1. http://www.youtube.com/watch?v=Cf8GGOZZ sWM http://www.youtube.com/watch?v=fxtKzTV6W LE

2. Global Distribution of Causes of Child Deaths: 2008

3. Regional Distribution of Causes of Child Deaths: 2008

4. Global Causes of Under-Five Deaths in 2010 Through synergy with infectious diseases undernutrition causes 35% of child deaths

5. 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).

6. Summary of Global Estimates in 2010 7.6 million deaths in children < 5 years 64% (4.9 million) of deaths were from infectious diseases Pneumonia18%1.40 million Diarrhea10%0.80 million Malaria7%0.56 million 40% (3.1 million) of deaths occurred in neonates PTB Complications14%1.08 million Intrapartum-related complications9%0.72 million Sepsis or meningitis5%0.39 million Pneumonia4%0.33 million

7. 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)

8. 8 Undernutrition: Underlying Cause in >1/3 of Childhood Deaths Underweight, stunted, wasted Lack of exclusive breastfeeding Micronutrient Deficiencies

9. 9 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

10. 10 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

11. 11 Disease Specifics Interventions = “biologic agent or action intended to reduce morbidity or mortality” – Prevention – Treatment

12. 12 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

13. 13 Growth Faltering, Weight Loss Micronutrient Deficiencies Lowered Immunity Increased Risk of Infectious Diseases Leaky Intestines, Malabsorption of Nutrients, Decreased Uptake & Reduced Efficacy of Oral Medications and Vaccines Infectious Diarrhea Intestinal Injury and Enteropathy Poverty and Food Insecurity HIV/AIDS The Vicious Cycle of Infectious Diarrhea, Malabsorption, and Undernutrition

14. 14 Prevention: WaSH – Clean Water drinking, food preparation – Sanitation Safe Feces Disposal – Hygiene Especially hand washing

15. 15 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)

16. 16 Diarrhea: Treatment How much does a sachet of ORS cost?

17. 17 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

18. 18 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

19. 19 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

20. 20 Pneumonia >1.4 million deaths/year in < 5yo’s Bacteria (60-70%)—especially – Pneumococcus – Haemophilus influenzae type b (Hib)

21. 21 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

22. 22 Pneumonia: Treatment Case management--Prompt treatment with appropriate antibiotic (right doses, full course) The good news: 1 st line oral antibiotics (amoxicillin, cotrimoxazole) are effective

23. 23 Pneumonia: Treatment Case management can pneumonia associated childhood mortality by 40% – S Sazawal, et al Lancet 2003

24. Pneumonia: Treatment Coverage What % of children with pneumonia are taken to a health care provider?

25. 25 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

26. 26 Pneumonia: Treatment 50 % world wide

27. 27 Causes of vaccine-preventable deaths among children <15 years, 2002 http://www.who.int/immunization_monito ring/diseases/en/

28. 28 Vaccine Preventable Deaths 1.4 million annual child deaths 14% of child deaths are due to vaccine preventable causes.

29. 29 Vaccine Coverage

30. 30 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

31. 31 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

32. 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 CausePercentEstimated # Birth Asphyxia52%0.37 million Sepsis54%0.24 million Preterm Birth Complications51%0.54 million Congenital Abnormalities47%0.13 million

33. 33 What is the coverage rate of ORT among children with diarrhea?

34. http://www.one.org/us/living-proof/# http://www.youtube.com/watch?v=oWebc7NXvMk

35. 35 Source:UN MDG Report. 2011 Access to Improved Water Sources

36. 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

37. Regional Causes of Deaths, 2010: Africa and Americas

38. Regional Causes of Deaths, 2010: Eastern Mediterranean and SE Asia

39. India 1.7m (23% of world total) U5 children died in 2010 51% deaths occurred in first month Major causes: – pneumonia – prematurity – diarrhea

40. China 0.31m total U5 deaths 58% of neonatal deaths Major causes – Pneumonia – Birth asphyxia – Prematurity

41. 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

42. 42 In many parts of the world, rural populations still lack access to safe drinking water

43. 43 http://www.childinfo.org/sanitation_status_trends.html Access to Improved Sanitation Facilities

44. 44

45. 45 Malaria Plasmodium parasites Anopheles mosquito – Pools of water—breeding ground

46. 46 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

47. 47 Malaria Morbidity – Major cause of anemia in endemic areas – Impact on growth and cognitive development Drains $2 billion from economies in sub- Saharan Africa

48. 48 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)

49. 49 ~50% of the worlds’ population live in malaria endemic areas Source: UNICEF childinfo.org

50. 50 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

51. 51 ITNs

52. 52 ITNs: Household Ownership Percentage of households owning at least one ITN (among African countries with at least two data points, 2000-2010) http://www.childinfo.org/malaria_progress.html

53. 53 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)

54. 54 http://www.childinfo.org/malaria_progress.html ITN use in sub-Saharan Africa Proportion of pregnant women sleeping under an ITN (among all African countries with 2 or more comparable points)

55. 55 http://www.childinfo.org/malaria_progress.html

56. 56 ITN Distribution in Ghana

57. 57 Malaria: Treatment Intermittent Preventative Treatment of malaria in pregnancy (IPTp) Prompt treatment with appropriate antimalarials

58. 58 Malaria: Treatment Resistance Artemisinin Combination Therapy (ACT)

59. 59 Africa: > 50% of children receive antimalarials, but often with ineffective medicines http://www.childinfo.org/ malaria_progress.html

60. 60 Changes in Treatment Recommendations  Changes in Monitoring Treatment Indicators http://www.childin fo.org/malaria_pr ogress.html Among all children who received an antimalarial drug, the proportion of children receiving ACT, African countries, 2007–2010

61. 61 Malaria: Future Interventions Vaccine Infant IPT

62. 62 Basic Vaccine Schedule BirthBCG 6weeksDPT1, OPV1, HepB1, Hib1 10 weeksDPT2, OPV2, HepB2, Hib2 14 weeksDPT3, OPV3, HepB3, Hib3 9 monthsMeasles BCG=Bacillus Calmette-Guerin (against TB) DPT=Diphtheria, Tetanus, Pertussis OPV=Oral Polio Vaccine HepB=Hepatitis B Hib=Hemophilus influenza b

63. 63 What is the Global Vaccine Coverage Rate?