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GLOBAL BURDEN OF NEONATAL DISEASE: ARING FOR THE … · “In 2014, preterm birth affected about 1...
Transcript of GLOBAL BURDEN OF NEONATAL DISEASE: ARING FOR THE … · “In 2014, preterm birth affected about 1...
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GLOBAL BURDEN OF NEONATAL DISEASE:
CARING FOR THE WORLD’S MOST VULNERABLE PATIENTSSHAUN ODELL MD
2017 NEWBORN PEDIATRIC CRITICAL CARE CONFERENCE
MAY 5, 2017
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OBJECTIVES
1. Discuss the disproportionately large impact that newborn disease has on the state of world health
2. Review known commonalities of at-risk neonates
3. Recognize ways to improve newborn health in local communities
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DEFINITIONS
• Neonate: child in the first month of life
• Childhood mortality: Deaths per 1000 in children less than 5
• Infant mortality: Deaths per 1000 in children less than a year
• Neonatal mortality: Deaths per 1000 children less than one month of age; must show evidence of life: HR, etc
• Excellence: A term best defined visually
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OUTLINE
• Background
• Demographics
• Causes of Neonatal Mortality
• Clinical Scenario
• Successes/Challenges
• Conclusions
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BACKGROUND
• Millennium Development Goals: World leaders from 189 countries, 8 goals
• Goal 4: Reduce by two thirds the rate of mortality in children under 5
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BACKGROUND
Between 1960 and 1990 childhood mortality decreased significantly (current mortality)
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BACKGROUND
• Progress made:
–28% decrease from 1990 to 2008
– Declined from 12.5 million deaths
in 1990 to 8.8 million in 2008
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BACKGROUND
• Progress slower than expected
–At present rate goal reduction would occur by 2045
• Reasons include:
–AIDS
– Increasing poverty
– Slow progress in reducing neonatal mortality
• Fewer resources available (PNA, diarrhea, etc)
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BACKGROUND
Lawn JE, Cousens S, Zupan J (2010)
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BACKGROUND
everynewborn.org
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BACKGROUND
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How many newborns are dying? Where? Why?
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OUTLINE
• Background
• Demographics
• Causes of Neonatal Mortality
• Clinical Scenario
• Successes/Challenges
• Conclusions
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DEMOGRAPHICS: HOW FREQUENTLY
3.6 million neonatal deaths
–32/1000 live births
–Double the number of deaths of any age due to HIV/AIDS
data.worldbank.org
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DEMOGRAPHICS: HOW FREQUENTLY
• Neonatal Period: 28 days long, but 46% of childhood mortality
–54% arise over the following 1800 days
• 25-50% of neonatal deaths in the first 24 hours
• 75% in the first week
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DEMOGRAPHICS: NEONATAL DEATHS BY DAY OF LIFE
Lawn JE, Cousens S, Zupan J (2010)
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DEMOGRAPHICS
• Neonatal mortality by income
– 99% in Low and Middle Income countries
– One of the major health inequities of the world
• Geographical risk can be broken down two ways:
– Neonatal mortality rate (NMR)
– Absolute number of neonatal deaths
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DEMOGRAPHICS
• Neonatal mortality by region (deaths per 1000 births)
– Africa 44 (range 9-70)
– Eastern Mediterranean 40 (range 4-63)
– SE Asia 38 (range 11-43)
– Western Pacific 19 (range 1-40)
– Americas 12 (range 4-34)
– Europe 11 (range 1-38)
• Two-thirds in Sub-Saharan Africa and South Asia
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1990
2010
% of Deaths in Children <5Attributable to Neonatal Causes
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DEMOGRAPHICS
• Countries with the largest numbers of neonatal deaths in percent of world total (neonatal mortality rate per 1000):
– India 27% (43)
– China 10% (21)
– Pakistan 7% (57)
– Bangladesh 4% (53)
– Ethiopia 4% (36)
– Congo 3% (47)
• 60% of the mortality in six countries
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OUTLINE
• Background
• Demographics
• Causes Of Neonatal Mortality
• Clinical Scenario
• Successes/Challenges
• Conclusions
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CAUSES OF NEONATAL MORTALITY
• <3% of neonatal deaths take place with reliable vital registration data
– ie higher mortality countries less likely to have resources for accurate records
• Information largely based on verbal autopsy methods (quality can be variable)
– Global estimates possible through statistical modeling
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NEONATAL MORTALITY
3 main causes: Asphyxiation (24%), Infections (15%), Prematurity (35%)
www.everynewborn.org
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NEONATAL MORTALITY: BIRTH ASPHYXIA
Estimated 6-7 million require some form of resuscitation at birth
4 million newborns with birth asphyxia each year
• 904,000 deaths
• Equal number have sequelae related to asphyxia (CP, epilepsy, sensory deficit)
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NEONATAL MORTALITY: BIRTH ASPHYXIA
• Perceived obstacles:
–Training
–Technology
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NEONATAL MORTALITY: BIRTH ASPHYXIA
Programs underway to assist with resuscitation in resource limited settings
– Based on simple algorithms
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NEONATAL MORTALITY: BIRTH ASPHYXIA
• Aided by data showing that resuscitation with ambient air is effective (or better than 100% O2)
• Would save up to 200,000 lives
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OUTLINE
• Background
• Demographics
• Causes of Neonatal Mortality
– Asphyxia
– Infections
– Preterm Complications
• Clinical Scenario
• Successes/Challenges
• Conclusions
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NEONATAL MORTALITY: INFECTIONS
INSTITUTE FOR HEALTH METRICS AND EVALUATION
More than 1,000,000 neonatalDeaths/year
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NEONATAL MORTALITY: INFECTIONS
In high mortality settings (NMR > 45) 50% of deaths due to infections
Incidence of Neonatal Sepsis (per 1000 live births):
• Asia 7.1 to 38
• Africa 6.5 to 23
• United States and Australasia 6 to 9
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NEONATAL MORTALITY: INFECTIONS
• Almost exclusively affect the poorest families
– Majority of infants who die of infections lack access to healthcare and antibiotics
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NEONATAL MORTALITY: INFECTIONS
• Sepsis
– Klebsiella
– Escherichia coli
– Pseudomonas
– Salmonella
– Staphylococcus aureus
– Coagulase negative staph
– Streptococcus pneumoniae
– Strep pyogenes
• Notably absent: GBS
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NEONATAL MORTALITY: INFECTIONS
1. Antenatal care
2. Hygienic care during childbirth and postnatally
3. Hand washing
4. Early breastfeeding
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OUTLINE
• Background
• Demographics
• Causes of Neonatal Mortality
– Asphyxia
– Infections
– Preterm Complications
• Clinical Scenario
• Successes/Challenges
• Conclusions
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NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH
INSTITUTE FOR HEALTH METRICS AND EVALUATION
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NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH
• Over 1,000,000 deaths per year
• Causes of preterm deliveries
– 45-50% idiopathic
– 30% premature rupture of membranes
– 15–20% medically indicated or elective preterm deliveries
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• Global incidence figures difficult to find. Statistical modeling estimates:
– 9.6% of all births were preterm (<37 weeks)
• 15 million births
– 85% in Africa and Asia
• Reflection of stark health disparities
NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH
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“In 2014, preterm birth affected about 1 of every 10 infants born in the United States. Preterm birth is the greatest contributor to infant death…preterm birth is also a leading cause of long-term neurological disabilities in children.”
- CDC 2015
“Every year, an estimated 15 million babies are born preterm, and this number is rising. Three-quarters of them could be saved with current, cost-effective interventions. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.”
- WHO 2015
NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH
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NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH
• Significant morbidity with higher rates of:
– Cerebral Palsy
– Sensory Deficits
– Learning Disabilities
– Respiratory Illnesses
• Financial costs of prematurity per year (US alone): $26.2 billion
– Medical expenses
– Educational programs
– Lost productivity
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NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH
Number of preterm births appear to be increasing:
1. Increasing rates of multiple births
2. Increased use of fertility treatments
3. Increased proportion of births in women older than 34
4. Changing clinical practices (increased use of ultrasound and C-section delivery)
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NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH
Most between 33 and 37 weeks
– Survival depends on treatment of difficulties breathing, infections, jaundice
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OUTLINE
• Background
• Demographics
• Causes of Neonatal Mortality
• Clinical Scenario
• Successes/Challenges
• Conclusions
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CLINICAL SCENARIO
A young physician in the US decides to expand his family
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CLINICAL SCENARIO
Meanwhile his twin living in Sub-Saharan Africa makes the same decision
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CLINICAL SCENARIO
Likelihood that:
– a skilled attendant will attend the delivery: >99% vs 25-33%
– the birth will take place in a health facility: 98% vs 33%
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CLINICAL SCENARIO
Risk of dying in the first 28 days in developing countries:
– 11-fold higher for infectious causes
– 8-fold higher for asphyxia
– 3-fold higher for causes related to prematurity
– Overall NMR 6x higher in low and middle income countries
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OUTLINE
• Background
• Demographics
• Causes of Neonatal Mortality
• Clinical Scenario
• Successes/Challenges
• Conclusions
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SUCCESSES/CHALLENGES
• “Reduce by two thirds, between 1990 and 2015, the under-five mortality rate”
– Between 1990 and 2008, childhood mortality was reduced by 28 percent
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SUCCESSES/CHALLENGES
Global rates of neonatal death are decreasing
– 64.7/100000 in 1990
– 28.6/100000 in 2013
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SUCCESSES/CHALLENGES
• 400,000 fewer neonatal deaths now compared to 10 years ago
– 150,000 fewer deaths from infectious causes
– 80,000 fewer deaths from asphyxia
– 80,000 fewer deaths from preterm complications
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• …Rates of disability due to neonatal conditions:
–64.7 years of life lost to disability (YLD) per 100000 in 1990
–120.6 years of life lost to disability (YLD) per 100000 in 2013.
• This trend is present in all neonatal conditions
–most prominent in preterm births which increased from 29.9 and 57.3/100000 YLD over the same time frame.
SUCCESSES/CHALLENGES
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SUCCESSES/CHALLENGES: PORTUGAL
Portugal: 30 years ago high neonatal and infant mortality
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SUCCESSES/CHALLENGES: PORTUGAL
1989 reform:
• Smaller maternal wards closed
• Nationwide transport system for pregnant women and newborns begun
• Training intensified (post graduate education in neonatology emphasized)
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SUCCESSES/CHALLENGES: PORTUGAL
Outcomes:
• Maternal and perinatal death rates decreased
• Infant mortality decreased from 12.2 to 4 per 1000 live births
• Neonatal mortality decreased from 8.1 to 2.7 per 1000 live births
• Achieved with no additional cost
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SUCCESSES/CHALLENGES: INDIA
Gujarat in India: 55 million inhabitants
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SUCCESSES/CHALLENGES: INDIA
Interventions
• Private Obstetricians/gynecologists contracted to provide delivery care
• Limited to the poor rural births
• 800 obstetricians, 176,000 women delivered in hospitals
• Increase from 27% of deliveries in hospitals to 53% after initiation
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SUCCESSES/CHALLENGES: INDIA
Outcomes
• Neonatal deaths decreased from 8,462 to 559
• Cost of extending to all of India: $250 million
• 27% of global neonatal mortality
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SUCCESSES/CHALLENGES
• Cuba: Fraction of low birth weight infants halved between 1978 and 2005
• Chile: Infant mortality decreased from 136/1000 to 16/1000 in the years from 1950 to 1990.
– A second phase of progress started in 1990 decreased deaths to 5/1000.
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SUCCESSES/CHALLENGES
Success of industrialized nations in the mid 20th century
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SUCCESSES/CHALLENGES: UNITED KINGDOM
• United Kingdom: NMR fell from 30/1000 live births in 1940 to 10/1000 in 1975.
• Availability of antibiotics
• Free antenatal care
• NICU facilities only became available after the NMR had fallen below 15
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SUCCESSES/CHALLENGES: TETANUS
• Tetanus: 1,000,000 neonatal deaths in 1980
• 59,000 deaths annually in 2008
• Not a major source of mortality in industrialized nations before the introduction of tetanus toxoid
• Example of the effect that targeted interventions can have
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Tetanus
Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S (2010)
SUCCESSES/CHALLENGES: TETANUS
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Tetanus
Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S (2010)
SUCCESSES/CHALLENGES: TETANUS
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SUCCESSES/CHALLENGES
Global mortality of newborns is declining. The Caveat:
Mostly in High-income countries:
Percentage change in NMR from 1996-2005
High-income countries: -29%
Low-income countries: -8%
Americas -40%
Africa +5%
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SUCCESSES/CHALLENGES
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COST EFFECTIVE INTERVENTIONS
Darmstadt G, Bhutta Z, Cousens S, Adam T, et al (2005)
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COST EFFECTIVE INTERVENTIONS
If scaled up would reduce neonatal mortality by 72%
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“High-tech, high-cost, specialist driven, hospital based neonatal care is not required to meet much of the present challenge of neonatal survival…”
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A LOCAL PROBLEM
• Neonatal Mortality rate in US 4x higher than in Iceland
– Rate amongst children of black women 11x higher
• 2000 more preterm births in the US in 2015 compared to 2014
– Seven states with highest increase in prematurity rates: Arkansas, Connecticut, Idaho, Nebraska, New Mexico, Utah and Wisconsin
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COMPLICATIONS OF PRETERM BIRTH
• “According to the latest data available from the World Health Organization, the U.S in 2010 ranked in the middle of the pack, falling behind Somalia, Afghanistan and Thailand.”
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A LOCAL PROBLEM
Institute for Health Metrics and Evaluation 2017
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WHY ARE RATES HIGHER IN THE US?
• High rates of prematurity
– Fertility treatment, elective inductions and cesarean deliveries
• Access to health care
• Pre-pregnancy planning
• Health
– Highest rates of obesity and diabetes in the developed world
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CONCLUSIONS
• 3.5 million neonates die yearly, the majority from a small number of causes
• The vast majority of deaths occur in low and middle income countries
• Decreasing global childhood mortality to goal levels is not possible without a greater focus on neonates
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CONCLUSIONS
• Interventions to decrease mortality do not need to be high tech or high cost solutions
• Room for improvement close to home
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REFERENCES
Saugstad OD. Reducing global neonatal mortality is possible. Neonatology. 2011; 99:250-257.Paul VK. The current state of newborn health in low income countries and the way forward. Sem in Fetal &
Neonatal Med. 2006; 11:7-14.Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S. 3.6 million neonatal deaths—what is progressing and
what is not? Sem in Perinatology. 2010; 34: 371-376.Lawn JE, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet. 2005; 365: 891-900.Darmstadt GL, Bhutto ZA, Cousens S, Adam T, Walker N. Evidence-based, cost-effective interventions: how
many newborn babies can we save? Lancet. 2005; 365: 977-988.Vergnano S, Sharland M, Kazembe P, Mwansambo C, Heath PT. Neonatal sepsis: an international perspective.
Arch Dis Child Fetal Neonatal Ed. 2005; 90(3):F220-4.Mathews TJ, MacDorman MF. Infant mortality statistics from the 2007 period linked birth/infant death data
set. National Vital Statistics Reports. 2011; 59(6):1-30.Rajaratnam JK, Marcus JR, Flaxman AD, et al. Neonatal, postneonatal, childhood, and under-5 mortality for
187 countries, 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet. 2010; 375: 1988-2008.
Oestergaard MZ, Inoue M, Yoshida S, et al. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Medicine. 2011; 8(8): 1-13.
Hill K, Choi Y. Neonatal mortality in the developing world. Demographic Research. 2006; 14: 429-452.Reid A. Neonatal mortality and stillbirths in early twentieth century Derbyshire, England. Population Studies.
2001; 55:213-232.
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Preterm Birth Complications
• Newborn weight, a predictor of adverse outcomes:
– 60-80% of neonatal deaths are low birth weight (LBW) infants
• Only 14% of births
– Higher amongst preterm LBW infants than term IUGR babies
• Mortality 5x higher for preterm LBW infants vs full-term growth restricted babies
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Acknowledgements…
• Adam Weinstein MD
• Alison Ricker
• John Modlin MD
• Diane Kittredge MD
• Heather Robertson MD
• Paul Palumbo MD
• Penninah Oberdorfer MD
• Somporn Chotinaruemol MD
• Woraporn Tiyaprasertkul MD
• George Little MD
• Claudia Zegans MD
• Gautham Suresh MD
• Dorothy Mullaney APRN, MHS
• Dianna Odell MSW, LICSW et al
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