Transcript Global Distribution of Causes of Child Deaths: 2008

http://www.youtube.com/watch?v=fxtKzTV6W
LE
http://www.youtube.com/watch?v=Cf8GGOZZ
sWM
Global Distribution of Causes of Child
Deaths: 2008
Regional Distribution of Causes of
Child Deaths: 2008
Global Causes of Under-Five Deaths in 2010
Through synergy with infectious diseases
Children Under 5 Years Old
• Collectively, infectious diseases (almost 2/3 of
deaths) are most important COD.
• Most important single causes are pneumonia and
preterm birth complications.
• Numbers of deaths varied widely across WHO
regions (most deaths in Africa and southeast
Asia).
• Despite continuing increase in population of
children under 5, mortality rate is declining (7.6
million in 2010 vs. 9.6 million in 2000).
Summary of Global Estimates in 2010
7.6 million deaths in children < 5 years
64% (4.9 million) of deaths were from infectious diseases
Pneumonia
18% 1.40 million
Diarrhea
10% 0.80 million
Malaria
7% 0.56 million
40% (3.1 million) of deaths occurred in neonates
PTB Complications
14% 1.08 million
Intrapartum-related complications
9% 0.72 million
Sepsis or meningitis
5% 0.39 million
Pneumonia
4% 0.33 million
2010 Estimates of Causes of Child
Deaths
• All children under 5 years – for 193 countries
– most important single COD:
• pneumonia
• preterm birth complications
– other important causes: diarrhea, birth asphyxia
and malaria
– measles responsible for 1% of deaths (successful
vaccination programs)
Undernutrition: Underlying Cause in >1/3
of Childhood Deaths
Underweight, stunted, wasted
Lack of exclusive
breastfeeding
Micronutrient Deficiencies
8
Impact of Breastfeeding on Childhood
Disease
Risk in not BF vs exclusively BF
Diarrhea
7x
risk death
Pneumonia
5x
risk death
CG Victoria et al, Am J Epidemiol 1989
9
Micronutrients
Example
Vitamin A Deficiency
20-24%
Risk of death from Diarrhea,
Measles, (Malaria)
AL Rice et al In: Comparative quantification of health risks, 2004
10
Disease Specifics
• Interventions = “biologic agent or action
intended to reduce morbidity or
mortality”
–Prevention
–Treatment
11
Acute Infectious Diarrhea
• 1.2 million child deaths/year (80% in < 2yo’s)
• Microbiologic Etiology--multiple
– Regional/local variation
– e.g. Rotavirus, Shigella, Enterotoxogenic E coli,
Campylobacter
• Spread
– water, food, utensils, hands, flies
• Deaths
– dehydration (water loss)
– electrolytes/salts loss (sodium, potassium, bicarbonate)
http://www.youtube.com/watch?v=06v4txfdWms&feature=channel
12
The Vicious Cycle of Infectious Diarrhea,
Malabsorption, and Undernutrition
Infectious Diarrhea
Growth Faltering, Weight Loss
Micronutrient Deficiencies
Lowered Immunity
Increased Risk of Infectious Diseases
Poverty and
Food Insecurity
Intestinal Injury and Enteropathy
Leaky Intestines,
Malabsorption of Nutrients,
Decreased Uptake & Reduced Efficacy of
Oral Medications and Vaccines
HIV/AIDS
13
Prevention: WaSH
– Clean Water
• drinking, food
preparation
– Sanitation
• Safe Feces Disposal
– Hygiene
• Especially hand washing
14
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)
15
Diarrhea: Treatment
How much does a sachet of ORS cost?
16
Diarrhea: Treatment
ORT
– Prevent and treat dehydration
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
• Selective use of antibiotics
– Dysentery
17
IMPACT OF ORT
• Saves 1 million lives per year
• Diarrhea deaths HALVED from 1990-2000
http://www.pbs.org/wgbh/rxforsurvival/series/video/d_dia1_dis_oralretherapy
_qt_h.html
18
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 can we break the enteropathy-undernutrition cycle?
How does water privatization impact access to water?
Vaccines—rotavirus, cholera
Elucidating etiologies of diarrhea/surveillance
19
Pneumonia
• >1.4 million deaths/year in < 5yo’s
• Bacteria (60-70%)—especially
– Pneumococcus
– Haemophilus influenzae type b (Hib)
20
Pneumonia: Prevention
• Immunization (measles, pertussis)
– “Newer” immunizations have slowly been incorporated
into vaccine schedules (pneumococcus, H influenzae b)--$$
• Nutrition
– Exclusive breastfeeding / appropriate complementary
feeding
– Vit A and Zinc through diet / supplementation
• Avoidance of indoor air pollution
– E.g., Unprocessed household solid fuels (wood, dung,
coal)1.8 increased risk of pneumonia
• Hand Hygiene
21
Pneumonia: Treatment
• Case management--Prompt treatment with
appropriate antibiotic (right doses, full course)
• The good news: 1st line oral antibiotics
(amoxicillin, cotrimoxazole) are effective
22
Pneumonia: Treatment
Case management can
pneumonia
associated childhood mortality by 40%
– S Sazawal, et al Lancet 2003
23
Pneumonia: Treatment Coverage
What % of children with
pneumonia are taken to
a health care provider?
Pneumonia: Treatment
What does it take?
• Caretaker recognizing symptoms of illness,
seeking prompt care, giving full course of
antibiotics
• Access to care
• Community case management—community
health workers can effectively identify and
treat pneumonia with oral antibiotics
25
Pneumonia: Treatment
50 % world wide
26
Causes of vaccine-preventable deaths among
children <15 years, 2002
http://www.who.int/immunization_monito
27
ring/diseases/en/
Vaccine Preventable Deaths
1.4 million annual child deaths
14% of child deaths are due to vaccine preventable causes.
28
Vaccine Coverage
29
Childhood Injuries
• Burns, pedestrian injuries, drowning, falls
• 250,000 deaths of children <5 years
• Most injuries are preventable
• Multi-sector approach to prevent injuries
• Simple protocols can reduce fatality and
disability
30
Summary: Interventions to Reduce Child
Mortality
2/3 of child deaths could be averted with
interventions that are already available and
recommended for universal coverage!
however
We need to make better progress in expanding coverage of
interventions
31
India, Nigeria, Pakistan, China and
Democratic Republic of Congo
• 49% (3.8 million) of all under-five deaths in
2010
• High proportions of global totals for neonatal
COD Cause
Percent Estimated #
Birth Asphyxia
52% 0.37 million
Sepsis
54% 0.24 million
Preterm Birth Complications
51% 0.54 million
Congenital Abnormalities
47% 0.13 million
What is the coverage rate of ORT among
children with diarrhea?
33
http://www.one.org/us/living-proof/#
http://www.youtube.com/watch?v=oWebc7NXvMk
Access to Improved Water Sources
Source:UN MDG Report. 2011
35
Regional Distribution of Deaths and their
Causes – Africa and southeast Asia
• Number of deaths varied widely across WHO regions - largest number of
deaths in:
– African region (3.5 million)
– Southeast Asian region (2.1 million)
• Differing patterns of neonatal causes of death:
– lower proportion of neonatal deaths in African region (30%, 1.1
million) than in Southeast Asian region (52%, 1.1 million),
– 73% of deaths in children < 5 years due to infectious causes in Africa,
including 96% of global child malaria deaths and 90% of global child
AIDS deaths.
– Pneumonia and preterm births important in SE Asia
Regional Causes of Deaths, 2010: Africa
and Americas
Regional Causes of Deaths, 2010:
Eastern Mediterranean and SE Asia
India
• 1.7m (23% of world
total) U5 children died
in 2010
• 51% deaths occurred in
first month
• Major causes:
– pneumonia
– prematurity
– diarrhea
China
• 0.31m total U5 deaths
• 58% of neonatal deaths
• Major causes
– Pneumonia
– Birth asphyxia
– Prematurity
Learning Objectives
• Describe the scope of the problem of child mortality
• List the 7 leading direct causes of childhood mortality
• State the major underlying risk factor for childhood
mortality
• Explain the prevention and treatment interventions that
are currently recommended for preventing child mortality
from pneumonia, diarrhea, and malaria
• State the approximate coverage rates for the most
important interventions
In many parts of the world, rural populations
still lack access to safe drinking water
42
Access to Improved Sanitation Facilities
43
http://www.childinfo.org/sanitation_status_trends.html
44
Malaria
• Plasmodium parasites
• Anopheles mosquito
– Pools of water—breeding ground
45
Malaria
Clinical presentation:
• Asymptomatic
• “Uncomplicated” malaria = fever, headache, malaise
(cough, diarrhea)
• “Severe” or “Complicated” malaria = multi-organ
system involvement
– Severe anemia
– Jaundice
– Cerebral malaria
• Malaria in pregnancy LBW
46
Malaria
• Morbidity
– Major cause of anemia in endemic areas
– Impact on growth and cognitive development
• Drains $2 billion from economies in subSaharan Africa
47
Malaria
• 225 million cases of clinical malaria/yr
• 781,000 deaths/year
– 90% in sub-Saharan Africa
– Majority in children
• Past couple of decades -- upsurge
– Environmental factors (climate, water development
projects)
– Areas of conflict (disruption in previous control
programs)
48
~50% of the worlds’ population live in malaria
endemic areas
Source: UNICEF childinfo.org
49
Malaria: Prevention
• Vector control
– Indoor Residual Spraying (IRS)
– Environmental measures (e.g. reduction of
standing water)
Insecticide Treated Nets (ITNs)
• High ITN use 17% reduction in childhood
mortality
50
ITNs
51
ITNs: Household Ownership
Percentage of households owning at least one ITN (among African
countries with at least two data points, 2000-2010)
52
http://www.childinfo.org/malaria_progress.html
ITN use in sub-Saharan Africa
Proportion of children sleeping under an ITN (among all African countries with 2
or more comparable points)
http://www.childinfo.org/malaria_progress.html
53
ITN use in sub-Saharan Africa
Proportion of pregnant women sleeping under an ITN (among all African countries
with 2 or more comparable points)
54
http://www.childinfo.org/malaria_progress.html
55
http://www.childinfo.org/malaria_progress.html
ITN Distribution in Ghana
56
Malaria: Treatment
• Intermittent Preventative Treatment of
malaria in pregnancy (IPTp)
• Prompt treatment with appropriate
antimalarials
57
Malaria: Treatment Resistance
Artemisinin Combination Therapy (ACT)
58
Africa: > 50% of children receive antimalarials,
but often with ineffective medicines
http://www.childinfo.org/
malaria_progress.html
59
Changes in Treatment Recommendations 
Changes in Monitoring Treatment Indicators
Among all children who received an antimalarial drug, the
proportion of children receiving ACT, African countries,
2007–2010
http://www.childin
fo.org/malaria_pr
ogress.html
60
Malaria: Future Interventions
• Vaccine
• Infant IPT
61
Basic Vaccine Schedule
Birth
BCG
6weeks
DPT1, OPV1, HepB1, Hib1
10 weeks
DPT2, OPV2, HepB2, Hib2
14 weeks
DPT3, OPV3, HepB3, Hib3
9 months
Measles
BCG=Bacillus Calmette-Guerin (against TB)
DPT=Diphtheria, Tetanus, Pertussis
HepB=Hepatitis B
OPV=Oral Polio Vaccine
Hib=Hemophilus influenza b
62
What is the Global Vaccine Coverage Rate?
63