2004.6.5
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?
• 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
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.
 1 st alternative – apply at regional level
 2 nd alternative – apply at country level
 Compromise – apply to each of 42 countries where 90% of worldwide under-5 deaths occur

• 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
2004.6.5
* 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
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

Each potential intervention was assigned to one of three levels based on the strength of evidence for its effect on under-5 mortality:
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)
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
2004.6.5
focused on an essential set judged to be feasible for all countries.

Treatment Prevention
Breastfeeding
Water/San/Hygiene
Complementary feeding
Zinc
Vitamin A
Exposure to diarrhoea
Diarrhoea
Oral rehydration therapy
Antibiotics for dysentry
Zinc
Die Survive
2004.6.5
Future: rotavirus vaccine

Treatment
Prevention
Breastfeeding
Complementary feeding
Zinc
Hib vaccine
Exposure to pneumonia
Pneumonia
Antibiotics
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Die Survive
Future: Pneumococcal vaccine, zinc for therapy, reduction of indoor air pollution

2004.6.5
Treatment Prevention
Clean delivery
Antibiotics for premature rupture of membranes
Breastfeeding
Exposure to infections
Severe bacterial infection
Antibiotics for sepsis
Die Survive

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*
2004.6.5
* Components: coverage (current and target), efficacy, affected fraction or population, evidence level

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

Treatment intervention
Vitamin A
Antibiotics for pneumonia
Antibiotics for dysentery
Antimalarials
Oral rehydration therapy
Antibiotics for sepsis
Newborn resuscitation
Zinc
Coverage (in %)
Mean - 42 countries Range India
29
20
10
3
0
55
40
30
**
3-66
4-50
-
-
-
-
-
11
7
10
3
0
22
40
30
2004.6.5
* Same as for prevention

2004.6.5
Three types of results calculated:
 By individual interventions
 By specific causes
 By groups of interventions

Under-5 deaths preventable through universal
India coverage with individual interventions (2000)
Deaths averted Percent (of
Preventive intervention
(in '000s) total deaths)
Breastfeeding
Complementary feeding
Clean delivery
Hib vaccine
Clean water, sanitation, hygiene
Zinc
Vitamin A
Antenatal steroids
Newborn temperature management
Tetanus toxoid
Antibiotics for premature rupture of membranes
Measles vaccine
Nivirapine and replacement feeding
Insecticide-treated materials
Antimalarial IPT in pregnancy
2004.6.5
373
125
123
107
106
101
84
72
62
43
36
14
10
2
0
16%
5%
5%
4%
4%
4%
3%
3%
3%
2%
1%
1%
0%
0%
0%

2004.6.5
Under-5 deaths preventable through universal coverage with individual interventions (2000)
Percent
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
India
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

Under-5 deaths preventable through universal coverage with individual interventions (2000)
India
Treatment intervention
Oral rehydration therapy
Antibiotics for sepsis
Antibiotics for pneumonia
Zinc
Newborn resuscitation
Antibiotics for dysentery
Vitamin A
Antimalarials
Deaths averted Percent (of
(in '000s) total deaths)
394
158
153
113
97
81
3
2
16%
7%
6%
5%
4%
3%
0%
0%
2004.6.5

Prevention
Antibiotics for premature rupture of membranes
Treated bednets &materials*
Intermittent preventive therapy
Antinatal steroids
Pregnant
Treatment
Premature
Newborn temperature management
Die Survive
2004.6.5
* Indoor residual spraying may be used as an alternative

Under-5 deaths from specific causes preventable through listed interventions (2000)
Preventable under-five deaths
India
Under-5 Percent of deaths total under-5
(in '000s) deaths
Number (in
'000s) Percent Disease or condition
Diarrhoea
Pneumonia
Measles
Malaria
HIV/AIDS
Neonatal
Birth asphyxia
Prematurity
Severe infections
Tetanus
Other
Other
TOTAL
2004.6.5
250
207
216
60
130
388
557
544
14
3
20
863
2402
10%
9%
9%
3%
5%
16%
23%
23%
1%
0%
1%
36%
100%
97
119
205
49
0
0
506
360
14
3
10
470
1362
91%
66%
100%
94%
48%
54%
39%
57%
95%
81%
0%
0%
57%

Under-5 deaths from specific causes preventable through listed interventions – as percent of deaths by cause (2000)
100%
India
90%
2004.6.5
80%
70%
60%
50%
40%
30%
20%
10%
0%
Di arr hoea
Pn eum oni a
Measle s
Malar ia
Cause
HIV/A
IDS
Neonatal
O ther

Under-5 deaths from specific causes preventable through listed interventions – as percent of total deaths (2000)
India 25%
20%
15%
10%
5%
2004.6.5
0%
D iarr hoea
Pneumonia
M eas les
M alaria
Cause
H
IV/
AI
D
S
N eonat al
Ot her

Under-5 deaths preventable with specific groups of interventions (2000)
India
Deaths
Group Interventions in group
Health type grouping
Nutrition
Breastfeeding, complementary feeding, vitamin A and zinc
Case management
ORT, antibiotics (diarrhea, pneumonia, neonatal sepsis) and antimalarials
(in '000s) total deaths)
599
730
25%
30%
2004.6.5

India
Under-5 deaths preventable with specific groups of interventions (2000)
Deaths
Group Interventions in group
Location grouping
Health facility centric
Antenatal steroids, temperature management, antibiotics-PRM, antibiotics-pneu, antibioticssepsis, rescusitation, antibiotics-dys, zinc-T and vitA-T
Health facility outreach
Zinc, Hib vaccine, vitA, tetanus toxoid, nivirapine, clean delivery, measles, IPT and antimalarials
Home care
Breastfeeding, complementary feeding, ITM and
ORT
2004.6.5
(in '000s) total deaths)
713
345
757
30%
14%
32%

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

• 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
2004.6.5
Next steps

Review interventions in Indian context, identify any changes, with supporting evidence, and reassess impact on reduction of under-5 deaths