2004.6.5

Childsurvival – how many deaths can we prevent?

Dr SK CHATURVEDI

Dr KANURPIYA CHATURVEDI

2004.6.5

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?

Child survival: focus

• 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

* 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

2004.6.5

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 evidenceEach potential intervention was assigned to one of three levels based on the strength of evidence for its effect on under-5 mortality:

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.

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)

2004.6.5

Interventions by cause - diarrhoea

Exposure to diarrhoea

Diarrhoea

SurviveDie

Breastfeeding

Complementary feeding

Treatment

Zinc

Future: rotavirus vaccine

Vitamin AAntibiotics for dysentry

Oral rehydration therapy

Zinc

Water/San/Hygiene

Prevention

2004.6.5

Interventions by cause - pneumonia

Exposure to pneumonia

Pneumonia

SurviveDie

Hib vaccine

Complementary feeding

Antibiotics

Prevention Treatment

Future: Pneumococcal vaccine, zinc for therapy, reduction of indoor air pollution

Breastfeeding

Zinc

2004.6.5

Interventions, neonatal - infections

Exposure to infections

Severe bacterial infection

SurviveDie

Breastfeeding

Antibiotics for sepsis

Prevention TreatmentClean delivery

Antibiotics for premature rupture of membranes

2004.6.5

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 interventionMean - 42 countries Range India

Breastfeeding - months 6 to 11 90 42-100 94Measles vaccine 68 36-99 56Vitamin A 55 11-99 22Clean delivery (skilled attendant at birth) 54 6-89 43Tetanus toxoid 49 13-90 60Clean water, sanitation, hygiene 47 8-98 28Exclusive breastfeeding (first 6 months) 39 1-84 37Nutrition - underweight, moderate and severe 29 4-48 47Newborn temperature management 20 - 20Antibiotics for premature rupture of membranes 10 - 10Nivirapine and replacement feeding 5 - 5Antenatal steroids 5 - 5Insecticide-treated materials 2 0-16 2Hib vaccine 1 - 1Antimalarial - IPT in pregnancy 1 - 1Zinc 0 - 0Complementary feeding * *

Coverage (in %)

2004.6.5

Current coverage – around 2000

* Same as for prevention

Treatment interventionMean - 42 countries Range India

Vitamin A 55 ** 22Antibiotics for pneumonia 40 - 40Antibiotics for dysentery 30 - 30Antimalarials 29 3-66 11Oral rehydration therapy 20 4-50 7Antibiotics for sepsis 10 - 10Newborn resuscitation 3 - 3Zinc 0 - 0

Coverage (in %)

2004.6.5

Under-5 deaths preventable - results

Three types of results calculated:

By individual interventions

By specific causes

By groups of interventions

2004.6.5

Preventive intervention

Deaths averted

(in '000s)Percent (of

total deaths)

Breastfeeding 373 16%Complementary feeding 125 5%Clean delivery 123 5%Hib vaccine 107 4%Clean water, sanitation, hygiene 106 4%Zinc 101 4%Vitamin A 84 3%Antenatal steroids 72 3%Newborn temperature management 62 3%Tetanus toxoid 43 2%Antibiotics for premature rupture of membranes 36 1%Measles vaccine 14 1%Nivirapine and replacement feeding 10 0%Insecticide-treated materials 2 0%Antimalarial IPT in pregnancy 0 0%

Under-5 deaths preventable through universal coverage with individual interventions (2000)

India

2004.6.5

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

Breastfeeding

Complementary feeding

Clean delivery

Hib vaccine

Clean water, sanitation, hygiene

Zinc

Vitamin A

Antenatal steroids

Newborn temperature management

Tetanus toxoid

Antibiotics for PRM

Measles vaccine

Nivirapine and replacement feeding

Insecticide-treated materials

Antimalarial IPT in pregnancy

Inte

rven

tion

Percent

Under-5 deaths preventable through universal coverage with individual interventions (2000)

India

2004.6.5

Under-5 deaths preventable through universal coverage with individual interventions (2000)

Treatment intervention

Deaths averted

(in '000s)Percent (of

total deaths)

Oral rehydration therapy 394 16%Antibiotics for sepsis 158 7%Antibiotics for pneumonia 153 6%Zinc 113 5%Newborn resuscitation 97 4%Antibiotics for dysentery 81 3%Vitamin A 3 0%Antimalarials 2 0%

India

2004.6.5

Interventions, neonatal - prematurity

Pregnant

Premature

SurviveDie

Treated bednets &materials*Intermittent preventive therapy

Newborn temperature management

Prevention Treatment

Antinatal steroids

Antibiotics for premature rupture of membranes

* Indoor residual spraying may be used as an alternative

2004.6.5

Under-5 deaths from specific causes preventable through listed interventions (2000)

Disease or condition

Under-5 deaths

(in '000s)

Percent of total under-5

deathsNumber (in

'000s) Percent

Diarrhoea 557 23% 506 91%Pneumonia 544 23% 360 66%Measles 14 1% 14 100%Malaria 3 0% 3 94%HIV/AIDS 20 1% 10 48%Neonatal 863 36% 470 54%

Birth asphyxia 250 10% 97 39%Prematurity 207 9% 119 57%Severe infections 216 9% 205 95%Tetanus 60 3% 49 81%Other 130 5% 0 0%

Other 388 16% 0 0%TOTAL 2402 100% 1362 57%

Preventable under-five deaths

India

2004.6.5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Diarrh

oea

Pneum

onia

Mea

sles

Mala

ria

HIV/A

IDS

Neona

tal

Other

Cause

Per

cent

Under-5 deaths from specific causes preventable through listed interventions – as percent of deaths by cause (2000)

India

2004.6.5

0%

5%

10%

15%

20%

25%

Diarrh

oea

Pneum

onia

Mea

sles

Mala

ria

HIV/A

IDS

Neona

tal

Other

Cause

Per

cent

Under-5 deaths from specific causes preventable through listed interventions – as percent of total deaths (2000)

India

2004.6.5

Under-5 deaths preventable with specific groups of interventions (2000)

India

Group Interventions in group

Deaths averted

(in '000s)Percent (of

total deaths)

Health type groupingNutrition

Breastfeeding, complementary feeding, vitamin A and zinc 599 25%

Case management

ORT, antibiotics (diarrhea, pneumonia, neonatal sepsis) and antimalarials 730 30%

2004.6.5

Under-5 deaths preventable with specific groups of interventions (2000)

India

Group Interventions in group

Deaths averted

(in '000s)Percent (of

total deaths)

Location groupingHealth facility centric

Antenatal steroids, temperature management, antibiotics-PRM, antibiotics-pneu, antibiotics-sepsis, rescusitation, antibiotics-dys, zinc-T and vitA-T 713 30%

Health facility outreach

Zinc, Hib vaccine, vitA, tetanus toxoid, nivirapine, clean delivery, measles, IPT and antimalarials 345 14%

Home careBreastfeeding, complementary feeding, ITM and ORT 757 32%

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