1. Multiple Indicator Cluster Surveys Data dissemination and further analysis workshop Child Health MICS4 Data dissemination and Further Analysis

2. Child health Immunization, Diarrhoea, Pneumonia, Malaria

3. Countdown to 2015 Decade Report (2000-2010)

4. Child Health in MICS4 Presentation overview Immunization

5. Background WHO Expanded Programme on Immunization It is recommended that all children receive the following immunizations: At birthBCG (tuberculosis) and Polio 0 At 6 weeksPolio 1 and DPT 1 (diphtheria, pertussis, tetanus) At 10 weeksPolio 2 and DPT 2 At 14 weeksPolio 3 and DPT 3 At 9 monthsMeasles Hepatitis B (HepB) and Haemophilus influenzae type B (Hib) have same schedules as Polio and DPT Up-to-date information on recommended vaccines can be obtained from www.who.int/immunization/documents/positionpapers/en/index.html www.who.int/immunization/documents/positionpapers/en/index.html

6. Indicators In MICS4, immunization indicators are calculated as -the percentage of children aged 12-23 months who received each specific vaccine at any time before the survey and by the age of 12 months (before their first birthday) and -the percentage of children aged 12-23 months who received BCG, DPT 1-3, Polio 1-3 and measles at any time before the survey and by the age of 12 months

7. Methodological issues The model schedule is adapted in some way by most countries so that it more closely meets their needs. Most importantly, the survey questions should reflect the national immunization schedule and take into account recent changes or vaccine introductions (if any)

8. Methodological issues In surveys, coverage estimates are obtained from information copied from observed child health cards and from maternal recall of specific immunizations. Immunization or child health cards are not subject to recall bias, but are not always accurate. Cards may not be shown to the survey interviewer, or immunizations may not have been recorded on the card.

9. Methodological issues In these cases, maternal recall may provide additional information. Maternal recall, however, can either over- or underestimate the true level of coverage Some suggest that maternal recall should not be used to determine coverage estimates, since it may introduce recall bias. Others maintain that inclusion of recall data yields a more accurate coverage estimate.

10. Methodological issues Indicators are calculated for children aged 12-23 months: –All children should have completed all vaccinations by this age –Their experience is the most recent experience which is not truncated

11. Calculation Children vaccinated according to card data + Children vaccinated according to mother’s recall = Total number of children vaccinated For children without cards (or who have cards with missing or incomplete dates), how do we compute the percentage of children vaccinated by 12 months of age (before the first birthday? –Assume the proportion vaccinated by 12 months of age is same as for children who have cards.

12. Example: BCG Percentage vaccinated according to card85.2 Percentage vaccinated according to mother’s report+3.7 Total percentage ever vaccinated88.9 Percentage vaccinated by 12 months according to card98.0 Apply percentage88.9 x.98 Percentage vaccinated by 12 months87.1

14. CH3: Neonatal Tetanus Protection Estimates the percentage of women age 15-49 years whose last live birth within the 2 years preceding the survey was protected against neonatal tetanus Found in women’s questionnaire Complex calculation: women can be protected from neonatal tetanus in a variety of circumstances based on the receipt of vaccinations in the previous years

15. CH3: Neonatal Tetanus Protection Percentage of women age 15-49 years whose last live birth within the past 2 years was protected against neonatal tetanus Calculation: The information contained in the first five columns of this table are calculated in a hierarchical fashion: –(Column 1) Received at least two tetanus toxoid injections during the most recent pregnancy (MN7>=2) –(Column 2) Received one tetanus toxoid injection during the last pregnancy and at least one dose prior to the pregnancy (MN7=1 and MN10>=1) OR received at least two tetanus toxoid injections, the last of which was less than 3 years ago (MN10>=2 and MN11<3) –(Column 3) Received at least 3 tetanus toxoid injections over lifetime, the last of which was in the last 5 years (MN10>=3 and MN11< 5) –(Column 4) Received at least 4 tetanus toxoid injections over lifetime, the last of which was in the last 10 years (MN10>=4 and MN11< 10) –(Column 5) Received five or more tetanus toxoid injections (MN10>=5) at any point The last live birth for all women who fall into one of the first 5 columns is considered ‘protected against tetanus’ and should be included in the sixth column. In many surveys, the sample sizes may be too small to present breakdowns by background characteristics.

16. Table CH.3: Neonatal tetanus protection Percentage of women age 15-49 years with a live birth in the last 2 years protected against neonatal tetanus, Country, Year Percentage of women who received at least 2 doses during last pregnancy Percentage of women who did not receive two or more doses during last pregnancy but received: Protected against tetanus 1 Number of women with a live birth in the last 2 years 2 doses, the last within prior 3 years 3 doses, the last within prior 5 years 4 doses, the last within prior 10 years 5 or more doses during lifetime Region Region 1 Region 2 Region 3 Region 4 Region 5 Area Urban Rural Education None Primary Secondary Higher Wealth index quintile Poorest Second Middle Fourth Richest Religion/Language/Ethnicity of household head Group 1 Group 2 Group 3 Total 1 MICS indicator 3.7

17. Child Health in MICS4 Presentation overview Care of illness tables –Diarrhoea (3 tables) –Pneumonia (4 tables) –Malaria (6 tables) Beyond the tables

18. Diarrhoea treatment Table CH.4: Oral rehydration solutions and recommended homemade fluids Percentage of children age 0-59 months with diarrhoea in the last two weeks, and treatment with oral rehydration solutions and recommended homemade fluids, Country, Year Had diarrhoea in last two weeks Number of children age 0-59 months Children with diarrhoea who received: Number of children age 0-59 months with diarrhoea in last two weeks ORS (Fluid from ORS packet or pre-packaged ORS fluid) Recommended homemade fluids ORS or any recommen ded homemad e fluid Fluid XFluid YFluid Z Any recommended homemade fluid Diarrhoea prevalence – varies by season and caretaker reporting ORS (Oral Rehydration Salts) – recent push to scale up Recommended home fluids vary according to country

19. Diarrhoea treatment Preventing dehydration is key to child survival Feeding should continue during the diarrhoea episode Table CH.5: Feeding practices during diarrhoea Percent distribution of children age 0-59 months with diarrhoea in the last two weeks by amount of liquids and food given during episode of diarrhoea, Country, Year Had diarrhoea in last two weeks Number of children age 0- 59 months Drinking practices during diarrhoea:Eating practices during diarrhoea: Number of children age 0- 59 months with diarrhoea in last two weeks Given much less to drink Given some- what less to drink Given about the same to drink Given more to drink Given noth- ing to drink Miss ing/ DK Given much less to eat Given some what less to eat Given about the same to eat Given more to eat Stop- ped food Had never been given food Miss- ing/ DK Total

20. Diarrhoea treatment ORT = Oral rehydration therapy = ORS and/or recommended home fluids and/or increased fluids Key diarrhoea indicator in this table – ORT with continued feeding (based on four components) Zinc is another key intervention Table CH.6: Oral rehydration therapy with continued feeding and other treatments Percentage of children age 0-59 months with diarrhoea in the last two weeks who received oral rehydration therapy with continued feeding, and percentage of children with diarrhoea who received other treatments, Country, Year Children with diarrhoea who received: Other treatments: Not given any treatm ent or drug Number of children age 0-59 months with diarrhoea in last two weeks ORS or increase d fluids ORT (ORS or recommen ded homemade fluids or increased fluids) ORT with continued feeding 1 Pill or syrupInjection Intra- venou s Home remed y, herbal medici neOther No other treatm ent Anti- biotic Anti- motili tyZincOther Un- known Anti- biotic Non- antibiot ic Unkno wn

21. Key diarrhoea indicators Bhutan MICS 2010 Percentage of children with diarrhoea in the two weeks preceding the survey, who received:

22. Child Health in MICS4 Presentation overview Care of illness modules –Diarrhoea (3 tables) –Pneumonia (4 tables) –Malaria (6 tables) Beyond the tables

23. Pneumonia Definition of suspected pneumonia = cough + rapid/difficult breathing + problem in the chest Suspected pneumonia prevalence – varies by season and caretaker reporting Appropriate health providers includes public and private sources (excludes private pharmacy) Two key pneumonia indicators = careseeking and antibiotics Table CH.7: Care seeking for suspected pneumonia and antibiotic use during suspected pneumonia Percentage of children age 0-59 months with suspected pneumonia in the last two weeks who were taken to a health provider and percentage of children who were given antibiotics, Country, Year Had suspected pneumonia in the last two weeks Number of children age 0-59 months Children with suspected pneumonia who were taken to: Any appro- priate provider 1 Percentage of children with suspected pneumonia who received antibiotics in the last two weeks 2 Number of children age 0- 59 months with suspected pneumonia in the last two weeks Public sourcesPrivate sourcesOther source Govt. hospit al Govt. health centre Govt. health post Villag e health work- er Mobile / out- reach clinic Other publi c Private hospit al/ clinic Private physici an Private pharm acy Mobile clinic Other private medic al Relativ e or friendShop Trad. Practi- tioner

24. Antibiotic treatment Bhutan MICS 2010 Percentage of children with suspected pneumonia in the last two weeks who received antibiotics

25. Antibiotic treatment Percentage of children with suspected pneumonia in the last two weeks who received antibiotics

26. Antibiotic treatment Percentage of children with suspected pneumonia in the last two weeks who received antibiotics Based on 54 unweighted cases!

27. Antibiotic treatment Percentage of children with suspected pneumonia in the last two weeks who received antibiotics Based on 54 unweighted cases! Note that *all* treatment indicators based on a subset of children!

28. Pneumonia Note this table is based on mothers/caretakers of all children under-five The two danger signs are fast breathing and difficult breathing Open-ended questions can lead to challenges during data collection Table CH.8: Knowledge of the two danger signs of pneumonia Percentage of mothers and caretakers of children age 0-59 months by symptoms that would cause the to take the child immediately to a health facility, and percentage of mothers who recognize fast and difficult breathing as signs for seeking care immediately, Country, Year Percentage of mothers/caretakers of children age 0-59 months who think that a child should be taken immediately to a health facility if the child: Mothers/caretak ers who recognize the two danger signs of pneumonia Number of mothers/caretake rs of children age 0-59 months Is not able to drink or breastfeed Becomes sicker Develops a fever Has fast breathing Has difficult breathing Has blood in stool Is drinking poorly Has other symptom s

29. Pneumonia MICS4 tables cover three essential steps needed to reduce deaths among children under five with pneumonia: 1. Recognize a child is sick 2. Seek appropriate care 3. Treat appropriately with antibiotics

30. Essential steps for reducing pneumonia deaths among children 1 2 3 Mongolia MICS 2005

31. Pneumonia Inhaling smoke from solid fuels is hazardous Variation by region How valid are data in CH10? Table CH.9: Solid fuel use Percent distribution of household members according to type of cooking fuel used by the household, and percentage of household members living in households using solid fuels for cooking, Country, Year Percentage of household members in households using: Number of household members Elec- tricity Liquefied Petroleum Gas (LPG) Natural Gas Bio- gasKerosene Solid fuels Other fuel No food cooked in the househol dTotal Solid fuels for cooking 1 Coal, lignite Char- coalWood Straw, shrubs, grass Animal dung Agricultural crop residue Region Urban-rural Education of household head Wealth index quintiles Religion/Language/Ethnicity of household head Total 100.0 1 MICS indicator 3.11 Table CH.10: Solid fuel use by place of cooking Percent distribution of household members in households using solid fuels by place of cooking, Country, Year Place of cooking: Number of household members in households using solid fuels for cooking In a separate room used as kitchen Elsewhere in the house In a separate buildingOutdoors At another placeTotal Region Urban-rural Education of household head Wealth index quintiles Religion/Language/Ethnicity of household head Total 100.0

32. Child Health in MICS4 Presentation overview Care of illness modules –Diarrhoea (3 tables) –Pneumonia (4 tables) –Malaria (6 tables) Beyond the tables

33. Standard MICS4 malaria tables Household availability of insecticide treated nets and protection by a vector control method Children sleeping under mosquito nets Pregnant women sleeping under mosquito nets Anti-malarial treatment of children with anti-malarial drugs Malaria diagnostics usage Intermittent preventive treatment for malaria

34. Take advantage of increasing focus on health for dissemination, advocacy and analysis! Further use of data

35. Health interventions across the continuum of care Countdown to 2015 Decade Report (2000-2010)

36. From Diarrhoea: Why children are still dying and what can be done A second look at diarrhoea- related data?

37. A second look at pneumonia- related data? Treatment Careseeking behavior Antibiotics Key prevention measures Adequate nutrition (including breastfeeding and zinc) Immunization (measles, Hib and pneumococcal conjugate) Reducing indoor air pollution Water, sanitation and hygiene

38. Thank You!