Adina Ekwerike, MPH Health Program Manager

Philadelphia Interdisciplinary Mortality Review

Thursday, May 18, 2006

Understanding and Preventing Infant Deaths in Philadelphia

Local Practice

Infant MortalityInfant MortalityUnited States, 1925-2003United States, 1925-2003

0

10

20

30

40

50

60

70

80

1925 1935 1945 1955 1965 1975 1985 1995

Rate per 1,000 live births

Source: National Center for Health Statistics, final mortality data Prepared by March of Dimes Perinatal Data Center, 2002

2003 preliminary rate - 6.85

Philadelphia’s Philadelphia’s DemographicsDemographics

• 5th largest US city

• Population estimate – 1.49M (7/2000)

• Infant Mortality Rate 10.7, in 2003

Source: Philadelphia Department of Public Health, Vital Statistics Report

Philadelphia - 2003Philadelphia - 2003

• 21,313 births21,313 births– 50% African American or Black50% African American or Black– 30% White30% White– 20% Other20% Other

• 228 infant deaths228 infant deaths– 62% African American62% African American– 32% White32% White– 6% Other6% Other

Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003

2003 Causes of Death among 2003 Causes of Death among InfantsInfants

Perinatal Conditions,

37.8

Congenital

Anomalies, 16.1Infections, 4.8

Injury, 2.4

SIDS, 23.1

Ill-defined, 5.1

Other, 10.7

Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003

Philadelphia Infant Mortality by Philadelphia Infant Mortality by Race 1990-2003Race 1990-2003

Source: Philadelphia Department of Public Health, Vital Statistics Report, 1990 - 2003

15.4

13.5

6.1 6.67.8

16

10.8 10.6 10.7

17.1

20

14.1

7.47.9

12.3

10.3

0

5

10

15

20

25

1990 1995 2002 2003

Rat

e

Black

White

Total

Trends in Infant Mortality in Philadelphia, Trends in Infant Mortality in Philadelphia, 1992 through 20031992 through 2003

10

12

14

16

18

20

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Infa

nt

Dea

ths

per

1,0

00 L

ive

Bir

ths

All Races

Black or African American

Source: The Philadelphia Department of Public Health, Vital Statistics Report, 1992 - 2003

Infant Mortality in Infant Mortality in PhiladelphiaPhiladelphia

32.6

10.7

4.5

0 10 20 30 40

1960

2003

HP2010

Source: Philadelphia Department of Public Health, Vital Statistics Report, 2003

Response to Local Public Response to Local Public Health ConcernHealth Concern

• 2003 MEO began death scene investigations

• “2004 A Bed of Tragedies”, Philadelphia Daily News

(City alerted to 43 deaths in 17 months while sleeping with others)

• City-wide Safe Sleeping Press conference

(The Philadelphia Department of Public Health and the Department of

Human Services)

Infant Deaths from Sudden Unexplained Infant Deaths from Sudden Unexplained Infant Death (SUID) and Hypoxia and Pending Infant Death (SUID) and Hypoxia and Pending

Deaths in Philadelphia, Deaths in Philadelphia,

71 Infant Deaths

48 in Co-sleeping Environment

8 Overlay Deaths

Location of Death

• Sofas/couches (5)

• In a crib w/ sibling (2)

• Adult bed (1)

23 not in Co-sleeping Environment

Source: Philadelphia Department of Public Health, April 1, 2003 – October 11, 2004

Collaboration with Community Collaboration with Community and Stakeholdersand Stakeholders

• Educate community and stakeholders about complex issues of infant safe-sleeping and bed sharing:

- safe sleeping initiative (e.g., cribs for Kids)- Sudden Unexplained Infant Death- back-to sleep- bed sharing- exposure to environmental tobacco smoke

Philadelphia Philadelphia Interdisciplinary Interdisciplinary Mortality Review Mortality Review

(PIMR)(PIMR)

Division of Maternal, Child & Family

Health

PIMR’s TeamsPIMR’s Teams

Rapid Review Infant Death Team

Fetal and Infant Mortality Review

Homicide Review Homicide Review

Non-Homicide Review Non-Homicide Review

Role of PIMRRole of PIMR

The PIMR program is a multidisciplinary, and multi-agency

process that reviews cases of deaths.

The team coordinates, collect and review data from law

enforcement, court systems, child protective services,

medical examiner, health and social services providers.

Philadelphia’s Rapid Philadelphia’s Rapid Review Review

Infant Death TeamInfant Death Team

Infant Deaths Receiving Rapid Infant Deaths Receiving Rapid ReviewReview

• 111 deaths111 deaths

– 27 in ’0327 in ’03– 46 in ’0446 in ’04– 38 from 01/05 – 09/05 (preliminary data)38 from 01/05 – 09/05 (preliminary data)– All reviewed by the same forensic investigatorAll reviewed by the same forensic investigator– All expired while sleepingAll expired while sleeping

Source: Philadelphia Department of Public Health, 2003 - 2005

Racial DisparitiesRacial Disparities’03 – 09/30/05’03 – 09/30/05

81

514

0

10

20

30

40

50

60

70

80

90

Black White Other

%

Source: Philadelphia Department of Public Health, 2003 - 2005

Gender DisparitiesGender Disparities’03 – 09/30/05’03 – 09/30/05

78

32

0

10

20

30

40

50

60

70

80

90

Male Female

%

Source: Philadelphia Department of Public Health, 2003 - 2005

Risk Factors PresentRisk Factors Present’03 – ‘04’03 – ‘04

ETS Not on back

Co-sleeping

2.9% 10.3%

0.0%

20.6%

35.3%

14.7%

7.4%

8.8% had no risk factorsSource: Philadelphia Department of Public Health, 2003 - 2005n=68, 5 missing

Comparing 03/04 through 09/04 to Comparing 03/04 through 09/04 to 03/05 through 09/0503/05 through 09/05

# of Deaths

# of Co-sleeping Deaths

03/04 – 09/04 03/05 – 09/05

19 25

14 15

p > 0.05Notes:

City-wide safe sleeping press conference and subsequent safe sleeping initiatives (e.g., Cribs for Kids) initiated in October ’04.

Time periods selected to control for seasonal differences.

Source: Philadelphia Department of Public Health, 2004 - 2005

Co-Sleeping and OverlayCo-Sleeping and Overlay52 Rapid Review Cases52 Rapid Review Cases

• Co-sleeping: 62% Co-sleeping: 62% (32 of 52 cases)(32 of 52 cases)

• Overlay: 16% Overlay: 16% (5 of 32 cases)(5 of 32 cases)

• Crib present, not used: 74% Crib present, not used: 74% (17 of 23 cases)(17 of 23 cases)

– 9 cases had no data on cribs9 cases had no data on cribs

Source: Philadelphia Department of Public Health, 2003 - 2005

PrematurityPrematurity52 Rapid Review Cases52 Rapid Review Cases

• Premature: 17% (9 cases of 52)Premature: 17% (9 cases of 52)

Source: Philadelphia Department of Public Health, 2003 - 2005

Funding SourceFunding Source

• City’s public funds

• Healthy Start federal grant

• Title V Block Grant

Proposed Recommendations Proposed Recommendations

Provide education and training on SIDS/SUID risk factors with emphasis on exposure to environmental

tobacco smoke (ETS) to the Department of Human Services (DHS) workers and community-wide providers.

Develop a specific focus on ETS prevention and education

Collaborate with the Fetal and Infant Mortality Review (FIMR) Community Action Team to create literature on ETS and infant health for childbirth and parenting classes

Source: Philadelphia Department of Public Health, Philadelphia Interdisciplinary Mortality Review Policy Committee

Proposed Recommendations Proposed Recommendations

Collaborate with the FIMR Community Action Team and DHS to develop a community education campaign/media strategy regarding ETS

Conduct a cross training between fire department staff and health department

Plan educational campaign for block captains

Source: Philadelphia Department of Public Health, Philadelphia Interdisciplinary Mortality Review Policy Committee

PIMR’s PlansPIMR’s Plans

• Conduct timely death reviews

• Facilitate PDPH’s access to medical records

• Link PIMR findings to MCFH, PDPH, DHS, state,

federal other citywide initiatives

• Link PIMR findings to community and policymaker’s

initiatives

• Maintain collaborate relationship with states and

national death reviews