Johanna Rubin A GLOBAL PERSPECTIVE ON Paediatrician PhD Karolinska/Södersjukhuset CHILDHOOD INFECTIONS Stockholm GLOBAL HEALTH- PUBLIC HEALTH ON A GLOBAL LEVEL?
Inequalities in health; - between regions - between sexes - between agegroups
CHILD MORTALITY
“Despite progress over the past two decades, in 2018 alone, an estimated 6.2 million children and young adolescents under age 15 died, mostly from preventable causes. Newborns account for 2.5 million of these deaths, children aged 1−11 months for 1.5 million, children aged 1−4 years for 1.3 million, and just under 1 million deaths for children and young adolescents aged 5- 14 years.”
(WHO website) Group I –other communicable, maternal, perinatal and nutritional conditions THE PEDIATRIC PERSPECTIVE PEDIATRIC INFECTIONS Pediatric perspective in medicine
Panorama of pediatric infections of public health importance Immunizations Access to care
Regional differences and focus areas
What to remember DEFINITION OF INDICATORS IN PEDIATRIC GLOBAL HEALTH
Under-five mortality rate: Probability of dying between birth and exactly 5 years of age, expressed per 1,000 live births. Infant mortality rate: Probability of dying between birth and exactly 1 year of age, expressed per 1,000 live births. Neonatal mortality rate: Probability of dying during the first 28 days of life, expressed per 1,000 live births. Probability of dying among children aged 5–14: Probability of dying at age 5–14 years expressed per 1,000 children aged 5. PEDIATRIC PERSPECTIVE IN MEDICINE
”Difficult” to treat ”Difficult” to diagnose
Caregiver dependent
Vaccine preventable WHAT IS CHILDHOOD INFECTIOUS DISEASES?
Age-specific infections? Age-specific symptoms and disease characteristics Primary infections
Neglected PEDIATRIC INFECTIONS Pediatric perspective in medicine
Panorama of pediatric infections of public health importance Immunizations Access to care
Regional differences and focus areas
What to remember MOST IMPORTANT CHILDHOOD INFECTIONS?
Pneumonia/pneumococcal infection/pertussis Diarrhoea Neonatal sepsis Malaria Hiv Neonatal tetanus Measles Meningitis IS INFECTIOUS DISEASE PREVENTION THE KEY TO REDUCING OVERALL CHILD MORTALITY?
Yes!
Quote from ”Levels and Trends in Child Mortality”, WHO 2015: “Most child deaths are caused by diseases that are readily preventable or treatable with proven, cost- effective and quality-delivered interventions. Infectious diseases and neonatal complicationsare responsible for the vast majority of under-five deaths globally”.
At least two-thirds of all child deaths are preventable. (WHO/Unicef Decade report 2010.) The burden In 2008, WHO estimated that 1.5 million of deaths among children under 5 years were due to diseases that could have been prevented by routine vaccination. This represents 17% of global total mortality in children under 5 years of age
WHAT HAS CONTRIBUTED TO THE DECLINE IN UNDER 5 MORTALITY?
A 79 per cent worldwide decrease in measles deaths between 2000 and 2015
Also: a major progress in preventing mother to child transmission of HIV (GOAL 4). HTTPS://SIGHT.NU/2019/06/28/A-NEW-ROADMAP-ON-GLOBAL-CHILD-HEALTH/ Group I –other communicable, maternal, perinatal and nutritional conditions NEONATAL DEATHS: The first 28 days of life – the neonatal period – are the most vulnerable time for a child’s survival. The global neonatal mortality rate fell from 36 deaths per 1,000 live births in 1990 to 18 in 2017. The decline in neonatal mortality over 1990–2017 has been slower than that of post-neonatal under-five mortality. Vaccine available
Group I –other Vaccine communicable, available maternal, perinatal and nutritional conditions
Vaccine available Vaccine available BENEFITS OF IMMUNISATION:
Approximately 17% of deaths in children under five are vaccine-preventable. If all children were immunized with existing vaccines, we could save nearly 25 million lives between 2011 and 2020. In 2014, an estimated 86 per cent of infants worldwide were vaccinated with three doses of the vaccine required to fully immunize them against diphtheria, tetanus and pertussis (DTP3 vaccine) – up from 20% in1980.
BCG- TB vaccine DTP- diphteria/tetan us/pertussis MCV- measles containing vaccine Hib3- Hemophilus influenzae PCV- pneumococcal vaccine Rota- rotavirus gastro-enteritis
NEONATAL SEPSIS
Interlinked with work on maternal and child health; maternity care, delivery in a hospital. Riskfactor; low birth weight; protective factor: beastfeeding. Related to WASH and health care facility hygiene WHO is promoting sepsis prevention, early and appropriate diagnosis, and timely and appropriate clinical management, in order to address sepsis comprehensively. LINK TO IMMUNIZATIONPROGRAMS WORLDWIDE http://apps.who.int/immunization_monitoring/globalsummary
App: Immunization summary, WHO NASOPHARYNX AS A RESERVOIR FOR THE PNEUMOCOCCI
1. NPH colonisation
2. Primary 4. Secondary dissemina 3. Bacteremia spread tion •Pneumonia •Meningitis •Septicemia NASOPHARYNX AS A RESERVOIR FOR THE PNEUMOCOCCI
1. NPH colonisation
2. Primary 4. Secondary dissemina 3. Bacteremia spread tion •Pneumonia
•Meningitis Antibiotic •Septicemia NASOPHARYNX AS A RESERVOIR FOR THE PNEUMOCOCCI
1. NPH colonisation
2. Primary 4. Secondary dissemina 3. Bacteremia spread tion •Pneumonia
•Meningitis Antibiotic •Septicemia Pneumococcal Vaccine
DIARRHOEA
.. In another lecture…. BUT: Vaccination reduces rotavirus-related hospitalizations by up to 92% and hospitalizations related to all causes of diarrhea by up to 55% in countries that implement the rotavirusvaccine. In some countries deaths from all causes of diarrhea declined by up to 50% (20- 50%) following rotavirus vaccine introduction.
As of August 2018, 98 countries have introduced rotavirus vaccines. 57% , over 70 million children still lack access to rotavirusvaccine. (Rota council webpage) MALARIA
Another lecture! Remember the pediatrc perspective!
MEASLES IS THE MOST CONTAGIOUS DISEASE KNOWN TO MAN.
Despite a 79 per cent worldwide decrease in measles deaths between 2000 and 2015, nearly 400 children still died from the disease every day, in 2015. MEASLES •transmitted via droplets from the nose, mouth or throat of infected persons. • the virus can stay active and contagious in the air or on surfaces for two hours. • 30-40 millions infected every year • decrease from 750 000 children died in 2001 to 118 000 children in 2011most of the deceased are < 5 years old.
Arabic proverb: ”Count your children before the mealses arrives” MEASLES: There is no specific antiviral treatment against the measles virus.
In populations with high levels of malnutrition and inadequate health care, measles can kill in up to 10% of cases.
Symptoms tend to be high fever, runny nose, cough, red and watery eyes, small white spots on the inside of the cheeks, and widespread rash all over the body.
HOW DANGERUOUS ARE THE MEASLES?- -COMPLICATIONS IN 20% OF CHILDREN
7-9 % otitis 1-6 % pneumonia 1-2 ‰ encefalitis 1 out of 1000-2000 dies 1-9 of 100 000 SSPE (Subacute sclerosing panencefalitis)
Bild: Margareta Blennow MEASLES IN EUROPE
• Usually around 1000 – 2000 measles cases/yr in EU EEA countries • Peak Around 14 000 cases during the years 2010 + 2011 • 2016: 5000 cases • 2017: 25 000 cases • 2018 over 80 000 cases MPR- VACCINE/MEASLES VACCINE
Ca 95% protective effect for all three diseases Live vaccine- after 1 to 2 weeks a weakened version of the disease can occur Percent vaccinated against measles-mumps-rubella vid 2 års ålder vid 3 års ålder 98 96 94 92 90 88 86 84 82 80
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 Immunizations coverage (%) Immunizations coverage Year of birth MEASLES OUTBREAK OCH HERD IMMUNITY https://www.theguardian.com/society/ng-interactive/2015/feb/05/-sp-watch-how- measles-outbreak-spreads-when-kids-get-vaccinated HERD PROTECTION JOHN CLEMENS, ICDDR,
Infection Basic Reproduction Number (R0) Herd Immunity Threshold (%) Time taken from infection to transmission Proportion protected individuals to prevent spread
Diphtheria 6-7 85
Measles 13-15 : England (1947) 90-95% 11-13: Candad (1912-13)
Mumps 11-14: Netherlands (1970-80) 72-88%
Pertussis 12-17 92-94
Polio 5-6: USA (1955) 50-93 Rubella 6-7: West Germany (1970-79) 95-98%
Smallpox 4-6: Bangladesh (1940) 80-85
Ebola 1.5-2.5 33-60 Varicella 7-8: USA (1943) 87-90 HIV-1 11-12: Kenya (1981-85) Influenza (h1n1) 1-1.5: England (2010) •Outbreak control, elimination and eradication strategies for Diphtheria, Measles and Rubella: Ann Lindstrand, EPI Coordinator, WHO, Geneva •The Americas verified rubella eliminated in 2015 and measles eliminated in 2016…. However re-establish measles transmission due to large outbreaks in Venezuela and Brasil in 2018-2019. •Combined bOPV/MCV SIA’s being implemented (Nepal, Myanmar, Uganda, Sierra Leone, Sudan, PNG, DRC) •Newt Global Vaccine Action Plan: The Immunization Agenda 2030-Vision and Strategy for immunization 2021-2030 (Draft has been shared on 15 May, 19 to get inputs by 14 June, 19)
Goal for 2020 was to eliminate measles from all 6 WHO regions and elimante rubella from atleast 2 WHO regions. Following are the results by 2019: WHO Region Elimination achieved in % of Countries Smallpox Measles Rubella No of countries Humans only Yes Yes Yes America (n=35) Measles: 33 94% host Clinically Yes No No Rubella: 35 100% distinctive Europe (n=53) Measles: 37 70% illness Contagiousne 5-7 12-18 6-7 Rubella: 37 70%
ss R0 Western Pacific Measles: 7 (+2 26% Herd 80-85% 92-94% 83-85% (n=27) nonMS) immunity 15% threshold Rubella: 4 (+1 nonMS) Spread prior Rare Common to rash Eastern - - Effective 1 ++++ ++ +++ Mediterranean dose (n=21) intervention South-East Asia Measles: 4 18% (n=11) Africa (n=47) - - Measles: 81 (43%)
Rubella: 76 (39%) TETANUS TETANUS IS CAUSED BY THE BACTERIUM CLOSTRIDIUM TETANI, THE SPORES OF WHICH ARE WIDESPREAD IN THE ENVIRONMENT. The disease is caused by the action of a neurotoxin, produced by the bacteria when they grow in the absence of oxygen, e.g. in dirty wounds or in the umbilical cord if it is cut with a non-sterile instrument. Tetanus is characterized by muscle spasms, initially in the jaw muscles. Tetanus can be prevented by the administration of tetanus toxoid, which induces specific antitoxins. To prevent maternal and neonatal tetanus, tetanus toxoid needs to be given to the mother before or during pregnancy, and clean delivery and cord care needs to be ensured. Time to symptoms: 10 (3-21) days. Mortality 10-70% 82% of children are protected in the neonatal period (by mothers immunisation) TETANUS
Prevention • DTP vaccination • 100% protection after 3 doses • Protection declines after 5-10 years • Booster needed in later childhood • Protection for 20-30 years after 5 doses • Immunisation to pregnant women important! • Wound hygiene and hygiene at deliveries Maternal and neonatal tetanus, which is extremely fatal in newborns, has been eliminated in all but 13 countries as of March 2019.
From https://www.unicef.org/immunization/files/unicef-who-immunization-coverage-2015.pdf PERTUSSIS- WHOOPING COUGH is a highly contagious bacterial disease of the respiratory tract, caused by Bordetella pertussis It occurs mainly in infants and young children, •The first symptoms generally appear 7–10 days after infection, and include mild fever, runny nose, and cough, which in typical cases gradually develops into a paroxysmal cough followed by whooping (hence the common name of whooping cough). •In the youngest infants, the paroxysms may be followed by periods of apnoea. Pneumonia is a relatively common complication; seizures and encephalopathy occur more rarely Whooping cough in Sweden 1940-2011 25000 Whole cell Vaccination Acellular stopped vaccine 20000
15000
10000
5000
0 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 year PERTUSSIS- VACCINE
In 2008, about 82% of all infants worldwide received 3 doses of pertussis vaccine. - averting about 687 000 deaths, but about 195 000 children died from the disease.
Pertussis toxoid and parts of the surface of the bacteria Effect 75-90% Immunity after immunisation is 6-7 years and after disease about 15 years – not life long! •In Sweden 1 child dies every other year in pertussis POLIO
1% of patients gets paralysis, half of these permanent paralysis. 1953 in Sweden 5000 cases. Massvaccination1957. 1961 ; 64 cases No domestic case in sweden since 1977. . In 1988, there were 350 000 annual cases of wild polio from 125 countries. In 2018, there were just 33 reported from two – Afghanistan and Pakistan Europe polio free 2002 Of the three wild poliovirus strains, type 2 is already eradicated and we are poised to certify the eradication of WPV3 (which has not been seen since 2012) in late 2019. Once three years have passed without any transmission of WPV1, wild poliovirus will be eligible to be certified as eradicated globally. This will be followed by the global cessation of OPV use and a separate, independent process to validate the absence of vaccine-derived polio. All stakeholders must remain committed to continuing vaccination campaigns until this disease is eradicated for good. Polio still endemic in i Nigeria, Pakistan, Afghanistan, Polio Endgame Strategy Källa: WHO/UNICEF
POLIO
Polio is eradicated, one strain at the time:
Type 2 Last seen 24 Oct 1999- declared eradicated!
Type 3: Last seen 10 Nov 2012 declared eradicated 2019!
Type 1: Is next…
Since 2014, countries have been preparing for the switch from trivalent OPV to bivalent OPV to minimize the risks associated with the phased removal of OPV. To maintain immunity levels to type 2 polio, high-risk countries introduced IPV into routine immunization programmes prior to the switch. POLIO- VACCINE
Good effect both oral (OPV) och and inj (IPV) Full effect with 4 doses MENINGOCOCCAL DISEASE
•Meningococcal meningitis is a bacterial form of meningitis. •The most common symptoms are a stiff neck, high fever, sensitivity to light, confusion, headaches and vomiting. Even when the disease is diagnosed early and adequate treatment is started, 5% to 10% of patients die, typically within 24 to 48 hours of the onset of symptoms. •Bacterial meningitis may result in brain damage, hearing loss or a learning disability in 10% to 20% of survivors. • It is fatal in 50% of cases if untreated. •Several different bacteria can cause meningitis. Neisseria meningitidis is the one with the potential to cause large epidemics. Twelve serogroups of N meningitidis have been identified, six of which (A, B, C, W135, X and Y) can cause epidemics. •Major epidemics have been occurring over the past 100 years in the African "meningitis belt”, that spans sub-Saharan Africa from Senegal to Ethiopia. •In 1996 to 1997, the largest epidemic in history swept across the belt, causing over 250000 cases, an estimated 25 000 deaths, and disability in 50 000 people. Large epidemics recur in the meningitis belt on a regular basis. MENIGOCOCCAL DISEASE
WHO recommends that all countries with high (>10cases /100000 population/year) or intermediate (2-10 cases/100000) endemic rates of invasive meningococcal disease and countries with frequent epidemics should introduce appropriate large scale meningococcal vaccination programmers Since the introduction of MenAfriVac, a revolutionary vaccine developed by WHO and PATH, more than 280 million people in African countries affected by the disease have been vaccinated. And this has led to the control and near elimination of the deadly meningitis A disease in the region. In 2012, MenAfriVac became the first vaccine to gain approval for travel outside the cold chain – for as long as four days without refrigeration and at temperatures of up to 40°C. The vaccine is now being integrated into routine national immunization programmes. HEPATITIS IN CHILDREN (A, B, C)
Hepatitis B prevalence is highest in sub-Saharan Africa and East Asia, where between 5–10% of the adult population is chronically infected. In the Middle East and the Indian subcontinent, an estimated 2–5% of the general population is chronically infected. Less than 1% of the population of Western Europe and North America is chronically infected. HEPATITIS B IN CHILDREN In infants and children: 80–90% of infants infected during the first year of life develop chronic infections 30–50% of children infected before the age of 6 years develop chronic infections. In adults: less than 5% of otherwise healthy persons who are infected as adults will develop chronic infection; and 20–30% of adults who are chronically infected will develop cirrhosis and/or liver cancer. HEPATITIS B IN CHILDREN
A vaccine against hepatitis B has been available since 1982. The vaccine is 95% effective in preventing infection and the development of chronic disease and liver cancer due to hepatitis B.
HEPATITIS B IN CHILDREN
As of 2014, 184 Member States vaccinate infants against hepatitis B as part of their vaccination schedules and 82% of children in these states received the hepatitis B vaccine. In many countries where between 8–15% of children used to become chronically infected with the hepatitis B virus, vaccination has reduced the rate of chronic infection to less than 1% among immunized children. http://www.plosntds.org/ http://www.end7.org/ https://www.youtube.com/watch?v=A0dccSabKas HELMINITIC INFECTIONS
The burden of disease associated with helminth infections (schistosomiasis and soil-transmitted helminth (STH) infections) ( intestinal worms!) is enormous, with at least 2 billion people affected worldwide. The highest rates of infection are often in children between the ages of 5 and 15 years. HELMINITIC INFECTIONS;
•Deworming improves health, nutrition and physical development, makes pregnancy safer and improves birth outcomes according to studies. • It is inexpensive, can be given in schools typically costing between US$ 0.25 and 0.50 per child per year. •The treatment is safe, even in pregnancy and when given to uninfected children. PEDIATRIC INFECTIONS Pediatric perspective in medicine
Panorama of pediatric infections of public health importance Immunizations Access to care
Focus areas; hesitancy, adolescents, Regional differences, TB, HIV What to remember HESITANCY………
In 2019, WHO declared vaccine hesitancy to be one of the top 10 threats to public health. Stages in vaccine acceptance and coverage NEGATIVE EFFECTS?!
In Sweden more than 1 million doses of vaccine are administered to children and adolescents every year. In 2013 about 500 reports on side-effects were made for children under 18 years of age. No deaths reported. ¼ of the reported side effects were considered serious events, but not all of these could be directly linked to the vaccine. Fever and skin reactions were the most common complaints.
GLOBAL HEALTH- INFECTIOUS DISEASES
Infectious diseases in children
The first 28 days Neonatal Infant (up to 1 yr) Under five 5-9? 10-14? 14-19? ADOLESCENTS
WHO defines adolescents as those aged 10-19 years, while young population includes those aged 15-24 years. Adolescent Health is part of the Child and Adolescent Health Programme. Most young people are thought of as healthy but many serious diseases in adulthood have their roots in adolescence. More than 1.1 million adolescents aged 10-19 years died in 2016, over 3000 every day, mostly from preventable or treatable causes. Road traffic injuries were the leading cause of death among adolescents in 2016. Other major causes of adolescent deaths include suicide, interpersonal violence, HIV/AIDS and diarrhoeal diseases. Globally, there are 44 births per 1000 to girls aged 15 to 19 per year. African region: Thanks to improved childhood vaccination, adolescent deaths and disability from measles have fallen markedly – for example, adolescent mortality from measles fell by 90% in the African Region between 2000 and 2012. Diarrhoea and lower respiratory tract infections are estimated to be among the top 10 causes of death for 10–19 year olds. These two diseases, along with meningitis, are all among the top five causes of adolescent death in African low- and middle- income countries. (WHO regional webpages) Most children and adolescents in the The Region enjoy a high standard of health and well-being. However, disparities in child health between and within countries persist. The Region includes countries WHAT REGION?! with the lowest infant and child mortality rates in the world, but mortality in In 2013 2.9 million children under five died. This is equivalent countries with the highest rate for children to five children under 5 years of age dying every minute. Two under 5 years is up to 20 times higher thirds of these deaths can be attributed to preventable than that in countries with the lowest rate. causes. The primary causes of death in children under-5 Every year, too many children in the include pneumonia, preterm birth complications, diarrhoea, Region die before the age of 5 – 52% of birth asphyxia and malaria. Approximately one third of all them in the first month of life. childhood deaths are linked to malnutrition.
Over the years, Member States in the Region have reported significant progress in reducing child mortality. However, at the Children below five years of age represent 12% of the total population in the current rate of progress the Region as a whole is unlikely to achieve the MDG 4 target by 2015. Infant mortality and under- Region. In 2011, about half a million more children in the Region were able to reach five child mortality remain high in some countries, though other countries have been able to reduce it. About one third of all child deaths in the world occur in Region. High neonatal mortality is their fifth birthday compared with 1990, thanks to country efforts to improve child still a big challenge in the Region, and is responsible for about health. Despite a remarkable reduction in child deaths in recent decades, more than half of under-five deaths. Pneumonia and diarrhoeal disease are the leading causes of 900 000 children under five still die in the Region each year. post-neonatal mortality in the Region. Effective and and relatively inexpensive interventions are available but their coverage remains low in several Member States. However, Over 40% of these deaths occur in the neonatal period, the first 28 days of life. immunization coverage is relatively better in most countries, suggesting that health systems have the potential to deliver Pneumonia and diarrhoea remain leading causes of mortality in countries with a high services. There is a large disparity in child health by sex, poverty, residence, mother's education level and social status, not under-five mortality rate. Malaria is also a major killer in one country in the region. only in mortality but also in the coverage of interventions. 1 in 4 boys and nearly 1 in 6 girls drink alcoholic beverages once a week at age 15 and trends vary very much across the ADOLESCENTS Region. 25% of 15-year-olds have had sexual intercourse, but more than 30% in some countries are not using condoms or any other form Adolescents are prone to early unwanted of contraception, resulting in sexually transmitted diseases and pregnancies, septic abortions, sexual unintended pregnancies. abuse, HIV, alcohol and substance use and abuse and vulnerability to risks associated a considerable proportion of children in many countries in the with early sexual activity and child region do not meet recommended levels of physical activity (1 in marriage, and limited access to family 3 children aged 6-9 are overweight or obese) and over 60% of children who are overweight before puberty will be overweight planning services. in early adulthood.
Major causes of death in adolescens Assault (homicide) Land transport accidents Itentional self harm suicide Accidental drownng and submersion malignant neoplasmd hematopoetic lymphoid tissue.
PREVENTION
• Breastfeeding helps prevent diarrhoea and helps to build a strong immune system in newborns and young children. • While most healthy children can thrive with their natural defences, malnutrition and children who are not exclusively breastfed can suffer compromised immune systems. • Exclusive breastfeeding for the first six months of life is recommended. • Adults who were breastfed as babies often have lower blood pressure, lower cholesterol, lower rates of overweight and obesity, and type 2 diabetes. • Breastfeeding contributes to the health and well-being of the mother and can reduce the risk of breast and ovarian cancers. • The promotion and support of breastfeeding alone is estimated to prevent 12% of deaths in children under-5 in the European Region . Malnutrition makes newborns and children vulnerable to both infectious and non-infectious diseases through a weakened immune system.
(WHO African Region and European Regional pages) Children are not small adults DIAGNOSING TB IN CHILDREN !TRADITIONAL WAYS DON'T WORK! TB IN CHILDREN
Young children and infants don't spread TB
Difficult diagnosis and treatment HIV IN CHILDREN PMTCT 77%
Access to PMTCT 2015 DOES CHILDREN GET ACCESS TO TREATMENT?
In the reportTowards universal access by WHO from Unicef and UNAIDS from 2009 the progress access to ARV treatment in 144 low and middle income countries was assessed: 15 countries including Botswana, Guyana and Southafrica, reached 80% of pregnant women with PMTCT programmes.
14 countries among them Brazilia, Namibia and Ukraine, had ARV access to 80% of children living with hiv SWAZILAND SWAZILAND: HIV PREVALENCE PREGNANT WOMEN
2004 42.6% 2006 39.2%
45,00% 40,00% 35,00% 30,00% 25,00% HIV prevalence 20,00% 15,00% 10,00% 5,00% 0,00% 1992 1994 1996 1998 2000 2002 2004 CHILDREN’S CLINICAL CENTRE OF EXCELLENCE WWW.BIPAI.ORG 1990 2006 2012 Life expectancy 57 35-40 år (2011) 50
Under 5 mortality (1980: 143) (per 1000 live births) 110 156 (2011) 104 (47% of deaths due to AIDS) (23% of deaths due to AIDS)
Maternal mortality 560 (2000) 320 (per 100 000 live 370 born infants)
Over all HIV 4% (2003) 38% (18-49) 32% (18-49 år) prevalence 25% 26%
TB prevalence 620 (2004) (2011) 1120 854
TAKE HOME MESSAGE: Children are not small adults