treated bednet we could reduce mortality by 25-30% • Treatment- only about half of children are treated appropriately • Also working on a malaria vaccine

38. Malaria • Per WHO, every 30 sec. a child dies of malaria (estimated 1 million deaths worldwide/year- mostly in children and 90% in Africa) • Threat of malaria is increasing due to climate changes, environment, development projects (such as dams), war, poverty

39. Malaria Roll Back Malaria Project- started in 1998 • Strategy includes • Early detection and prompt treatment • Treated bednets and other vector control measures • Preventive intermittent treatment in pregnancy (a Kenya/Malawi study- decrease complications by 75%) • Disease surveillance

40. Vaccine Preventable Diseases • Tetanus (neonatal/maternal), measles, polio • Goal is eradication- • Most dramatic progress so far is with polio- since 1988, incidence has decreased >99%; in 2002, only 1,920 cases worldwide; mostly concentrated in India, Nigeria, and Pakistan • For tetanus, by the end of 1999, 104 of 161 developing countries had eliminated neonatal tetanus • Measles- still have 14 countries with coverage of <50%; global rate =72%

41. Vaccine Preventable Diseases • Strategy for elimination includes: • Use National Immunization Days (NID), sub-NID, and mop-up activities (including house to house) to improve coverage • Improved surveillance and accurate reporting • In the case of polio, have established technical advisory groups for each country as well as interagency coordination committees • Challenges

42. Conclusions • United States vs. the world • Large role of infectious diseases in the developing world contributing towards mortality • Challenges of education, nutrition, war, poverty • Successes