global burden of neonatal disease: aring for the … · “in 2014, preterm birth affected about 1...

GLOBAL BURDEN OF NEONATAL DISEASE:

CARING FOR THE WORLD’S MOST VULNERABLE PATIENTSSHAUN ODELL MD

2017 NEWBORN PEDIATRIC CRITICAL CARE CONFERENCE

MAY 5, 2017

OBJECTIVES

1. Discuss the disproportionately large impact that newborn disease has on the state of world health

2. Review known commonalities of at-risk neonates

3. Recognize ways to improve newborn health in local communities

DEFINITIONS

• Neonate: child in the first month of life

• Childhood mortality: Deaths per 1000 in children less than 5

• Infant mortality: Deaths per 1000 in children less than a year

• Neonatal mortality: Deaths per 1000 children less than one month of age; must show evidence of life: HR, etc

• Excellence: A term best defined visually

OUTLINE

• Background

• Demographics

• Causes of Neonatal Mortality

• Clinical Scenario

• Successes/Challenges

• Conclusions

BACKGROUND

• Millennium Development Goals: World leaders from 189 countries, 8 goals

• Goal 4: Reduce by two thirds the rate of mortality in children under 5

BACKGROUND

Between 1960 and 1990 childhood mortality decreased significantly (current mortality)

BACKGROUND

• Progress made:

–28% decrease from 1990 to 2008

– Declined from 12.5 million deaths

in 1990 to 8.8 million in 2008

BACKGROUND

• Progress slower than expected

–At present rate goal reduction would occur by 2045

• Reasons include:

–AIDS

– Increasing poverty

– Slow progress in reducing neonatal mortality

• Fewer resources available (PNA, diarrhea, etc)

BACKGROUND

Lawn JE, Cousens S, Zupan J (2010)

BACKGROUND

everynewborn.org

BACKGROUND

How many newborns are dying? Where? Why?

OUTLINE

• Background

• Demographics




• Conclusions

DEMOGRAPHICS: HOW FREQUENTLY

3.6 million neonatal deaths

–32/1000 live births

–Double the number of deaths of any age due to HIV/AIDS

data.worldbank.org

DEMOGRAPHICS: HOW FREQUENTLY

• Neonatal Period: 28 days long, but 46% of childhood mortality

–54% arise over the following 1800 days

• 25-50% of neonatal deaths in the first 24 hours

• 75% in the first week

DEMOGRAPHICS: NEONATAL DEATHS BY DAY OF LIFE

Lawn JE, Cousens S, Zupan J (2010)

DEMOGRAPHICS

• Neonatal mortality by income

– 99% in Low and Middle Income countries

– One of the major health inequities of the world

• Geographical risk can be broken down two ways:

– Neonatal mortality rate (NMR)

– Absolute number of neonatal deaths

DEMOGRAPHICS

• Neonatal mortality by region (deaths per 1000 births)

– Africa 44 (range 9-70)

– Eastern Mediterranean 40 (range 4-63)

– SE Asia 38 (range 11-43)

– Western Pacific 19 (range 1-40)

– Americas 12 (range 4-34)

– Europe 11 (range 1-38)

• Two-thirds in Sub-Saharan Africa and South Asia

1990

2010

% of Deaths in Children <5Attributable to Neonatal Causes

DEMOGRAPHICS

• Countries with the largest numbers of neonatal deaths in percent of world total (neonatal mortality rate per 1000):

– India 27% (43)

– China 10% (21)

– Pakistan 7% (57)

– Bangladesh 4% (53)

– Ethiopia 4% (36)

– Congo 3% (47)

• 60% of the mortality in six countries

OUTLINE

• Background

• Demographics

• Causes Of Neonatal Mortality



• Conclusions

CAUSES OF NEONATAL MORTALITY

• <3% of neonatal deaths take place with reliable vital registration data

– ie higher mortality countries less likely to have resources for accurate records

• Information largely based on verbal autopsy methods (quality can be variable)

– Global estimates possible through statistical modeling

NEONATAL MORTALITY

3 main causes: Asphyxiation (24%), Infections (15%), Prematurity (35%)

www.everynewborn.org

NEONATAL MORTALITY: BIRTH ASPHYXIA

Estimated 6-7 million require some form of resuscitation at birth

4 million newborns with birth asphyxia each year

• 904,000 deaths

• Equal number have sequelae related to asphyxia (CP, epilepsy, sensory deficit)


• Perceived obstacles:

–Training

–Technology


Programs underway to assist with resuscitation in resource limited settings

– Based on simple algorithms


• Aided by data showing that resuscitation with ambient air is effective (or better than 100% O2)

• Would save up to 200,000 lives

OUTLINE

• Background

• Demographics


– Asphyxia

– Infections

– Preterm Complications



• Conclusions

NEONATAL MORTALITY: INFECTIONS

INSTITUTE FOR HEALTH METRICS AND EVALUATION

More than 1,000,000 neonatalDeaths/year


In high mortality settings (NMR > 45) 50% of deaths due to infections

Incidence of Neonatal Sepsis (per 1000 live births):

• Asia 7.1 to 38

• Africa 6.5 to 23

• United States and Australasia 6 to 9


• Almost exclusively affect the poorest families

– Majority of infants who die of infections lack access to healthcare and antibiotics


• Sepsis

– Klebsiella

– Escherichia coli

– Pseudomonas

– Salmonella

– Staphylococcus aureus

– Coagulase negative staph

– Streptococcus pneumoniae

– Strep pyogenes

• Notably absent: GBS


1. Antenatal care

2. Hygienic care during childbirth and postnatally

3. Hand washing

4. Early breastfeeding

OUTLINE

• Background

• Demographics


– Asphyxia

– Infections

– Preterm Complications



• Conclusions

NEONATAL MORTALITY: COMPLICATIONS OF PRETERM BIRTH

INSTITUTE FOR HEALTH METRICS AND EVALUATION


• Over 1,000,000 deaths per year

• Causes of preterm deliveries

– 45-50% idiopathic

– 30% premature rupture of membranes

– 15–20% medically indicated or elective preterm deliveries

• Global incidence figures difficult to find. Statistical modeling estimates:

– 9.6% of all births were preterm (<37 weeks)

• 15 million births

– 85% in Africa and Asia

• Reflection of stark health disparities


“In 2014, preterm birth affected about 1 of every 10 infants born in the United States. Preterm birth is the greatest contributor to infant death…preterm birth is also a leading cause of long-term neurological disabilities in children.”

- CDC 2015

“Every year, an estimated 15 million babies are born preterm, and this number is rising. Three-quarters of them could be saved with current, cost-effective interventions. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.”

- WHO 2015



• Significant morbidity with higher rates of:

– Cerebral Palsy

– Sensory Deficits

– Learning Disabilities

– Respiratory Illnesses

• Financial costs of prematurity per year (US alone): $26.2 billion

– Medical expenses

– Educational programs

– Lost productivity


Number of preterm births appear to be increasing:

1. Increasing rates of multiple births

2. Increased use of fertility treatments

3. Increased proportion of births in women older than 34

4. Changing clinical practices (increased use of ultrasound and C-section delivery)


Most between 33 and 37 weeks

– Survival depends on treatment of difficulties breathing, infections, jaundice

OUTLINE

• Background

• Demographics




• Conclusions

CLINICAL SCENARIO

A young physician in the US decides to expand his family

CLINICAL SCENARIO

Meanwhile his twin living in Sub-Saharan Africa makes the same decision

CLINICAL SCENARIO

Likelihood that:

– a skilled attendant will attend the delivery: >99% vs 25-33%

– the birth will take place in a health facility: 98% vs 33%

CLINICAL SCENARIO

Risk of dying in the first 28 days in developing countries:

– 11-fold higher for infectious causes

– 8-fold higher for asphyxia

– 3-fold higher for causes related to prematurity

– Overall NMR 6x higher in low and middle income countries

OUTLINE

• Background

• Demographics




• Conclusions

SUCCESSES/CHALLENGES

• “Reduce by two thirds, between 1990 and 2015, the under-five mortality rate”

– Between 1990 and 2008, childhood mortality was reduced by 28 percent


Global rates of neonatal death are decreasing

– 64.7/100000 in 1990

– 28.6/100000 in 2013


• 400,000 fewer neonatal deaths now compared to 10 years ago

– 150,000 fewer deaths from infectious causes

– 80,000 fewer deaths from asphyxia

– 80,000 fewer deaths from preterm complications

• …Rates of disability due to neonatal conditions:

–64.7 years of life lost to disability (YLD) per 100000 in 1990

–120.6 years of life lost to disability (YLD) per 100000 in 2013.

• This trend is present in all neonatal conditions

–most prominent in preterm births which increased from 29.9 and 57.3/100000 YLD over the same time frame.


SUCCESSES/CHALLENGES: PORTUGAL

Portugal: 30 years ago high neonatal and infant mortality


1989 reform:

• Smaller maternal wards closed

• Nationwide transport system for pregnant women and newborns begun

• Training intensified (post graduate education in neonatology emphasized)


Outcomes:

• Maternal and perinatal death rates decreased

• Infant mortality decreased from 12.2 to 4 per 1000 live births

• Neonatal mortality decreased from 8.1 to 2.7 per 1000 live births

• Achieved with no additional cost

SUCCESSES/CHALLENGES: INDIA

Gujarat in India: 55 million inhabitants


Interventions

• Private Obstetricians/gynecologists contracted to provide delivery care

• Limited to the poor rural births

• 800 obstetricians, 176,000 women delivered in hospitals

• Increase from 27% of deliveries in hospitals to 53% after initiation


Outcomes

• Neonatal deaths decreased from 8,462 to 559

• Cost of extending to all of India: $250 million

• 27% of global neonatal mortality


• Cuba: Fraction of low birth weight infants halved between 1978 and 2005

• Chile: Infant mortality decreased from 136/1000 to 16/1000 in the years from 1950 to 1990.

– A second phase of progress started in 1990 decreased deaths to 5/1000.


Success of industrialized nations in the mid 20th century

SUCCESSES/CHALLENGES: UNITED KINGDOM

• United Kingdom: NMR fell from 30/1000 live births in 1940 to 10/1000 in 1975.

• Availability of antibiotics

• Free antenatal care

• NICU facilities only became available after the NMR had fallen below 15

SUCCESSES/CHALLENGES: TETANUS

• Tetanus: 1,000,000 neonatal deaths in 1980

• 59,000 deaths annually in 2008

• Not a major source of mortality in industrialized nations before the introduction of tetanus toxoid

• Example of the effect that targeted interventions can have

Tetanus

Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S (2010)

SUCCESSES/CHALLENGES: TETANUS


Global mortality of newborns is declining. The Caveat:

Mostly in High-income countries:

Percentage change in NMR from 1996-2005

High-income countries: -29%

Low-income countries: -8%

Americas -40%

Africa +5%

COST EFFECTIVE INTERVENTIONS

Darmstadt G, Bhutta Z, Cousens S, Adam T, et al (2005)

COST EFFECTIVE INTERVENTIONS

If scaled up would reduce neonatal mortality by 72%

“High-tech, high-cost, specialist driven, hospital based neonatal care is not required to meet much of the present challenge of neonatal survival…”

A LOCAL PROBLEM

• Neonatal Mortality rate in US 4x higher than in Iceland

– Rate amongst children of black women 11x higher

• 2000 more preterm births in the US in 2015 compared to 2014

– Seven states with highest increase in prematurity rates: Arkansas, Connecticut, Idaho, Nebraska, New Mexico, Utah and Wisconsin

COMPLICATIONS OF PRETERM BIRTH

• “According to the latest data available from the World Health Organization, the U.S in 2010 ranked in the middle of the pack, falling behind Somalia, Afghanistan and Thailand.”

http://www.who.int/mediacentre/factsheets/fs363/en/

A LOCAL PROBLEM

Institute for Health Metrics and Evaluation 2017

WHY ARE RATES HIGHER IN THE US?

• High rates of prematurity

– Fertility treatment, elective inductions and cesarean deliveries

• Access to health care

• Pre-pregnancy planning

• Health

– Highest rates of obesity and diabetes in the developed world

CONCLUSIONS

• 3.5 million neonates die yearly, the majority from a small number of causes

• The vast majority of deaths occur in low and middle income countries

• Decreasing global childhood mortality to goal levels is not possible without a greater focus on neonates

CONCLUSIONS

• Interventions to decrease mortality do not need to be high tech or high cost solutions

• Room for improvement close to home

REFERENCES

Saugstad OD. Reducing global neonatal mortality is possible. Neonatology. 2011; 99:250-257.Paul VK. The current state of newborn health in low income countries and the way forward. Sem in Fetal &

Neonatal Med. 2006; 11:7-14.Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S. 3.6 million neonatal deaths—what is progressing and

what is not? Sem in Perinatology. 2010; 34: 371-376.Lawn JE, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet. 2005; 365: 891-900.Darmstadt GL, Bhutto ZA, Cousens S, Adam T, Walker N. Evidence-based, cost-effective interventions: how

many newborn babies can we save? Lancet. 2005; 365: 977-988.Vergnano S, Sharland M, Kazembe P, Mwansambo C, Heath PT. Neonatal sepsis: an international perspective.

Arch Dis Child Fetal Neonatal Ed. 2005; 90(3):F220-4.Mathews TJ, MacDorman MF. Infant mortality statistics from the 2007 period linked birth/infant death data

set. National Vital Statistics Reports. 2011; 59(6):1-30.Rajaratnam JK, Marcus JR, Flaxman AD, et al. Neonatal, postneonatal, childhood, and under-5 mortality for

187 countries, 1970-2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet. 2010; 375: 1988-2008.

Oestergaard MZ, Inoue M, Yoshida S, et al. Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Medicine. 2011; 8(8): 1-13.

Hill K, Choi Y. Neonatal mortality in the developing world. Demographic Research. 2006; 14: 429-452.Reid A. Neonatal mortality and stillbirths in early twentieth century Derbyshire, England. Population Studies.

2001; 55:213-232.

Preterm Birth Complications

• Newborn weight, a predictor of adverse outcomes:

– 60-80% of neonatal deaths are low birth weight (LBW) infants

• Only 14% of births

– Higher amongst preterm LBW infants than term IUGR babies

• Mortality 5x higher for preterm LBW infants vs full-term growth restricted babies

Acknowledgements…

• Adam Weinstein MD

• Alison Ricker

• John Modlin MD

• Diane Kittredge MD

• Heather Robertson MD

• Paul Palumbo MD

• Penninah Oberdorfer MD

• Somporn Chotinaruemol MD

• Woraporn Tiyaprasertkul MD

• George Little MD

• Claudia Zegans MD

• Gautham Suresh MD

• Dorothy Mullaney APRN, MHS

• Dianna Odell MSW, LICSW et al

global burden of neonatal disease: aring for the … · “in 2014, preterm birth affected about 1...

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