Child survival

1
Childsurvival how many deaths can we prevent?
Dr SK CHATURVEDI Dr KANURPIYA CHATURVEDI
2
Child survival focus

• Issue
• Worldwide over 10 million children under 5 years
  of age are dying each year.
• What interventions are appropriate for reducing
  these deaths, and what would their impact be if
  full coverage of the interventions were achieved?

• India contributes nearly 25 to the worldwide
  total of under-5 deaths, so a major reduction by
  India will have a major worldwide impact.

3
Child survival the Lancet approach

• Review the state of evidence for interventions to
  reduce mortality for each of the major direct and
  underlying causes of death in children under
  five. Determine their efficacy and apply to
  current situation to assess how many under-5
  deaths could be prevented.

• 1st alternative apply at regional level

• 2nd alternative apply at country level

• Compromise apply to each of 42 countries where
  90 of worldwide under-5 deaths occur

4
Child survival - interventions

• Focus on interventions addressing proximal
  determinants of child mortality and those that
  can be delivered mainly through the health sector.

• Take each of the main causes of under-5 deaths
  and examine the effectiveness of available
  interventions for each cause of death

diarrhoea, pneumonia, measles, malaria,
HIV/AIDS, and the underlying causes of
undernutrition for deaths among under-5s, and
asphyxia, preterm delivery, sepsis, and tetanus
for deaths among neonates
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Intervention search strategy

• Estimates of effectiveness of interventions taken
  from
• either published articles that summarized
  earlier research results
• or systematic reviews by the authors and
  participants in the Bellagio Child Survival Study
  Group, together with input from other experts

Included search of MEDLINE, POPLINE, and other
databases, including the Cochrane database of
randomized controlled trials and the WHO
Reproductive Health Library
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Interventions level of evidence

• Each potential intervention was assigned to one
  of three levels based on the strength of evidence
  for its effect on under-5 mortality

Level 1 sufficient evidence causal
relationship between intervention and reduction
of under-5 mortality established Level 2
limited evidence effect is possible, but data
not sufficient to establish causal
relationship Level 3 inadequate evidence -
includes those that hold promise of substantial
effects on under-5 mortality but have not yet
been fully assessed (ex rotavirus, pneumo.
vaccine, indoor air pollution)
Feasibility for delivery at high coverage levels
is a central criterion for any intervention
intended to reduce child mortality. But what is
feasible varies widely among countries.
Therefore the approach focused on an essential
set judged to be feasible for all countries.
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Interventions by cause - diarrhoea
Treatment
Prevention
Breastfeeding
Exposure to diarrhoea
Water/San/Hygiene
Complementary feeding
Oral rehydration therapy
Zinc
Vitamin A
Diarrhoea
Antibiotics for dysentry
Zinc
Survive
Future rotavirus vaccine
8
Interventions by cause - pneumonia
Treatment
Prevention
Exposure to pneumonia
Breastfeeding
Complementary feeding
Zinc
Hib vaccine
Pneumonia
Antibiotics
Survive
Future Pneumococcal vaccine, zinc for therapy,
reduction of indoor air pollution
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Interventions, neonatal - infections
Prevention
Treatment
Clean delivery
Exposure to infections
Antibiotics for premature rupture of membranes
Breastfeeding
Severe bacterial infection
Antibiotics for sepsis
Survive
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Methods and assumptions

• For India, and each of the other 42 countries,
  how many deaths from a specific cause could be
  prevented were calculated with present coverage
  levels increased to universal coverage (99,
  except exclusive breastfeeding at 90). Three
  types

• Exclusive and continuing breastfeeding
• Complementary feeding
• All other interventions

Components coverage (current and target),
efficacy, affected fraction or population,
evidence level
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Current coverage around 2000
12
Current coverage around 2000
Same as for prevention
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Under-5 deaths preventable - results

• Three types of results calculated
• By individual interventions
• By specific causes
• By groups of interventions

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Under-5 deaths preventable through universal
coverage with individual interventions (2000)
India
15
Under-5 deaths preventable through universal
coverage with individual interventions (2000)
India
16
Under-5 deaths preventable through universal
coverage with individual interventions (2000)
India
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Interventions, neonatal - prematurity
Prevention
Treatment
Antibiotics for premature rupture of membranes
Pregnant
Treated bednets materials Intermittent
preventive therapy
Antinatal steroids
Premature
Newborn temperature management
Survive
Indoor residual spraying may be used as an
alternative
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Under-5 deaths from specific causes preventable
through listed interventions (2000)
India
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Under-5 deaths from specific causes preventable
through listed interventions as percent of
deaths by cause (2000)
India
20
Under-5 deaths from specific causes preventable
through listed interventions as percent of
total deaths (2000)
India
21
Under-5 deaths preventable with specific groups
of interventions (2000)
India
22
Under-5 deaths preventable with specific groups
of interventions (2000)
India
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Further deaths that could be prevented

• Four reasons why these estimates of preventable
  under-5 deaths are conservative

• Only interventions for which cause-specific
  evidence of effect was available were included
  (evidence levels 1 and 2)
• Restricted to interventions that are feasible at
  high coverage in low-income countries
• Excluded promising interventions that are
  currently being assessed (e.g. rotavirus)
• Limited to interventions that address the major
  causes of child death and selected underlying
  causes (e.g. did not include anaemia)

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Conclusions on under-5 deaths that could be
prevented in India

• Full coverage of listed interventions is
  estimated to result in a 57 reduction in under-5
  deaths in India
• This is a conservative estimate for reasons given
  in previous slide

Next steps ? Review interventions in Indian
context, identify any changes, with supporting
evidence, and reassess impact on reduction of
under-5 deaths