Children and Infectious Diseases: Vaccine Preventable Diseases and Maternal Health

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Children and Infectious Diseases Vaccine
Preventable Diseases and Maternal Health

• Yvonne Maldonado, MD
• Departments of Pediatrics and Health Research
  and Policy
• Stanford University School of Medicine

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Ten Great Public Health Achievements United
States, 1900 - 1999

• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard
• Source Center for Disease Control and
  Prevention, 1999

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Decreased Mortality in the US from Infectious
Diseases in the 1900s

• Sharp drop in infant and child mortality
• In 1900
• 30.4 of all deaths among children lt5 by 1997
  only 1.4
• Leading causes of death pneumonia, tuberculosis,
  diarrhea, and diphtheria
• 29.2 year increase in life expectancy

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Vaccine Successes and Failures

• Pediatric vaccinations have had the most profound
  impact of any intervention on increasing global
  child survival, accounting for 3 million
  childrens lives saved annually.
• Even in the 21st century, however,
  vaccine-preventable infectious diseases,
  including tetanus, measles and pertussis, cause
  disease and death in many parts of the world.

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Global Burden of Disease Where do vaccine
preventable diseases fit in?

• World Health Organization assessment of global
  scope and cause of death
• Many sources of information to assess mortality
  throughout the world
• Categories infectious, non-infectious, trauma

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Leading Global Causes of Death - 1990
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Global Burden of Infections

• One death in three of the 54 million deaths
  worldwide is from an infectious cause
• Virtually all of these deaths are in developing
  areas of the world mainly India and sub-Saharan
  Africa
• Disproportionately affect children
• Many of the developing world deaths are due to
  preventable causes
• Pneumonia and Diarrhea account for 40 of these
  deaths
• Tuberculosis
• Measles
• Malaria

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Limitations of GBD Index

• In most developing areas, this is just an
  estimate of death
• Does not account for incapacitating illness
• Acute and chronic illness may have long term
  effects on family and social structure
• Individuals in marginal circumstances, even in
  developed settings, are at higher risk

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The Global Infectious Disease Threat

• Infectious diseases are a leading cause of death
  worldwide
• Spread due to two major causes
• Changes in human behavior--including lifestyles
  and land use patterns, increased trade and
  travel, inappropriate use of antibiotics
• Microbial factors mutations, antibiotic
  resistance

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The Global Infectious Disease Threat and Its
Implications for the United States

• Of the seven biggest killers worldwide, TB,
  malaria, hepatitis, and, in particular, HIV/AIDS
  continue to surge
• HIV/AIDS and TB likely to account for the
  overwhelming majority of deaths from infectious
  diseases in developing countries by 2020
• Acute lower respiratory infections, diarrheal
  diseases and measles appear to have peaked at
  high incidence levels

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The Global Infectious Disease Threat and Its
Implications for the United States
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Global Burden of Vaccine Preventable Deaths
2.5M deaths/year
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What is the global status of immunization?

• Each year 130 million children are born, 91
  million of them (70) in developing countries.
• Almost 30 million children have no access to
  immunization.
• Due to immunization, and in particular to the
  global Expanded Programme on Immunization (EPI),
  launched by the World Health Assembly in 1974,
  almost 3 million lives have been saved each year,
  and 750 000 children are saved from disability.

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Global Impact of Immunization on
Vaccine-Preventable Diseases
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What is the global status of immunization?

• In 1990, worldwide average vaccination coverage
  of children under five was 80 but by 1999 fell
  to 74.
• One in four children in the world remains without
  immunization against the six diseases initially
  covered by EPI (measles, polio, pertussis,
  diphtheria, tetanus and tuberculosis).

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Access to immunization varies greatly across the
world

• A child in a developing country is ten times more
  likely to die of a vaccine-preventable disease
  than a child from an industrialized one.
• In some countries, up to 70 of children do not
  receive the full set of vaccines the lowest
  coverage is found in sub-Saharan Africa.
• In Africa as a whole, over 40 of children are
  not immunized against measles, a major cause of
  infant mortality that kills one child every
  minute.

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Access to immunization varies greatly across the
world

• WHO has been recommending vaccination against
  Hepatitis B since 1993, yet it kills
  approximately one million people each year.
• Recommendations have also been made for yellow
  fever, yet 30 000 deaths occur each year.

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What is the global status of immunization?

• There is no equality of access to vaccines for
  children in industrialized and developing
  countries, and there is a lack of equality
  between rural and urban areas within countries.
• It is estimated that a child in an industrialized
  country receives eleven vaccines on average,
  while a child from a developing country is lucky
  to receive half that number.

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What is the global status of immunization?

• There is a lack of investment in research and
  development for new vaccines or to disseminate
  existing vaccines to combat the diseases that are
  prevalent in developing countries
• Diarrhoeal diseases (Rotavirus, E. coli,
  Salmonella, Shigella, Cholera)
• Malaria
• Tuberculosis
• Pneumonia (Pneumococcus, H. influenzae type B,
  RSV)
• HIV/AIDS.

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Progress in Eradication of Global Infections

• Eradication of Smallpox in 1977
• Elimination of Poliomyelitis from the Western
  Hemisphere in 1994
• Potential elimination of global poliomyelitis in
  the next 5 to 10 years
• Potential elimination of measles in the next 10
  to 20 years
• Vaccines in development for prevention of
  diarrheal diseases, cervical cancer (HPV)

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New Modes of Vaccination

• Administration of vaccines is a major area of
  research
• Many antigens given in the first year of life so
  combination vaccines available and in development
• Needle-less injections a global priority for
  compliance and safety reasons (decrease spread of
  HIV and HBV through reuse of needles)
• Development of edible vaccines (bananas,
  potatoes)
• Nasal or other mucosal routes

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Impact of Infectious Diseases in the Next 20 years

• Three variables will affect the immediate future
• Relationship between increasing microbial
  resistance and scientific efforts to develop new
  antibiotics and vaccines
• Trajectory of developing and transitional
  economies, especially concerning the basic
  quality of life of the poorest groups in these
  countries
• Degree of success of global and national efforts
  to create effective systems of surveillance and
  response
• The interplay of these drivers will determine the
  overall outlook

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Why Global Eradication of Infectious Diseases?

• Immunization is one of the most cost effective
  health interventions in existence.
• If polio is eradicated by 2005, 1.5 billion per
  annum will be saved on immunization costs alone.
• Similarly, eradication of smallpox in 1979 led to
  direct savings of 275 million per annum.
• Immunization reduces the social and financial
  costs of treating diseases, offering
  opportunities for poverty reduction and greater
  social and economic development.

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Why Global Eradication of Infectious Diseases?

• Improved survival generally result in improved
  standard of living for all
• Benefits to society when most members are healthy
  and productive
• Overall global stability

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Maternal and Neonatal Health

• Maternal-Perinatal
• Morbidity Mortality
• Infections
• Inadequate Perinatal Care
• Premature Births
• Obstructed Labor
• Fistulas
• Genital Mutilation
• Cancer

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Maternal and Neonatal Health

• Women and their babies
• suffer at the hands of
• Poverty
• Poor nutrition
• Infection
• Lack of effectively trained health workers and
  medical staff
• Natural disasters

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Maternal and Neonatal Health

• 529,000 pregnant women die per annum, 1 per
  minute, and 5.7 million newborns die, almost all
  in the developing countries of the world
• In addition, for every woman who dies in
  childbirth, 20 more suffer injury, infection and
  disease 10 million women a year.
• A woman living in sub-Saharan Africa has a 1 in
  16 chance of dying on pregnancy or childbirth,
  compared with a 1 in 2,800 risk for a woman in a
  developed country.

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Maternal and Neonatal Health

• 70 of maternal deaths are due to hemorrhage,
  obstructed labor, eclampsia, sepsis, and unsafe
  abortion.
• Of the 529,000 maternal deaths, 527,000 are from
  the developing world.
• 2.7 million newborns are born dead each year and
  3 million will not survive the first week of
  life the astonishing total of 5.7 million!

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Maternal and Neonatal Health

• The WHO Department of
• Making Pregnancy Safer (MPS)
• every birth should be attended by a skilled
  health worker if the terrible toll of maternal
  deaths is to be reduced many of the deaths
  could be avoided if all women had the assistance
  of a skilled health care worker before, during
  and after pregnancy, including access to
  emergency medical care if complications should
  arise.

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Maternal and Neonatal Health

• Goals
• UN Goal is to reduce by three-quarters the rate
  that women die by childbirth by 2015
• WHO Goal is to dramatically increase the number,
  training and availability of trained health care
  workers in areas where there is unmet need.

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Pediatric Preventable Infections Immigrant
Populations

• Immunizations are key
• Lack of a sustained medical home
• Poor tracking by immunizations registries
• Tuberculosis rates are high among immigrant
  populations in the US
• Exposure to infected adults
• Disease most severe in infants and young
  children
• Maternal prenatal care important for good
  perianatal outcomes
• Lack of consistent prenatal care in immigrant
  women