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