Child survival – how many deaths can we prevent?

Childsurvival – how many deaths can we prevent? Dr SK CHATURVEDI Dr KANURPIYA CHATURVEDI

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.

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

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

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

Interventions – level of evidence 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) Each potential intervention was assigned to one of three levels based on the strength of evidence for its effect on under-5 mortality: 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.

Die Interventions by cause - diarrhoea Prevention Treatment Breastfeeding Exposure to diarrhoea Water/San/Hygiene Complementary feeding Oral rehydration therapy Zinc Vitamin A Diarrhoea Antibiotics for dysentry Zinc Survive Future: rotavirus vaccine

Die 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

Die Interventions, neonatal - infections Prevention Treatment Clean delivery Exposure to infections Antibiotics for premature rupture of membranes Breastfeeding Severe bacterial infection Antibiotics for sepsis Survive

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

Current coverage – around 2000

Current coverage – around 2000 * Same as for prevention

Under-5 deaths preventable - results • Three types of results calculated: • By individual interventions • By specific causes • By groups of interventions

Under-5 deaths preventable through universal coverage with individual interventions (2000) India

Die 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

Under-5 deaths from specific causes preventable through listed interventions (2000) India

Under-5 deaths from specific causes preventable through listed interventions – as percent of deaths by cause (2000) India

Under-5 deaths from specific causes preventable through listed interventions – as percent of total deaths (2000) India

Under-5 deaths preventable with specific groups of interventions (2000) India

Further deaths that could be prevented • 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) Four reasons why these estimates of preventable under-5 deaths are conservative:

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

Child survival – how many deaths can we prevent?