Moving the needle on neonatal and child health
Authors: Zoë Mullan
Journal: The Lancet Global Health (2014)

Babies and children feature heavily in this August issue of The Lancet Global Health, as well they should at a time when unfinished agendas are top of the agenda. In its 2014 report on the Millennium Development Goals, released on July 7, the UN described the under-5 mortality goal as “slipping away from achievement by 2015”. The research and opinion in this month's issue harnesses a variety of different angles from which to “move the needle” on neonatal and child health. How can we ensure that neonatal interventions reach the very poorest families who need them the most? Are we doing enough for children with tuberculosis? What is the role of malaria in low birthweight? And are there any unintended adverse consequences of the introduction of new vaccines in Africa?In their Comment, Tanja Houweling and colleagues attack the first question on the back of the launch on June 30 of the Every Newborn Action Plan. The plan called for investment in perinatal care, better quality of care, greater access, community engagement, and better data collection and management. In order to realise these objectives, Houweling and colleagues advocate for greater use of women's participatory groups—whereby women themselves identify and prioritise problems during pregnancy, delivery, and post partum, and then plan and implement locally feasible strategies to address them. Such groups are well placed to identify and inform the lowest-income families and to empower them to demand respectful, high-quality care. Alone, however, they cannot tackle the problems of underinvestment, substandard medical education, and poor regulation that can only be solved with the help of our old friend political will.Both political and private-sector will come into play in the question of paediatric tuberculosis. In their modelling study, Peter Dodd and colleagues estimate that the burden of tuberculosis is about 25% higher than previously thought. Looking at the 22 countries that account for 80% of the world's burden of tuberculosis, they estimate that around 650 000 children developed the disease in 2010. A comparison with official notifications suggested that the case detection rate for children was a mere 35% (compared with 66% for adults). National programmes are clearly failing children, and diagnostic tests and treatment regimens for this age group still lag behind those for adults. Dodd and colleagues are hopeful that careful estimation of the burden of tuberculosis in children can spur action. As Dodd stated in a press release to accompany the paper, “without good numbers, there can be no targets for improvement, no monitoring of trends; and there is a lack of evidence to encourage industry to invest in developing medicines or diagnostics that are more appropriate for children than those available today.”The biggest single cause of child mortality is preterm birth, and infection during pregnancy is an important risk factor for that. In their Article, Patrick Walker and colleagues use mathematical modelling to estimate the burden of low birthweight (due to either preterm birth or intrauterine growth restriction) caused by malaria in Africa. They calculate that, without pregnancy-specific protection, a woman in Africa has a roughly 50-50 chance of being exposed to malaria infection during pregnancy, and a one in five chance of developing placental infection. This figure relates to 900 000 entirely preventable low birthweight deliveries per year. Since most transmission occurs before or early in pregnancy, Walker and colleagues recommend synergy between malaria prevention programmes and antenatal and family planning programmes and rightly call for protection of pregnant women from malaria to be made a public-health priority.Joined-up thinking is also a lesson that emerges from Ane Fiske and colleagues' observational study in Guinea-Bissau. In their Article, they describe a decrease in measles vaccine coverage by 12 months of age after the introduction of pentavalent vaccine (diphtheria, tetanus, pertussis, Haemophilus influenzae type b, and hepatitis B). What went wrong? The answer probably lies in a concurrent decision to introduce a stricter wastage policy and to focus on vaccination by 12 months of age. These policies, which were instigated in response to GAVI guidance but which were not in themselves proposed by GAVI, seem to have resulted in vaccinators not opening any ten-dose vials of measles vaccine unless at least six children were present. Some children's vaccinations thus seem to have been delayed until they passed 12 months, after which they no longer became a priority age group.Be sure to read the rest of the issue for more varied and thought-provoking analysis of efforts to keep a grip on the slippery goal of MDG5. Babies and children feature heavily in this August issue of The Lancet Global Health, as well they should at a time when unfinished agendas are top of the agenda. In its 2014 report on the Millennium Development Goals, released on July 7, the UN described the under-5 mortality goal as “slipping away from achievement by 2015”. The research and opinion in this month's issue harnesses a variety of different angles from which to “move the needle” on neonatal and child health. How can we ensure that neonatal interventions reach the very poorest families who need them the most? Are we doing enough for children with tuberculosis? What is the role of malaria in low birthweight? And are there any unintended adverse consequences of the introduction of new vaccines in Africa? In their Comment, Tanja Houweling and colleagues attack the first question on the back of the launch on June 30 of the Every Newborn Action Plan. The plan called for investment in perinatal care, better quality of care, greater access, community engagement, and better data collection and management. In order to realise these objectives, Houweling and colleagues advocate for greater use of women's participatory groups—whereby women themselves identify and prioritise problems during pregnancy, delivery, and post partum, and then plan and implement locally feasible strategies to address them. Such groups are well placed to identify and inform the lowest-income families and to empower them to demand respectful, high-quality care. Alone, however, they cannot tackle the problems of underinvestment, substandard medical education, and poor regulation that can only be solved with the help of our old friend political will. Both political and private-sector will come into play in the question of paediatric tuberculosis. In their modelling study, Peter Dodd and colleagues estimate that the burden of tuberculosis is about 25% higher than previously thought. Looking at the 22 countries that account for 80% of the world's burden of tuberculosis, they estimate that around 650 000 children developed the disease in 2010. A comparison with official notifications suggested that the case detection rate for children was a mere 35% (compared with 66% for adults). National programmes are clearly failing children, and diagnostic tests and treatment regimens for this age group still lag behind those for adults. Dodd and colleagues are hopeful that careful estimation of the burden of tuberculosis in children can spur action. As Dodd stated in a press release to accompany the paper, “without good numbers, there can be no targets for improvement, no monitoring of trends; and there is a lack of evidence to encourage industry to invest in developing medicines or diagnostics that are more appropriate for children than those available today.” The biggest single cause of child mortality is preterm birth, and infection during pregnancy is an important risk factor for that. In their Article, Patrick Walker and colleagues use mathematical modelling to estimate the burden of low birthweight (due to either preterm birth or intrauterine growth restriction) caused by malaria in Africa. They calculate that, without pregnancy-specific protection, a woman in Africa has a roughly 50-50 chance of being exposed to malaria infection during pregnancy, and a one in five chance of developing placental infection. This figure relates to 900 000 entirely preventable low birthweight deliveries per year. Since most transmission occurs before or early in pregnancy, Walker and colleagues recommend synergy between malaria prevention programmes and antenatal and family planning programmes and rightly call for protection of pregnant women from malaria to be made a public-health priority. Joined-up thinking is also a lesson that emerges from Ane Fiske and colleagues' observational study in Guinea-Bissau. In their Article, they describe a decrease in measles vaccine coverage by 12 months of age after the introduction of pentavalent vaccine (diphtheria, tetanus, pertussis, Haemophilus influenzae type b, and hepatitis B). What went wrong? The answer probably lies in a concurrent decision to introduce a stricter wastage policy and to focus on vaccination by 12 months of age. These policies, which were instigated in response to GAVI guidance but which were not in themselves proposed by GAVI, seem to have resulted in vaccinators not opening any ten-dose vials of measles vaccine unless at least six children were present. Some children's vaccinations thus seem to have been delayed until they passed 12 months, after which they no longer became a priority age group. Be sure to read the rest of the issue for more varied and thought-provoking analysis of efforts to keep a grip on the slippery goal of MDG5. How to reach every newborn: three key messagesThe Every Newborn Action Plan (ENAP) launched on June 30–July 1, 2014, envisages a world without preventable deaths of newborn infants.1 The challenge is not technical (effective interventions exist), but instead social. The odds of a child surviving the first month of life are grossly unequal, even within one country, and are affected by wealth, education, caste, and access to health care. Large gains are achievable when interventions reach people who are in need, but this rarely occurs. Without dedicated efforts to reach poor people, ENAP initiatives are likely to favour wealthier people who have the lowest mortality risk. Full-Text PDF Open AccessBurden of childhood tuberculosis in 22 high-burden countries: a mathematical modelling studyOur model has shown that the incidence of paediatric tuberculosis is higher than the number of notifications, particularly in young children. Estimates of current household exposure and cumulative infection suggest an enormous opportunity for preventive treatment. Full-Text PDF Open AccessEstimated risk of placental infection and low birthweight attributable to Plasmodium falciparum malaria in Africa in 2010: a modelling studyOur calculations are the only contemporary estimates of the geographical distribution of placental infection and associated low birthweight. The risk of placental infection across Africa in unprotected women is high. Prevention of malaria before conception or very early in pregnancy is predicted to greatly reduce incidence of low birthweight, especially in primigravidae. The underlying lifetime risk of low birthweight changes slowly with decreasing transmission, drawing attention to the need to maintain protection as transmission falls. Full-Text PDF Open AccessEffects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in MozambiqueThe large decreases in child mortality seen in Mozambique between 2000 and 2010 could have been partly caused by improvements in the public-sector health workforce, institutional birth coverage, and government health financing. Increased attention should be paid to service availability, because population per health facility is increasing across Mozambique and is associated with increased under-5 mortality. Investments in health information systems and new methods to track potentially increasing subnational health disparities are urgently needed. Full-Text PDF Open Access