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Problems and Interventions in Global Child Health

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Title: 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
  • gt9 million children under 5 years of age die each
    year.

4
Trends in U5MR
  • 1970146 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 gt1/3 of
Childhood Deaths
  • Underweight
  • Lack of exclusive
  • breastfeeding
  • Micronutrient Deficiencies

15
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

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 lt 2yos)
  • 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

22
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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
DiarrheaQuestions 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?
  • Vaccinesrotavirus, cholera
  • Elucidating etiologies of diarrhea/surveillance

32
Pneumonia
  • gt1.5 million deaths/year in lt 5yos
  • 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 carecommunity health workers can
    effectively identify and treat pneumonia with
    oral antibiotics

39
Malaria
  • Plasmodium parasites
  • Anopheles mosquito
  • Pools of waterbreeding ground

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

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

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 lt5 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

51
Vaccine Preventable Deaths
  • 1.7 million annual deaths

52
Causes of vaccine-preventable deaths among
children lt15 years, 2000
53
Basic Vaccine Schedule
Birth BCG
6weeks DPT 1, OPV 1, HepB1
10 weeks DPT 2, OPV2, HepB2
14 weeks DPT3, OPV3, HepB3
9 months Measles
BCGBacillus Calmette-Guerin (against
TB) DPTDiphtheria, Tetanus, Pertussis OPVOral
Polio Vaccine HepBHepatitis B
54
What is the Global Vaccine Coverage Rate?

55
Vaccine Coverage

56
Measles Treatment
  • Treatment with high dose vitamin A reduces
    mortality from measles by 25
  • Treatment of sequelae
  • Pneumonia
  • Diarrhea
  • Tuberculosis

57
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)

58
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)

59
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

60
Three Components of IMCI
  • Improves health worker skills
  • Improves health systems
  • Improves family and community practices

61
IMCI Addresses Most Causes of Death
  • Sepsis
  • Meningitis
  • Dehydration
  • Anemia
  • Ear infection
  • HIV/AIDS
  • Wheezing
  • Sore throat
  • Pneumonia
  • Diarrhea
  • Measles
  • Malaria
  • Malnutrition

62
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

63
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

64
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

65
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 services?IMCI
    cannot impact child mortality.

66
Improving Health Worker Skills, Community Care,
and Health Systems
67
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68
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

69
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70
Treatment Issues Need for community based
treatment and access to care
WHO Progress Against Malaria. 2007
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