Child Health Overview

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					Child Health: Overview
  Dr E Malek, Principal Specialist
Department of Paediatrics, University
   of Pretoria, Witbank Hospital
    emalek@postino.up.ac.za
           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
                                  10 million child deaths
                                       – Why?
                                                          HIV/AIDS
                                  Measles                          Injuries
                                                             3%
                                    4%                                3%

    For these 4                  Malaria
     causes, ~                    8%                                                                   Neonatal
      53% of                                                                                            deaths
    deaths are                                                                                           36%
    malnourish
    ed children                  Diarrhoea
                                    17%


  AIDS is much bigger
 proportion in Southern                      Pneumonia                                            Other
         Africa.                                19%                                                10%
Source: Bryce J et al for the Child Health Epidemiology Reference Group. The Lancet, March 2005. As used in WHR 2005
                      4 million newborn deaths –
                                 Why?


                                          60 to 90% of
                                        neonatal deaths
                                        are in low birth
                                         weight babies,
                                        mostly preterm


  Three causes
 account for 86%
  of all neonatal
      deaths
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
                                Under five mortality rates: Trends from 1990-
                                                     2000
                                 200
                                         181                                                                                1990
                                 180           175
                                                                       Least                                                2000
                                                                    reduction
                                 160                                    3%
U5MR (deaths per 1000 births)




                                 140
                                                        128

                                 120
                                                              100
                                 100
                                                                                                                                   Greatest
                                                                      80                                                          reduction
                                  80                                                                                                 32%
                                                                             64
                                                                                      58
                                  60                                                                   53
                                                                                             44                       45
                                                                                                             37              38
                                  40

                                  20
                                                                                                                                        9      6

                                   0
                                        Sub-Saharan    South Asia   Middle East &   East Asia and   Latin America   CEE/CIS and     Industrialized
                                            Africa                   North Africa       Pacific      & Caribbean       Baltics         countries


                                       Source: UNICEF, 2001                                                                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      5. Reduce MMR by three
  poverty and hunger         quarters
2. Achieve universal      6. Combat HIV/AIDS,
  primary education          malaria
                             and other diseases
3. Promote gender
                          7. Ensure environmental
  equality                   sustainability
   and empowerment of
   women                  8. Develop global
                             partnerships
4. Reduce child mortality   for development
   by two thirds
Integrated Management of
 Chilldhood Illness (IMCI)
                         Assess and classify
Finding                    Classification                    Treatment
Danger signs               Severe disease                    Urgent referral
Cough or difficulty in     Severe disease                    Urgent referral
breathing
Diarrhoea                  Disease with specific             Specific medical treatment
Fever                      therapy

Ear problem                Disease without specific          Symptomatic treatment
                           therapy
Nutritional status/
anaemia
Vaccination status         Complete/incomplete               Vaccinate




                                      Department of Child and Adolescent Health
                                                              and Development
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 progress
                                                      to MDG 4
                                 150                                                    N eo nat al M o r t alit y
                                                                                        R at e
                                                                                        U nd er 5 M o r t alit y R at e
    .
    Mortality per 1,000 births




                                                                                        Inf ant M o r t alit y R at e
                                 10 0
                                                                                        M D G 4 T ar g et

                                                                                               67
                                  50                                                           54
                                                                                 21
                                                                                                                        20
                                   0
                                        19 8 0    19 8 5   19 9 0       19 9 5   2000    2005        2 0 10      2 0 15

   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)
Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006
                 Causes of U5M

                            Others: 30%

         PEM: 5%

 Pneumonia: 6%
                                                     Low birth weight,
                                          Neonatal          12%
Diarrhoea: 11%                              18%

                                                      Asphyxia, 3%

                                                      Infections, 3%


                   HIV/AIDS: 40%




                             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 children
   under 5 years, South Africa 2000 (NBD)



           90
           80
           70
           60
           50                                           East
           40                                           West
           30                                           North
           20
           10
            0
                1st Qtr   2nd Qtr   3rd Qtr   4th Qtr
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.
                        Child deaths in RSA - Why?
                                             Child PIP (%) (1532 deaths)           WHO* (%)
                                                                                  Child PIP in
                                                         1 month to 5 years       Mpumalanga:
                                                                                   Zero to 5 years
   HIV/AIDS                                  -
                                            Most deaths 1 month to 5 yrs            57 88% HIV if
                                                                                  ChPIP Data:
                                                                                              exclude
   Pneumonia                                                     HIV test         Witbank Hospital
                                               22                                    1       neonatal
                                                            ~ 54% tested          had 2244 child
   Septicaemia/meningitis                      21           26% +ve                  -
                                                                                  admissions & 101
                                                            20% exposed           child deaths in
   Diarrhoea                                   20                                    1
                                                                                  2006; overall case
                                                            Only 8% tested -ve
   TB                                                                             fatality rate 4.5;
                                                5                                    -
                                                            HIV clinical stage    31% of all deaths
   PCP                                         11           ~ 58% staged             -
                                                                                  within 1st 24
                                                            of which half were    hours of
   Other                                       19                                    1
                                                                                  admission
                                                            Stages III & IV
   Malaria                                      -                                 ChPIP Sites:
                                                                                     0
                                                                                  2004: Witbank
   Measles                                      -                                   0
                                                                                  2006: Witbank &
   Injuries                                 Included under “other”                  5
                                                                                  Barberton
   Neonatal                                  (16% of all admissions but causes     35
                                                                                  2007: above plus 8
                                              tabulated for 1 month to 5 years)
* Source: WHO World health Statistics 2006 www.who.int                            new sites
Causes of death of children in hospitals
                                 (n = 1695)

    35
    30   33
    25
    20
%                                       20
    15
              15                                   16
    10                                        12              13
                   12
    5                   10                                7
                             3
    0
                     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. Immunisation
3. Treatment of common childhood illnesses
4. Care of children with HIV-infection
5. Provision of Vitamin A
6. PMTCT
National Health Targets
        Key MCH interventions
MATERNAL CARE    NEONATAL CARE           CHILD CARE
                 Basic neonatal     1.    Infant and
1. Focused ANC      care                  Young Child
2. PMTCT-Plus    1. Resuscitation         Feeding
3. Skilled       2. LBW care        2.    HIV care
   attendant     3. Early EBF       3.    IMCI (clinic)
   deliveries    4. KMC             4.    Hospital care
4. EMOC          5. PMTCT-Plus      5.    EPI
5. Family        6. Infection       6.    Vitamin A
   planning         management      7.    HIV testing,
                                          cotrim, ARV
                                              South Africa:
                              Coverage along the
                             MNCH continuum of care
       100%

                                                                          The days
         75%                                                           of highest risk
                                                                      have the lowest
         50%                                                          coverage of care

         25%

                                                                             no data     7%
                            94%                     84%                                               93%
           0%
                    Antenatal care                Skilled            Postnatal care    Excl. BF   Immunisation
                     (at least one              attendant                                           (DPT3)
                         visit)                   during
                                                childbirth

Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006
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
   100


   90
                                                                   Not BF
   80


   70


   60


   50                                           Solid mushy food

   40


   30
                                Other liquids

   20

                      Plain water only
   10

           EBF at 6 months
    0
         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: Bringing it all together

        Nutrition
                         Appropriate
       (Vitamin A)          infant
                           feeding



         IMCI               PMTCT      Maternal
 EPI                         Plus
                                       Health
              Care of HIV
            infected children



HOUSEHOLD AND COMMUNITY IMCI
Active Site

Future Site


                                  TINTSWALO


                                                        TEMBA

                    MIDDELBURG        ROB FERREIRA


                WITBANK          CAROLINA
                                               BARBERTON
              EVANDER        ERMELO



              STANDERTON
                                               PIET RETIEF
  Witbank NNMR 2000-2005
   trend (=/> 1000 grams)
250

200

150                                        1000-1499g
                    NICU                   1500-1999g
100                                        2000-2499g
                                           >2500g
                                  nCPAP
50

  0
      2000   2001   2002   2003    2005*
               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