In the name of ALLAH, most gracious, most merciful

Infant Mortality Rate (IMR)5 Major Diseases, Factors & Levels of Intervention of IMR By: Sumayya Naseem, Optometrist, MMSPH Student

Contents of the Presentation1. Introduction to IMR2. IMR of various Countries3. Causes & main Diseases responsible for high IMR4. Factors Responsible5. Strengthening of Child Health Services (Levels)6. Integration of Infant Health services with other Sectors

and Programs7. Organizations Currently working for reduction of IMR

What is Infant Mortality Rate (IMR) ?

• Definition:  Infant mortality is the death of a child less than one year of age. Infant mortality is the death of a child before the child's first birthday.

• Globally, ten million infants and children die each year before their fifth birthday. Out of which 99% belong to developing countries.

• This rate is often used as an indicator for the level of health in a country.

Forms of infant mortality

1. Neonatal mortality is newborn death occurring within 28 days postpartum. Neonatal death is often attributed to inadequate access to basic medical care, during pregnancy and after delivery. This accounts for 40-60% of infant mortality in developing countries.

2. Perinatal mortality is late fetal death (22 weeks gestation to birth), or death of a newborn up to one week postpartum

3. Post neonatal mortality is the death of children aged 29 days to one year. The major contributors to post neonatal death are malnutrition, infectious disease, and problems with the home environment.

IMR of Various Countries (latest) Country & Infant mortality rate (deaths/1,000 live births)

• Afghanistan 121.6 (highest in the World)• Ethiopia 75.2 (14th Rank)• Pakistan 61.2 (26th Rank)• Bangladesh 48.9 (47th Rank)• India 46.07 (50th Rank)• China 15.6 (111th Rank)• Singapore 2.6 (218th Rank)• Japan 2.2 (220th Rank)• Monaco 1.8 (Lowest in the World)

Causes of Infant Mortality• Some causes of infant mortality are malformations, sudden infant death syndrome, maternal complications during pregnancy accidents and unintentional injuries.

• Environmental and social barriers prevent access to basic medical resources and thus contribute to an increasing infant mortality rate.

• Ninety-nine percent of infant deaths occur in developing countries, and eighty-six percent of these deaths are due to infections, premature births, complications during delivery and birth injuries.

•  Common causes are preventable with low-cost measures.

• In the United States a primary determinant of infant mortality risk is infant birth weight with lower birth weights increasing the risk of infant mortality.

• The determinants of low birth weight include socio-economic, psychological,

behavioral and environmental factors

Main 5 Diseases responsible for high IMRs

1. Acute Respiratory Infection (Pneumonia)2. Diarrheal Diseases3. Malnutrition (under nutrition)4. Malaria5. Other diseases which are preventable through

Immunization

Some other causes are HIV AIDS, Meningococcal Meningitis, Dengue, Tuberculosis and Childhood Disabilities (physical and psychological).

1. Acute Respiratory Infections (ARI)

• Pneumonia is one of the deadliest diseases in Pakistan.  This bacterial disease kills approximately 2 millions children in Pakistan each year.

• Respiratory infections are infections in any area of respiratory tract, including nose, middle ear, throat, wind pipe, air passages and lungs.

• The common symptoms are fever, breathlessness, headaches, runny nose, ear problems and coughs.

• Some interventions are marked according to their effectiveness, as high effectiveness and medium effectiveness.

• High Effectiveness (Potential Impact more than 10%):

• Pneumococcal Vaccines• Reduction of Indoor Pollution• Reduction of Low Birth Weights• Reduction of Underweight

• Medium Effectiveness (Potential Impact

5-10%):

• Increase in Measles Immunization• Pneumonia Vaccine• Increase in Breast Feeding

2. Diarrhea• Diarrhea stand second in line among the factors that consume lives

of approximately 15 % of our children under 5 years.

• Diarrheal diseases and dehydration are responsible for 3 M children deaths every year. Mostly in developing countries, e.g. Pakistan.

• Diarrhea causes dehydration of fluids in body as well as electrolyte imbalance and this can prove fatal within hours.

• One of the most important reasons of Diarrhea is contaminated water and poor living conditions. Others are lack of awareness, lack of awareness/access to ORS, lack of health facilities or incorrect case management (at home or health facility).

• 5 causing organisms are : Rota virus, Escherichia coli, Shigella, Campylobacter jejuni and cryptosporidium.

 4 Types of Diarrhea are:

1. Acute Watery Diarrhea: Including cholera which lasts for several hours or days. Main danger is dehydration. Also weight loss.

2. Acute Bloody Diarrhea: Also called Dysentery. Main dangers are intestinal damage, sepsis and malnutrition. Dehydration can occur.

3. Persistent Diarrhea: which lasts for 14 days or longer. Dangers are malnutrition and dehydration.

4. Diarrhea with severe malnutrition (Marasmus or Kwashiorkor): Main dangers are severe infection, dehydration, heart failure and minerals and vitamins deficiency.

Usually more than 3 times in 24 hours. But number does not matter, it is the consistency that matters.

Prevention of Diarrhea Diarrhea can be prevented by pursuing multisectoral efforts:

• Improving access to clean water and safe sanitation, promoting hygiene education, exclusive breast feeding.

• Improved complementary feeding practices, immunizing all children especially against measles.

• Using latrines, keeping food and water clean, washing hands with soap before touching food, and sanitary disposal of stools.

• The common thread that links these infectious diseases is the nutrition of the mother and child. Malnutrition predisposes children to disease, and diseases often result in worse nutritional status, and consequently a vicious circle of cause and effect is established.

• Adequate health care services, also access to ORS/ ORT.

3. Malnutrition (under nutrition)

• Malnutrition plays a very significant direct or indirect role in more than half of the nearly 12 million deaths each year of children under five in developing countries.

• In turn, malnutrition itself also intensify the symptoms of preventable illnesses.

• It has multiple causes, including a lack of food, common and preventable infections, inadequate care, and unsafe water.

• Strategies and interventions to improve the nutritional status of women and children aim to overcome many of the major health challenges posed by malnutrition.

• About 20 per cent of babies born in developing countries weigh less than 2.5 kg (UNICEF 1997) which is an important factor contributing to the burden of malnutrition in developing countries.

• Few specific actions in developing countries have been supported to reduce the prevalence of low birth weight. The most effective interventions are considered to be smoking cessation, antimalarial chemoprophylaxis, and balanced protein-energy supplementation for the mother.

• Zinc, folate, iron, and magnesium supplementation in gestation and probably the reduction of teenage pregnancies.

• Protecting, promoting, and supporting exclusive breast feeding for 4 to 6 months from birth and continued breast feeding with adequate complementary foods for 2 years or beyond is crucial in developing countries.

• In case of infant feeding formula, access to the knowledge that how to prepare, feeding formula, clean boiled water and fuel.

• Fortified food for the mother and children, e.g. fortified milk, oils, salt etc with Vitamin A, E, Iron, Iodine, etc.

• Vitamin A Deficiency causes Eye Damage, Blindness, skin disorders, impaired immunity and Death. • Prevention: Vitamin A capsules, Fortified foods and awareness

about Vitamin A rich foods. etc.

• Iodine Deficiency causes mental and physical retardation, Goiter, Cretinism and speech and hearing defects. • Prevention: Iodized Salt, awareness about iodine rich foods.

• Iron Deficiency Anemia in mother causes Low Birth Weight in infant, poor growth and development, impaired cognitive abilities and reduced resistance to disease, impairing their right to achieve their fullest potential.

• Prevention: Fortified food for mother, Iron tablets, Supplementation and use of Iron rich food.

4. Malaria• This formidable tropical parasitic disease kills at least a million

people annually, three-quarters of them are children.• Million people who die of malaria-related causes each year, 90

per cent are in Africa. • Malaria is the third in ranking among the fatal diseases for the

kids. • Some of other symptoms are fever, shivering, flu and anemia,

which may range over severe types. • Malaria is considered as the deadliest and the most life

threatening disease in human history. It was obliterated in 1960’s era but it has slowly and gradually reappeared and haunting our society.

•  Now, owing to floods in the country malaria become contagious and it’s constantly on the rise. Anti-malarial medication can be used to effectively cure this ailment.

•  Malaria infection contributes to (severe) anemia during pregnancy, putting the woman at risk of hemorrhage and death. Maternal anemia increase the risk of low birth weight, the single greatest risk factor for neonatal mortality.

• For children, wherever malaria is common and access to diagnostic facilities scarce, it is important to treat any fever as if it were malaria. A full course of a recommended anti malarial drug should be given to the child immediately, even if the fever disappears rapidly.

• Malaria is a disease of poverty. It affects primarily the poor, who tend to live in malaria-prone areas, in dwellings that offer no or few barriers against mosquitoes. By sapping peoples' health, strength, and productivity, malaria generates still more poverty.

• Prevention: • Insecticide treated Bed Nets• Drainage of stagnant water pools• Governments should help by encouraging the commercial sector to make quality nets insecticide more affordable and more available.

5. Other diseases which are preventable through Immunization

• Although vaccines are one of the most cost-effective ways in which to reduce child mortality, many children in the poor areas of the world do not have access to childhood vaccines. In some countries, only 30 per cent of children may be vaccinated.

• Even fewer children have access to the recently licensed and expensive vaccines that are likely to have a major additional impact on decreasing child mortality such as vaccine for Haemophilus influenzae type B (for pneumonia).

• Immunization has been one of the greatest public health success stories. Between 1980 and 1990, a massive effort raised coverage rates worldwide from 5 to 80 per cent. Organizations funding in vacciantion are USAID, GAVI, WHO, World Bank, UNICEF and Rockefeller foundation.

• Deaths from six major childhood diseases (measles, tetanus, whooping cough, tuberculosis, polio, and diphtheria) have been slashed by 3 million a year. At least 750000 fewer children are left blind, paralyzed, or mentally disabled.

• Newer vaccines, such as those for hepatitis B, Haemophilus influenzae type B, and yellow fever are now widely used in developed countries. While children in developing countries may have access to six or seven vaccines, children in industrialized countries can now expect to receive 11 or 12. Thus the gap between rich and poor children is widening.

• In 1999, GAVI (Global Alliance for Vaccines and Immunization )has established five strategic objectives:

• improve access to sustainable immunization services; • expand the use of all existing, safe, and cost-effective vaccines where

they address a public health problem;• accelerate the development and introduction of new vaccines and

technologies;• accelerate research and development efforts for vaccines needed

primarily in developing countries; • make immunization coverage a centerpiece in development efforts.

• Tuberculosis and HIV AIDS are discussed in detail.

a. HIV/ AIDS• HIV/AIDS is today the world's most rapidly spreading infectious disease for which science still has no cure. HIV/AIDS

has reversed the survival, health, and wider human development gains of many countries and will continue to negatively affect all aspects of community life and children's well being in the regions most heavily affected for decades to come

• Nearly 12 million children have already been orphaned• 11 men, women, and children around the world get infected per

minute. 1 child per minute.• Nearly 4.5 million children below the age of 15 years have been

infected with HIV since the AIDS epidemic began, and more than 3 million of them have already died of AIDS.

• Though Africa accounts for only 10 per cent of the world's population, it is home to 90 per cent of the world's HIV-infected children, largely as a consequence of high fertility rates combined with very high levels of HIV infection among women.

• Mother-to-child transmission is by far the largest source of HIV infection in children below the age of 15 years.

• In countries where blood for transfusion and blood products are regularly screened, and where clean syringes and needles are widely available in health centres and hospitals, mother-to-child transmission is virtually the only source of infection in young children.

• The virus may be transmitted during pregnancy, childbirth, or breast feeding. Where no preventive measures are taken, the risk of a baby acquiring the virus from an infected mother ranges from 25 to 45 per cent in developing countries.

• Evidence suggests that the risk of transmission increases when the mother has a higher viral load (this is the case when a person is newly infected with HIV or is in an advanced stage of disease), or if the baby is highly exposed to the mother's infected body fluids during birth.

• It is estimated that a child born uninfected to an HIV-positive mother has a 20 per cent chance of acquiring the virus from her milk if he or she is breast fed. In places where breast feeding is the norm, this route may account for more than one-third of mother-to-child transmissions of the virus.

• Since there is a possibility of transmitting HIV through breast feeding, replacement feeding is an option for mothers. If an HIV-infected mother has access to an adequate supply of breast-milk substitutes, knows how to use them, has access to fuel and clean water, and the time to prepare breast-milk substitutes safely, refraining from breast feeding will reduce the risk of transmitting HIV through breast feeding.

• In countries where families live in poverty, have limited education, and poor access to the resources required to provide safe feeding alternatives to breast feeding and counseling, the risk of death from diarrhea, respiratory, and other infections associated with replacement feeding can be as great or greater than the risk of transmitting HIV through breast feeding.

• In cultures where breast feeding is the norm, the very fact that she chooses not to breast feed may draw attention to her HIV status and invite discrimination or even violence and abandonment by her family and community.

Prevention• The strategy is sometimes referred to as 'primary prevention'. It involves

promoting safe and responsible sexual behaviour in couples, providing them with knowledge about HIV/AIDS and how to prevent infection.

• It also means providing good-quality user-friendly prevention and treatment programmes for other sexually transmitted diseases, the presence of which increases the risk of HIV transmission up to 10-fold.

• Crucially, it means taking steps to deal with the cultural, legal, and economic factors that make girls and women especially vulnerable to HIV infection by limiting their autonomy and power to protect themselves.

• The provision of efficient and accessible family planning services to enable women to avoid unwanted pregnancies and births. The aim is to ensure informed reproductive choice.

• The provision of antiretroviral drugs for HIV-positive pregnant women (and sometimes their babies), counselling on infant feeding, and support for the feeding method(s) chosen by the mother. This package is often referred to as the antiretroviral drug strategy.

• Provision of family planning services• Youth Participation • Confidential counseling and testing

b. Tuberculosis

• Someone in the world is newly infected with tuberculosis every second• Tuberculosis is the single largest killer of children in the world, 250 000 children. (UNICEF 2000). • Tuberculosis is a contagious disease. Like the common cold, it spreads

through the air.• Only people who are ill with pulmonary tuberculosis (tuberculosis of the lungs)

are infectious. When infectious people cough, sneeze, talk, or spit, they propel tuberculosis germs known as bacilli into the air. A person needs only to inhale these to be infected.

• DOTS Short-course chemotherapy refers to a process treatment regimen lasting 6 to 8 months and uses a combination of powerful anti tuberculosis drugs.

• Standardized regimens are based on whether the patient is classified as a new case or a previously treated case. The most common antituberculosis drugs used are isoniazid, rifampicin, pyrazinamide, streptomycin, and ethambutol.

• Drug treatment of each patient needs to be observed for at least the first 2 months.

Factors responsible  Many factors contribute to infant mortality such as:

• Maternal Factors: The mother’s level of education, no empowerment and decision making power, mother’s sickness, mothers nourishmment status, awareness, age of the mother and birth spacing.

• Medical Factors: Child born with low weight, born with diseases, premature birth.

• Socioeconomic Factors : Low incomes and high cost of health facilities, Poverty.

• Catastrophies: whether man made or natural say floods , earth quakes, wars etc.

• Malnutrition: Protein energy malnutrition and micronutrient deficiency. Vitamin A deficicency, lack of breast feeding and complementary feeding

• Infectious Diseases: Acute respiratory infection, diarrhea, measles

• Inaccessibility : To iodized salt, breast milk substitutes and health services.

• Unacceptability: e.g. polio vaccination in Pakistan

• Unawareness: Low Literacy rate

• Lack of care/interest: By mother, father and family.

• Socio Cultural norms: Decision maker in the family, Not availing health facilities even free ones, consulting traditional healers, taking home remedies.

• Environmental conditions: Unhygienic home environment and exposure to cigarette smoke in the womb or after birth.

• Poor Sanitation and access to clean drinking water

• Immunization: Not availing free service of Immunization

• Political will and Health policies

Levels for strengthening child health services/ Reducing IMR

Strengthening of child health services should be considered at the following levels:

• Policy level: Advocacy with governments and major donors for child-friendly

movements, including national health systems management and financing strategies that ensure equitable access and quality of essential health care for marginal groups (including health insurance systems for the poor), especially in the context of privatization and decentralization, as well as review of policies on decentralization, cost-sharing, and co-management of health systems.

• District level: Improving access, quality, sustainability, and equity of health

systems through child- and women-friendly movements can be instrumental to efforts being made in the regional context of privatization, decentralization, and economic crisis.

• Community level: Strengthening community links, which are essential to facilitate family care, referrals of obstetric complications and sick children, and increase health staff

accountability for quality care and equity of access. This includes improving the capacity and motivation of primary health care staff (especially midwives), community health and social volunteers, teachers, and mass organizations to support family care. Improve capacities and motivation to identify limiting factors in family care practices and resources and develop appropriate communication and intersectoral support strategies to improve care and empower families.

• Family level and Mother Level: Improving family care practices, especially breast feeding,

household-level integrated management of childhood illness, promotion of hygiene practices, use of bed nets, and women's empowerment and psychosocial stimulation (which are not only essential for prevention of protein-energy malnutrition and sanitation but also for maternal mortality reduction and child mortality goals). This implies identifying limiting factors in family care practices and resources as well as developing appropriate communication and intersectional

support strategies to improve care and to empower families.

Integration of Infant Health programs with other Sectors & Programs

• The integration of child health activities with activities in other sectors – such as water and sanitation, education, food security, agriculture, economic growth, microfinance, and democracy and governance – can potentially achieve high-yield gains for health.

• Also integration with other related programs: HIV, Family Planning/Reproductive Health, Maternal Newborn and Child Health .

• Doing awareness sessions and Advocacy for making the programs effective.

• Organizations working for infant health are: UNICEF, USAID, WHO, FDA, Save the children, Hope for children, Children in the new millennium, etc.

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