New evidence on intervention efficacy & effectiveness

1. New evidence on intervention efficacy & effectiveness Betty Kirkwood London School of Hygiene & Tropical Medicine

2. Is there any major new evidence concerning interventions to improve newborn and child survival that adds to or changes our current thinking? Thanks to

3. Evidence-based Interventions • Lancet Bellagio Child Survival Series 2003 23 interventions • 15 preventive (9 child, 6 newborn) • 8 case-management (6 child, 2 newborn) • Lancet Neonatal Series 2005 8 additional “cost-effective” interventions

4. Is there new evidence: • that significantly changes our assessment about the potential impact or delivery of any of the 31 interventions? • for new intervention(s) to be added? • about effective delivery strategies?

5. NEW evidence re 31 interventions: ANTIBIOTICS FOR PNEUMONIA • Current guidelines • Non-severe pneumonia: treat at home with oral antibiotics • Severe pneumonia: admit & give parenteral antibiotics • Oral amoxycillin as effective as injectable penicillin: multi-centre trial • Potential benefits include decreases in: • Risk of needle-borne infections • Need for referral or admission • Administration costs • Costs to the family Addo-Yobo et al for the Amoxicillin Penicillin Pneumonia International Study (APPIS) Group, Lancet 2004; 364: 1141–48

6. NEW evidence re 31 interventions: EARLY INITIATION OF BREASTFEEDING Ghana: Risk of Neonatal Mortality after 1st day Various measures taken to address potential reverse causality POSTERS 20 & 21

7. NEW evidence re 31 interventions: EARLY INITIATION OF BREASTFEEDING • 60 priority countries • Two intervention models: • A: BF initiated within 1st hour • B: BF initiated within 1st day • (but not necessarily 1st hour)

8. NEW evidence re 31 interventions: • HANDWASHING • Meta-analysis 11 studies: 37% reduction in diarrhoea (CI 23-48%) (Fewtrell et al, Lancet Inf Dis 2005; 5: 42-52) • A randomised controlled trial of handwashing on child health in Karachi, Pakistan Luby et al, Lancet 2005; 366: 225–33

9. New intervention to add? RUTF (highly fortified Ready to Use Therapeutic Foods) for community-based management of SEVERE MALNUTRITION ISSUE: • 10 million children severely malnourished, High risk of mortality • Usual recommendation: refer to hospital or specialised treatment unit • Coverage low CONSULTATION (WHO, UNICEF, SCF; Geneva 21-23 Nov 2005): • Community based approach with RUTF feasible & effective • Very low case fatality rate • Only a small proportion of severely malnourised children needed to be referred to hospital • Potential to save 100,000’s child deaths • YES: STRONG EVIDENCE

10. New intervention to add? Cotrimoxazole prophylaxis for children with clinical signs of HIV

11. New intervention to add? Chlorhexidine Cleansing: Nepal • A single cleansing of newborn skin as soon as possible after delivery (median 6 h): • 28% reduction in mortality among LBW infants • Cleansing umbilical cord with 4% chlorhexidine on days 0,1,2,3,5,7,9: • 24% reduction in overall neonatal mortality (Lancet in press) Courtesy Darmstadt & colleagues POSTERS 39 & 41

12. New VACCINES to add? TO CONSIDER: • Pneumococcal conjugate vaccine (3 doses): The Gambia: 16% reduction in mortality (CI 3-28%) Cutts et al, The Lancet 2005; 365: 1139-46 Issues: Affordability, Availability, Composition NOT YET: • Rotavirus: • High efficacy LA/US • Trials needed in less developed countries • Malaria RTS,S/AS02A vaccine: The Gambia: 58% reduction in severe malaria (CI 16-81%) Alonso et al, Lancet 2004; 364: 1411–20

13. NEWevidence re effective delivery WOMEN’S GROUPS: Makwanpur Effect of a participatory intervention with women’s groups on birth outcomes in Nepal: cluster RCT(Manandhar et al, Lancet 2004) 0·70 [95% CI 0·53–0·94]) >6000 deliveries 12 pairs

14. NEWevidence re effective delivery NEWBORN CARE HOME VISITS: Shivgarh Shivgarh (India): Impact of 4 home visits by CHWs to PROMOTE ESSENTIAL NEWBORN CARE* through Community Mobilization & Behavior Change Communications POSTER *As defined in Lancet Neonatal Survival Series paper 2: Lancet 2005;365:977-88.

15. COMPLEMENTARY FEEDING PERU: Educational intervention delivered through health services RCT: Government health facilities (6 intervention, 6 control) Aim of intervention: enhance quality & coverage of existing nutrition education & introduce accrediation system Evaluation: Birth cohort, 187 infants NEWevidence re effective delivery OR 3.04 (CI 1.21-7.64)

16. Intervention to reconsider? Zanzibar: Pemba RCT (IFA, IFA+zinc, Zinc, Placebo) • IFA arms stopped because adverse effects • Adverse events: 12% higher, CI=2 to 23%, P=0.02 • Deaths: 15% higher, CI=-7 to 41%, P=0.19 • “Current guidelines for universal IFA supplementation should be reconsidered” Sazawal et al, Lancet in press PROPHYLACTIC IRON SUPPLEMENTS IN MALARIA ENDEMIC AREAS

17. Coming soon • Impact of routine zinc supplements on child mortality • RESULTS from 2 trials in Pemba & Nepal • Next 6 months

18. NEW evidence: IMPLICATIONS • ADD IMMEDIATELY • RUTF for severely malnourished children • Oral amoxycillin for pneumonia • Cotrimoxazole prophylaxis for HIV+ children • Indicator for handwashing • CONSIDER • Newborn skin/cord cleansing • Pneumococcal vaccine • GET MORE EVIDENCE • Early initiation of BF & neonatal mortality • IF Ghana findings replicated, ADD to list

19. NEW evidence: IMPLICATIONS • Reconsider Iron Guidelines • EVALUATING INTERVENTIONS IS ESSENTIAL, as is monitoring outcomes after implementation • Evidence supports increased emphasis on community-based involvement • NEED: Evidence on scaling up