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  1. Interventions in Global Child Health Donna M. Denno

  2. GLOBAL CHILD HEALTH PROBLEMS Big Picture: What are they? How Many? Where? Disease Specific: Interventions for Prevention & Treatment Strategies for Intervention Delivery: Integrated Management of Childhood Illnesses (IMCI)

  3. Scope of the Problem 10.6 million children under 5 years of age die each year.

  4. Trends in U5MR • 35 years of improvement • Uneven Progress • Between and within countries • Disparities in wealth • Recently some countries—stalled progress or reversal

  5. Slowing trends in child mortality Source: WHO Report 2005: Make Every Mother and Child Count

  6. Trends in U5MR • 1970—146 deaths/1000 • 2003– 79 deaths/1000 • However reductions in U5MR are slowing down • 1970-1990 U5MR 20%/decade • 1990-2000 U5MR 12%/decade

  7. Trends in U5MR: Regional differences • Africa • Started w/ highest levels • Saw smallest reductions (5%/decade) • Most marked slow down in progress

  8. Trends in U5MR: Regional differences • Africa • 43% of all child deaths • SE Asia • 28% of all child deaths

  9. Bryce J, et al. “WHO estimates of the causes of death in children.” Lancet 2005.

  10. Major Causes of Child Death (1998) Total deaths: 10.8 million Perinatal (20%) Respiratory diseases (17%) Diarrhoeal diseases (17%) Measles (8%) 49% of Malaria (7%) child Injuries (6%) deaths Congenital (4%)) HIV/AIDS (3%)) All other (18%) Malnutrition is estimated to contribute to around 50% of all childhood deaths. EIP/WHO

  11. Malnutrition Underlying Cause/Contributor in 50% of Childhood Deaths

  12. Nutrition: Underweight Breastfeeding Micronutrient Deficiencies

  13. Diarrhea 7x risk death Pneumonia 5x risk death CG Victoria et al, Am J Epidemiol 1989 Impact of Breastfeeding on Childhood DiseaseRisk in not BF vs exclusively BF

  14. 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

  15. Underlying Causes of Disease and Malnutrition Poverty Inequality Lack of access to care Conflict/War/Disaster

  16. Causes of Death Multifactorial/Comorbidites Currently not well elucidated

  17. Co-morbidity/Underlying Cause Example WarDisruption Immunization Services Child with measles Diarrhea & Pneumonia DEATH

  18. Disease Specifics • Interventions=“biologic agent or action intended to reduce morbidity or mortality” • Prevention • Treatment

  19. Acute Infectious Diarrhea • 1.5 million child deaths/year (80% in < 2yo’s) • 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)

  20. Diarrhea: Prevention • Clean Water • drinking, food preparation • Sanitation • Adequate supply of water/hygiene • Safe Feces Disposal

  21. In many parts of the world, rural populations still lack access to safe drinking water Source: Based on UNICEF, End-Decade Databases, January 2005.

  22. http://www.childinfo.org/eddb/sani/trend.htm

  23. 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)

  24. Diarrhea: Treatment • ORT—Home based • Recognition of symptoms • Initiation and continuation of ORT • Knowledge • ORT does not treat diarrhea • Prevents and treats dehydration

  25. Diarrhea: Treatment/Facility Based • ORT • Recognition of dehydration • Selective use of antibiotics • Dysentery • 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

  26. IMPACT OF ORT--estimates • Saves 1 million lives per year • Diarrhea deaths HALVED from 1990-2000

  27. Diarrhea—Questions 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? Vaccines—rotavirus, cholera Elucidating etiologies of diarrhea/surveillance

  28. Acute Respiratory Infection (ARI)/Pneumonia • 2 million deaths/year in < 5yo’s • Bacteria • Pneumococcus • Haemophilus influenzae type b (Hib) • Staphylococcus aureus • Mycobacterium tuberculosis

  29. Pneumonia: Prevention • Immunization(measles, pertussis) • “Newer” immunizations not readily available (pneumococcus, H influenzae b)--$$ • Nutrition • Exclusive breastfeeding/complementary feeding • Vit A and Zinc supplementation • Avoidance of indoor air pollution (ex 2nd hand smoke)

  30. Pneumonia: Treatment • Recognizing symptoms of illness • Case Management • Access to care • Quality of care • Health worker classifies illness based on increased respiratory rate (pneumonia) and chest in drawing (severe pneumonia) • Treat non severe pneumonia with appropriate antibiotic for full course • Refer severe pneumonia

  31. Pneumonia: Treatment Case management can pneumonia associated childhood mortality by 40% • S Sazawal, et al Lancet 2003

  32. Pneumonia: Treatment 50 % world wide

  33. Plasmodium parasites Anopheles mosquito Pools of water—breeding ground Malaria

  34. Clinical presentation: Asymptomatic “Uncomplicated” malaria = fever, headache, malaise (cough, diarrhea) “Severe” or “Complicated” malaria = multi-organ system involvement Severe anemia Jaundice Cerebral malaria Malaria

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

  36. 41% of worlds’ population live in malaria endemic areas

  37. 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)

  38. Malaria: Prevention • Vector control • Spraying • Insecticide treated materials (ITMs) including insecticide treated bednets (ITNs) • High ITN use 17% reduction in childhood mortality • C Lengeler The Cochrane Library, Issue 4, 2001 • PA Phillips-Howard PA. Am J Trop Med Hyg 2003

  39. ITNs

  40. Malaria: Prevention • Vector control • Intermittent Presumptive Treatment of malaria (IPT)

  41. Malaria: Treatment • Home based management • Case management • Prompt and appropriate treatment

  42. Malaria: Treatment Resistance • More effective drug combinations

  43. Malaria: Future Interventions • Immunization • Infant IPT

  44. Vaccine Preventable Deaths 1.7 million annual deaths

  45. Causes of vaccine-preventable deaths among children <15 years, 2000

  46. Basic Vaccine Schedule BCG=Bacillus Calmette-Guerin (against TB) DPT=Diphtheria, Tetanus, Pertussis OPV=Oral Polio Vaccine HepB=Hepatitis B *

  47. Vaccine Coverage