PRIMARY CARE PAEDIATRICS Social and Preventive Paediatrics

1. PRIMARY CARE PAEDIATRICS (Social and Preventive Paediatrics) Dr Adegoke, SA Lecturer/ Consultant, Dept of Paediatrics/ Child Health, OAU/ OAUTHC, Ile-Ife.

2. Outline Introduction Health problems of Nigerian children Determinants of health & diseases in children PHC: Historical perspectives PHC: Definition, components, relevance, challenges & solutions Childhood survival strategies Preventive paediatrics Conclusion

3. Introduction Most African countries are still in the 1st phase of national development, i.e. fertility and mortality rates are high, cf. with developed nations. 2nd phase: High fertility and low mortality 3rd phase: Low fertility and low mortality Children in developing nations constitute about 45% of the entire population. Greater burden of deaths in most Africa countries occur in children. (70% vs. 5% of total deaths in developing and developed countries)

4. introduction Globally, more than 10 million children die each year >90% of them occur in developing countries. 50% occur in 6 countries (India, Nigeria, China, Pakistan, DR Congo, Ethiopia). >70% are caused by preventable diseases.

5. Introduction: Primary care Paediatrics. Refers to preventive aspects of Paediatrics An integral part of Child health It focuses on wellness of children rather than treating childhood illnesses Researches have shown that Preventive paediatrics hold the key to childhood survival in developing nations, where modern medical infrastructures and enabling conditions are not usually available.

6. Health problems of Nigerian children Undernutrition and infections are the two leading health problems in African children Malnutrition (Under nutrition) account for 40% of childhood morbidities, either singly or in combination with other diseases. Prevalence of stunting = 45.5%, wasting = 17%, underweight = 29%. Infections: Malaria 25% Diarrhoea 25% RTI 25% Other infections (HIV, TB, Measles)

7. Other paediatric problems Neonatal problems: Birth asphyxia, Jaundice and Kernicterus, infections including tetanus, LBW (Preterm, SGA) Haematological problems: SCA, G6PD def, etc Childhood injuries: Gradually becoming a significant cause of childhood deaths Malignancies: Burkitt Lymphoma, Leukaemia, etc Renal conditions

8. Childhood mortality in Nigeria Neonatal mortality rate: Number of deaths of newborn (first 28 days of life) per 1000 live births. NMR = 47/ 1000 live births Infant mortality rate: Number of deaths of infants (<12 months) per 1000 live births. IMR = 107/ 1000 live births U5MR: Number of U5 deaths per 1000 live births U5MR = 189/ 1000 live births. Perinatal mortality rate: Number of deaths in the first week of life and stillbirths per 1000 total births. PMR = 87/ 1000 births

9. Nigeria and some other countries

10. Relevance of the vital statistics PMR Is a reliable index of: 1. Status of women and their health 2. Quality of antenatal, natal and neonatal care IMR and U5MR are indicators of national health (they reflect nutritional health, immunization, food security, clean and safe water of a nation). What are the other indices of national development? MMR, Life expectancy, Literacy rate, GDP/ GNP, PQLI

11. Determinants of health & diseases in children Hereditary: genetic make-up of individual Environment: Physical, biological, chemical Life style: Nutrition, exercise/ sedentary lifestyle, personal habits etc. Socioeconomic conditions

12.  SOCIAL, ECONOMIC, POLITICAL AND CULTURAL FACTORS. 1. Poverty: 70% of Nigerian are poor (spend > 40% of income on food or earn < 1 dollar/ day). GDP and GNP are low 2. Ignorance: Literacy level is low (36% vs. 98%) 3. Beliefs: Eating of meats may lead to stealing etc 4. Culture/ traditional practices: FGM, polygamy, male sex preference etc 5. Poor political will

13. 6. Ethno-religious or political conflicts and war 7. Inadequate resources: low health budget (WHO recommends 15%, Nigeria gives <5% of her total budget. 8. Lack of basic amenities: safe water, food security & hygiene, proper sanitation, good transportation 9. Unequal distribution of resources: 80% resources vs. 20% population 10. Corruption: The bane of every sector.

14. Primary Health Care- history WHO/ UNICEF international conference was held at Alma Ata in USSR in September 1978 There, the aim and objectives of PHC (to bring health care closer to the populace) were highlighted and endorsed by the participating nations. PHC was identified as the key to attaining the basic or essential health for all. The declaration made at the end of that conference is known as Declaration of Alma Ata.

15. PHC: Definition, components, relevance, challenges and solution. Defined as: An essential health care Based on practical, scientifically sound and socially acceptable methods and technology Made universally accessible to individuals and families in the community Through their full participation and - At a cost that the community and country can afford to maintain at every stage of their devpt.

16. Principles of PHC A successful PHC is based on: 1. Equitable distribution of resources: Since health is a fundamental right of every individual, health services should be provided for all. 2. Manpower development: Training and retraining of health staff 3. Community involvement/ participation: Involve community members e.g. TBA, Village health workers 4. Appropriate technology: Methods in keeping with the local culture e.g. ORSS 5. Intersectoral collaboration: Involve other sectors

17. Components of PHC 1. Health education: To improve awareness on prevailing health problems and methods of preventing them so as to change health behaviour of people 2. Provision of food & proper nutrition To ensure food security in terms of quality, quantity, balanced nutrition and nourishment

18. Provision of safe water and basic sanitation: Ensure adequate quality: Free from biologic & chemical contaminants b. Quantity: 20 - 40L/ person/ day c. Makes environment unsuitable for vectors of infections d. Reduces contamination of water, food and soil.

19. Immunization.... 4. IMMUNIZATION: means of acquiring specific immunity to microorganism. Immunity: Body’s ability to resist disease Could be: Artificial or Natural immunity NATURAL: Transfer of antibodies through the placental or breast milk (passive), or transfer of antigen following an infective illness (active). NB: Antibodies that are acquired naturally decay some months after birth (e.g. Malaria antibodies by about 6 months) Immunity following exposure to infection may be life long (e.g. Immunity following measles).

20. ARTIFICIAL: - Process of inducing immunity artificially, either actively or Passively Passive immunization: Giving of antibody (e.g. ATS, hepatitis immunoglobulins, etc) Active immunization: Giving of antigens artificially, known as VACCINATION. Vaccines may consist of (a) Whole organism either killed or attenuated (b) Part of the organism (c) Modified portion of the organism e.g. toxins

21. Burden of Vaccine Preventable Diseases (VPD) Worldwide, about 3 million children die of VPD, annually (measles 2m, tetanus 0.8m, pertusis 0.6m, TB 0.4- 0.5m, polio 0.2m) Another 3 million children are disabled yearly as a result of VPD globally (Cripple, deaf, blind, MR etc) In Nigeria, 20 – 35% of U5M are due to VPD

22. Immunization schedules in Nigeria EPI: Launched in 1979 a. Targeted at 6 killer diseases, giving in the first 2 years of life. b. Had poor start and was revised in 1984 c. Thereafter, coverage improved to about 80% in 1990. NPI replaced EPI in August 1997. (a) Re-engineer the existing policy so as to improve the dwindling coverage (b) Target some other diseases (Hep, YF) NID was introduced in 1996 to complement the routine immunization in polio eradication. Was modified in 2006 to include Vit A and Measles vaccination.

24. Types of vaccines: Life, killed, toxoid BCG- Live vaccine Polio: Oral form (Sabin) is a live vaccine, while IM form (Salk) is a killed vaccine. Hepatitis: Live vaccine Diphtheria and Tetanus: Toxoid Pertusis: Killed form Measles: Live Yellow fever: Live

25. Special considerations Preterm: should be fully immunized, but it’s usually commenced when about 2.5kg or about 2 months old. HIV (Exposed or infected) / AIDS: should have all the routine immunization & some others, but with caution when giving live vaccines- Sickle cell anaemic and others with asplenia: Pneumococcal Conjugate Vaccine (PCV) & Hib vaccines Hepatitis vaccines to babies born to hepatitis seropositive mothers within 72 hours of delivery. Some important vaccines not routinely given in Nigeria: MMR, PCV& Hib vaccine (2,4,6,12-15 mo), rotavirus vaccine etc.

26. Contraindications to immunization Concurrent moderate to severe illness Previous anaphylactic reaction to the vaccine Local sepsis of intended injection site Severely immunocompromised should not be given live vaccines COMPLICATIONS Pertusis encephalopathy Risk of infection Injection abscess or cellulitis Fever Pain and irritability

27. 5. Maternal and Child health (Women and children are the most vulnerable groups in the society). a. Includes family planning. b. Child care: Well child clinic visits, Growth monitoring, IMCI c. Mother care: ANC, Safe labour & delivery services, PNC.

28. 6. Supply of essential drugs: Antimalarials, ORSS, antibiotics, haematinics etc 7. Treatment of common illnesses and injuries a. Achievable with the use of essential drugs b. Encourage early treatment of diseases c. Reduces severity/ complications

29. 8. Prevention and control of locally endemic diseases (e.g. Malaria, diarrhoea, pneumonia etc.) Others Mental health Dental heath

30. Problems of PHC Corruption Lack of personnel Lack of supervision Not readily affordable Health facilities are not easily accessible Sustainability Ignorance/ Illiteracy Cultural factors: Taboos, beliefs

31. Strengthening PHC Proper funding Separate budget for PHC Private partnership International/ NGO support Proper supervision and evaluation Personnel performance enhancement Proper recruitment Motivation Training and re-training

32. Cont’d Proper community involvement To include funding & management Intersectoral collaboration Strengthening referral system

33. Childhood survival strategies (gobifffeeth) These are low-cost strategies adopted by UNICEF to reduce childhood mortalities. They include: Growth Monitoring Oral Rehydration Therapy Breastfeeding Immunization Female education Food supplementation Family Planning Environmental protection and sanitation Essential drug supply Treatment of common diseases Health education

34. Preventive Paediatrics There are three main levels of disease prevention. 1. PRIMARY PREVENTION: Aim at preventing disease from occurring. It is subdivided into: a. General prevention: Growth monitoring, Breastfeeding, Female education, Health education, Personal & environmental hygiene, provision of safe water, premarital counselling b. Specific prevention: Immunization against a disease, Iodine/ Iron/ Vitamin A supplementation, drug prophylaxis etc. 2. SECONDARY PREVENTION: Make prompt diagnosis and treatment

35. 3. TERTIARY PREVENTION: a. Limitation of disabilities i.e. ameliorate or arrest physical/ mental disabilities from the illness: Physiotherapy, Psychotherapy, use of prosthesis etc. b. Rehabilitation: Use of hearing aid, speech therapy, special education for deaf, blind, mentally retarded etc.

36. Conclusion Preventable diseases account for a large proportion of childhood morbidities and deaths in developing nations. Primary care paediatrics therefore involves: 1. Identifying childhood preventable diseases 2. Understanding the underline socio-economic factors associated with childhood diseases 3. Describing cost-effective and highly efficacious strategies (PHC & CSS) 4. Using the classical levels of disease prevention

37. Assignment Discuss the roles of the following in childhood survival: Growth monitoring Female education Immunization Family planning Breastfeeding

38. THANKS