Under-5 deaths preventable

Report
Child
survival –
how many
deaths can
we
prevent?
Dr SK CHATURVEDI
Dr KANURPIYA
CHATURVEDI
2004.6.5
Child survival: focus
Issue
• Worldwide over 10 million children under 5 years of
age are dying each year.
• What interventions are appropriate for reducing
these deaths, and what would their impact be if full
coverage of the interventions were achieved?
• India contributes nearly 25% to the worldwide total
of under-5 deaths, so a major reduction by India
will have a major worldwide impact.
2004.6.5
Child survival – the Lancet approach
Review the state of evidence for interventions to reduce
mortality for each of the major direct and underlying
causes of death in children under five. Determine their
efficacy and apply to current situation to assess how
many under-5 deaths could be prevented.
 1st alternative – apply at regional level
 2nd alternative – apply at country level
 Compromise – apply to each of 42 countries
where 90% of worldwide under-5 deaths occur
2004.6.5
Child survival - interventions
• Focus on interventions addressing proximal
determinants of child mortality and those that can
be delivered mainly through the health sector.
• Take each of the main causes* of under-5 deaths
and examine the effectiveness of available
interventions for each cause of death
2004.6.5
* diarrhoea, pneumonia, measles, malaria, HIV/AIDS,
and the underlying causes of undernutrition for
deaths among under-5s, and asphyxia, preterm
delivery, sepsis, and tetanus for deaths among
neonates
Intervention search strategy
Estimates of effectiveness of interventions taken from:
•
either – published articles that summarized earlier
research results
•
or – systematic reviews by the authors and
participants in the Bellagio Child Survival Study
Group, together with input from other experts
Included search of MEDLINE, POPLINE, and other
databases, including the Cochrane database of
randomized controlled trials and the WHO
Reproductive Health Library
2004.6.5
Interventions – level of evidence
Each potential intervention was assigned to one of three
levels based on the strength of evidence for its effect on
under-5 mortality:
Level 1 – sufficient evidence – causal relationship between
intervention and reduction of under-5 mortality
established
Level 2 – limited evidence – effect is possible, but data not
sufficient to establish causal relationship
Level 3 – inadequate evidence - includes those that hold
promise of substantial effects on under-5 mortality
but have not yet been fully assessed (ex: rotavirus,
pneumo. vaccine, indoor air pollution)
Feasibility for delivery at high coverage levels is a central criterion for
any intervention intended to reduce child mortality. But what is
feasible varies widely among countries. Therefore the approach
focused on an essential set judged to be feasible for all countries.
2004.6.5
Interventions by cause - diarrhoea
Prevention
Treatment
Breastfeeding
Water/San/Hygiene
Exposure to
diarrhoea
Complementary feeding
Oral rehydration
therapy
Zinc
Vitamin A
Diarrhoea
Antibiotics for
dysentry
Zinc
Die
2004.6.5
Future: rotavirus vaccine
Survive
Interventions by cause - pneumonia
Treatment
Prevention
Breastfeeding
Exposure to
pneumonia
Complementary feeding
Zinc
Hib vaccine
Pneumonia
Antibiotics
Die
2004.6.5
Survive
Future: Pneumococcal vaccine, zinc for therapy,
reduction of indoor air pollution
Interventions, neonatal - infections
Prevention
Treatment
Clean delivery
Antibiotics for premature
rupture of membranes
Exposure to
infections
Breastfeeding
Severe bacterial
infection
Antibiotics for sepsis
Die
2004.6.5
Survive
Methods and assumptions
For India, and each of the other 42 countries,
how many deaths from a specific cause could
be prevented were calculated with present
coverage levels increased to universal coverage
(99%, except exclusive breastfeeding at 90%).
Three types:
Exclusive and continuing breastfeeding
Complementary feeding
All other interventions*
* Components: coverage (current and target), efficacy,
affected fraction or population, evidence level
2004.6.5
Current coverage – around 2000
Preventive intervention
Breastfeeding - months 6 to 11
Measles vaccine
Vitamin A
Clean delivery (skilled attendant at birth)
Tetanus toxoid
Clean water, sanitation, hygiene
Exclusive breastfeeding (first 6 months)
Nutrition - underweight, moderate and severe
Newborn temperature management
Antibiotics for premature rupture of membranes
Nivirapine and replacement feeding
Antenatal steroids
Insecticide-treated materials
Hib vaccine
Antimalarial - IPT in pregnancy
Zinc
2004.6.5
Complementary feeding
Coverage (in %)
Mean - 42
countries
Range
India
90
42-100
94
68
36-99
56
55
11-99
22
54
6-89
43
49
13-90
60
47
8-98
28
39
1-84
37
29
4-48
47
20
20
10
10
5
5
5
5
2
0-16
2
1
1
1
1
0
0
*
*
Current coverage – around 2000
Treatment intervention
Vitamin A
Antibiotics for pneumonia
Antibiotics for dysentery
Antimalarials
Oral rehydration therapy
Antibiotics for sepsis
Newborn resuscitation
Zinc
2004.6.5
* Same as for prevention
Coverage (in %)
Mean - 42
countries
Range India
55
**
22
40
40
30
30
29
3-66
11
20
4-50
7
10
10
3
3
0
0
Under-5 deaths preventable - results
Three types of results calculated:
 By individual interventions
 By specific causes
 By groups of interventions
2004.6.5
Under-5 deaths preventable through universal
coverage with individual interventions (2000)
India
Preventive intervention
Breastfeeding
Complementary feeding
Clean delivery
Hib vaccine
Clean water, sanitation, hygiene
Zinc
Vitamin A
Antenatal steroids
Newborn temperature management
Tetanus toxoid
Antibiotics for premature rupture of membranes
Measles vaccine
Nivirapine and replacement feeding
Insecticide-treated materials
Antimalarial
IPT in pregnancy
2004.6.5
Deaths
averted
(in '000s)
Percent (of
total deaths)
373
125
123
107
106
101
84
72
62
43
36
14
10
2
0
16%
5%
5%
4%
4%
4%
3%
3%
3%
2%
1%
1%
0%
0%
0%
Under-5 deaths preventable through universal coverage
with individual interventions (2000)
Percent
India
0%
Breastfeeding
Complementary feeding
Clean delivery
Hib vaccine
Clean water, sanitation, hygiene
Intervention
Zinc
Vitamin A
Antenatal steroids
Newborn temperature management
Tetanus toxoid
Antibiotics for PRM
Measles vaccine
Nivirapine and replacement feeding
Insecticide-treated materials
2004.6.5
Antimalarial IPT in pregnancy
2%
4%
6%
8% 10% 12% 14% 16% 18%
Under-5 deaths preventable through universal
coverage with individual interventions (2000)
India
Treatment intervention
Oral rehydration therapy
Antibiotics for sepsis
Antibiotics for pneumonia
Zinc
Newborn resuscitation
Antibiotics for dysentery
Vitamin A
Antimalarials
2004.6.5
Deaths
averted
(in '000s)
Percent (of
total deaths)
394
158
153
113
97
81
3
2
16%
7%
6%
5%
4%
3%
0%
0%
Interventions, neonatal - prematurity
Prevention
Treatment
Antibiotics for premature
rupture of membranes
Pregnant
Treated bednets &materials*
Intermittent preventive
therapy
Antinatal steroids
Premature
Newborn temperature
management
Die
2004.6.5
Survive
* Indoor residual spraying may be used as an alternative
Under-5 deaths from specific causes preventable
through listed interventions (2000)
India
Disease or condition
Diarrhoea
Pneumonia
Measles
Malaria
HIV/AIDS
Neonatal
Birth asphyxia
Prematurity
Severe infections
Tetanus
Other
Other
TOTAL
2004.6.5
Preventable under-five
deaths
Under-5 Percent of
deaths total under-5
(in '000s)
deaths
557
544
14
3
20
863
250
207
216
60
130
388
2402
23%
23%
1%
0%
1%
36%
10%
9%
9%
3%
5%
16%
100%
Number (in
'000s)
Percent
506
360
14
3
10
470
97
119
205
49
0
0
1362
91%
66%
100%
94%
48%
54%
39%
57%
95%
81%
0%
0%
57%
Under-5 deaths from specific causes preventable through
listed interventions – as percent of deaths by cause (2000)
India
100%
90%
80%
Percent
70%
60%
50%
40%
30%
20%
10%
2004.6.5
Cause
r
O
th
e
ta
l
N
eo
na
S
IV
/A
ID
H
M
al
ar
ia
es
M
ea
sl
ia
m
on
eu
Pn
D
ia
rrh
oe
a
0%
Under-5 deaths from specific causes preventable through
listed interventions – as percent of total deaths (2000)
India
25%
Percent
20%
15%
10%
5%
2004.6.5
Cause
er
th
O
ta
l
na
eo
N
H
IV
/
AI
D
S
ia
M
al
ar
s
sl
e
M
ea
on
um
Pn
e
D
ia
rrh
oe
a
ia
0%
Under-5 deaths preventable with specific
groups of interventions (2000)
India
Group Interventions in group
Health type grouping
Nutrition
Breastfeeding, complementary feeding, vitamin A and
zinc
Deaths
averted Percent (of
(in '000s) total deaths)
599
25%
730
30%
Case management
ORT, antibiotics (diarrhea, pneumonia, neonatal
sepsis) and antimalarials
2004.6.5
Under-5 deaths preventable with specific
groups of interventions (2000)
India
Group Interventions in group
Location grouping
Health facility centric
Antenatal steroids, temperature management,
antibiotics-PRM, antibiotics-pneu, antibioticssepsis, rescusitation, antibiotics-dys, zinc-T and
vitA-T
Deaths
averted Percent (of
(in '000s) total deaths)
713
30%
345
14%
757
32%
Health facility outreach
Zinc, Hib vaccine, vitA, tetanus toxoid,
nivirapine, clean delivery, measles, IPT and
antimalarials
Home care
Breastfeeding, complementary feeding, ITM and
ORT
2004.6.5
Further deaths that could be prevented
Four reasons why these estimates of preventable
under-5 deaths are conservative:
– Only interventions for which cause-specific
evidence of effect was available were included
(evidence levels 1 and 2)
– Restricted to interventions that are feasible at high
coverage in low-income countries
– Excluded promising interventions that are currently
being assessed (e.g. rotavirus)
– Limited to interventions that address the major
causes of child death and selected underlying
causes (e.g. did not include anaemia)
2004.6.5
Conclusions on under-5 deaths that
could be prevented in India
• Full coverage of listed interventions is
estimated to result in a 57% reduction in
under-5 deaths in India
• This is a conservative estimate for
reasons given in previous slide
Next steps  Review interventions in Indian
context, identify any changes, with
supporting evidence, and reassess
impact on reduction of under-5
deaths
2004.6.5

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