1. Harvard University Initiative for Global Health Global Health Challenges Social Analysis 76: Lecture 20

2. Harvard University Initiative for Global Health Attributable Disease Burden of 20 Risk Factors

3. Harvard University Initiative for Global Health Iron Deficiency Anaemia Vitamin A Deficiency Zinc Deficiency Review of Diseases, Injuries and Risk Factors

4. Harvard University Initiative for Global Health Summary OR: 0.72 Perinatal mortality: OR’s for each 1 g/dL Hb increase From Stoltzfus et al, 2005

5. Harvard University Initiative for Global Health

6. Prevalence of anaemia among children 0 – 4 years old by CRA region 5 - 16 16 - 28 28 - 39 39 - 51 51 - 63 Prevalence (%) From Stoltzfus et al, 2005

7. Harvard University Initiative for Global Health

9. Effect of Iron/Folic Acid (IFA) Supplementation on Adverse Events in Children 1-48 Months Old Nepal (19,299 child-years IFA, 9,799 placebo) – no effect on deaths 1 Zanzibar (16,950 child-years IFA, 8,574 placebo) – 12% increase in all hospitalizations/deaths, 16% in malaria, 33% in pneumonia 2 1 Tielsch et al, submitted 2 Sazawal et al, submitted

10. Harvard University Initiative for Global Health Effect of Iron/Folic Acid Supplementation on Adverse Events (Hospitalization and Death) in Children in Zanzibar (following 16,950 child-years in supplemented and 8,574 in placebo groups) Outcome Relative Risk95% CI All1.121.02 – 1.23 Malaria1.161.02 – 1.32 Cerebral malaria1.221.02 – 1.46 Pneumonia1.331.07 – 1.65 Other infections1.321.10 – 1.59 From Sazawal et al, submitted

11. Harvard University Initiative for Global Health Iron Deficiency Anaemia Vitamin A Deficiency Zinc Deficiency Review of Diseases, Injuries and Risk Factors

12. Harvard University Initiative for Global Health Effects of Vitamin A on Infectious Disease Morbidity Possible effect on diarrhea severity, but not all morbidity No effect on pneumonia morbidity Effect on measles complications

13. Harvard University Initiative for Global Health Prevalence of vitamin A deficiency among children 0-4 years old by CRA regions From West et al., 2002 0 - 10 10 - 19 19 - 29 29 - 38 38 - 48 Prevalence (%)

14. Harvard University Initiative for Global Health Major Trials of Vitamin A to Prevent Mortality Over 165,000 children participated in these 8 trials

15. Harvard University Initiative for Global Health Vitamin A Implementation Widespread implementation of Vitamin A supplementation often linked to immunization programs. Is coverage sustainable outside of immunization campaigns?

16. Harvard University Initiative for Global Health Iron Deficiency Anaemia Vitamin A Deficiency Zinc Deficiency Review of Diseases, Injuries and Risk Factors

17. Harvard University Initiative for Global Health

18. Global Zinc Deficiency 0 – 14.9 % Deficient15 – 24.9 % Deficient> 25 % Deficient From Brown et al, 2004

19. Harvard University Initiative for Global Health Preventive Effect of Zinc Supplementation on Diarrheal Prevalence in Continuous Supplementation Trials

20. Harvard University Initiative for Global Health Preventive Effect of Zinc Supplementation on Pneumonia Incidence in Continuous Supplementation Trials 3 India(S) Peru Vietnam Jamaica India(B) Pooled 00.511.522.5 Relative Risk and 95% CI

21. Harvard University Initiative for Global Health Effect of Zinc Supplementation on Malaria in Children Location Reduction in Clinic Visits for Malaria The Gambia 1 32% (p=0.09) Papua New Guinea 2 38% (p<0.05) Combined36% (CI 9-55%, p<0.05) 1 Bates et al, Brit J Nutr, 1993 2 Shankar et al, Am J Trop Med Hyg, 2000

22. Harvard University Initiative for Global Health Trial in Bangladesh Evaluating the Preventive Effect of Weekly Zinc Supplementation 1-23 mo. old children, weekly zinc (70 mg) 6% less diarrhea, 17% less pneumonia, 49% less severe pneumonia and 42% less otitis media, 85% less mortality From Brooks et al, Lancet 2005

23. Harvard University Initiative for Global Health Efficacy Trials of Zinc Supplementation on Child Mortality Zanzibar and Nepal Children 1-35 mo. old (>60,000 child-years) Randomized, controlled trials Daily 10 mg zinc (5 mg if <12 mo old) All children receive vitamin A Trial to be completed in Zanzibar in September 2005 and Nepal in January 2006

24. Harvard University Initiative for Global Health Iron Deficiency Anaemia Vitamin A Deficiency Zinc Deficiency Review of Diseases, Injuries and Risk Factors

25. Harvard University Initiative for Global Health Leading Causes of the Global Burden of Disease 2002 1. 1.Perinatal conditions 6.5 2. 2.Lower respiratory infections 6.1 3. 3.HIV/AIDS 5.7 4. 4.Depression4.5 5. 5.Diarrhoeal diseases 4.2 6. 6.Ischaemic heart disease3.9 7. 7.Cerebrovascular disease 3.3 8. 8.Malaria 3.1 9. 9.Road traffic accidents 2.6 10. 10.Tuberculosis2.3 DALYs % Source: World Health Report, 2004

26. Harvard University Initiative for Global Health Attributable Disease Burden of 20 Risk Factors

27. Harvard University Initiative for Global Health What diseases, injuries or risk factors are missing from these lists? What is Missing?