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Interventions in Global Child Health Donna M. Denno 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)

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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)

scope of the problem
Scope of the Problem

10.6 million children under 5 years of age die each year.

trends in u5mr
Trends in U5MR
  • 35 years of improvement
  • Uneven Progress
    • Between and within countries
    • Disparities in wealth
  • Recently some countries—stalled progress or reversal
slowing trends in child mortality
Slowing trends in child mortality

Source: WHO Report 2005: Make Every Mother and Child Count

trends in u5mr6
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
trends in u5mr regional differences
Trends in U5MR: Regional differences
  • Africa
    • Started w/ highest levels
    • Saw smallest reductions (5%/decade)
    • Most marked slow down in progress
trends in u5mr regional differences8
Trends in U5MR: Regional differences
  • Africa
    • 43% of all child deaths
  • SE Asia
    • 28% of all child deaths

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%)


Injuries (6%)


Congenital (4%))

HIV/AIDS (3%))

All other (18%)

Malnutrition is estimated to

contribute to around 50% of

all childhood deaths.



Underlying Cause/Contributor in 50% of Childhood Deaths




Micronutrient Deficiencies

impact of breastfeeding on childhood disease risk in not bf vs exclusively bf

7x risk death


5x risk death

CG Victoria et al, Am J Epidemiol 1989

Impact of Breastfeeding on Childhood DiseaseRisk in not BF vs exclusively BF


Vit A Deficiency

20-24% Risk of death from Diarrhea, Measles, (Malaria)

AL Rice et al In: Comparative quantification of health risks, 2004

underlying causes of disease and malnutrition
Underlying Causes of Disease and Malnutrition



Lack of access to care


causes of death
Causes of Death


Currently not well elucidated

co morbidity underlying cause
Co-morbidity/Underlying Cause


WarDisruption Immunization Services

Child with measles

Diarrhea & Pneumonia


disease specifics
Disease Specifics
  • Interventions=“biologic agent or action intended to reduce morbidity or mortality”
    • Prevention
    • Treatment
acute infectious diarrhea
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)
diarrhea prevention
Diarrhea: Prevention
  • Clean Water
    • drinking, food preparation
  • Sanitation
    • Adequate supply of water/hygiene
    • Safe Feces Disposal
in many parts of the world rural populations still lack access to safe drinking water
In many parts of the world, rural populations still lack access to safe drinking water

Source: Based on UNICEF, End-Decade Databases, January 2005.

diarrhea treatment
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)
diarrhea treatment25
Diarrhea: Treatment
  • ORT—Home based
    • Recognition of symptoms
    • Initiation and continuation of ORT
    • Knowledge
      • ORT does not treat diarrhea
      • Prevents and treats dehydration
diarrhea treatment facility based
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
impact of ort estimates
IMPACT OF ORT--estimates
  • Saves 1 million lives per year
  • Diarrhea deaths HALVED from 1990-2000
diarrhea questions and future interventions
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

acute respiratory infection ari pneumonia
Acute Respiratory Infection (ARI)/Pneumonia
  • 2 million deaths/year in < 5yo’s
  • Bacteria
    • Pneumococcus
    • Haemophilus influenzae type b (Hib)
    • Staphylococcus aureus
    • Mycobacterium tuberculosis
pneumonia prevention
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)
pneumonia treatment
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
pneumonia treatment33
Pneumonia: Treatment

Case management can pneumonia associated childhood mortality by 40%

  • S Sazawal, et al Lancet 2003
pneumonia treatment34
Pneumonia: Treatment

50 % world wide

Plasmodium parasites

Anopheles mosquito

Pools of water—breeding ground

Clinical presentation:


“Uncomplicated” malaria = fever, headache, malaise (cough, diarrhea)

“Severe” or “Complicated” malaria = multi-organ system involvement

Severe anemia


Cerebral malaria


Major cause of anemia in endemic areas

Impact on growth and cognitive development

Drains $2 billion from economies in sub-Saharan Africa

  • 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)
malaria prevention
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
malaria prevention43
Malaria: Prevention
  • Vector control
  • Intermittent Presumptive Treatment of malaria (IPT)
malaria treatment
Malaria: Treatment
  • Home based management
  • Case management
  • Prompt and appropriate treatment
malaria treatment resistance
Malaria: Treatment Resistance
  • More effective drug combinations
malaria future interventions
Malaria: Future Interventions
  • Immunization
  • Infant IPT
vaccine preventable deaths
Vaccine Preventable Deaths

1.7 million annual deaths

basic vaccine schedule
Basic Vaccine Schedule

BCG=Bacillus Calmette-Guerin (against TB)

DPT=Diphtheria, Tetanus, Pertussis

OPV=Oral Polio Vaccine

HepB=Hepatitis B *

measles prevention
Measles: Prevention
  • 1st dose at 9 months
  • 2nd ‘opportunity’
    • Increases chance that all get 1 dose
    • 2nd dose increases protection against disease
measles treatment
Measles: Treatment
  • Vit A supplementation reduces mortality from measles by 25%
  • Treatment of sequelae:
    • Pneumonia
    • Diarrhea
    • Tuberculosis
intervention delivery
Intervention Delivery
  • Vertical Programs
    • Focus on control of one disease
    • Often separate implementation from existing health system
  • Primary Health Care—comprehensive, intersectoral prevention and treatment services delivered at the community level
  • Integrated Management of Childhood Illnesses (IMCI)
integrated management of childhood illnesses imci
Integrated Management of Childhood Illnesses (IMCI)
  • integrated approach
  • aims to reduce death, illness and disability, and to promote improved growth and development
  • includes both preventive and curative elements
  • implemented by families, communities and health facilities
imci addresses most causes of death









Ear infection



Sore throat

IMCI Addresses Most Causes of Death
three components of imci
Three Components of IMCI
  • Improves health worker skills
  • Improves health systems
  • Improves family and community practices
improves family and community practices
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
improves health worker skills
Improves Health Worker Skills
  • Targets first level health facilities
  • Addresses causes of at least 70% of deaths
  • Case management guidelines
  • Training
  • Supervision
  • Monitoring
improves health systems
Improves Health Systems
  • Planning and Management
  • Availability of drugs and supplies
  • Organization of work
  • Monitoring and supervision
  • Referral pathways and systems
  • Health information systems
imci multicountry evaluation
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.
improving health worker skills community care and health systems



and treatment by health workers



and skills


Capacity, structure

and functions of

health system

Improving Health Worker Skills, Community Care, and Health Systems
  • 7 in 10 of the 10.6 millionannual deaths in children younger than 5 years are attributable to six causes
  • Effective interventions exist
  • Effective interventions need to be available to the poorest populations
  • Need strong communities and health systems