Problems and Interventions in Global Child Health

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Problems and Interventions in Global Child Health

• Donna M. Denno
• Affiliate Assistant Professor, Dept of Pediatrics
• Clinical Assistant Professor, Dept of Global
  Health

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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)

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Scope of the Problem

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

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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

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Slowing trends in child mortality
Source WHO Report 2005 Make Every Mother and
Child Count
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Millennium Development Goal 4
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Millennium Development Goal 4

• Reduce child mortality rates by 2/3 by the year
  2015

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Trends in U5MR Regional differences

• Sub-Saharan Africa
• Started w/ highest levels
• Saw smallest reductions (5/decade)
• Most marked slow down in progress

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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
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Trends in U5MR

• In 21 developing countries
• Overall U5MR
• Gaps in U5MR between rich and poor

while
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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)

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What are the leading causes of childhood
mortality worldwide?
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What are the leading causes of childhood
mortality worldwide?
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Undernutrition Underlying Cause in gt1/3 of
Childhood Deaths

• Underweight
• Lack of exclusive
• breastfeeding
• Micronutrient Deficiencies

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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

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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

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Underlying Causes of Disease and Malnutrition

• Poverty
• Inequity
• Lack of maternal education
• Lack of access to care
• Conflict/War/Disaster

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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)

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Disease Specifics

• Interventions biologic agent or action
  intended to reduce morbidity or mortality
• Prevention
• Treatment

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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)

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Diarrhea Prevention

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

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In many parts of the world, rural populations
still lack access to safe drinking water
Source Based on UNICEF, End-Decade Databases,
January 2005.
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http//www.childinfo.org/eddb/sani/trend.htm
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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)

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Diarrhea Treatment

• How much does a sachet of ORS cost?

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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

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IMPACT OF ORT

• Saves 1 million lives per year
• Diarrhea deaths HALVED from 1990-2000

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

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Pneumonia

• gt1.5 million deaths/year in lt 5yos
• Bacteria (60-70)
• Pneumococcus
• Haemophilus influenzae type b (Hib)
• Staphylococcus aureus
• Mycobacterium tuberculosis

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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

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Pneumonia Treatment

• Case management--Prompt treatment with
  appropriate antibiotic (right doses, full course)
• The good news 1st line oral antibiotics
  (amoxicillin, cotrimoxazole) are effective

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Pneumonia Treatment

• Case management can pneumonia associated
  childhood mortality by 40
• S Sazawal, et al Lancet 2003

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Pneumonia Treatment Coverage
What of children with pneumonia are taken to a
health care provider?
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Pneumonia Treatment
50 world wide
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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

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Malaria

• Plasmodium parasites
• Anopheles mosquito
• Pools of waterbreeding ground

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Malaria

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

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Malaria

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

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Almost half of the worlds population live in
malaria endemic areas
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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)

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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

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Household surveys 2006-2007, DHS, MICS, MIS
Household ITN ownership
Use by children lt5 years of age
WHO World Malaria Report 2008
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ITNs
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Malaria Treatment

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

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Malaria Treatment Resistance

• Artemisinin Combination Therapy (ACT)

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Malaria in children Treatment Coverage

• 38 with fever ? any antimalarial
• 19 ? antimalarial on day 1 or 2 of onset of
  fever
• 3 ? ACT

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Malaria Future Interventions

• Vaccine
• Infant IPT

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Vaccine Preventable Deaths

• 1.7 million annual deaths

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Causes of vaccine-preventable deaths among
children lt15 years, 2000
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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
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What is the Global Vaccine Coverage Rate?

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Vaccine Coverage

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Measles Treatment

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

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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)

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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)

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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

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Three Components of IMCI

• Improves health worker skills
• Improves health systems
• Improves family and community practices

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IMCI Addresses Most Causes of Death

• Sepsis
• Meningitis
• Dehydration
• Anemia
• Ear infection
• HIV/AIDS
• Wheezing
• Sore throat

• Pneumonia
• Diarrhea
• Measles
• Malaria
• Malnutrition

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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

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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

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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

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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.

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Improving Health Worker Skills, Community Care,
and Health Systems
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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

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