South-East Asia Regional Conference on Epidemiology

184 | <strong>South</strong>-<strong>East</strong> <strong>Asia</strong> <strong>Regional</strong> <strong>Conference</strong> on Epidemiology
At more than 1000 people in a square kilometre, Bangladesh is the most densely populated country
in the world. The extreme level of crowding has string effects on disease transmission and on other
living conditions that contribute to increased risk of disease. Bangladesh has an estimated 42 million
people living in urban areas, which is likely to double in the next 20 years. Major adjustments will
need to be made in health-care delivery systems to respond to this shift. There is a need to focus on
urban areas which have a very different disease burden mix and practices. About 100 000 people live
in the largest slum in Dhaka. Disease transmission increases in crowded areas with poor living and
insanitary conditions, use of unsafe water and extreme air pollution. There are also issues of lack of
social support for families with sick children. People migrating to Dhaka, and particularly those living
in the slums, lack social support and have to take care of themselves and their families. Economic
demands also mean that both parents may have to be working. They have to cope with inadequate
time for child care and an extreme diversity of health-care providers. These problems will increase
with increasing urbanization.
Diarrhoea and pneumonia prevention and control is now subsumed under the WHO/UNICEF’s
Integrated Management of Childhood Illness (IMCI) strategy initiated in the 1990s. IMCI aims to
reduce death and disability and promote growth and development of under-five children. It includes both
preventive and curative interventions and has three main components: improvements in case-management
skills of health staff, health systems and community and family health practices. In many ways, IMCI was
designed around treatment as a key strategy for child survival. At the core is the IMCI case management
guidelines for health facility-based management. It promotes accurate assessment of illness of the child and
appropriate treatment and improves the counselling of caregivers on appropriate care-seeking behaviours,
improved nutrition and preventive care and correct implementation of the prescribed care.
In 2006, IMCI in Bangladesh moved away from being a strategy and acquired the status of a
programme with the merger of previous acute respiratory infections (ARI) and diarrhoea control
programmes into it. An effect of this was that all support from WHO/UNICEF that had been historically
for ARIs and diarrhoea was shifted to IMCI, severely affecting programmes in areas where IMCI has
not yet been scaled up. IMCI implementation in Bangladesh is also characterized by an emphasis on
health-facility worker training. There was an underlying assumption that IMCI will be dealing with all
five main causes of child deaths - diarrhoea, pneumonia, measles, malnutrition and malaria. However,
the programme lost sight of the fact that the control of pneumonia required other interventions to happen
as well to achieve the reduction in child mortality; for example, the use of antibiotics, breastfeeding,
reduction in indoor air pollution, immunization, etc. It is critical that we carefully assess what needs
to be done comprehensively to reduce the burden of pneumonia and diarrhoea.
In 2006, UNICEF and WHO released a report on pneumonia as ‘the forgotten killer’ of children.
This has now been followed by a global action plan for the prevention and control of pneumonia. It
basically highlights three interventions that need to be implemented at scale and high coverage: (1)
protection of children by providing an environment so that they have a low risk of pneumonia, i.e.
promotion of breastfeeding, adequate nutrition, preventing and reducing air pollution and increased
hand washing; (2) preventing children becoming ill by vaccination with DPT, measles, Hib and
pneumococcal vaccines, preventing and treating HIV, and providing zinc as part of treatment of
diarrhoea; and (3) treatment of children who become sick with pneumonia. The action plan includes
recommendation to countries to take actions in terms of designating, preferably an existing group,
to take on this charge, generating political will through advocacy, and undertake a situation analysis
for pneumonia involving other programmes; for example, hand washing, sanitation and indoor air
pollution. The areas of collaboration within health services include increasing the coverage for
vaccination as well as access to case management which is currently not very high. Most importantly,
a way has to be found for tracking progress. Interestingly, for pneumonia, there is no data on a key
indicator, i.e. the percentage of pneumonia that is treated with antibiotics.