Transcript International Health- The State of Our World’s Children

International Health- The
State of Our World’s Children
Barbara Oettgen, MD
Introduction
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Present and discuss the statistics of Infant and
Child mortality
Compare and contrast child mortality in
developed vs. developing countries
Discuss some of the most common causes of
child mortality in developing countries and what
is being done to decrease mortality
Discuss status of progress towards mitigation or
eradication of causes of mortality
Why talk about Global Health of
Children?
“A society in which human rights are
promoted and protected and in which
human dignity is respected is a healthy
society; that is, a society in which people
can best achieve physical, mental and
social well-being.”
Jonathan Mann, “Human Rights and the
New Public Health” 1995
Why talk about Global Health of
Children?
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There is a stark contrast between developed
and developing countries in terms of morbidity
and mortality
88% of the world’s children live in developing
countries (Population Reference Bureau)
Through immigration, we will see children from
developing countries; we must have an
understanding of what medical issues for which
to screen to care for these children and protect
the health of the public
Infant Mortality
120
100
80
1990
2000
60
40
20
World
Least
developed
Developing
0
Industrial.
IMR (deaths/1,000 live births)
US(2000)=6.9 Least developed (2000)=102
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IMR (deaths/1000 live births)
Infant Mortality by World region
120
100
80
60
1990
2000
40
20
0
Infant Mortality in Selected
Developed Countries (2000)*
Singapore
2.9
Hong Kong
3.0
Finland
3.8
France
4.4
Germany
4.4
Switzerland
4.9
Canada
5.3
*Pediatrics, Dec. 2003
Belgium
UK
New Zealand
Cuba
USA
5.2
5.6
6.1
6.2
6.9
Percent of GDP spent on Health
Care (2000)*
Finland
6.7
UK
France
9.3
New Zealand
Germany
10.6
US
Switzerland
10.4
Canada
8.9
Belgium
8.8
* From Org. for Economic Cooperation and
Development
7.3
7.9
13
Child (Under 5) Mortality Rate
Deaths per 1000 live births
US(2001)=8
Least developed (2001)= 157
200
180
160
140
120
100
80
60
40
20
0
1990
2000
Industrialized
Developing
Least
developed
World
200
180
160
140
120
100
80
60
40
20
0
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2000
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Deaths per 1000 live births
Child (Under 5) Mortality rate by
Region
Major Causes of Mortality
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Currently, epidemiologic work is being done to
try to accurately measure causes of death
Difficult to get completely accurate numbers that
can be tracked over time
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Many deaths are due to a combination of reasons
such as diarrhea and measles
At least 60% of deaths are thought to be associated
with malnutrition
The breakdown of causes of death varies by country
and region
Lack of public health infrastucture to accurately
collect data
Major Global Causes of Mortality
for Children under 5, in 2002 *WHO
Other
25%
ARI
18%
Diarrhea
15%
Perinatal
23%
HIV/Aids Measles
5%
4%
Malaria
10%
Major Causes of Mortality for
children < 5, SS Africa- 2002
Other
19%
Perinatal
13%
ARI
16%
Diarrhea
14%
HIV
8%
Measles
8%
Malaria
22%
Major Causes of Infant (< age 1)
deaths in the US, 2000 *Pediatrics 12/03
Infant deaths (27,983); IMR=6.9
Cong. Malform
21%
other
39%
LBW/Short gest
15%
Unint.Injuries
3%
Perinatal
14%
SIDS
8%
Major Causes of Childhood Death
in the US (ages 1-4), 2000 *Pediatrics 12/03
Child deaths (4942)
other
38%
Injuries
36%
Heart Disease
Cong. Malform
Assault
3%
Neoplasm
9%
6%
8%
Causes of death
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Use data to formulate a public health
approach to reducing mortality
What are the challenges for each major
morbidity?
How can we affect the most change?
What are the goals? (World Summit for
Children)
Are we making progress?
Acute Respiratory Tract Infection
(ARI)
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Killed ~ 2 million Children in 2000
Estimated that ~60% of deaths could be
prevented with selective antibiotics
WHO recommends using many types of
caregivers to evaluate children and
provide Abx if necessary including village
health workers; children should seek care
outside the home
Acute Respiratory Tract Infection
(ARI)
How can the situation change?
 Improve care-seeking behavior- get the word out
to families and communities about having their
children evaluated if sick
 IMCI (Integrated Management of Childhood
Illness) Initiative
 Work on case management skills of health
workers
Acute Respiratory Tract Infection
(ARI)
Progress
 So far little- in nearly half of 81 developing
countries with available data, < 50% if children
with ARI were taken to an appropriate provider
but there is wide inter-country variability
 Biggest problem area is sub-Saharan Africa
 Access is a big issue: urban vs. rural; also
availability of meds
Diarrhea
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In early 1990’s was the #1 killer; still
important
Tactics so far have included ORT,
breastfeeding promotion, measles
immunization, safer water supply, and safe
feces disposal
Between 1990-2000 diarrheal related
deaths decreased by 50%
Diarrhea
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Most of success attributed to ORT
Evolution of ORT
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Early 1980’s ORT= ORS (Oral Rehydration
Salts)
Since 1993- ORT=increased fluids and
continued feeding (IF/CF)
Diarrhea
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Different countries use different versions
of ORT so a little difficult to compare data
but overall there is wide use of ORT and
either increasing or stable trends in use
Still lots of work needed to reach families
Still need to work on infrastructure to
establish safe water and sewage disposal
HIV/AIDS
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Actuality of epidemic (in its 3rd decade) is far
worse than predictions in early 1990’s
As of 12/04, 40 mil infected (2.2 mil children
<15)
Newly infected in 2003= 5 mil; deaths=3 mil
(600,000 children)- 8,000 people every day
95% of those infected live in low and middle
income countries
Largest numbers are in sub-Saharan Africa
Epidemics emerging in Eastern Europe, Central
Asia, and Asia/Pacific region (China/India)
HIV/AIDS in Africa- end 2003
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25 million Africans with HIV
19 million have already died
80% of world’s children who are orphaned due
to HIV live in Africa
60% of world’s young people (15-24) with HIV
live in Africa (10 million)
Half of all new infections occur in the 15-24 age
range (women are 2.5 times as likely to be
infected in this age group)
HIV/AIDS
Problems
 Lack of education- >50% don’t know about AIDS
or how it is transmitted in the 20 of 22 countries
for which there is information
 Young people do not go for education even if its
available because of lack of privacy, threatening
environment, insensitive staff
 Drug Abuse, Risky sexual behavior
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Percentage who do not know
Percentage of 15-19 girls
who do not know that a HIV-infected person
may look healthy, 1994-1999
100
90
80
70
60
50
40
30
20
10
0
Source: UNICEF, DHS surveys and other nationwide surveys, 1994-99.
01 July 2002 slide number SSA-42
Risk perception
percentage of sexually active women (15-19)
that perceive not to be at risk at all of getting AIDS
Nicaragua
Nepal
Colombia
Bolivia
Guatemala
Brazil
Dominican Rep.
Niger
Benin
Chad
Mali
Cameroon
Togo
Haiti
CAR
Kenya
Uganda
Zambia
Zimbabwe
HIV
Prevalence
(at time of
survey *)
10
0%
90
%
80
%
70
%
60
%
50
%
40
%
30
%
20
%
10
%
0%
Percentage of
15-19 year old
girls who think
they are not at
risk of AIDS
*HIV prevalence in women attending antenatal care clinics in major urban areas
Source: UNICEF, DHS surveys, 1994-1999
01 July 2002 slide number SSA-45
Knowledge of condoms
among adolescent boys
100%
Percentage of 15-19
year old boys
Do not know condoms
75%
50%
25%
Do
m
in
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an r az
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it
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Bo r u
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ca w i
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Za ua
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Ta bw
nz e
an
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M o N ali
za ige
m r
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Ch e
ad
0%
Source: UNICEF, DHS surveys, 1994-1999
01 July 2002 slide number SSA-43
Know condoms but
not where to get them
Know condoms and
where to get them
Life-time risk for HIV/AIDS
Changes in life expectancy in selected African countries
with high and low HIV prevalence: 1950-2005
65
Life expectancy (years)
60
with high HIV prevalence:
Zimbabwe
South Africa
Botswana
55
50
45
with low HIV prevalence:
40
Madagascar
Senegal
Mali
35
30
1950– 1955- 1960- 1965- 1970- 1975- 1980- 1985- 1990- 1995- 20001955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision
01 July 2002 slide number SSA-31
HIV/AIDS
Other issues
 Maternal-Child transmission- U5MR could
increase by 100% in most affected areas by
2010
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In 2003, 630,000 newly infected children <15 (mostly
all perinatal)
Only 8% of infected pregnant women have access to
meds (In SS Africa, <5%)
Orphaned children due to HIV
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Already 14 million
HIV/AIDS
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Need to be educating children, even
before they reach the 15-24 age group on
the disease, its severity, and prevention.
World HIV conference
HIV Vaccine
Antiretroviral Treatment; the “3 by
5” initiative
Malnutrition
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In 1990, 1/3 of children <5 were
malnourished (174 million)
Malnutrition contributes to >50% of all
child deaths
Poverty, low status of women, poor care
during pregnancy, high population
densities, poor access to health care and
feeding practices contribute
Malnutrition- Progress
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Since 1990, the percent of underweight children
has decreased from 32 to 28% (150 million).
(The WSC goal was to reduce it by half).
Greatest decline has been in East Asia
(especially China) from 24-16%.
South Asia remains the most affected area- with
a small decline since 1990 from 55% to 48%
where half of undernourished children live
Problem is 1.5 times greater in rural areas
13
17
LA/Carribean
16
ME/Nafrica
EAsia/Pacific
SS-Africa
60
50
40
30
20
10
0
South Asia
% Children <5- Underweight
Malnutrition
55
48
32 31
24
1990
2000
11 8
Malaria
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Problem areas are sub-Saharan Africa,
India, northern South America
Prevention: treated bednets- if every child
slept under a treated bednet we could
reduce mortality by 25-30%
Treatment- only about half of children are
treated appropriately
Also working on a malaria vaccine
Malaria
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Per WHO, every 30 sec. a child dies of
malaria (estimated 1 million deaths
worldwide/year- mostly in children and
90% in Africa)
Threat of malaria is increasing due to
climate changes, environment,
development projects (such as dams),
war, poverty
Malaria
Roll Back Malaria Project- started in 1998
 Strategy includes
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Early detection and prompt treatment
Treated bednets and other vector control
measures
Preventive intermittent treatment in
pregnancy (a Kenya/Malawi study- decrease
complications by 75%)
Disease surveillance
Vaccine Preventable Diseases
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Tetanus (neonatal/maternal), measles, polio
Goal is eradication
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Most dramatic progress so far is with polio- since
1988, incidence has decreased >99%; in 2002, only
1,920 cases worldwide; mostly concentrated in India,
Nigeria, and Pakistan
For tetanus, by the end of 1999, 104 of 161
developing countries had eliminated neonatal tetanus
Measles- still have 14 countries with coverage of
<50%; global rate =72%
Vaccine Preventable Diseases
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Strategy for elimination includes:
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Use National Immunization Days (NID), subNID, and mop-up activities (including house to
house) to improve coverage
Improved surveillance and accurate reporting
In the case of polio, have established
technical advisory groups for each country as
well as interagency coordination committees
Challenges
Conclusions
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United States vs. the world
Large role of infectious diseases in the
developing world contributing towards
mortality
Challenges of education, nutrition, war,
poverty
Successes