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  • UNICEF has very recently reviewed the progress made on achieving the World Summit for Children goals. The results of this review have been included in an update to the UN Secretary General’s 2001 report The present slide is taken from this update and shows progress in the reduction of the under-five mortality rate (U5MR) during the 1990s. The region with the smallest reduction is where U5MR is highest, in sub-Saharan Africa, and the largest reduction is where U5MR is lowest, in the industrialized countries.
  • ..comparing 2004 and 2005, the differences noted are mainly due to changes in ChIP’s classification of causes of death rather than reflecting any significant change in the profile. AIDS is no longer used but rather each child’s HIV experience is recorded as mentioned earlier. PCP, both suspected and confirmed, is new to the classification and one can see that by adding ARI and PCP in 2005 one gets a similar total to that for ARIs in 2004. TB refers to all TB (pulm, mening and miliary).

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  • Child Health: Overview Dr E Malek, Principal SpecialistDepartment of Paediatrics, University of Pretoria, Witbank Hospital emalek@postino.up.ac.za
  • Acknowledgements• 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)• 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? HIV/AIDS Measles Injuries 3% 4% 3% For these 4 Malaria causes, ~ 8% Neonatal 53% of deaths deaths are 36% malnourish ed children Diarrhoea 17% AIDS is much bigger proportion in Southern Pneumonia Other Africa. 19% 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 deathsSource: Lawn JE, Cousens SN, Zupan J Lancet 2005. for 192 countries based on cause specific mortalitydata and multi cause modelled estimates. As used in World Health Report 2005
  • Under five mortality rates: Trends from 1990- 2000 200 181 1990 180 175 Least 2000 reduction 160 3%U5MR (deaths per 1000 births) 140 128 120 100 100 Greatest 80 reduction 80 32% 64 58 60 53 44 45 37 38 40 20 9 6 0 Sub-Saharan South Asia Middle East & East Asia and Latin America CEE/CIS and Industrialized Africa North Africa Pacific & Caribbean Baltics countries Source: UNICEF, 2001 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 5. Reduce MMR by three poverty and hunger quarters2. Achieve universal 6. Combat HIV/AIDS, primary education malaria and other diseases3. Promote gender 7. Ensure environmental equality sustainability and empowerment of women 8. Develop global partnerships4. Reduce child mortality for development by two thirds
  • Integrated Management of Chilldhood Illness (IMCI) Assess and classify Department of Child and Adolescent Health and Development
  • IMCI facility based usage in Bangladesh (Lancet, 2004)
  • WHO Initiatives to improvequality 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 forChildren: Hospital IMCIEvidence-Based Guidelines
  • Child Health in South Africa• 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 SAChild Health Priorities conference (Dec 2007, Durban)
  • Distribution of Resources
  • Slide: Ngashi Ngongo
  • South Africa progress 150 to MDG 4 N e o na t a l M o r t a lit y R ate U nd e r 5 M o r t a li t y R a t e . Mortality per 1,000 births Inf a nt M o r t a l ity R a t e 10 0 M D G 4 Targ et 67 50 54 21 20 0 198 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% Low birth weight, Neonatal 12%Diarrhoea: 11% 18% 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 protein- energy 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 50 East 40 West 30 North 20 10 0 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
  • Leading causes of death among infantsunder 1 year of age, South Africa 2000
  • Leading causes of death among infantsunder 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) WHO* (%) Child PIP in 1 month to 5 years Mpumalanga: Zero to 5 years HIV/AIDS - Most deaths 1 month to 5 yrs 57 88% HIV if ChPIP Data: exclude Pneumonia 22 HIV test Witbank Hospital 1 neonatal ~ 54% tested had 2244 child Septicaemia/meningitis 21 26% +ve - admissions & 101 20% exposed child deaths in Diarrhoea 20 Only 8% tested -ve 1 2006; overall case TB 5 fatality rate 4.5; - HIV clinical stage 31% of all deaths PCP 11 ~ 58% staged - within 1st 24 of which half were hours of Other 19 Stages III & IV 1 admission Malaria - ChPIP Sites: 0 2004: Witbank Measles - 0 2006: Witbank & Injuries Included under “other” 5 (16% of all admissions but causes Barberton Neonatal tabulated for 1 month to 5 years) 35* Source: WHO World health Statistics 2006 www.who.int 2007: above plus 8
  • Causes of death of children in hospitals (n = 1695) 35 30 33 25 20% 20 15 15 16 10 12 13 12 5 10 7 3 0 2004 2005 ARI DD 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 pre- transitional 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 Strategies1. Infant and Young Child Feeding (including EBF)2. Immunisation3. Treatment of common childhood illnesses4. Care of children with HIV-infection5. Provision of Vitamin A6. PMTCT
  • National Health Targets
  • Key MCH interventionsMATERNAL CARE NEONATAL CARE CHILD CARE Basic neonatal 1. Infant and1. Focused ANC care Young Child2. PMTCT-Plus 1. Resuscitation Feeding3. Skilled 2. LBW care 2. HIV care attendant 3. Early EBF 3. IMCI (clinic) deliveries 4. KMC 4. Hospital care4. EMOC 5. PMTCT-Plus 5. EPI5. Family 6. Infection 6. Vitamin A planning management 7. HIV testing, cotrim, ARV
  • South Africa: Coverage along the MNCH continuum of care 100% The days 75% of highest risk have the lowest 50% coverage of care 25% no data 7% 94% 84% 93% 0% Ant enat al care Skilled Post nat al care Excl. BF I m m unisat ion ( at least one at t endant ( DPT3) visit ) during childbirt hSource: Lawn JE, Kerber K Opportunities for Africa’s Newborns. PMNCH, 2006
  • 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 7-9 10-12 Source: Demographic Health Survey 2003 Slide: Ngashi Ngongo
  • Immunisation• 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• Primary Health Care package• District Hospital package• Regional hospital package• Service Transformation Plan• Modernization of Tertiary Services
  • Existing norms and standards• IMCI• Clinic supervisors manual• EDL• WHO pocketbook
  • Staffing norms• No official staffing norms for the country• Various systems have been used
  • Service transformation plan• 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 3- 3.5million 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 Appropriate (Vitamin A) infant feeding IMCI PMTCT Maternal EPI Plus Health Care of HIV infected childrenHOUSEHOLD AND COMMUNITY IMCI
  • Active SiteFuture Site TINTSWALO TEMBA MIDDELBURG ROB FERREIRA WITBANK CAROLINA BARBERTON EVANDER ERMELO STANDERTON PIET RETIEF
  • Witbank NNMR 2000-2005 trend (=/> 1000 grams)250200150 1000-1499g NICU 1500-1999g100 2000-2499g >2500g nCPAP 50 0 2000 2001 2002 2003 2005*
  • References• SA IMCI chart booklet: UP Intranet (Block 10)• www.who.int/child-adolescent-health/publications/CH• 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