Transcript Child Health: Overview - Department of Library Services

Child Health: Overview
Dr E Malek, Principal Specialist
Department of Paediatrics, University
of Pretoria, Witbank Hospital
[email protected]
Acknowledgements
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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)
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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?
Measles
4%
For these 4
causes, ~
53% of
deaths are
malnourish
ed children
HIV/AIDS
Injuries
3%
3%
Malaria
8%
Neonatal
deaths
36%
Diarrhoea
17%
AIDS is much bigger
proportion in Southern
Africa.
Pneumonia
19%
Other
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 19902000
200
1990
2000
181
U5MR (deaths per 1000 births)
180
175
Least
reduction
3%
160
140
128
120
100
100
Greatest
reduction
32%
80
80
64
58
60
53
45
44
37
40
38
20
9
6
0
Sub-Saharan
Africa
South Asia
Source: UNICEF, 2001
Middle East &
North Africa
East Asia and
Pacific
Latin America
& Caribbean
CEE/CIS and
Baltics
Industrialized
countries
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
5. Reduce MMR by three
quarters
6. Combat HIV/AIDS,
malaria
and other diseases
7. Ensure environmental
sustainability
8. Develop global
partnerships
for development
4. Reduce child mortality
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
breathing
Severe disease
Urgent referral
Diarrhoea
Disease with specific
therapy
Specific medical treatment
Disease without specific
therapy
Symptomatic treatment
Complete/incomplete
Vaccinate
Fever
Ear problem
Nutritional status/
anaemia
Vaccination status
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
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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
Mortality per 1,000 births
.
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
Inf ant M o r t alit y R at e
10 0
M D G 4 T ar g et
67
54
50
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%
Neonatal
18%
Diarrhoea: 11%
Low birth weight,
12%
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 proteinenergy 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
East
West
North
50
40
30
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)
1 month to 5 years
HIV/AIDS
Pneumonia
Septicaemia/meningitis
Diarrhoea
TB
PCP
Most
- deaths 1 month to 5 yrs
22
21
20
5
Other
11
19
Malaria
-
Measles
-
Injuries
Neonatal
HIV test
~ 54% tested
26% +ve
20% exposed
Only 8% tested -ve
HIV clinical stage
~ 58% staged
of which half were
Stages III & IV
Included under “other”
(16% of all admissions but causes
tabulated for 1 month to 5 years)
* Source: WHO World health Statistics 2006 www.who.int
Child
PIP in
WHO*
(%)
Mpumalanga:
Zero to 5 years
88% HIV if
57 Data:
ChPIP
exclude
Witbank Hospital
1
neonatal
had 2244 child
admissions
& 101
child deaths in
1 overall case
2006;
fatality rate 4.5;
31% of all deaths
within
- 1st 24
hours of
1
admission
ChPIP
0 Sites:
2004: Witbank
0
2006: Witbank &
5
Barberton
35 above plus 8
2007:
new sites
Causes of death of children in hospitals
(n = 1695)
35
30
33
25
%
20
20
15
10
15
12
5
12
16
10
7
3
0
2004
ARI
DD
13
2005
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 pretransitional 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
1. Focused ANC
2. PMTCT-Plus
3. Skilled
attendant
deliveries
4. EMOC
5. Family
planning
Basic neonatal
care
1. Resuscitation
2. LBW care
3. Early EBF
4. KMC
5. PMTCT-Plus
6. Infection
management
1.
2.
3.
4.
5.
6.
7.
CHILD CARE
Infant and
Young Child
Feeding
HIV care
IMCI (clinic)
Hospital care
EPI
Vitamin A
HIV testing,
cotrim, ARV
South Africa:
Coverage along the
MNCH continuum of care
100%
The days
of highest risk
have the lowest
coverage of care
75%
50%
25%
no data
0%
94%
84%
Antenatal care
(at least one
visit)
Skilled
attendant
during
childbirth
Postnatal care
Source: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006
7%
Excl. BF
93%
Immunisation
(DPT3)
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
Source: Demographic Health Survey 2003
7-9
10-12
Slide: Ngashi Ngongo
Immunisation
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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
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Primary Health Care package
District Hospital package
Regional hospital package
Service Transformation Plan
Modernization of Tertiary Services
Existing norms and standards
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IMCI
Clinic supervisors manual
EDL
WHO pocketbook
Staffing norms
• No official staffing norms for the country
• Various systems have been used
Service transformation plan
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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 33.5million 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
(Vitamin A)
EPI
IMCI
Appropriate
infant
feeding
PMTCT
Plus
Maternal
Health
Care of HIV
infected children
HOUSEHOLD AND COMMUNITY IMCI
Active Site
Future Site
TINTSWALO
TEMBA
MIDDELBURG
WITBANK
ROB FERREIRA
CAROLINA
BARBERTON
EVANDER
ERMELO
STANDERTON
PIET RETIEF
Witbank NNMR 2000-2005
trend (=/> 1000 grams)
250
200
1000-1499g
1500-1999g
2000-2499g
>2500g
150
NICU
100
nCPAP
50
0
2000
2001
2002
2003
2005*
References
• SA IMCI chart booklet: UP Intranet (Block 10)
• www.who.int/child-adolescenthealth/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