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 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.