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VIEWS: 40 PAGES: 25

									Effective Interventions to Reduce
Child Mortality and Undernutrition:
           The Evidence

       Robert E. Black, M.D., M.P.H.
    Johns Hopkins Bloomberg School of
              Public Health
      Outline of Presentation

• Global child mortality today
• Undernutrition, including vitamin A and
  zinc deficiencies, as an underlying cause
  of child mortality
• Preventive and therapeutic interventions to
  reduce child mortality
Where and Why Are 10 Million
 Children Dying Every Year?
 10.6 Million Annual Childhood Deaths




Black RE et al. Where and why are 10 million children dying every year. Lancet 2003
            Trends in Child Mortality
               Relative to MDG-4

                                                                           Sub-Saharan Africa
                                                                           South Asia
                    244
                                                                           Latin America
                    206
                                          188                              East Asia
 Under-                                                   171

  Five              123
Mortality                                 129

  Rate              122                                   92
                                          58
                                                                  62
                                                          36
                                         54
                                                                  42.6   MDG-4
                                                          31      19.1   Goals
                                                                  17.8
                1970                 1990            2004       2015

        Source: The State of the World’s Children, 2006
Causes of Under 5 Child Mortality,
           2000-2003




   Bryce et al. WHO estimates of the causes of death in children. Lancet 2005
           Causes of Under 5 Mortality
             by Region, 2000-2003




Bryce et al. WHO estimates of the causes of death in children. Lancet 2005
           Causes of Under 5 Mortality
             by Region, 2000-2003

African Region
    4.396 million

                      21%

                      16%

                      18%

                      5%

                      6%

                      26%

                      2%

                      5%




Bryce et al. WHO estimates of the causes of death in children. Lancet 2005
Percentage of Child Deaths Due to ADIS
by Country in Sub-Saharan Africa




0-4%

5-9%

10-19%

> 20%
Undernutrition as an Underlying
   Cause of Child Mortality:
 Synergy of Undernutrition and
           Infections
Relative Risk (RR) of Death by Cause
Due to Underweight Estimated From
       Random Effects Models
                             RR by Cause of Death

       14
       12
                                                                           Diarrhea
       10
                                                                           Pneumonia
       8
  RR




                                                                           Malaria
       6
                                                                           Measles
       4
                                                                           Overall
       2
       0
                  -3.5              -2.5               -1.5
                    Average weight-for-age z-score

  Caulfield et al. Undernutrition as an underlying cause of child deaths associated with
  diarrhea, pneumonia, malaria and measles. Am J Clin Nutr 2004
           Prevalence of Underweight in Children
                       0 - 4 Years Old




Prevalence (%)
     2 - 11
     11 - 20
     20 - 28
     28 - 37
     37 - 46
From: de Onis and Blossner, 2001
 Contribution of Undernutrition to
Under-Five Mortality by Cause, 2000



       100%

        80%

        60%

        40%

        20%

         0%
                Diarrhea         Malaria       Pneumonia          Measles        All-cause
                 Proportion of deaths associated with undernutrition        All Deaths

     Caulfield LE, de Onis M, Blossner M, Black RE. Undernutrition as an
     underlying cause of child deaths associated with diarrhoea, pneumonia, malaria
     and measles. Am J Clin Nutr 2004
              Prevalence of Vitamin A Deficiency Among
                       Children 0-4 Years Old




Prevalence %
    0 - 10
    10 - 19
    19 - 29
    29 - 38
    38 - 48


West et al., 2002
              Prevalence of Zinc Deficiency




      0 – 14.9 % Deficient   15 – 24.9 % Deficient   > 25 % Deficient



Brown et al, 2004
      Micronutrient Deficiency and
       Attributable Child Mortality

• Vitamin A deficiency - 23% of deaths in
                         children 6-59 months old
• Zinc deficiency -     9% of deaths in children
                        1-47 months old (19% in
                        children 12-47 months
                        old) in addition to
                        mortality attributable
                        to vitamin A
 What are the Preventive and
Therapeutic Interventions that
Would Reduce Child Mortality?
Potential Child Mortality Reduction
  from Preventive Interventions
                                                     Deaths prevented
                                          Number as proportion of
Preventive Intervention                  (thousands)  all child deaths
Breastfeeding                                1301               13%

Insecticide-treated materials                  691                   7%

Complementary feeding                          587                   6%

Zinc                                           459                   5%

H influenzae vaccine                           403                   4%

Antiseptic delivery                            411                   4%

Water, sanitation, hygiene                     326                   3%

Jones et al. How many deaths can we prevent this year? Lancet 2003
 Potential for Community-Based and Outreach
Delivery of Preventive Interventions to Achieve
   Effective Coverage and Mortality Impact

 • Current benefits of immunizations, and potential for
   Hib, pneumococcal and rotavirus vaccines
 • Substantial effects of ITMs, but coverage is still low
 • Exclusive breastfeeding and complementary food
   quality can be improved by nutritional counseling
 • Vitamin A supplementation successful, but needs
   to be sustained in routine health services
 • Intrapartum and newborn care in home-based
   deliveries can be improved to reduce neonatal
   mortality
 • Use of nevirapine to prevent MTCT of HIV needs to
   increase greatly
            Schedule for Integrated Delivery of
                Preventive Interventions




Bryce et al, Lancet 2005
    Potential Child Mortality Reduction
     from Therapeutic Interventions
                                                           Deaths prevented
                                            Number          as proportion of
  Treatment Intervention                    (thousands)     all child deaths
  Oral rehydration therapy                      1477                 15%
  Antibiotics for neonatal sepsis                 583                6%

 Antibiotics for pneumonia                        577                6%

 Antimalarials                                    467                5%

  Zinc for diarrhea                               394                4%

 Newborn resuscitation                            467                5%

 Antibiotics for dysentery                        310                3%



Jones et al. How many deaths can we prevent this year? Lancet 2003
Potential for Community-based Delivery
of Therapeutic Interventions to Achieve
           Effective Coverage
• ORT and zinc for diarrhea treats the
  episode and has preventive effect
  for 2-3 months
• Antimicrobials for malaria, dysentery,
  neonatal sepsis, and pneumonia need
  to be available close to home
  - C-B treatment of malaria reduced
    mortality by 40% in Ethiopia1
  - C-B treatment of neonatal sepsis/
    pneumonia reduced neonatal
    mortality by 59% in India2

1Kidane   et al, Lancet 2000; 2Bang et al, Lancet 1999
                    Percentage Reduction in Mortality by
                    Community-Based Case Management
                               of Pneumonia



               75                                                   All cause
Percentage

Reduction                                                           Pneumonia
               50
    In                                                         42
                                        36
                                                .
 Mortality                                          27
                             24
               25




                0
                              0 - 4 years           <1 month




     Sazawal S, Black RE, Lancet Inf Dis 2003
 Health and Nutrition Interventions
           at All Levels

• Global (trade regulations, standards,
  resources)
• National (legislation)
• District and health system (supplies,
  training, supervision)
• Family and community (food distribution,
  access to services)
                We Know Enough to Act

• Available, feasible interventions could
  prevent 6 million (63%) global child
  deaths if they reached all mothers and
  children.
• Cost of implementing these interventions
  would be $5 billion per year
• Extensive effort is needed and we must
  act now before more children die
Jones et al. How many deaths can we prevent this year? Lancet 2003

Bryce et al. Can the world afford to save the lives of 6 million children each year?
Lancet 2005

								
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