Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 10

Harvard University Initiative for Global Health

Global Health ChallengesSocial Analysis 76: Lecture 10


Global Causes of Child DeathGlobal Causes of Child DeathDiarrhoeal Diseases

Biology, Clinical Manifestations and InterventionsGlobal EpidemiologyHistory of Health System Response

Respiratory InfectionsBiology, Clinical Manifestation and InterventionsGlobal EpidemiologyHistory of Health System Response


HIV/AIDS3%

Diarrhoeal diseases

15%

Pertussis3%

Measles5%

Tetanus2%

Malaria11%

Respiratory infections

18%

Low birth weight12%

Birth asphyxia and birth trauma

7%

Other perinatal conditions

4%

Nutritional deficiencies

2%

Congenital anomalies

4%

Injuries3%

Other11%

WHO Estimates Under-Five Deaths by Cause, WHO Estimates Under-Five Deaths by Cause, 20022002






Diarrhoeal diseases are a complex of diseases that are Diarrhoeal diseases are a complex of diseases that are characterized by diarrhoea.characterized by diarrhoea.

Diarrhoea can be divided into bloody diarrhoea, watery Diarrhoea can be divided into bloody diarrhoea, watery diarrhoea and epidemic diarrhoea.diarrhoea and epidemic diarrhoea.

Although it is often difficult to isolate the pathogen, the Although it is often difficult to isolate the pathogen, the main agents for watery diarrhoea are rotavirus, main agents for watery diarrhoea are rotavirus, pathogenic E.coli, Campylobacter. pathogenic E.coli, Campylobacter.

The main cause of acute bloody diarrhoea is Shigella. The main cause of acute bloody diarrhoea is Shigella.

Vibrio cholera is the major cause of epidemic Vibrio cholera is the major cause of epidemic diarrhoea. diarrhoea.

Diarrhoeas due to faecal-oral transmission Diarrhoeas due to faecal-oral transmission

Diarrhoea


Dehydrating Diarrhoeal DiseaseDehydrating Diarrhoeal Disease


1)1) Breastfeeding – promotion of infant formula in Breastfeeding – promotion of infant formula in 1970s was a cause of increased diarrhoea 1970s was a cause of increased diarrhoea

2)2) Water, sanitation and personal hygiene – interrupt Water, sanitation and personal hygiene – interrupt faecal-oral transmissionfaecal-oral transmission

3)3) Complementary feedingComplementary feeding

4)4) Zinc supplementation Zinc supplementation

5)5) Vitamin A supplementationVitamin A supplementation

6)6) Rotavirus vaccination – two effective vaccines now Rotavirus vaccination – two effective vaccines now licensedlicensed

Diarrhoea Preventive Interventions


Standard therapy in a high-income countries is to give Standard therapy in a high-income countries is to give a dehydrated child intravenous fluids. These are a dehydrated child intravenous fluids. These are costly and require access to health services. costly and require access to health services.

Research at the ICDDR,B lead to the development of Research at the ICDDR,B lead to the development of oral rehydration therapy in the 1970s. oral rehydration therapy in the 1970s.

A simple solution of sugar and salt in the right A simple solution of sugar and salt in the right proportions has been demonstrated to provide proportions has been demonstrated to provide effective rehydration and reduce diarrhoea case-effective rehydration and reduce diarrhoea case-fatality rates.fatality rates.

ORT (oral rehydration therapy) has been promoted as ORT (oral rehydration therapy) has been promoted as a safe, low-cost therapy for home or clinic a safe, low-cost therapy for home or clinic management of diarrhoea. management of diarrhoea.

Diarrhoea Treatment Interventions


Zinc has also been demonstrated to reduce severity of Zinc has also been demonstrated to reduce severity of diarrhoeal episodes.diarrhoeal episodes.

For bloody diarrhoeas, there is also a role for antibiotic For bloody diarrhoeas, there is also a role for antibiotic treatment. treatment.

Diarrhoea Treatment Interventions


SourceSource: Kosek M, Bern C, Guerrant RL. The global burden of diarrhoeal disease, as estimated : Kosek M, Bern C, Guerrant RL. The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000. from studies published between 1992 and 2000. Bulletin of the World Health OrganizationBulletin of the World Health Organization, 2003,81(3)., 2003,81(3).


Deaths of Children Under-5 from Diarrhoeal Disease by WHO Subregion, 2002

AFRO D

AFRO E

AMRO A

AMRO B

AMRO D

EMRO B

EMRO D

EURO A

EURO B

EURO C

SEARO B

SEARO D

WPRO A

WPRO B

Total Deaths: 1,608,773


Child mortality has declined in the 1990s. Child mortality has declined in the 1990s.

Direct evidence on causes of death is limited, but we Direct evidence on causes of death is limited, but we suspect that deaths from diarrhoea declined.suspect that deaths from diarrhoea declined.

Little evidence on trends of diarrhoea due to different Little evidence on trends of diarrhoea due to different pathogens.pathogens.

Trends in Diarrhoeal Disease


With the advent of ORT, WHO initiated a major effort in With the advent of ORT, WHO initiated a major effort in 1979 to 1979 to

• Raise awareness of the magnitude of diarrhoeal Raise awareness of the magnitude of diarrhoeal disease mortality disease mortality

• Demonstrate the effectiveness of ORS in different Demonstrate the effectiveness of ORS in different settings settings

• Launch educational campaigns to teach mothers to Launch educational campaigns to teach mothers to use ORS at home and to encourage clinic workers use ORS at home and to encourage clinic workers to provide ORS to dehydrated children to provide ORS to dehydrated children

• In the 1980s, 110 countries developed control of In the 1980s, 110 countries developed control of diarrhoeal disease programsdiarrhoeal disease programs

Diarrhoeal Disease Control


During 1980s and early 1990s, the WHO strategy for During 1980s and early 1990s, the WHO strategy for delivering oral rehydration therapy evolved. delivering oral rehydration therapy evolved.

The initial focus was delivering preformulated packets The initial focus was delivering preformulated packets of Oral Rehydration Salts (ORS) to peripheral of Oral Rehydration Salts (ORS) to peripheral facilities. facilities.

With the recognition that most children with dehydrating With the recognition that most children with dehydrating diarrhoea never made it to a clinic, the emphasis diarrhoea never made it to a clinic, the emphasis was on recommended home fluids (home made was on recommended home fluids (home made sugar/salt solutions) and ORS. sugar/salt solutions) and ORS.

By the early 1990s, the emphasis had shifted to By the early 1990s, the emphasis had shifted to increased fluids and maintaining feeding. increased fluids and maintaining feeding.

Diarrhoeal Disease Control


We suspect diarrhoeal disease mortality fell during the We suspect diarrhoeal disease mortality fell during the 1990s; was the decline due to ORT? Or 1990s; was the decline due to ORT? Or improvement in nutritional status, better water improvement in nutritional status, better water supply, increased breastfeeding, Vitamin A?supply, increased breastfeeding, Vitamin A?

Comparable time-series data on ORS use is very Comparable time-series data on ORS use is very limited. limited.

UNICEF Multiple-Indicator Cluster Surveys suggest UNICEF Multiple-Indicator Cluster Surveys suggest that ORS coverage has reached one third to one that ORS coverage has reached one third to one half of children. half of children.

ORT Coverage


Estimated ORT Use (UNICEF Estimates)Estimated ORT Use (UNICEF Estimates)


Since 1992, WHO has focused efforts on the Since 1992, WHO has focused efforts on the development of an integrated strategy to manage development of an integrated strategy to manage sick children.sick children.

The logic is based on the similarity of symptom The logic is based on the similarity of symptom complexes for a number of childhood illnesses. complexes for a number of childhood illnesses.

Strictly “vertical”, one disease at a time approaches Strictly “vertical”, one disease at a time approaches would miss the reality of clinical interaction for both would miss the reality of clinical interaction for both sick children and health workers treating these sick children and health workers treating these children. children.

IMCI Strategy


Three components of the strategy: Three components of the strategy:

1)1) Improve health worker diagnostic/treatment skills by Improve health worker diagnostic/treatment skills by training them to use evidence based standardized training them to use evidence based standardized algorithms for managing dehydrating diarrhoea, algorithms for managing dehydrating diarrhoea, malaria and acute lower respiratory infections.malaria and acute lower respiratory infections.

2)2) Improve health systems support through district Improve health systems support through district planning and management, increased drug planning and management, increased drug availability, quality improvement and supervision, availability, quality improvement and supervision, referral pathways, and health information systems.referral pathways, and health information systems.

3)3) Improve family and community health practices Improve family and community health practices including promoting appropriate care-seeking, including promoting appropriate care-seeking, nutrition, and home case management.nutrition, and home case management.

IMCI Strategy








Acute Respiratory Infection (ARI)Acute Respiratory Infection (ARI)


Acute Lower Respiratory Infections

The major burden of respiratory infections are caused by The major burden of respiratory infections are caused by lower respiratory infections, namely pneumonia.lower respiratory infections, namely pneumonia.

Pneumonia, infection of the tissue of the lung, can be Pneumonia, infection of the tissue of the lung, can be caused by a range of organisms. caused by a range of organisms.

The main identified causes are Streptococcus The main identified causes are Streptococcus pneumoniae, Hemophilus influenzae type B (HiB) and pneumoniae, Hemophilus influenzae type B (HiB) and respiratory syncitial virus (RSV).respiratory syncitial virus (RSV).

From the perspective of child health in developing From the perspective of child health in developing countries, it is rare that a particular pathogen is isolated; countries, it is rare that a particular pathogen is isolated; huge uncertainty on the distribution of different etiologic huge uncertainty on the distribution of different etiologic agents of pneumonia remains. agents of pneumonia remains.


PneumoniaPneumonia


1)1) Breastfeeding – exclusive breast feeding for the first Breastfeeding – exclusive breast feeding for the first 4-6 months provides a protective effect.4-6 months provides a protective effect.

2)2) Complementary feeding – improved nutritional Complementary feeding – improved nutritional status reduces case-fatality ratesstatus reduces case-fatality rates

3)3) Hemophilus influenza type B vaccination – already Hemophilus influenza type B vaccination – already incorporated in GAVI new vaccine fundsincorporated in GAVI new vaccine funds

4)4) Conjugate pneumococcal vaccine -- 7-serotype Conjugate pneumococcal vaccine -- 7-serotype vaccine FDA licensed 2000; 9-valent tested in The vaccine FDA licensed 2000; 9-valent tested in The Gambia with 16% reduction child mortality; many Gambia with 16% reduction child mortality; many others being tested.others being tested.

5)5) ZincZinc

Acute Respiratory Infection Preventive Interventions


Antibiotics for severe lower respiratory infections are Antibiotics for severe lower respiratory infections are essential to reduce the case-fatality rate.essential to reduce the case-fatality rate.

WHO uses a sensitive and relatively non-specific WHO uses a sensitive and relatively non-specific definition of pneumonia to govern antibiotic definition of pneumonia to govern antibiotic treatment: fast breathing or lower chest wall treatment: fast breathing or lower chest wall indrawing in a child presenting with cough or difficult indrawing in a child presenting with cough or difficult breathing. breathing.

Gold standard diagnosis is based on a chest X-ray.Gold standard diagnosis is based on a chest X-ray.

Respiratory Infection Treatment Interventions


Deaths of Children Under-5 from Respiratory Infections by WHO Subregion, 2002

AFRO D

AFRO E

AMRO A

AMRO B

AMRO D

EMRO B

EMRO D

EURO A

EURO B

EURO C

SEARO B

SEARO D

WPRO A

WPRO B

Total Deaths: 1,761,854


As a major component of child mortality, we expect the As a major component of child mortality, we expect the decline in child deaths in the 1990s was in part due decline in child deaths in the 1990s was in part due to declines in pneumonia. There is, however, little to declines in pneumonia. There is, however, little direct evidence to back up this claim. direct evidence to back up this claim.

The average number of episodes of lower respiratory The average number of episodes of lower respiratory tract infections is much lower. tract infections is much lower.

Trends in Acute Respiratory Infections


WHO launched a Programme for Control of Acute WHO launched a Programme for Control of Acute Respiratory Infections in 1984.Respiratory Infections in 1984.

Strategy was to promote early detection and treatment Strategy was to promote early detection and treatment of pneumonia with antibiotics by first-level health of pneumonia with antibiotics by first-level health facility workers. facility workers.

Standard treatments based on cotrimoxazole or Standard treatments based on cotrimoxazole or amoxycillin. amoxycillin.

In 1992, diarrhoea and ARI programmes merged into In 1992, diarrhoea and ARI programmes merged into Integrated Management of Childhood Illness Integrated Management of Childhood Illness strategy. strategy.

ARI Programme


Coverage of Antibiotic Treatment for ARI Coverage of Antibiotic Treatment for ARI (UNICEF MICS Surveys) (UNICEF MICS Surveys)


IMCI evaluation undertaken in Bangladesh, Brazil, Peru, IMCI evaluation undertaken in Bangladesh, Brazil, Peru, Tanzania and Uganda. Tanzania and Uganda.

IMCI programs successful in improving quality of care of IMCI programs successful in improving quality of care of sick children presenting at government health facilities.sick children presenting at government health facilities.

Except in Tanzania, only 5-20% of sick children visit a Except in Tanzania, only 5-20% of sick children visit a government health facility. Impact of IMCI very limited government health facility. Impact of IMCI very limited because utilization of care is low. because utilization of care is low.

No mortality impact except for a statistically non-significant No mortality impact except for a statistically non-significant reduction in Tanzania.reduction in Tanzania.

Challenge for child survival is to reach children in the Challenge for child survival is to reach children in the community using a strategy that does not depend on community using a strategy that does not depend on high utilization of health services for sick children. high utilization of health services for sick children.

IMCI Evaluation


IMCI evaluation in Bangladesh IMCI evaluation in Bangladesh 19% of sick children in 19% of sick children in the IMCI area were taken to a health worker the IMCI area were taken to a health worker compared with 9% in the non-IMCI area. compared with 9% in the non-IMCI area.

Growing movement to reconsider IMCI as the main Growing movement to reconsider IMCI as the main strategy for managing major illnesses for children in strategy for managing major illnesses for children in poor countries. poor countries.

Given that HiB and Pneumococcus are the largest Given that HiB and Pneumococcus are the largest contributors to pneumonia deaths, including these contributors to pneumonia deaths, including these vaccines in GAVI and national vaccine programs is vaccines in GAVI and national vaccine programs is an important strategy for the future. an important strategy for the future.

IMCI and New Vaccines


Period of major increase in attention for child survival Period of major increase in attention for child survival interventions. interventions.

UNICEF has a new Executive Director, Ann Venneman UNICEF has a new Executive Director, Ann Venneman who has declared that UNICEF will return to its who has declared that UNICEF will return to its 1980s focus on child survival. 1980s focus on child survival.

New Partnership for Maternal, Newborn and Child New Partnership for Maternal, Newborn and Child Health launched in January 2006.Health launched in January 2006.

Norway and the Gates Foundation are developing an Norway and the Gates Foundation are developing an MDG4 (reduce child mortality) business plan. MDG4 (reduce child mortality) business plan.

Global Initiatives

Documents

Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 10