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Child Health and Mortality Prevention Surveillance- Bangladesh Site
Background
Childhood mortality is gradually declining over the past two decades, but still remains high. Despite multiple initiatives, approximately six million children under the age of five (16,000/day) still die every year (World Health Organization, 2015). Majority of those deaths are in the low income settings in sub-Saharan Africa and south Asia. In lower and middle income countries, individuals often die without having been seen by qualified medical personnel and are frequently buried or cremated without a documented medical history, before an evaluation of the cause of death can be conducted; many times these deaths are not counted at all. Even for those that die at a health facility, determining cause of death is often difficult due to the scarcity of diagnostic tools and multiple coexisting illnesses, which often leads to an incorrect or imprecise physician ascribed cause of death.
In response to the limitations of currently available data, the Child Health and Mortality Prevention Surveillance (CHAMPS) Network was established to develop a long-term network of sites in developing countries to collect robust and standardized primary data aimed at understanding and tracking the preventable causes of childhood deaths globally. These sites will help gather better data in a faster way and about how, where and why children are getting sick and dying. This data will help the global community and the countries in improving health delivery system and to manage cases in a better way to reduce child mortality. Furthermore, this data will help take the right interventions to the right children in the right place to save lives. The overall goal of the CHAMPS Network is, to-
Provide accurate, timely and reliable data on the causes of death for children under age five
Inform policy and program decisions aimed at reducing child deaths.
CHAMPS is a multi-country project, currently being implemented in seven countries in Africa and Asia with a plan to expand in thirty countries over the next 20 years; Bangladesh site is the initial selection from South East Asia. Funded by Bill and Melinda Gates Foundation (BMGF), the Network is a collaborative effort of
Current CHAMPS sites in Sub-Sahara and South Asia |
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more than 135 global partners, including ongoing engagement with National Public Health Institutes, governments, in country organizations, universities, and program office staff from the Emory Global Health Institute of the Emory University, the International Association of National Public Health Institutes, the United States Centers for Disease Control and Prevention, the Task Force for Global Health's Public Health Informatics Institute, the Barcelona institute for Global Health (ISGlobal).
CHAMPS Bangladesh Site
In the last decades, Bangladesh has performed miraculously in reducing under five deaths and maternal deaths. The child mortality went down from 133 deaths per 1000 live-birth in 1994 to 46 deaths per 1000 live-births in 2014. Though the progress is satisfying, Bangladesh feels that, there still is a long way to go. To understand the causes of under five deaths and still births, and to find out the evidence based ways to prevent those, Bangladesh joined the CHAMPS network with the following key objectives;
1. To identify under-5 deaths and stillbirths in Baliakandi sub-district of Rajbari district
2. To determine causes of under-5 deaths and stillbirths in the study population in Baliakandi and the extended area, including using minimally invasive tissue sampling (MITS)
3. To estimate overall and cause-specific mortality rates (stillbirth and under-5)
To oversee the planned activities of CHAMPS in Bangladesh, to aid its smooth functionality, to determine the cause of deaths in under-five children and also to find out the preventive measures to minimize deaths, three committees with concerned stakeholders and different terms of references were formed; those are-
1. Technical Committee
2. Coordination Committee
3. DeCoDe Committee
CHAMPS’s Site Partners in Bangladesh
CHAMPS-Bangladesh is being implemented by the well-known research organization, International Centre for Diarrhoeal Diseases, Bangladesh (icddr,b), in collaboration with the Bangabandhu Sheikh Mujib Medical University (BSMMU), and the Institute of Epidemiology, Disease Control and Research (IEDCR) under the ministry of Health and Family Welfare (MoHFW) of the people’s Republic of Bangladesh. The main objective of this project is to identify the exact cause of stillbirths and deaths among children less than five years of age and the ways to prevent those. Baliakandi upazila (sub-district) under Rajbari district was selected as the CHAMPS-Bangladesh study field site due to its high child mortality of more than 50 deaths/1000 live births. The sentinel facilities are in the Faridpur Medical College Hospital (FMCH), Zahid Memorial Children Hospital (ZMCH) and the Baliakandi Upazila Health Complex (BUHC), where MITS facilities are established with trained human resources. To further strengthen the MITS activities in FMCH and ZMCH, six upazilas of Faridpur districts were later included as the extended field study sites.
CHAMPS Bangladesh Field Site:
Baliakandi upazilla, situated in the west-central part of Bangladesh, has more than thirty medical facilities, including seven union health and family welfare centers, 23 community clinics and few private clinics. The main hospital for the sub-district is the fifty bed Baliakandi Upazila Health Complex (BUHC), which receives patient referral from all other area facilities. BUHC provides both curative and preventive services including, general health care, maternal and child health, adolescent and reproductive health, mental health, nutritional and immunization services to the upazilla population. The hospital is equipped to handle child delivery and small surgical procedures. Cases that cannot be treated at BUHC are referred to the Rajbari Sadar Hospital or the Faridpur Medical College Hospital.
CHAMPS Bangladesh Field Site area:
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CHAMPS Bangladesh Activities:
CHAMPS-Bangladesh has established a demographic surveillance system (DSS) with GIS mapping at Baliakandi upazila, to collect demographic information from the households. In addition, pregnancy surveillance in conjunction with the demographic surveillance is facilitating identification of stillbirths and neonatal deaths to assist in understanding the causes of these deaths, which are often unaccounted for. An extensive community engagement process was initiated and will continue throughout the project to sensitize the community about CHAMPS-Bangladesh activities. In addition, formative research on cultural and religious beliefs and practices was conducted prior to implementation and research on these topics and on general community perceptions will continue throughout the project period to identify and respond to the influences of socio-behavioral factors on CHAMPS activities. These community engagement and qualitative research activities allow CHAMPS to understand community perceptions of MITS and pregnancy surveillance in order to assess feasibility and increase acceptance of CHAMPS. In addition, a call center was established to provide the community with general medical advice and referral support to foster community engagement and support for MITS.
The CHAMPS mortality surveillance is aiming to capture both perinatal causes of deaths and deaths in infants and children under five years, and deaths caused by both infectious and non-infectious aetiologies. CHAMPS will follow all children till their fifth birthday. Any children who die, including children stillborn, will be identified from both sentinel health facilities and the community. In Bangladesh, in the first phase the MITS activities will evolve around the sentinel health facilities. For deaths identified in a health facility, after obtaining consent from parents/guardians, the body is moved to a private room at the facility for the MITS procedure. In the forthcoming second phase, for deaths detected in the Baliakandi community, after consent, corpse will be transported either to BUHC, or specially equipped vehicle/mobile site for MITS, based on discussions, ethnographic information and advice of the supervisory committees.
In the ongoing first phase, by using minimally invasive tissue sampling (MITS) techniques, CHAMPS-Bangladesh is collecting tissue samples from lung, heart, brain, liver, bone marrow of recently deceased children or still borne by trained experts. Advanced laboratory techniques including both conventional and advanced histopathology and molecular screening for various pathogens is being used on the collected specimens to attribute cause of death. Further training of the BSMMU and icddr,b laboratory scientists were arranged to facilitate proper diagnosis. Additionally, along with epidemiologic data, standard WHO verbal autopsies are also being conducted on all fatal cases. Clinical information on the mother and the diseased are also collected for proper determination of cause of death by the DeCoDe committee and ultimately to find out the ways for preventing those premature deaths. DeCoDe panel, consisting of experts from different medical college, institutes and universities are reviewing all the cases in deciding on the cause of death.
IANPHI supported capacity building activities for the Institute of Epidemiology, Disease Control and Research (IEDCR) are going on to improve data to action capacities related to child mortality prevention by using CHAMPS data. IEDCR personnel along with other child health program implementing partners will receive training on data analysis, cost benefit, decision analysis, data outcomes sharing, and policy development. Establishment of a web based platform for dissemination of CHAMPS findings through IEDCR website is completed.
It is anticipated that, having pathologically confirmed data from the CHAMPS-Bangladesh site and also from other sites, we will know the definitive information on the cause of death of children, can formulate ways to prevent those, and will be able to implement timely effective measures to reduce these premature morbidity and mortality of children to a minimum level in Bangladesh.