International Health- The State of Our World’s Children

International Health- The State of Our World’s Children

Barbara Oettgen, MD

Introduction

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?

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 MortalityUS(2000)=6.9 Least developed (2000)=102

0

20

40

60

80

100

120In

du

stri

al.

Dev

elop

ing

Lea

std

evel

oped

Wor

ldIMR

(d

eath

s/1,

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live

bir

ths)

19902000

Infant Mortality by World region

0

20

40

60

80

100

120

IMR

(d

eath

s/10

00 l

ive

bir

ths)

19902000

Infant Mortality in Selected Developed Countries (2000)*

Singapore 2.9 Belgium 5.2

Hong Kong 3.0 UK 5.6

Finland 3.8 New Zealand 6.1

France 4.4 Cuba 6.2

Germany 4.4 USA 6.9

Switzerland 4.9

Canada 5.3

*Pediatrics, Dec. 2003

Percent of GDP spent on Health Care (2000)*

Finland 6.7 UK 7.3

France 9.3 New Zealand 7.9

Germany 10.6 US 13

Switzerland 10.4

Canada 8.9

Belgium 8.8

* From Org. for Economic Cooperation and Development

Child (Under 5) Mortality RateUS(2001)=8 Least developed (2001)= 157

020406080

100120140160180200

Industrialized Developing Leastdeveloped

World

Dea

ths

per

100

0 li

ve b

irth

s

19902000

Child (Under 5) Mortality rate by Region

020406080

100120140160180200

Dea

ths

per

100

0 li

ve b

irth

s

19902000

Major Causes of Mortality

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 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

ARI18%

Diarrhea15%

Malaria10%

Measles5%

HIV/Aids4%

Perinatal23%

Other25%

Major Causes of Mortality for children < 5, SS Africa- 2002

ARI16%

Diarrhea14%

Malaria22%

Measles8%

HIV8%

Perinatal13%

Other19%

Major Causes of Infant (< age 1) deaths in the US, 2000 *Pediatrics 12/03

Infant deaths (27,983); IMR=6.9Cong. Malform

21%

LBW/Short gest15%

SIDS8%Perinatal

14%

Unint.Injuries3%

other39%

Major Causes of Childhood Death in the US (ages 1-4), 2000 *Pediatrics 12/03

Child deaths (4942)

Cong. Malform9%Neoplasm

8%

Assault6%

Heart Disease3%

other38%

Injuries36%

Causes of death

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)

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


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


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

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

Most of success attributed to ORT Evolution of ORT

Early 1980’s ORT= ORS (Oral Rehydration Salts)

Since 1993- ORT=increased fluids and continued feeding (IF/CF)

Diarrhea

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

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

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

01 July 2002 slide number SSA-42

Percentage of 15Percentage of 15--19 girls 19 girls who do not know that a HIVwho do not know that a HIV--infected person infected person

may look healthy, 1994may look healthy, 1994--19991999

0

10

20

30

40

50

60

70

80

90

100

Per

cent

age

who

do

not kn

ow

Source: UNICEF, DHS surveys and other nationwide surveys, 1994-99.


Risk perceptionpercentage of sexually active women (15percentage of sexually active women (15--19) 19)

that perceive not to be at risk at all of getting AIDSthat perceive not to be at risk at all of getting AIDS

*HIV prevalence in women attending antenatal care clinics in major urban areas

ZimbabweZambiaUgandaKenyaCARHaitiTogo

CameroonMali

ChadBeninNiger

Dominican Rep.Brazil

GuatemalaBolivia

ColombiaNepal

Nicaragua

HIV Prevalence (at time of survey *)

Percentage of 15-19 year old girls who think they are not at risk of AIDS

Source: UNICEF, DHS surveys, 1994-1999


Knowledge of condoms Knowledge of condoms among adolescent boysamong adolescent boys

0%

25%

50%

75%

100%

Do not know condomsDo not know condoms

Know condoms but Know condoms but not where to get themnot where to get them

Know condoms and Know condoms and where to get themwhere to get them

Per

cent

age

of 1

5-1

9 ye

ar o

ld b

oys

Source: UNICEF, DHS surveys, 1994-1999

Life-time risk for HIV/AIDS


Changes in life expectancy in selected African countries Changes in life expectancy in selected African countries with high and low HIV prevalence: 1950with high and low HIV prevalence: 1950--20052005

with high HIV prevalence:ZimbabweSouth AfricaBotswana

with low HIV prevalence:MadagascarSenegalMali

Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision

30

35

40

45

50

55

60

65

Life exp

ectanc

y (yea

rs)

1950–1955

1955-1960

1960-1965

1965-1970

1970-1975

1975-1980

1980-1985

1985-1990

1990-1995

1995-2000

2000-2005

HIV/AIDS

Other issues Maternal-Child transmission- U5MR could

increase by 100% in most affected areas by 2010 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

Already 14 million

HIV/AIDS

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

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

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

Malnutrition

55

3224

13 11

48

31

16 178

0

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20

30

40

50

60S

ou

th A

sia

SS

-Afr

ica

EA

sia/

Pac

ific

ME

/Naf

rica

LA

/Car

rib

ean

% C

hil

dre

n <

5- U

nd

erw

eig

ht

1990

2000

Malaria

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

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

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

Tetanus (neonatal/maternal), measles, polio Goal is eradication-

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

Strategy for elimination includes: Use National Immunization Days (NID), sub-

NID, 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

United States vs. the world Large role of infectious diseases in the

developing world contributing towards mortality

Challenges of education, nutrition, war, poverty

Successes

International Health- The State of Our World’s Children

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