GH 101 Module 8

Ten Leading Causes of Under-5 Deaths by World Bank Region, for High-Income Countries, and Globally, 2010

East Asia & Pacific Europe & Central Asia Carribean Middle East & North Africa 1. Preterm birth 1. Lower respiratory 1. Preterm birth 1. Preterm birth complications infections complications complications 2. Lower respiratory 2. Congenital anomalies 2. Congenital anomalies 2. Congenital anomalies infections 3. Neonatal 3. Preterm birth 3. Lower respiratory 3. Lower respiratory enceophalopathy complications infections infections 4. Congential anomalies 4. Neonatal encephalopathy 4. Neonatal encephalopathy 4. Diarrheal diseases 5. Diarrheal diseases 5. Diarrheal diseases 5. Neonatal sepsis 5. Neonatal sepsis 6. Neonatal sepsis 6. Neonatal sepsis 6. Diarrheal diseases 6. Neonatal encephalopathy 7. Drowning 7. Meningitis 7. Forces of nature 7. Protein-energy malnutrition 8. Meningitis 8. Drowning 8. Protein-energy 8. Road injury malnutrition 9. Road injury 9. Stroke 9. Meningitis 9. Meningitis 10. Measles 10. SIDS 10. Road injury 10. Other cardiovascular and circulatory causes South Asia Sub-Saharan Africa High-Income Countries Global 1. Preterm birth 1. Malaria 1. Preterm birth 1. Preterm birth complications complications complications 2. Lower respiratory 2. Lower respiratory 2. Congenital anomalies 2. Lower respiratory infections infections infections 3. Diarrheal diseases 3. Diarrheal diseases 3. Neonatal encephalopathy 3. Malaria 4. Neonatal sepsis 4. Preterm birth 4. SIDS 4. Diarrheal diseases complications 5. Neonatal encephalopathy 5. Neonatal sepsis 5. Neonatal sepsis 5. Neonatal sepsis 6. Congenital anomalies 6. Protein-energy 6. Lower respiratory 6. Neonatal encephalopathy malnutrition infections 7. Meningitis 7. Neonatal encephalopathy 7. Road injury 7. Congenital anomalies 8. Protein-energy 8. Meningitis 8. Drowning 8. Protein-energy malnutrition malnutrition 9. Measles 9. HIV/AIDS 9. Interpersonal violence 9. Meningitis 10. Encephalitis 10. Congenital anomalies 10. Meningitis 10. HIV/AIDS

Selected Measures to Reduce Intimate Partner Violence

Prevention and education campaigns to increase awareness of intimate partner violence and change cultural norms about violence against women Treatment for those who engage in intimate partner violence Programs to strengthen ties to family and jobs Couples counseling Shelters and crisis centers for battered women Mandatory arrest for offenders

Basic care packages for pregnancy at the primary level

Routine Prenatal Care Clinical examination Obstetric and gynecological examination Urine test Laboratory tests: hemoglobin, blood type and rhesus status, syphilis and other symptomatic testing for sexually transmitted diseases Advice on emergencies, delivery, lactation, and contraception Education Iron and folic acid supplementation Tetanus toxoid immunization Screening and treatment for syphilis Delivery Care Clean delivery technique, clean cord cutting, clean delivery of baby and placenta Active management of the third stage of labor Episiotomy in appropriate cases Recognition and first-line management of delivery complications Intravenous fluid Intravenous uterotonics, if bleeding occurs Partograph Essential newborn care Intravenous antibiotics

Reducing Maternal Mortality in Tamil Nadu, India

-Maternal mortality attributed to three delays, poverty, and sex-selective mortality. -To revamp its health care system Tamil Nadu sate government made policies aimed to preventing and terminating unwanted pregnancies, provide greater access to obstetric care at primary level, policies seek to provide access to emergency obstetric care at first referral level -Increased availability and accessibility to family planning -ambulance service -creation of 62 health centers -Women are getting pregnant less frequently and later in life due to greater use of family planning -Challenges: high incidence of stillborn babies, closing regional disparities, expanding access to emergency care facilities, and targeting urban health issues.

Addressing Female Genital Mutilation in Senegal

-Tostan is a U.S. based nongovernmental organization dedicated to community led development in Africa -Uses Community Empowerment Program (CEP), a 30 months education program that consists of two parts: Kobi sessions on democracy, human rights, and problem solving and later covers health topics including hygiene vaccinations, mental and physical development, the reproductive services, STIs, HIV, and risks involving FGM and forced child marriage. Awade which focuses on economic empowerment. -"Organized diffusion" model- participants directly involved in CEP share their knowledge with others. Participants "adopt" others to teach -It's mission is not to eradicate FGM, but to educate participants about human rights and responsibilities so that the may become empowered within their communities. -Feedback from participants is crucial-able to adapt and understand local conditions -villages in which Tostan is directly or indirectly involved have have experienced significantly reduces FGM rates.

Reducing Fertility in Bangladesh

-launched a program to reduce national birth rate -(1) young women were trained at outreach workers to visit and offer info on contraceptive services. Virtually all Bangladeshi women were contacted by family welfare assistants (FWA) (2) family planning methods (3) clinics in rural areas (4) Information, education, and communication (ex. persuade men to talk to women about using contraceptives and informative soap opera) -contraceptive use went from 8% to 50%, fertility declined, increased education and employment opportunities for women -Data provided by Matlab center helped to constantly identify problems

Maternal Mortality in Sri Lanka

First, Sri Lanka improved access to health services. Second, as early as the 1940s, Sri Lanka introduced policies to expand the number of midwives, who were the frontline workers dealing with pregnant women and child- birth. Another step that Sri Lanka took to reduce maternal deaths was to make use of its civil registration data to identify what areas of the country had the most significant problems with maternal mortality. At the same time, the government made consider- able progress in other health areas.

Countries throughout the world progressively adopted EPI until the 1980s when the program became universal. When EPI was created in 1974, WHO established a stan- dardized vaccine schedule that included four vaccines: Bacil- lus Calmette-Guérin (BCG), diphtheria-tetanus-pertussis (DTP), oral polio (OPV), and measles. For the first 20 to 30 years after EPI was created, global immunization efforts consistently included these four vaccines. Starting around the year 2000, however, scientific advances in the vaccines them- selves and in logistics and storage, combined with a renewed global commitment to immunization, began to increase the number of introductions of new and underused vaccines (NUVIs), even in low- and middle-income countries.41 Thus, EPI added hepatitis B (HepB), yellow fever in countries endemic for the disease, and Haemophilus influenzae b (Hib) vaccine to its recommended list of vaccines.

From the beginning of EPI, it was clear that the costs associated with national immunization programs would be prohibitive for some countries.37,42 In 1977, therefore, the Pan American Health Organization (PAHO) created the PAHO Revolving Fund for Vaccine Procurement. This fund, which pooled the resources of 41 countries, allowed those countries to bargain as a group to buy large quantities of high-quality vaccines, syringes, and related supplies at the lowest possible price and then distribute them among the individual coun- tries. This purchasing system helped enable the vaccination of tens of millions of children in the Americas and avert mil- lions of deaths from vaccine-preventable disease. In addition, it made it possible for the Region of the Americas to become the first of the six WHO regions to eliminate polio and the only region to eliminate indigenous transmission of measles and rubella.43 The fund promotes self-sufficiency by using economies of scale to bring prices down to affordable levels. Today PAHO member states cover 95 percent of vaccination costs from their own national budgets.

Key Links Between Child Health and the MDGs

Goal 1: Eradicate Extreme Hunger and Poverty Link: More than 50 percent of child deaths worldwide are associated with malnutrition. Goal 2: Achieve Universal Primary Education Link: Enrollment, attendance, and performance of children in schools is closely linked with their health. Goal 3: Promote Gender Equality and Empower Women Link: Empowering women will enhance their health, their education, and their ability to raise healthier children. Goal 4: Reduce Child Mortality Link: This is directly related to child health. Goal 5: Improve Maternal Health Link: Maternal health is a major predictor of the birthweight of a child and the child's subsequent health and survival prospects. Goal 6: Combat HIV/AIDS, Malaria, and Other Diseases Link: HIV/AIDS and malaria are major killers of young children. Goal 7: Ensure Environmental Sustainability Link: An important share of childhood illnesses and deaths are related to unsafe water and poor sanitation. Indoor air pollution is also very detrimental to the health of children.

Key Links Between Nutrition and the MDGs

Goal 1: Eradicate Poverty and Hunger Link: Poor nutritional status is both a cause and a consequence of poverty. Improving income and nutritional status will improve health status. Goal 2: Achieve Universal Primary Education Link: Children who are properly nourished enroll in school at higher rates than undernourished children, attend school for more years, and perform better while they are there than undernourished children. Goal 3: Promote Gender Equality and Empower Women Link: Women suffer very high rates of some nutritional deficiencies, such as iron deficiency anemia, that constrain their health and their productivity. Overweight and obesity are also associated with diseases that can constrain the productivity of females. Improving the nutritional status of women will enhance their income earning potential and ability to be more productive in all of their work. Goal 4: Reduce Child Mortality Link: About 45 percent of all child deaths worldwide are associated with malnutrition. It will not be possible to make major strides in reducing child mortality without significant improvements in the nutritional status of young children. Goal 5: Improve Maternal Health Link: Maternal health and pregnancy outcomes for women and for children are intimately connected to the nutritional status of the pregnant women. Some problems arise from nutritional deficits. Others are linked to overweight and obesity. Goal 6: Combat HIV/AIDS, Malaria, and Other Diseases Link: Poor nutritional status makes people more susceptible to illness and to being sick for longer periods of time. Good nutrition is especially important for people suffering from some health conditions, such as tuberculosis and HIV/AIDS.

Reducing Child Mortality in Nepal Through Vitamin A

Intervention Prior to the late 1980s, it was widely held that micronutrient deficiencies were a result of diarrhea and other infant ill- nesses, rather than a cause of them. Yet, as early as the 1970s, Alfred Sommer noticed in conjunction with studies in Indo- nesia that vitamin A deficiency appeared to be linked with child death. A later randomized controlled trial conducted in Nepal by Keith West and Sommer indicated that periodic vitamin A delivery could reduce mortality in children ages 6 to 60 months by as much as 30 percent.109 In light of these research findings and Nepal's exces- sive infant mortality rate, the Nepalese Ministry of Health initiated a plan of action on vitamin A in 1992. The ministry worked closely with other government agencies and NGOs to develop a pilot program to deliver vitamin A capsules throughout Nepal. A technical assistance group was created to assist the health ministry in running the program. His Majesty, the King of Nepal, also demonstrated long-term commitment to this effort by incorporating Nepal's National Vitamin A Program into the Ten Year National Program of Action. This program aimed to reduce child morbidity and mor- tality by prophylactic supplementation of high-dose vitamin A capsules to children 6 to 60 months of age, twice each year; the treatment of xerophthalmia, severe malnutrition, and prolonged diarrhea; and the promotion of behavior change to increase dietary intake of vitamin A and promote exclusive breastfeeding for the first 6 months of a baby's life. The action plan on vitamin A focused on expanding the intervention in phases as Nepal's administrative capacity for the program was strengthened. The program was expanded to 32 priority districts at a rate of eight districts per year over 4 years. From 1993 to 2001, the program was brought to Nepal's remaining 43 districts. Children and new mothers in districts where the National Vitamin A Program was not yet established received one dose of vitamin A as part of national immunization campaigns. Once the National Vitamin A Program was operating in their district, the children received vitamin A supplementation twice a year. Nepal's public health system faced severe problems at the time the vitamin A program was developed, from low utiliza- tion rates by people who had no confidence in the system to absenteeism by health workers. Consequently, the vitamin A intervention was revised to build upon and improve the exist- ing networks of female community health volunteers (FCHVs) who helped deliver primary health care and family planning services to the villages of Nepal. Before the intervention, there were 24,000 FCHVs throughout 58 districts. However, many were not respected in their communities and had little incen- tive to remain committed to volunteering. The leader of the program's technical assistance group, Ram Shrestha, changed the way FCHVs were viewed by communities and themselves by focusing on notions of respect, recognition, and opportu- nity. Shrestha challenged deeply rooted gender biases by giving women responsibilities valued by their families and communi- ties and the opportunity to make a difference. A few years later, the number of FCHVs had more than doubled to 49,000 strong, and they were able to reach 3.7 mil- lion children twice a year with vitamin A capsules. By directly administering the capsules, the FCHVs served as a critical bridge between the public health sector and the community. Families were urged to bring their children to the distribution site, and many government sectors began to integrate mes- sages about the importance of vitamin A into their programs.

Today, there remain a number of critical challenges to uni- versal childhood immunization. These challenges center on healthcare infrastructure and human resources, demand, supply, and financing. Low- and middle-income countries often do not have the healthcare infrastructure or human resources necessary to run a successful national immuniza- tion program on their own. In addition, lack of demand for immunization due to lack of information or traditional anti-vaccine beliefs is a significant impediment to universal immunization. Once demand has been stimulated, national immunization programs must be able to procure the neces- sary number of doses at an affordable price and on a predict- able basis to ensure that children can be fully vaccinated according to recommended schedules. This requires an ade- quate supply provided at an affordable cost to the purchasing country. There are also challenges associated with financing these programs. A number of low-income countries will not have the resources needed in the short to medium run to finance effective immunization programs solely from their own funds. For these countries, universal immunization will require a combination of country-level action and support from public and private organizations, domestically and internationally.

Lack of infrastructure and human resources. Low-income countries often lack the most basic healthcare facilities and infrastructure. Delivering routine immunization services where the healthcare infrastructure is fragile or nonexistent is a major hurdle for many low-income countries. Although brick-and-mortar medical facilities may not be necessary to implement an immunization program, there must be a means by which to safely stockpile doses and transport them to the target population, as well as a reliable and accurate method for recording who has received vaccines and when. As new vaccines are introduced and scaled up, surveillance is needed to monitor outcomes and watch for changes in the epidemiol- ogy and disease characteristics.66

The Global Polio Eradication Initiative

Largest public-private partnership and largest-ever internationally-coordinated public health effort in history. Spearheaded by governments, WHO, Rotary International, the CDC and UNICEF, supported by key partners such as the Bill and Melinda Gates Foundation. Global network of more than 20 million volunteers worldwide who have collectively immunized more than 2.5 billion children over the past 20 years.

Next-Generation Vaccines and Vaccine Delivery With the cooperation and support of organizations like Gavi, PATH, WHO, individual country donors, and the pharmaceutical industry, new vaccines and new vaccine delivery systems are currently being developed and tested. WHO anticipates that new vaccines against cholera, dengue, malaria, polio, and typhoid will be introduced during the Decade of Vaccines, which began in 2010.51,64 In addition, research is under way to develop new vaccine formulations that are safer, easier to store and transport due to thermo- stability, and packaged in smaller vials to decrease waste.73 An international cholera vaccine stockpile has been cre- ated, and discussions are under way to determine how best to distribute the vaccines.55 Although there is currently no commercially available vaccine that protects against dengue, researchers predict that such a vaccine will reach the market in the next several years and that coverage of the new vaccine will rise to 49 percent by 2020.64

One of the most important recent developments in vaccine-preventable diseases relates to typhoid. Typhoid fever is caused by the salmonella typhi bacterium, and exposure usually occurs through ingestion of contaminated food or water. There are an estimated 21 million typhoid cases and between 216,000 and 600,000 typhoid-related deaths each year.74 Existing vaccines do not provide long-term protection and are not safe for use among children under 2 years of age, when the disease is most lethal.75 In fact, earlier vaccines were not approved for use among children under 5 years.76 In 2013, Bharat Biotech, an Indian company, launched the first typhoid conjugate vaccine that has been clinically proven to provide long-term protection to adults and infants over 6 months of age.77 Prices for the new vaccine are not yet available.

Measles—Progress and Challenges

Progress Against Measles—But Large Challenges Remain There has been substantial progress against measles in the last decade, with measles deaths falling globally from 548,000 in 2000 to 158,000 in 2011.95 Nonetheless, measles remains the 12th largest killer of children under 5 years of age globally.96 In addition, measles is still a top 10 cause of death for chil- dren under 5 in South Asia and Southeast Asia.96 Moreover, in 2012, 15 countries had large measles outbreaks, including countries in Europe, Africa, South Asia, and Southeast Asia.95 This brief discusses what measles is, the vaccine against it, trends in the burden of disease, global goals, and the barriers the world faces in trying to address measles. The Measles Virus Measles is a highly contagious viral disease. In the absence of being vaccinated, almost anyone exposed to the virus will contract measles. The measles virus typically grows in the cells that line the back of the throat and lungs.16 The virus that causes measles is transmitted by coughing and sneezing, as well as by close contact with infected nasal or throat secre- tions.16 The virus continues to be active and contagious in the air or on infected surfaces for up to 2 hours.16 It can be trans- mitted by an infected person from 4 days before symptoms start to occur to 4 days after the onset of symptoms. The first sign of measles is usually high fever, which begins about 10 to 12 days after exposure to the virus.16 In the initial stage of the virus, the symptoms include a runny nose, a cough, red and watery eyes, and small white spots inside the cheeks.16 A rash will appear about 14 days after exposure to the virus and will last about 5 to 6 days.16 The greatest risk of a severe reaction to measles is among poorly nourished young children, children with insufficient vitamin A, or those whose immune systems have been weakened by HIV/AIDS or other diseases.16 The Measles Vaccine The measles vaccine is safe, effective, and inexpensive—it costs less than $1.00 to purchase and deliver95 in low-income countries. The measles vaccine is often combined with a rubella vaccine, with the result known as "MR" vaccine. WHO recommends that each child receive two doses of the vaccine to ensure immunity and to prevent further out- breaks.16 In countries where there is ongoing transmission of measles, WHO recommends the first dose be given to children when they are 9 months of age.97 The second dose can be given through routine immunization programs or supplementary immunization.98 Even with only one dose of the vaccine, however, there is an 85 percent chance that the child will develop immunity to the measles virus.16

Tamil Nadu State, India Background The Tamil Nadu Integrated Nutrition Project in India is one of the most important efforts ever undertaken to improve nutritional status on a large scale. This project began in 1980 in the South Indian state of Tamil Nadu. It aimed at improving the nutritional status of poor women and children in the rural areas of the state through a set of well-focused interventions.

The Intervention In line with this approach, the project included a package of services that were delivered by health and nutrition work- ers that consisted of nutrition education, primary health care, supplementary on-site feeding for children who were not growing properly, vitamin A supplementation, periodic deworming, education of mothers for managing childhood diarrhea, and the supplementary feeding of a small number of women. An important innovation of the project was that it used growth monitoring of the children as a device for mobilizing community action. Groups of mothers met regularly to weigh their young children. They then plotted their weight-for-age on a growth chart. Together with the community nutrition worker, they identified which children were not growing properly.

To address gaps in supply, Gavi has developed an immunization supply chain strategy and has identified supply chain design and optimization as a priority for country-level funding.83 In addition, WHO and UNICEF have developed an initiative to create supply chain hubs.83 Supply-related challenges are also being addressed through advances such as the development of the pentavalent vaccine, which minimizes the number of vaccines and vac- cine doses necessary to fully immunize a child.

Thus, after a vaccine has been proven safe and effective, it has generally taken 15 to 20 years for it to be widely distributed among poor populations in low- and middle-income countries. To break this cycle in the case of pneumococcal vaccine, Gavi has funded the Pneu- mococcal Accelerated Development and Introduction Plan (pneumoADIP). Due to this program, the pneumococcal vaccine was introduced in low-income countries just 1 year after it was first introduced in high-income countries.51