The Reality of Child Mortality

A. Barbara Oettgen, MD, MPH, FAAP Ambika Mathur, PhD David A. Sleet, PhD, FAAHB

— Dr LEE Jong-wook, former World Health Organization Director-General

* CURRENT STATUS OF CHILD MORTALITY

Global child mortality has significantly decreased in the last 20 years from 12.6 million deaths per year in children younger than 5 years in 1990 to 6.6 million deaths per year in 2012. The younger-than-5 mortality rate has decreased by 47% since 1990 from 90 deaths per 1,000 live births to 48, and the decline rate is accelerating. Of the 61 countries with the highest mortality, 25 decreased their child mortality rate by more than two-thirds, including successes in Bangladesh (72%), Malawi (71%), and Nepal (71%). Despite these great strides, 18,000 children die every day — the majority from preventable causes. Deaths are increasingly concentrated in neonates (now 40% of all child deaths), as global public health efforts have resulted in declines in the mortality rate among older infants and children. Figure 1-1 shows the primary causes of global child mortality, including neonatal causes, pneumonia, diarrhea, and malaria. The past 5 years have seen significant declines in measles and HIV. Globally, pneumonia is the number one cause of child death.

However, global statistics fail to describe the great inequality of childhood mortality rates from country to country. While child mortality has declined in all regions of the world, the rate of decline is much slower in sub-Saharan Africa and South Asia, and it is in these regions that the greatest burden of child mortality is increasingly concentrated (Figure 1-2). Sub-Saharan Africa continues to have the highest mortality rate (98 per 1,000 live births), which is double that of other developing regions and 16 times more than developed countries. Child death is also disproportionately seen in rural areas among children whose mothers are not educated and those living in poverty and war-torn regions.

There is also regional variation in childhood death patterns. Malaria is the primary killer of children younger than 5 years in Sub-Saharan Africa; while infectious diseases account for 64% of deaths globally, they are responsible for 81% of the deaths in Africa. More than half of deaths caused by infections can be ascribed to 5 pathogens: Plasmodium falciparum, Streptococcus pneumoniae, rotavirus, measles, and Haemophilus influenzae type b (Hib).

Malnutrition contributes to more than one-third of deaths in this age group, while war, poverty, lack of education, and indirect effects of the HIV epidemic have also contributed significantly to child mortality across the globe. Undoubtedly, great progress has been made, but the current status of child health remains morally and ethically unacceptable.

* GLOBAL BURDEN OF DISEASE 2010

Statistics of global health for people of all ages have been examined independently by the Global Burden of Disease Study 2010, funded by the Bill & Melinda Gates Foundation. This comprehensive data summary includes 235 causes of morbidity and mortality for people of all ages and looks at causes of death and trends in morbidity and mortality from 1990 to 2010. The overall global trend across all ages is a movement away from maternal, neonatal, nutritional, and communicable causes of death to noncommunicable causes, such as ischemic heart disease, stroke, lung cancer, and injury. This trend is driven by population growth and aging. Deaths related to diabetes doubled, and the number of deaths from road traffic crashes rose by 46%. Yet the picture can look quite different regionally. Specifically, communicable diseases and maternal, neonatal, and nutritional causes of mortality account for 76% of deaths in sub-Saharan Africa. Figures 1-3a,b,c show the primary causes of death (both sexes combined) for neonates, infants younger than 1 year, and children 1 to 4 years of age.

* MILLENNIUM DEVELOPMENT GOALS FOR 2015

In 2000, 189 governments and at least 23 international organizations convened at the UN Millennium Summit to adopt a uniform worldwide set of 8 goals — Millennium Development Goals (MDGs) — to promote continued progress toward improving global public health. Several of these goals pertain to child health. Millennium Development Goal 4 sets the goal to decrease the mortality of children younger than 5 years to 5 million per year by 2015. Essentially, successful implementation of MDG 4 will decrease deaths by two-thirds of the levels seen in 1990 (13 million).

Other MDGs will indirectly improve child mortality rates. For example, MDG 5 is aimed at reducing maternal mortality by three-fourths (which will affect neonatal mortality), and MDG 6 strives to reverse the spread of HIV/AIDS and malaria. While injury prevention was not part of the original MDG, Anupama Rao Singh, regional director of United Nations Children's Fund (UNICEF) East Asia and Pacific, points out, "If we are ultimately going to meet the Millennium Development Goal to reduce child mortality, it is imperative that we take action to address the causes of childhood injury."

The MDGs are a valuable benchmark intended to move the world forward. Despite the overall decline in child mortality, only 23 of the 75 Countdown countries are on track to achieve MDG 4. These 75 Countdown countries carry 95% of the burden of maternal, newborn, and child death. Their progress is monitored as the world "counts down" to 2015. The current rate of decline needs to accelerate if we are to achieve the 2015 goal (Figure 1-4).

* THE EVOLUTION OF GLOBAL CHILD HEALTH

From 1960 to 1999, there was already significant success in global child health — a 50% reduction in child mortality attributable to a variety of public health approaches. Mass immunization campaigns conducted in the 1950s through 1970s resulted in smallpox eradication and reductions in other vaccine-preventable diseases. The Expanded Program on Immunization (EPI), established in 1974, allowed for continued strides in improving worldwide vaccination status among children, from a baseline of 5% (3 doses of diphtheria, pertussis, tetanus [DPT3] vaccine) in 1974 to a current rate of 83% (2012). The UNICEF growth monitoring for undernutrition, oral rehydration, breastfeeding, and immunization program, instituted in 1982, expanded the focus of public health programs from solely immunizations to include other important interventions. There began a growing awareness and interest in improving primary care infrastructure to better disseminate a greater number of interventions that positively affect child health.

The Integrated Management of Childhood Illness (IMCI) program was created in the mid-1990s. In this program, local-level caseworkers were identified in rural and urban communities and trained to provide health education and support to families for a variety of maternal and childhood diseases and conditions. The IMCI program was initially created as a facility- based program using case management with a defined set of evidence-based guidelines for sick children. It was eventually expanded to include interventions that could be performed in the household, in the community, or by referral. Such a change required improving case management and health systems, as well as family and community services, including health education in growth promotion and development, disease prevention, care, and compliance with the advice of health workers.

Adoption of all IMCI program aspects (ie, facility-based services, case management, and family and community health services) is not complete, even in countries with the most effective implementation. While these countries have well-trained community health workers, changes in their health systems and family health practices have been slow. Evaluators note that one of the significant problems associated with IMCI implementation is high staff turnover, which makes it difficult to achieve a sustained effect. The staffing problem is a greater issue among facility-based staff (who could be moved from the area) than with staff who are local community women, demonstrating that it may be preferential to increase participation of local workers. Future success of the IMCI program requires that regions work from the top down (strengthening the health service system) and also from the bottom up (mobilizing the community to use those services).

MAJOR CAUSES OF CHILD MORTALITY

Further reducing child mortality requires improving primary care infrastructure across a continuum for women, newborns, and children, allowing for the successful dissemination of interventions known to be effective for the major causes of maternal, newborn, and child mortality. The following recurrent themes emerge in the description of progress addressing the major causes of child mortality:

1. A need to strengthen and improve community-based services for a greater effect on diseases (ie, pneumonia, diarrhea, malaria)

2. A need to address the inequities of how effective interventions are being disseminated among people of different socioeconomic statuses and urban versus rural

Pneumonia

Pneumonia is associated with 18% or 1.2 million childhood deaths every year, a number greater than deaths from malaria and diarrhea combined and the number one cause of death in children younger than 5 years globally. Morbidity from pneumonia is estimated at 156 million cases annually. Ninety percent of pneumonia deaths occur in South Asia and sub-Saharan Africa. The pathogens S pneumoniae, Hib, respiratory syncytial virus, and influenza cause the majority (estimated at 55%) of pneumonia deaths, while household air pollution and overcrowding are environmental contributors. It is estimated that 3 billion people use solid fuel for cooking (wood, crop waste, coal), contributing to indoor pollution (Figure 1-5).

Together, pneumonia and diarrhea account for almost 30% of deaths in children younger than 5 years; several of the most effective interventions to combat these diseases overlap, including improved nutrition, breastfeeding, and zinc therapy. In April 2013, the World Health Organization (WHO), UNICEF, and Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the Global Action Plan for Pneumonia and Diarrhoea (GAPPD). It is a framework for governments to plan and implement effective interventions for prevention and control of both diseases; this is one of the biggest opportunities in global health. Scaling up these activities could prevent 95% of diarrhea deaths and 67% of pneumonia deaths by 2025.

The current global health approach to decreasing deaths from pneumonia involves prevention and early detection with prompt treatment.

Early Detection and Treatment

It is essential to educate and encourage families to seek care early in the course of respiratory illness; the IMCI program is an ideal conduit for education and treatment. First, families can be taught to observe respiratory rates and chest wall appearance (eg, in-drawing). The IMCI program workers can also look at these physical signs, refer severe cases, and treat non-severe cases with selective antibiotics. Statistics show that worldwide, too few people know to access care when their child is ill with respiratory symptoms. Only 60% of caregivers worldwide seek care, with little progress over the last decade (54% sought care in 2000).This number is even lower in sub-Saharan Africa (49%). Only one-third of those needing antibiotics are getting them. The case management approach also suffers due to a lack of caregivers, inadequate training and program coordination, and trouble with the supply chain for items such as antibiotics. While most countries agree that case management is important, the number of countries who implemented the policy to scale, reaching all children, is few (Figure 1-6); thus, more work must be done to expand the reaches of the IMCI program.

Prevention

Not only can IMCI workers instigate prompt treatment, they can also encourage breastfeeding, improved nutrition (including increased zinc intake), and hand washing. Human milk can provide antibodies as well as have a positive economic and social effect on families. All-cause mortality increased 566% in infants 6 to 11 months and 223% in children 12 to 23 months who were not breastfed.

Expanded use of Hib, pneumococcal, pertussis, measles, and influenza vaccines is also an important approach to decreasing childhood pneumonia. H influenzae type b vaccination is very effective in Kenya, where the incidence of the disease decreased to 12% of its baseline level in children younger than 5 years over the first 3 years it was distributed. For years, access to Hib vaccine demonstrated a rich/ poor gap between countries. Thankfully, that gap is closing, owing to an increase in funding as well as global and national leadership. In 2000, Gavi, the Vaccine Alliance, began financially supporting Hib vaccination in 72 of the poorest countries. Countries apply for Gavi funding based on a financial plan, vaccine introduction plan, and 5-year national vaccine strategy. Initially, uptake of Hib vaccine was very slow. When the Hib Initiative was launched in 2005 to accelerate introduction of the Hib vaccine, there was a sharp increase in the number of eligible countries using the vaccine (Figure 1- 7). Eighty-five percent to 90% of all-income countries introduced the Hib vaccine by the end of 2011.

Since 2007, WHO has recommended global use of pneumococcal vaccine, especially because pneumococcus is the leading cause of pneumonia globally. It is estimated that 500,000 child deaths could be averted annually with the use of pneumococcal vaccine. While the uptake of pneumococcal vaccine globally is slowly rising, there are significant numbers of unimmunized children and a large gap in access between the rich and the poor. Hopefully, with initiatives (ie, advance market commitment) intended to lower vaccine prices and increase distribution, the financing and organizational mechanisms that improved Hib vaccine uptake will also lead to expanded coverage of pneumococcal vaccine.

Diarrhea

Diarrhea is responsible for 11% (750,000) of child deaths annually worldwide. Fortunately, significant strides have been made in diarrhea control over the last 15 years. Rotavirus, enteropathogenic Escherichia coli, calicivirus, and enterotoxigenic E coli cause more than 50% of severe diarrhea episodes (ie, those most likely to result in death). It is estimated that rotavirus causes 38% of diarrheal deaths. Diarrheal control and decreases in mortality are achieved through prevention and also adequate treatment during the illness. One of the leading success stories in public health is the use of oral rehydration therapy (ORT) as a key element in fighting diarrhea. Oral rehydration therapy is associated with a 69% decrease in mortality. Deaths caused by diarrhea decreased by more than two-thirds since 1980; diarrhea is no longer the number one cause of death.

The GAPPD goal is to decrease mortality from diarrhea to fewer than 1 per 1,000 live births and have 90% case management coverage by 2025. Treatment includes ORT, continued feeding (especially human milk for young children), and zinc. Prevention includes safe water supply, feces disposal (MDG 7), hand washing, immunization (for rotavirus and measles, specifically), and improved nutrition (including adequate vitamin A). Stunting, a chronic marker of malnutrition, occurs when there are repeated diarrhea episodes, setting up a vicious cycle of undernutrition and infection that needs to be broken.

Oral rehydration solution (ORS) is the mainstay of ORT. Oral rehydration solutions evolved over time and now are composed of a lower salt concentration than previously recommended in the 1980s and 1990s. Homemade rehydration solutions are loosely encouraged in regions where ORS is not available. Zinc has become an important adjunct to diarrhea control. It is estimated that 17% of the world's population is zinc deficient. While ORS acts to rehydrate, zinc decreases the amount of diarrhea and length of illness. In addition to ORS and zinc, families are encouraged to continue feeding and increase fluids in general. Unfortunately, treatment use slowed after an initial dramatic rise in the uptake of rehydration recommendations in the early 1990s. Overall, only about 34% of children with diarrhea receive low-osmolar ORS and only 5% get zinc; however, there are regional variations. Treatment inequities occur depending on socioeconomic status: children are 1.5 times as likely to receive treatment in households with higher income levels. There are also urban/rural inequities: those in urban settings are more likely to receive treatment than those in rural areas (43% versus 34%).