WHO priorities and plans 2012/13 Dr Jarno Habicht WHO Representative 15 December 2011.
1 Risk of mortality is greater among women without access to hygiene, sanitation,water RR of Infant...
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Transcript of 1 Risk of mortality is greater among women without access to hygiene, sanitation,water RR of Infant...
1
Risk of mortality is greater among women without access to hygiene,
sanitation,water
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2.5
5.2
0
1
2
3
4
5
6
Exclusive BF no BF (with toilet
& piped water)
no BF (no toilet or
piped water)
Rel
ativ
e Ris
k
RR of Infant Mortality by Feeding Mode and Health Environment
Habicht et al., 1988
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Percent of Total Population with Access to Safe Water
0
20
40
60
80
100Bot
swan
a
Mal
awi
Nig
eria
Tan
zani
a
Indi
a
Hon
dura
s
Rural
Urban
UNICEF, 2002
3
Percent of Total Population with Access to Adequate Sanitation
0
20
40
60
80
100
Botswana Malawi Nigeria Tanzania India Honduras
Rural
Urban
UNICEF, 2002
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Feeding Options Currently Recommended by WHO (1998)
• Breastfeeding
– exclusive breastfeeding
– heat-treated breast milk
– wet-nursing
– milks banks
– early cessation of breastfeeding (as soon as feasible)
• Replacement feeding
– commercial infant formula
– home prepared infant formula (modified, with additional nutrients)
– enriched family diet with BMS/MN supplements after 6 months
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What do we know about the feasibility of exclusive
breastfeeding? (BFHI/MCH/IMCI) -1
0%
20%
40%
60%
80%
100%
Program Control
% infants breastfed exclusively in previous 24 hours < 6 months
< 4 months
@ 3 months @ 5 months
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EBF rates at 6 weeks - over time and after the introduction of an education and
counseling program on safer breastfeeding practices in Harare, Zimbabwe (n=9,931)
0102030405060
11/97 to
6/98
7/98 to
1/99
2/99 to
8/99
9/99 to
10/99
11/99 to
01/00
Study Period
%
Education and counseling intervention began
ZVITAMBO data
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Exclusive breastfeeding rates in PMTCT programs with infant feeding counseling - Barcelona
AIDS abstracts
87%
59%
42%31%
0%
20%
40%
60%
80%
100%
Zambia South Africa India Botswana
Methodologies and ages at measurement varied
8
Methods used for measuring exclusive breastfeeding produce different rate
estimates n=970 mothers exposed to infant feeding counseling
ZVITAMBO data
Exclusive Breastfeeding at 3 months
14.120.9
31.738.8
01020
304050
Conditional
Ever
Ever 7 day recall 24 hr recall
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What do we know about the feasibility of early/rapid
breastfeeding cessation? -1Potential risks for
infant
• Dehydration
• Anorexia
• Later behavior problems
• Malnutrition
• Illness or death
Potential risks for mother
• Engorgement • Mastitis• Increased risks of
pregnancy• Depression • Stigma• Possible reversion to
breastfeeding
Piwoz et al, 2002
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What do we know about the feasibility of early breastfeeding
cessation? -2 Barcelona AIDS Conference
• Early, rapid cessation is possible (Uganda, Zambia, Botswana)
• Problems encountered– breast engorgement; mastitis; babies crying, trouble
sleeping, appetite loss, diarrhea; financial constraints with replacement feeding; family objections
– more problems when cessation < 6 months (Botswana)
• Trained counselors were able to help mothers overcome problems
• Provision of replacement feeds, family support facilitated process
• Impact on HIV transmission, survival not yet known
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Breast milk contributes > 50% of the nutrient intake of children
> 6 months in developing countries and won’t be easy to
replace
0102030405060708090100
Energy Protein Calcium Vitamin A Vitamin C Folate Zinc
% c
ontr
ibut
ion
of B
M
6- 8 months 9- 11 months
Adapted from WHO, 1998; Dewey and Brown, 2002 using data from Bangladesh, Ghana, Guatemala, Peru
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What do we know about the feasibility of other
breastfeeding options?• Heat-treated breast milk
– heating milk to 56-62.5 degrees C for 12-15 min inactivates HIV in human milk (Jeffreys et al 2001)
– no data on feasibility of daily use from birth
– may be practical during transition period with early cessation
• Use of wet nurse - no data – monitoring HIV status of wet nurse a challenge
– practice may be less common because of HIV
• Milk banks - no data– may be feasible in some settings (Brazil, LA Region)
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What do we know about the feasibility of commercial
formula?• High acceptance/adherence in some countries with
access to clean water, health care, subsidized cost
– Thailand, Brazil, South Africa, Botswana
• Adherence with exclusive use may be higher than for exclusive BF (Botswana)
• Stigma associated with its use widely reported in Africa
• Access to safe water, health care needed
• Proper instruction on safe preparation, feeding
• Cost - > 6 months supply
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Formula use in selected programs where provided
free100% 98% 89%
46%33%
0%
20%
40%
60%
80%
100%
Brazil Thailand Botswana Uganda Cote
d'I voire
Barcelona AIDS Conference
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Uptake of Infant Formula in PMTCT program sites in SA
0%
20%
40%
60%
80%
100%
W. Cape Mpumalanga Kwa Zulu
Natal
Eastern Cape
Peri/Urban Rural
McCoy et al, 2002
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Evidence of Spillover?Infant feeding patterns in PMTCT vs.
non-PMTCT sites in Botswana (< 6 months, 24 hr recall)
0%10%20%30%40%50%60%70%80%
Exclusive
BF
Use Infant
Formula
Give other
fluids
PMTCT: HIV- negmothers
Comparison: Statusunknown
MOH/UNICEF, 2002
P< 0.001
EBF is lower, mixed feeding is higher in PMTCT sites
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What do we know about the feasibility of home prepared
formula?• Nutritional adequacy and cost studied in KwaZulu
Natal, SA
• Fresh and powdered full-cream milk
• Findings:
– intakes of vitamins E, C, folic acid, pantothenic acid < 33% of adequate intake (AI)
– intakes of zinc, copper, selenium, vitamin A < 80% AI
– intakes of EFA were < 20-60% AI
– cost was $9.80/month or 20% of average monthly income
– preparation time was 20-30 minutes for 120 ml
Papathakis et al, 2002
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Challenges for the Future• Policy issues:
– Can we reframe the debate on breastfeeding versus replacement feeding?
– What is the role of commercial infant formula?
• Implementation:– How do we implement October 2000 guidance/scale up?
• Research:– Risk analysis and counseling hampered by uncertainty
– Can breastfeeding or replacement feeding be made safer for HIV+ women?
• Learning from ALL our experience
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Can we reframe our thinking and discussion on this issue? -1
• Let’s talk about improving HIV-free survival instead of reducing HIV transmission– reflects higher objective
– resolves conflicting strategies
• Let’s talk about reducing postnatal transmission instead of HIV transmission through breastfeeding– more accurate
– less emotional
– less burdened with the weight of history
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Can we reframe our thinking and discussion on this issue? -2
• Focus on maternal health & nutrition – Keeping HIV+ mothers well may be among the most
important things we can do to prevent P/N transmission
– BF transmission was ~2% between 6 w-24 months in WA study among women with CD4 >500 (Leroy et al, 2002)
– Nutrition depletion, weight loss during BF may increase risk of maternal mortality (Nduati et al, 2001)
– Keeping mothers alive will improve child’s chances for survival (Nduati et al, 2001)
– ARV use during BF now being studied
21
Can we make breastfeeding safer for HIV+ women? -1
• Enhance health/nutrition care for women
• Provide adequate lactation counseling and support, involving families/communities
– increase adherence to exclusive breastfeeding
– promote good breastfeeding techniques
– prevent cracked nipples, maintain breast health
• Immediate treatment for mastitis, other systemic infections that could affect viral load in BM
– could prevent a sizeable fraction of BF transmission
– may be most important in early month(s)
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Can we make breastfeeding safer for HIV+ women? -2
• Assist families with early breastfeeding cessation
– assess health status of mother and infant
– prepare for the process so that the transition is safe (cup-feeding, safe preparation/hygiene, stigma)
– heat treat breast milk if weaning is gradual
– could prevent sizeable fraction of BF transmission
• Provide adequate nutrition after breastfeeding ends
– appropriate breast milk substitutes and/or multi-nutrient supplements should be provided to prevent malnutrition
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HIV and Infant Feeding Risk Analysis in Setting where IMR=89/1000:
Improving maternal health & safer BF practices
750
800
850
900
950
1000
0 6 12 18 24
Age (months)
HIV
-fr
ee S
urvi
vors
SBF+HM
RF
Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during delivery, healthy mother, EBF, lactation management (SBF+HM) reduces postnatal transmission by 67%; IMR=89/1000
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HIV and Infant Feeding Risk Analysis in Setting where IMR=100/1000:
Improving maternal health & safer BF practices
750
800
850
900
950
1000
0 6 12 18 24
Age (months)
HIV
-fr
ee S
urvi
vors
SBF+HM
RF
Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during delivery, healthy mother, EBF, lactation management (SBF+HM) reduces postnatal transmission by 67%;
25
HIV and Infant Feeding Risk Analysis in Setting where IMR=135/1000:
Improving maternal health & safer BF practices
750
800
850
900
950
1000
0 6 12 18 24
Age (months)
HIV
-fr
ee S
urvi
vors
SBF+HM
RF
Assumptions: 1000 live births; 20% prevalence; 20% transmission before & during delivery, healthy mother, EBF, lactation management (SBF+HM) reduces postnatal transmission by 67%;
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What is the role of commercial formula for replacement
feeding? • It is the best option for RF if conditions can be met
– formulated specially for humans, nutritionally fortified
– safe water, access to health care, training in safe preparation, feeding required to make it safe
– postnatal follow-up also required (monitor growth, ensure adequate access/availability)
– cost will make it NOT affordable for poor families to purchase
– cost may make it NOT sustainable for governments
– Code of Marketing of BMS protects against misuse if enacted/enforced
– But “spillover” may be unavoidable if BF support for HIV-negative and status unknown mothers is not adequate
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Can we make replacement feeding safer for HIV+ women?
• Provide safe water & environmental conditions
• Family support, community understanding
• Postnatal follow-up and enhanced care
– essential child health interventions
• Screen mothers, target use to those most at risk
• Take measures to prevent unnecessary use of RF
• We must strengthen, not abandon, our efforts to support optimal infant feeding for all because of HIV. The need is even greater when PMTCT programs provide infant formula to HIV+ women.