1. 2004.6.5 Child survival – how many deaths can we prevent? Dr SK CHATURVEDI Dr KANURPIYA CHATURVEDI

2. 2004.6.5 Issue Worldwide over 10 million children under 5 years of age are dying each year. What interventions are appropriate for reducing these deaths, and what would their impact be if full coverage of the interventions were achieved? Child survival: focus India contributes nearly 25% to the worldwide total of under-5 deaths, so a major reduction by India will have a major worldwide impact.

3. 2004.6.5 Child survival – the Lancet approach Review the state of evidence for interventions to reduce mortality for each of the major direct and underlying causes of death in children under five. Determine their efficacy and apply to current situation to assess how many under-5 deaths could be prevented.  1 st alternative – apply at regional level  2 nd alternative – apply at country level  Compromise – apply to each of 42 countries where 90% of worldwide under-5 deaths occur

4. 2004.6.5 Child survival - interventions Focus on interventions addressing proximal determinants of child mortality and those that can be delivered mainly through the health sector. Take each of the main causes* of under-5 deaths and examine the effectiveness of available interventions for each cause of death * diarrhoea, pneumonia, measles, malaria, HIV/AIDS, and the underlying causes of undernutrition for deaths among under-5s, and asphyxia, preterm delivery, sepsis, and tetanus for deaths among neonates

5. 2004.6.5 Intervention search strategy Estimates of effectiveness of interventions taken from: either – published articles that summarized earlier research results or – systematic reviews by the authors and participants in the Bellagio Child Survival Study Group, together with input from other experts Included search of MEDLINE, POPLINE, and other databases, including the Cochrane database of randomized controlled trials and the WHO Reproductive Health Library

6. 2004.6.5 Interventions – level of evidence Each potential intervention was assigned to one of three levels based on the strength of evidence for its effect on under-5 mortality: Feasibility for delivery at high coverage levels is a central criterion for any intervention intended to reduce child mortality. But what is feasible varies widely among countries. Therefore the approach focused on an essential set judged to be feasible for all countries. Level 1 – sufficient evidence – causal relationship between intervention and reduction of under-5 mortality established Level 2 – limited evidence – effect is possible, but data not sufficient to establish causal relationship Level 3 – inadequate evidence - includes those that hold promise of substantial effects on under-5 mortality but have not yet been fully assessed (ex: rotavirus, pneumo. vaccine, indoor air pollution)

7. 2004.6.5 Interventions by cause - diarrhoea Exposure to diarrhoea Diarrhoea Survive Die Breastfeeding Complementary feeding Treatment Zinc Future: rotavirus vaccine Vitamin A Antibiotics for dysentry Oral rehydration therapy Zinc Water/San/Hygiene Prevention

8. 2004.6.5 Interventions by cause - pneumonia Exposure to pneumonia Pneumonia Survive Die Hib vaccine Complementary feeding Antibiotics Prevention Treatment Future: Pneumococcal vaccine, zinc for therapy, reduction of indoor air pollution Breastfeeding Zinc

9. 2004.6.5 Interventions, neonatal - infections Exposure to infections Severe bacterial infection Survive Die Breastfeeding Antibiotics for sepsis PreventionTreatment Clean delivery Antibiotics for premature rupture of membranes

10. 2004.6.5 Methods and assumptions For India, and each of the other 42 countries, how many deaths from a specific cause could be prevented were calculated with present coverage levels increased to universal coverage (99%, except exclusive breastfeeding at 90%). Three types:  Exclusive and continuing breastfeeding  Complementary feeding  All other interventions* * Components: coverage (current and target), efficacy, affected fraction or population, evidence level

11. 2004.6.5 Current coverage – around 2000

12. 2004.6.5 Current coverage – around 2000 * Same as for prevention

13. 2004.6.5 Under-5 deaths preventable - results Three types of results calculated:  By individual interventions  By specific causes  By groups of interventions

14. 2004.6.5 Under-5 deaths preventable through universal coverage with individual interventions (2000) India

15. 2004.6.5 Under-5 deaths preventable through universal coverage with individual interventions (2000) India

16. 2004.6.5 Under-5 deaths preventable through universal coverage with individual interventions (2000) India

17. 2004.6.5 Interventions, neonatal - prematurity Pregnant Premature Survive Die Treated bednets &materials* Intermittent preventive therapy Newborn temperature management PreventionTreatment Antinatal steroids Antibiotics for premature rupture of membranes * Indoor residual spraying may be used as an alternative

18. 2004.6.5 Under-5 deaths from specific causes preventable through listed interventions (2000) India

19. 2004.6.5 Under-5 deaths from specific causes preventable through listed interventions – as percent of deaths by cause (2000) India

20. 2004.6.5 Under-5 deaths from specific causes preventable through listed interventions – as percent of total deaths (2000) India

21. 2004.6.5 Under-5 deaths preventable with specific groups of interventions (2000) India

22. 2004.6.5 Under-5 deaths preventable with specific groups of interventions (2000) India

23. 2004.6.5 Further deaths that could be prevented Four reasons why these estimates of preventable under-5 deaths are conservative: –Only interventions for which cause-specific evidence of effect was available were included (evidence levels 1 and 2) –Restricted to interventions that are feasible at high coverage in low-income countries –Excluded promising interventions that are currently being assessed (e.g. rotavirus) –Limited to interventions that address the major causes of child death and selected underlying causes (e.g. did not include anaemia)

24. 2004.6.5 Conclusions on under-5 deaths that could be prevented in India Full coverage of listed interventions is estimated to result in a 57% reduction in under-5 deaths in India This is a conservative estimate for reasons given in previous slide Next steps  Review interventions in Indian context, identify any changes, with supporting evidence, and reassess impact on reduction of under-5 deaths