Childhood Diseases Workgroup

1
Childhood Diseases Workgroup

• Malnutrition, Final Report David Sanders Louis
  Reynolds
• Low Birth Weight Phumza Nongena Tharina van
  Heerden
• HIV/AIDS Brian Eley and Max Kroon
• ARI Heather Zar Mary-Ann Davies
• Diarrhoea Tony Westwood
• with advice from George Swingler

2
Overview of Presentation

• Contribution of Child Mortality to BoD
• Human rights and SAs commitments
• Burden of young child mortality in W Cape
• Major determinants of young child BoD in W Cape
• Key interventions to address young child BoD in W
  Cape
• Inequities between BoD and resource allocation
• Lessons from international experience
• Recommended PHC and Social interventions

3
'Gastro-tsunami' 2007

• RXH admissions in Feb highest for gt decade
• Costly in terms of finance, staff, general
  standard of care
• HHH experienced the same problem
• Overwhelmingly from informal settlements
• TBH lower rate of increase predominantly
  formal housing in drainage area

4
'Gastro-tsunami' 2007

• Overall Hospital Occupancy at RCCH rose to 91 in
  March 2007, the highest recorded in recent years.
  
• It is clear that in 2007 preventive efforts
  surrounding diarrhoea in the Metro district were
  inadequate and too late. The unprecedented size
  of the epidemic would have been somewhat
  mitigated if community based work and
  communication strategies had been implemented in
  a more coordinated fashion.
• It is strongly recommended that the partner
  departments identified by the Burden of Disease
  project be brought on board early in the planning
  i.e. DWAF and City for water and sanitation areas
  identified in 2005/6.

Prof A Westwood, Clinical Co-ordinator, Child
Health Services,PGWC, June 2007
5
Where to focus?
CONTRIBUTOR TO THE BURDEN OF DISEASE MEASURED AS PREMATURE MORTALITY ( YLL)
HIV/AIDS/ TB 22.0
Homicide/Violence/Road Traffic Accidents 19.8
Mental disorders 0 but high morbidity burden
Ischaemic Heart Disease/Stroke 10.5
Childhood diseases 6.0 minimum
Total 58.3
6
Health an 'investment' or a human right?

• DALYs undervalue childrens lives
• They incorporate questionable assumptions about
  the value of life
• They assign different values to years of life
  lost at different ages
• zero at birth
• peak at age 25
• declines with increasing age
• The young, the elderly, and disabled people are
  less likely to contribute to society in economic
  terms
• Fewer DALYs will be saved by health interventions
  which address their ills
• Therefore such interventions are less deserving
  of public support

7
Caring for childrenWhich values goals do we
share?

• National
• Constitution
• UNCRC
• MDGs
• Provincial
• 2010
• Institutional
• Patient related
• Staff related
• Community related

8
The challenge of MDG 4
9
Age distribution of deaths, Western Cape, 2000

• The great majority occur in infancy (under one
  year of age) and 1-4 age group
• U-5 deaths account for a significant percentage
  of all deaths
• Mainly due to communicable diseases and
  malnutrition

10
IMR in Cape Town 2001 - 2004
IMR per 1000 live births by sub district, Cape
Town 2001 - 2004
Substantial numbers dieoutside health facilities
11
Causes risk factors
12
Leading causes of U5MR, WC 2000
Bradshaw, et al. SOUTH AFRICAN NATIONAL BURDEN OF
DISEASE STUDY WESTERN CAPE PROVINCE. ESTIMATES OF
PROVINCIAL MORTALITY 2000
13
Leading causes of U5MR, SA 2000
Direct/non-synergistic
Bradshaw D, Bourne D, Nannan N. MRC Policy Brief
No3, 2003
14
Children under 5 Nutritional Status

• Overall, 12 percent of children are underweight,
  27 percent are stunted and 5 percent are wasted
  (DHS 2003).
• There are no indications that the nutritional
  status of children has changed substantially over
  the past 10 years.

15
Malnutrition in W Cape urban infants

• 15 percent of Western Cape children were stunted
• Cross-sectional study in disadvantaged WC urban
  black and 'coloured' communities
• coloured infants 18 stunted and 7 underweight
• black infants 8 stunted and 2 underweight
• micronutrient intake lower in black infants than
  in coloured infants
• Anaemia 64 of coloured and 83 of black infants
• Zinc deficiency 35 of coloured and 33 of
  black infants
• Vitamin A deficiency 2 of coloured infants
  23 of black infants
• Overall 6 of coloured infants 42 of black
  infants were deficient in two or more
  micronutrients

NFCS,1999 Oelofse A et al 2002
16
Conceptual framework of causality
17
Nutrition and Dietary Intake
The National Food Consumption Survey (1999)
showed that in a large national sample of
children aged 1-3 45 received less than
two-thirds of their daily energy requirements 80
received less than two-thirds of their daily iron
requirements 65 received less than two-thirds of
their daily Vitamin A requirements
18
Benefits of Breast Feeding

• Exclusive breastfeeding (ie giving nothing but
  breastmilk to the infant) reduces under-five
  mortality by 13 percent (Jones et al., 2003).
• Compared with infants who are exclusively
  breastfed, infants aged 0-5 months who are not
  breastfed have six-fold and two-and-a-half-fold
  increased risks of death from diarrhea and
  pneumonia respectively (WHO Collaborative Study
  Team, 2000).

19
Duration of breast feeding

• The Western Cape has the shortest median duration
  of breast feeding
• median duration of breastfeeding in South Africa
  varies
• 10 months in the Western Cape
• 20 months in the Northern Province
• other provinces 14-17 months
• The duration of breastfeeding varies widely
  according to population group
• African 17 months
• Coloured 11 months
• Asian 5 months
• White less than 1 month

SADHS 1998
20
Children under 5Height-for-age percentage below
-2 SD


DHS 2003
21
Malnutrition household expenditure SA
Zere McIntyre 2003
22
(No Transcript)
23
The impact burden of ARI

• Global 1.9 million under-5 deaths each year
• SA 6110 under-5 deaths in 2000 5.8 of U-5MR
• ARI increases mortality of associated conditions
• 30 - 40 of hospital admissions
• Case-fatality rate 15 - 28
• Impact of HIV/AIDS on ARI
• Increases case fatality rate 3 - 6 times
• Changes spectrum of pathogens PCP c
• Increases complexity of case management
• Prolongs hospitalization

24
Conceptual framework for ARI
Conceptualframeworks forMalnutrition other
conditions
Modified from Davies Zar, 2007. Acute
Respiratory InfectionW Cape BoD Workgroup
25
Risk factors for Low Birth Weight

• Risk-taking behaviour and substance abuse
• Drinking alcohol during pregnancy
• Smoking during pregnancy
• Illicit drugs
• Physical labour
• Obstetric
• Poor family spacing, inadequate ANC
• HIV infection
• Poverty

26
Risk factors for diarrhoea

• immediate determinants
• breast-feeding and care-giving practices
• underlying determinants
• malnutrition
• quality of health services including prenatal
  care
• environmental services including water supply,
• sanitation and hygiene
• handwashing with soap.
• basic determinants
• Maternal education
• Poor socioeconomic status

27
Khayelitsha as example

• Khayelitsha 2003
• Almost 30 of residents did not have easy access
  to water and 80 lived in shacks
• 14 521 households did not have access to water
  while the sanitation backlog was around 29 811
  households
• There were an average of 105 people per toilet in
  Sites B and C
• One toilet per seven households where toilets had
  been provided
• In other areas there were none

Anso Thom, 2006. Widening gulf between
Khayelitsha and Cape Town. Health-e,
28/2/2006Stern R, Scott V, 2005. Research
action to address inequities Cape Town Equity
Gauge, City of Cape Town 2003/4..
28
Risk factors for vertical transmission of HIV

• Immediate
• under-utilisation of Family Planning Services
• late or no booking for ante-natal care
• poor uptake of HIV testing.
• Ill-considered and unsafe infant feeding policy
• Sub-optimal choice of ARV regimens
• Underlying Basic
• as in generalised HIV epidemic

29
Interventions
30
Interventions to improve immunity

• Promote breast feeding -
• Maternity leave, BF
• time at work
• Incentives equivalent to formula
• Counsellors
• Mixed feeding out
• Nutrition programmes
• INP
• CBNP incl GMP
• Micronutrients, esp Vit A
• Improved PSNP
• Appropriate complementary feeding
• Immunisation coverage
• Extend EPI through increased community coverage
• Pneumococcal vaccine?

31
Interventions to reduce exposure

• PMTCT
• EBF, rapid deployment of new mid-level
  community workers
• Smoking alcohol control programmes, incl
  pricing legislation
• Control indoor and outdoor air pollution
• Insulation electrification, energy efficiency
• Increase basic allocation of free water
• Sanitation
• Handwashing with soap and water

32
Examples of interventions for ARI

• To address specific risk factors
• Malnutrition, LBW, breastfeeding
• Immunisation improve coverage of EPI
• Zn supplementation
• Smoking control programmes successful in 4/18
  studies
• Air pollution at household level
  electrification, insulation
• Handwashing soap water
• Broader interventions
• IMCI pneumonia deaths cut by 42 in neonates
  36 in children 1-5
• Comprehensive community-based programmes
• Maternal education
• Poverty alleviation eliminate obstacles to
  existing grants

33
Inequity demands targeting
34
Inequity demands targeting

• WC Index of Multiple Deprivation
• Domains
• Income material deprivation
• Employment deprivation
• Health deprivation
• Education deprivation
• Living environment deprivation
• Most deprived areas are in Beaufort West, Breede
  Valley, City of Cape Town Khayelitsha, George
  Knysna

35
The metro determinants and health
Cape Town Equity Gauge, UWC SOPH, 2002
36
Equity requires a balance between resources and
needs
NEEDS
Resources
Health District Geographic Area
37
Distance to Equity in Resource Allocation for
Primary Care (Health Centres and Clinics)
38
Ceará, Brazil

• Early 1980s IMR gt100 per 1,000 and malnutrition
  very common
• 1986 statewide survey ? new health policies,
  including GOBI plus vitamin-A supplementation
• Coverage improvement through CHWs and TBAs,
  health services decentralised to rural
  municipalities with worst health indicators
• social mobilisation campaign using media and
  small radio stations
• 1990 and 1994 surveys repeated, and results
  incorporated into health policy.
• This process was sustained by four consecutive
  state governors

39
Ceará, Brazil

• Improved outputs
• By 1994
• ORS use increased to more than 50 per cent
• nearly all children had a growth chart
• half had been weighed within the previous three
  month
• immunisation coverage was 90 per cent or higher
• median breastfeeding duration increased from 4.0
  to 6.9 months.
• Improved outcome indicators
• low W/A fell from 12.7 to 9.2 low H/A from
  27.4 to 17.7
• reduced diarrhoea from 26.1 to 13.6
• IMR fell from 63 per 1,000 live births in 1987
  to 39 per 1,000 in 1994
• diarrhoea deaths fell from 48 to 29
• perinatal deaths increased as a proportion from
  7 per cent to 21 per cent and
• respiratory infections from 10 per cent to 25 per
  cent. (Victora et al, 2000)).

40
PHC interventions in WC

• Rapidly increase coverage through CHWs of key
  interventions eg ORT, vaccination, Vit A,
  exclusive breast feeding, GMP, handwashing
• Improve support and QOC at health centres and
  clinics
• Improve intersectoral collaboration esp. water,
  sanitation, housing
• Massively increase HR numbers and competence - ?
  HRH fund
• Develop integrated multi-level Academic Health
  Service Complexes to improve service and training

41
Oportunidades, Mexico

• Progresa-Oportunidades, now known as
  Oportunidades
• Principal anti-poverty program of Mexican
  government
• Comprehensive focus on human capital through
  nutrition, health, education and evaluation
• Being considered for replication in other
  countries and cities
• Monetary educational grants to participating
  families for each child under 22 years of age who
  is enrolled in school between the third grade of
  primary and the third grade of high school
• Cash transfers are also linked to regular health
  clinic visits
• more than 5 million poor families break out of
  poverty since 1997

World Bank Brookings Institution. 2007.
42
Key elements for success

• Large growing in scale
• operates in more than 70000 localities,
• financial allocation almost half (46,5) of
  Mexicos annual anti-poverty budget
• only 6 of its budget goes to operating costs
• Strong government commitment ensures
  sustainability
• Targets poor and marginalised communities
• 96 of its localities are in marginalised rural
  areas
• In urban areas it focuses on smaller cities with
  significant levels of marginalisation.
• Strong gender focus - improvement of the
  condition of women a priority
• About 98 of heads of households that get cash
  benefits are women
• Strategic focus on youth monetary value of
  scholarships increases as learners enter higher
  grades where school dropout rates are higher
• Effective review mechanism
• regular evaluation of management, results and
  impact with clear indicators

UNICEF State of the World's Children 2005. pp
32-33
43
Social interventions in WC

• Target education at vulnerable groups esp poor
  women
• Old age pensions, esp to women-headed households
• Increased WFH by 1.9 SD in U5 girls Duflo
• CSG
• significantly boosted child height
• Projected to increase adult earning by up to 230
  
• 
  Agüero et al 2004
• Generate employment
• Expand and professionalize EPWP for health
  infrastructure

44
Conclusions

• BoD estimates undervalue childrens lives
• Although W Cape better than other provinces,
  unacceptable mortality/morbidity and major
  inequalities exist
• Health services are under immense strain
• Major causes of BoD are rooted in social and
  economic inequalities and eminently preventable
  by non- health sector interventions
• International experience provides a guide to
  success factors