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Child Health: Overview
Dr E Malek, Principal SpecialistDepartment of Paediatrics, University
of Pretoria, Witbank [email protected]
Acknowledgements• Dr Joy Lawn (Save the Children Fund)• DR Lesley Bamford (National DOH)• Dr Debbie Bradshaw (MRC NBD unit)• Prof T Duke (CICH, University of Melbourne)• Dr M Weber (WHO-CAH, Geneva)• Dr N McKerrow (PMB Hospital)• DR Macharia (UNICEF, Pretoria)• Dr N Rollins (UKZN)• DR C Sutton (MEDUNSA, Polokwane)
Outline• Global child health• Child Health in South Africa
Global Context (1)
• Child Health Inequity• Causes of global child mortality• Child disability and development• Neonatal Health• Adolescent Health• Children in complex emergencies • Effect of poor child health on communities
Global Context (2)
• Child Health in context of Maternal Health• International Conventions and child health• Evidence for effective intervention in
reducing child mortality• Pathways to & principles of global child
health
Source: Bryce J et al for the Child Health Epidemiology Reference Group. The Lancet, March 2005. As used in WHR 2005
Injuries3%
Pneumonia19%
Neonatal deaths
36%
Other10%
HIV/AIDS3%Measles
4%
Malaria8%
Diarrhoea17%
10 million child deaths – Why?
For these 4 causes, ~
53% of deaths are malnourished children
AIDS is much bigger proportion in Southern
Africa.
4 million newborn deaths – Why?
Source: Lawn JE, Cousens SN, Zupan J Lancet 2005. for 192 countries based on cause specific mortality data and multi cause modelled estimates. As used in World Health Report 2005
60 to 90% of neonatal deaths are in low birth weight babies, mostly preterm
Three causes account for 86% of all neonatal
deaths
Source: UNICEF, 2001
181
128
80
5853
45
175
100
64
4437 38
9 6
0
20
40
60
80
100
120
140
160
180
200
Sub-SaharanAfrica
South Asia Middle East &North Africa
East Asia andPacific
Latin America& Caribbean
CEE/CIS andBaltics
Industrializedcountries
U5M
R (d
eath
s pe
r 100
0 bi
rths)
19902000Least
reduction 3%
Greatest reduction
32%
Under five mortality rates: Trends from 1990-2000
Slide: Ngashi Ngongo
International Conventions
• Declaration of Alma Ata: “Health for All by the year 2000”
• UN Convention of the Rights of the Child (1990)
• UN Millenium Development Goals (MDGs)
Millennium Development Goals (MDGs)
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empowerment of women
4. Reduce child mortality by two thirds
5. Reduce MMR by three quarters6. Combat HIV/AIDS,
malaria and other diseases
7. Ensure environmental sustainability
8. Develop global partnerships
for development
Integrated Management of Chilldhood Illness (IMCI)
Department of Child and Adolescent Health and Development
Finding Classification Treatment
Danger signs Severe disease Urgent referral
Cough or difficulty inbreathing
Severe disease Urgent referral
Diarrhoea
FeverDisease with specifictherapy
Specific medical treatment
Ear problem
Nutritional status/anaemia
Disease without specifictherapy
Symptomatic treatment
Vaccination status Complete/incomplete Vaccinate
Assess and classify
IMCI facility based usage in Bangladesh (Lancet, 2004)
WHO Initiatives to improve quality of care for children at
hospital level: state of the art and prospects
Martin Weber, Harry Campbell, Susanne Carai, Trevor Duke, Mike English, Giorgio Tamburlini
25th International Congress of Paediatrics, Athens, 25-30 August 2007
Standards of Hospital Care for Children: Hospital IMCI Evidence-Based Guidelines
Child Health in South Africa
• Child Health Inequity• Causes of Child Mortality• Neonatal Health• National interventions for improving child
health• Children’s Act (Amendment Bill: 2007)• Challenges
UNICEF remarks at opening of SA Child Health Priorities conference
(Dec 2007, Durban)
Distribution of Resources
Slide: Ngashi Ngongo
South Africa progressto MDG 4
Under 5 mortality is increasing, related to HIV (73 000 a year)Neonatal mortality is probably static and accounts for ~30% of
under five deaths (23,000 newborn deaths a year)
21
6754
200
50
100
150
1980 1985 1990 1995 2000 2005 2010 2015
Mor
talit
y pe
r 1,0
00 b
irths
.
Neonatal MortalityRateUnder 5 Mortality Rate
Infant Mortality Rate
MDG 4 Target
Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006
Causes of U5M
Low birth weight, 12%
Asphyxia, 3%
Infections, 3%
Others: 30%
PEM: 5%
Pneumonia: 6%
Diarrhoea: 11%
HIV/AIDS: 40%
Neonatal18%
Source: MRC 2003
Every Death Counts
Challenges: Health Service in South Africa
Child Mortality (1)• The National Burden of Disease study estimated
just over half a million deaths of which• 106 000 were of children under the age of 5
years • A further 7800 were children aged 5-14 years.• An estimated 4564 deaths are from protein-
energy malnutrition (Kwashiorkor)• In general, young babies are much more
vulnerable than older• The cause of death patterns in the different age
groups are very different.
Top twenty specific causes of death in childrenunder 5 years, South Africa 2000 (NBD)
0102030405060708090
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
EastWestNorth
Leading causes of death among infants under 1 year of age, South Africa 2000
Leading causes of death among infants under 1 year of age, South Africa 2000
Child Mortality (2)
• The NBD study estimates that by the year 2000, – the Infant Mortality Rate had risen to 60 per 1000 live
births and – the Under-5 mortality rate had risen to 95 per 1000.
• This deterioration in child health occurred despite the introduction of free health care and nutrition programmes and was attributable to paediatric AIDS, commensurate with the high prevalence of HIV observed among pregnant women.
Leading causes of death among children aged 1-4 years, South Africa 2000
Leading causes of death among children aged 1-4 years, South Africa 2000
Child Mortality (3)• As children get older, external causes of death
(eg. road traffic injuries and drowning) rise in importance.
• This is particularly noticeable among boys who die in greater numbers than girls. This pattern becomes particularly marked among the 10 -14 year age group, where road traffic accidents is the leading cause of death.
• Homicide and suicide feature in the top causes among the 10-14 year age group, homicide is the second leading cause of death.
* Source: WHO World health Statistics 2006 www.who.int
Child PIP (%) (1532 deaths)1 month to 5 years
WHO* (%)Zero to 5 years
HIV/AIDS - 57Pneumonia 22 1Septicaemia/meningitis 21 -Diarrhoea 20 1TB 5 -PCP 11 -Other 19 1Malaria - 0Measles - 0Injuries Included under “other” 5Neonatal (16% of all admissions but causes
tabulated for 1 month to 5 years) 35
Child deaths in RSA - Why?
HIV test ~ 54% tested26% +ve20% exposedOnly 8% tested -ve
HIV clinical stage~ 58% stagedof which half were Stages III & IV
88% HIV if exclude neonatal
Most deaths 1 month to 5 yrs
Child PIP in Mpumalanga:
ChPIP Data: Witbank Hospital had 2244 child admissions & 101 child deaths in 2006; overall case fatality rate 4.5;31% of all deaths within 1st 24 hours of admissionChPIP Sites:2004: Witbank
2006: Witbank & Barberton
2007: above plus 8 new sites
Causes of death of children in hospitals
(n = 1695)
33
1512
103
20
1216
7
13
0
5
10
15
20
25
30
35
%
2004 2005
ARI DD Sepsis AIDS TB PCP
Child Mortality: HIV/AIDS
• 1998 SADHS U5MR 61/1000 (1994-8)• 2003 SAHDS U5MR 58/1000 (1999-2003)?• Without PMTCT one third of babies born to HIV+
mothers will be infected: of these, 60% expected to die before 5 years of age
• 40% U5 hospital deaths due to AIDS • Child mortality in SA too high for middle-income
country, and increasing, despite children’s rights
Child mortality: HIV/AIDS
• Vertical transmission rate 20.8% (KZN)• <50% pregnant women being tested• 2/3 all HIV+ infants needing ART by 10
months of age – without access to ARV 1/3 of HIV+ children die in 1st year of life
• One in 6 qualifying children get ARV
Policy Brief: Child Mortality• The Medical Research Council published the
Initial Burden of Disease Estimates for South Africa, 2000 in March 2003.
• A major finding of the study was the quadruple burden of disease experienced in South Africa resulting from the combination of the pre-transitional causes related to underdevelopment, the emerging chronic diseases, the injury burden and HIV/AIDS.
Policy Implications (1)
• The mortality data indicates that many of the child deaths occurring in South Africa are preventable.
• We have identified three broad areas that will require differing approaches for intervention:
Policy Implications (2)
1. The prevention of mother-to-child transmission of HIV, even at its current efficacy, is the single most effective intervention to reduce mortality among under-5-year olds, eclipsing all other interventions for other causes of death combined.
Policy Implications (3)2. Although dominated by the rise of HIV/AIDS, the classic
infectious diseases such as diarrhoea, respiratory infections and malnutrition are still important causes of mortality. Environment and development initiatives such as access to sufficient quantities of safe water, sanitation, reductions in exposure to indoor smoke, improved personal and domestic hygiene as well as comprehensive primary health care will go a long way to preventing these diseases. Poverty reduction initiatives are also important in this regard.
Policy Implications (4)
3. Road traffic accidents and violence, which includes homicide and suicide is another group of high mortality conditions that will require dedicated interventions.
PMTCT (1)
• Most important intervention to reduce HIV infection in children
• Almost all ANC services provide PMTCT, but many barriers to testing and effective treatment.
• Cotrimoxazole prophylaxis from 6 weeks of age reduces HIV related child mortality by as much as 43%
PMTCT (2)
• Recommendation: Mandatory testing all children at 6 week immunisation visit & double testing of pregnant women
• Currently 300 000 HIV infected children – 50-60% expected to currently need ARV’s
• SA is one of only 9 countries world-wide where child mortality is increasing
PMTCT (3)
• Routine provider-initiated testing for all 6 week old infants is currently excluded from the NSP on HIV/AIDS
• Memorandum of concern: Maternal & Child survival (2007)
• TAC Media Statement: Call for finalisation of Revised PMTCT Guidelines (Jan 2008)
Key Child Survival Strategies
1. Infant and Young Child Feeding (including EBF)
2. Immunisation3. Treatment of common childhood illnesses4. Care of children with HIV-infection5. Provision of Vitamin A6. PMTCT
National Health Targets
Key MCH interventionsMATERNAL CARE
1. Focused ANC 2. PMTCT-Plus 3. Skilled
attendant deliveries
4. EMOC5. Family
planning
NEONATAL CAREBasic neonatal care1. Resuscitation2. LBW care3. Early EBF4. KMC5. PMTCT-Plus6. Infection
management
CHILD CARE1. Infant and
Young Child Feeding
2. HIV care3. IMCI (clinic)4. Hospital care5. EPI6. Vitamin A7. HIV testing,
cotrim, ARV
South Africa:Coverage along the
MNCH continuum of care
7%84%94% 93%
0%
25%
50%
75%
100%
Antenatal care(at least one
visit)
Skilledattendant
duringchildbirth
Postnatal care Excl. BF Immunisation(DPT3)
no data
Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006
The days of highest risk
have the lowest coverage of care
Infant and Young Child Feeding
• Exclusive breastfeeding (BFHI)• Provision of good quality complementary
feeds• Appropriate care of children with
malnutrition
Only 12% of infants EBF by 6 months
EBF at 6 months
Plain water only
Other liquids
Solid mushy food
Not BF
0
10
20
30
40
50
60
70
80
90
100
0-4 4-6 7-9 10-12
Source: Demographic Health Survey 2003 Slide: Ngashi Ngongo
Immunisation• Good coverage• Major reduction in number of children with measles• South Africa declared polio free• Need to ensure high coverage is maintained, and to use
every opportunity to immunise children• Community outreach programmes RED STRATEGY• Management issues e.g. cold chain, monitoring
coverage
• Not linked to HIV screening (6 week visit!)
Existing norms and standards
• Primary Health Care package• District Hospital package• Regional hospital package• Service Transformation Plan• Modernization of Tertiary Services
Existing norms and standards
• IMCI• Clinic supervisors manual• EDL• WHO pocketbook
Staffing norms
• No official staffing norms for the country• Various systems have been used
Service transformation plan
• PHC clinics: 1 for 10 000 people• CHC: 1 for 60 000 people• District hospital: 1 for 300 000 people• Regional (Level II) hospital:1 for 1.2 million• Tertiary (Level III) hospital:1 for 3-
3.5million people
Standard Treatment Guidelines & Essential Drug List
Care of children with HIV-infection
• Prevention is key• Early diagnosis and
preventive care• Staging and referral for
ART when appropriate• Psychosocial support
IMCI
IMCI: Bringing it all together
Maternal
Health
HOUSEHOLD AND COMMUNITY IMCI
EPI
Nutrition (Vitamin
A)
Care of HIV infected children
PMTCT Plus
Appropriate infant feeding
TEMBA
BARBERTON
PIET RETIEF
ERMELO
CAROLINA
STANDERTON
WITBANK
MIDDELBURG
TINTSWALO
EVANDER
ROB FERREIRA
Active Site
Future Site
Witbank NNMR 2000-2005 trend (=/> 1000 grams)
0
50
100
150
200
250
2000 2001 2002 2003 2005*
1000-1499g1500-1999g2000-2499g>2500g
NICU
nCPAP
References• SA IMCI chart booklet: UP Intranet (Block 10)• www.who.int/child-adolescent-health/publications/
CHILD_HEALTH/PB.htm
• www.who.int/child-adolescent-health/over.htm• www.ichrc.org• www.unhchr.ch/html/menu3/b/k2crc.htm• www.unicef.org/sowc02• www.developmentgoals.org/Child_Mortality.htm• www.doh.gov.za • www.thelancet.com
“There can be no keener revelation of a society’s soul than the way it treats its children”
Nelson Mandela, 1988