Effective Interventions to Reduce Child Mortality and Undernutrition: The Evidence
Robert E. Black, M.D., M.P.H. Johns Hopkins Bloomberg School of Public Health
Outline of Presentation
Global child mortality today Undernutrition, including vitamin A and zinc deficiencies, as an underlying cause of child mortality Preventive and therapeutic interventions to reduce child mortality
Where and Why Are 10 Million Children Dying Every Year?
10.6 Million Annual Childhood Deaths
Black RE et al. Where and why are 10 million children dying every year. Lancet 2003
Trends in Child Mortality Relative to MDG-4
Sub-Saharan Africa South Asia
244
Latin America
206 188
East Asia
171
UnderFive Mortality Rate
123
129 92 58 36 54 31
122
62 42.6 19.1 17.8
MDG-4 Goals
1970
1990
2004
2015
Source: The State of the Worlds Children, 2006
Causes of Under 5 Child Mortality, 2000-2003
Bryce et al. WHO estimates of the causes of death in children. Lancet 2005
Causes of Under 5 Mortality by Region, 2000-2003
Bryce et al. WHO estimates of the causes of death in children. Lancet 2005
Causes of Under 5 Mortality by Region, 2000-2003
African Region
4.396 million
21% 16% 18% 5% 6% 26% 2% 5%
Bryce et al. WHO estimates of the causes of death in children. Lancet 2005
Percentage of Child Deaths Due to ADIS by Country in Sub-Saharan Africa
0-4% 5-9% 10-19% > 20%
Undernutrition as an Underlying Cause of Child Mortality: Synergy of Undernutrition and Infections
Relative Risk (RR) of Death by Cause Due to Underweight Estimated From Random Effects Models
RR by Cause of Death
14 12 10
RR
Diarrhea Pneumonia Malaria Measles Overall
8 6 4 2 0 -3.5 -2.5 -1.5 Average weight-for-age z-score
Caulfield et al. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria and measles. Am J Clin Nutr 2004
Prevalence of Underweight in Children 0 - 4 Years Old
Prevalence (%) 2 - 11 11 - 20 20 - 28 28 - 37 37 - 46
From: de Onis and Blossner, 2001
Contribution of Undernutrition to Under-Five Mortality by Cause, 2000
100% 80% 60% 40% 20% 0% Diarrhea Malaria Pneumonia Measles All-cause
All Deaths Proportion of deaths associated with undernutrition
Caulfield LE, de Onis M, Blossner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhoea, pneumonia, malaria and measles. Am J Clin Nutr 2004
Prevalence of Vitamin A Deficiency Among Children 0-4 Years Old
Prevalence %
0 - 10 10 - 19 19 - 29 29 - 38 38 - 48
West et al., 2002
Prevalence of Zinc Deficiency
0 14.9 % Deficient
15 24.9 % Deficient
> 25 % Deficient
Brown et al, 2004
Micronutrient Deficiency and Attributable Child Mortality
Vitamin A deficiency - 23% of deaths in children 6-59 months old
Zinc deficiency 9% of deaths in children 1-47 months old (19% in children 12-47 months old) in addition to mortality attributable to vitamin A
What are the Preventive and Therapeutic Interventions that Would Reduce Child Mortality?
Potential Child Mortality Reduction from Preventive Interventions
Preventive Intervention Breastfeeding Insecticide-treated materials Deaths prevented Number as proportion of all child deaths (thousands) 1301 691 13% 7%
Complementary feeding Zinc H influenzae vaccine
Antiseptic delivery Water, sanitation, hygiene
587 459 403
411 326
6% 5% 4%
4% 3%
Jones et al. How many deaths can we prevent this year? Lancet 2003
Potential for Community-Based and Outreach Delivery of Preventive Interventions to Achieve Effective Coverage and Mortality Impact Current benefits of immunizations, and potential for Hib, pneumococcal and rotavirus vaccines Substantial effects of ITMs, but coverage is still low Exclusive breastfeeding and complementary food quality can be improved by nutritional counseling Vitamin A supplementation successful, but needs to be sustained in routine health services Intrapartum and newborn care in home-based deliveries can be improved to reduce neonatal mortality Use of nevirapine to prevent MTCT of HIV needs to increase greatly
Schedule for Integrated Delivery of Preventive Interventions
Bryce et al, Lancet 2005
Potential Child Mortality Reduction from Therapeutic Interventions
Number
(thousands)
Treatment Intervention Oral rehydration therapy Antibiotics for neonatal sepsis
Deaths prevented as proportion of all child deaths 15% 6% 6% 5% 4% 5% 3%
1477 583 577 467 394 467 310
Antibiotics for pneumonia
Antimalarials Zinc for diarrhea Newborn resuscitation Antibiotics for dysentery
Jones et al. How many deaths can we prevent this year? Lancet 2003
Potential for Community-based Delivery of Therapeutic Interventions to Achieve Effective Coverage
ORT and zinc for diarrhea treats the episode and has preventive effect for 2-3 months Antimicrobials for malaria, dysentery, neonatal sepsis, and pneumonia need to be available close to home - C-B treatment of malaria reduced mortality by 40% in Ethiopia1 - C-B treatment of neonatal sepsis/ pneumonia reduced neonatal mortality by 59% in India2
1Kidane
et al, Lancet 2000; 2Bang et al, Lancet 1999
Percentage Reduction in Mortality by Community-Based Case Management of Pneumonia
Percentage Reduction
75
All cause
Pneumonia
50
In
Mortality
42 36
. 25
24
27
0 - 4 years
<1 month
Sazawal S, Black RE, Lancet Inf Dis 2003
Health and Nutrition Interventions at All Levels
Global (trade regulations, standards, resources) National (legislation) District and health system (supplies, training, supervision) Family and community (food distribution, access to services)
We Know Enough to Act Available, feasible interventions could prevent 6 million (63%) global child deaths if they reached all mothers and children. Cost of implementing these interventions would be $5 billion per year Extensive effort is needed and we must act now before more children die
Jones et al. How many deaths can we prevent this year? Lancet 2003 Bryce et al. Can the world afford to save the lives of 6 million children each year? Lancet 2005
