Monitoring & Evaluation Unit NATIONAL CHILD HEALTH REPORT. Strategic Information Department

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1 SI Y I N Q A B A KINGDOM OF SWAZILAND MINISTRY OF HEALTH NATIONAL CHILD HEALTH REPORT Expanded Program on Immunization (EPI), Management of Childhood Illnesses (IMNCI) Program, Nutrition Program 2015 Monitoring & Evaluation Unit Strategic Information Department

2 This publication was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-0AA-L Views expressed are not necessarily those of USAID or the United States government

3 TABLE OF CONTENTS Acronyms...v Acknowledgements...vi Executive Summary...vii Indicator Summary...viii Chapter 1: Introduction...1 Chapter 2: Program Background Expanded Program on Immunizations Integrated Management of Childhood Illnesses Swaziland Nutrition Program The Swaziland National Nutritional Council (SNNC)...7 Chapter 3: Immunization Coverage for Children Routine Immunization Trends on Routine Immunization by region, Measles DT Polio Rota Vaccinations Dewormming of Children in Swaziland Vitamin A Coverage Vaccines Supply, Quality and Management Cold Chain...14 Chapter 4: Health Data on Management of Childhood Illnesses Health Data on Management of Childhood Illnesses Under 1 Death by Sex Contribution to Under 1 Year by Condition Contribution of diseases to Mortality Under 1 Status of Health Admissions by Region Top 10 leading causes of admissions for under 1s in Top causes of admissionsby Region Under 5 Mortality in Facilities Under 5 Mortality rate by sex Death by Region Causes of death for Under 5 in Swaziland Leading causes of death by sex, Admissions of Under 5 by Region and sex Causes of Under 5 admissins Contribution of In-patient diseases for Under 5 by Region Illnesses in Under 5 in Outpatient Departments Diarrheal diseases Endocrine nutritional & metabolic diseases Infectious and parastic diseases Notifiable diseases Ear, Eye, and Dental Problems, by Region, Injury and Road Traffic Accidents...32

4 Respiratory diseases Home Based Care and Child Health Nutritional Status Nutritional status by age Nutritonal Status by Age Group and Region...37 Chapter 5: Program Achievements Achievement of EPI Program Activities Achievement of IMNCI Program Activities Nutrition Program Program Challenges EPI Challenges IMNCI Challenges Nutritional...43 Chapter 6: Conclusions and Recommendations Conclusions Recommendations...45 References...46 List of Figures Figure 1: Child Mortality Status, Figure 2: Nutritional Status of Children under 5 in Swaziland, Figure 3: Annualized DPT3, Measles and Polio 3 administrative coverage...9 Figure 4: Number of Measles Vaccines Administered, Figure 5: DT3 Immunization Coverage by Region, Figure 6: Number of DPT3 Vaccines Administered, Figure 7: OPV 3 (Polio Vaccine) Coverage by region, Figure 8: Number of Rota 1 and 2 Vaccinations by Region, Figure 9: Albendazole 1st Dose Coverage by ANC Visit, Figure 10: Number of Albendazole Vaccinations for TB administered by region, Figure 11: Number of Vitamin A doses administered by region, Figure 12: Under 1 Mortality by Year Figure 13: Under 1 Admissions and Death Rates by Region Figure 14: Under 1 Mortality by Year by Region Figure 15: Proportion of deaths by sex, under Figure 16: Proportion contribution of Under 1 deaths to Under 5 Mortality Figure 17: Top 10 leading causes for Under 1s in Figure 18: Total number of Under 5 deaths in facilities Figure 19: Under 5 mortality rates in Health facilities...23 Figure 20: Number of Under 5 Deaths in Facilities by Sex Figure 21: Number of Under 5 Deaths in Facilities by Region and Sex Figure 22: Leading Causes of Under 5 Deaths by Sex Figure 23: Proportion causes of Death for Under 5 in Swaziland Figure 24: Leading Causes of deaths by sex Figure 25: Leading Causes of admissions Figure 26: Leading causes of under 5 admissions Figure 27: National Proportional Contribution of Top 10 Causes of Admissions for Under 5 years List of Tables Table 1: Schedule for EPI antigens...5 Table 2: Leading causes of Under 5 admissions by diagnosis and region

5 LIST OF ACRONYMS Ads AEFI AFP CCIT CHMT CMS CVS RHMT DPT-Hep B+Hib DQA RSFP RVD EPI FY GAVI HF DPG HepB Hib HSSP ICC IDSR IEC LMIS MDVP MOH MSD NGO NNT PBM PNFP RCCO RED REC RHMT SIAs RVS SNIDs SMT TT UNICEF VMA VPD VVM WHO Auto-Disable Syringes Adverse Events Following Immunization Flaccid Paralysis Cold Chain Inventory Tool Council Health Management Team Central Medical Stores Central Vaccine Stores Regional Health Management Team Diphtheria, Pertussis, Tetanus, Hepatitis B and Haemophilus influenzae b vaccine Data Quality Audit Regional Surveillance Focal Person Regional Vaccine Depot Expanded Programme on Immunization Financial Year Global Alliance on Vaccines and Immunization Health Facilities Development Partners Group for Health Hepatitis B Haemophilus Influenzae type b Health Sector Strategic Plan Interagency Coordinating Committee Integrated Disease Surveillance Response Information, Education and Communication Logistics Management Information System Multi Dose Vial Policy Ministry of Health Medical Stores Department Non-Governmental Organization Neonatal Tetanus Paediatric Bacterial Meningitis Private Not for Profit Regional Cold Chain Officer Reaching Every District Reaching Every Child Regional Health Management Team Supplemental Immunization Activities Regional Vaccine Store Sub-national Immunization Days Stock Management Tool Tetanus Toxoid United Nations Children s Fund Vaccine Management Tool Vaccine Preventable Diseases Vaccine Vial Monitor World Health Organization

6 ACKNOWLEDGEMENT This annual report would not have been possible without the tireless hard work of health care providers, RHMTs, and Ministry of Health leadership and direction. The following programs are mentioned for the review, writing, and support, Expanded Program on Immunization, Integrated Management of Childhood Illnesses, and the Nutritional Program. Funding and support was provided through the Institute for Health Measurement, and technical support towards child health in Swaziland is made possible through continuous support from UNICEF, and WHO. Lastly the strategic information department within the Ministry of Health which ensures data collection at facility level through HMIS, and analysis and reporting through M&E has made the report possible.

7 EXECUTIVE 71% SUMMARY DEMOGRAPHICS The majority of deaths occur before the child has turned 1 years old. Under 1 death contributed 71% to the under 5 mortalities in Swaziland Child Mortality and Morbidity Total Swaziland Population for 2015: of which: Infant mortality by sex: 48% 52% 6.1% 3,588 admissions for children under the age of 1 in 2015 Total of 219 (6.1%) resulted in death children under the age of 1 16% 16% of Swazi population are children under the age of 5 Regional Distribution of children: MANZINI HHOHHO Population of children is under the age of 5 LUBOMBO SHISELWENI CHILD IMMUNIZATION IN SWAZILAND 82.6% 98% Overall Immunization: Immunization coverage for all children was 82.6%. 6,936 admissions for children under 5 in 2015 Total of 283 (4.1%) 4.1% resulted in death. Leading causes of deaths in health facilities in 2015: - 17% Gastroenteritis and Colitis - 9% Disorders related to short gestation - 9% Infections in the perinatal period - 5% Acquired Immune Deficiency Syndrome Leading cause of admissions: - The highest leading cause of admission is other none-infective gastroenteritis and colitis (n=1499) followed by pneumonia, organism unspecified (445). Leading episodes seen at Outpatient in 2015 for children aged 5 and under - 46% Gastroenteritis and Colitis - 14% Pneumonia - 8% Infections in the perinatal period - 6% Bronchopneumonia CHILD NUTRITIONAL STATUS Routine immunization coverage has slightly decreased from 88% DPT-HepB Hib3 in 2014 to 82.6% in MCV1: 81.5% in 2015 has slightly increased from 78% in 2014 and OPV3: 80.7% was achieved cumulatively; January to December % of all children in health facilities are normal weight There has been a decrease in Diarrhea diseases between 2014, and 2015 from cases to Achievements Introduction of Rota Virus Vaccinations in Swaziland with almost vaccines administered for Rota 1 and 2 in 2015 Overall, Immunization coverage remains high at 80% in 2015 Decrease in child mortality in health facilities from 371 in 2014 to 283 In 2015 Diarrhea diseases seen in OPD for children under the age of 5 has decreased from in 2014 to in EPI has procured more cold storage devices for distribution of vaccinations. Recommendations Revise community mobilization on Immunization for children Conduct study on cause of Mortality for children under the age of 1, and implement recommendations Strengthen capacity of regional hospitals in Shiselweni and Lubombo to provide quality services for Neonatal, Infant, and Child Health Strengthen interventions around child nutrition in selected regions

8 INDICATOR SUMMARY Key Performance Indicators: Child Impact Indicators Indicators Baseline 2014 Result 2016 Targets Status 2018 Target Neonatal Mortality Rate 19/ / / / Infant Mortality Rate 79/ / / / Under five Mortality Rate 104/ / / /1 000 EPI Indicator name Target 2015 Result Status Routine Immunization DPT-HepB- Hib3 80% 82.6% Polio 3 80% 80.7% MCV1 80% 81.5% Disease surveillance and control AFP Measles Neonatal Tetanus 2/ population (10 cases) 1/1000 population per region 1/1000 live births Paediatric Bacterial Meningitis (Pneumonia) 100 cases 106 Rotavirus (Diarrhoea) 100 cases 177

9 IMNCI Indicator 2015 Target 2015 Result Status % of children under five years with pneumonia correctly assessed and treated with antibiotics 95% 90% No of facilities with functional ORT Corners % of children with diarrhoea treated with ORS No of facilities with at least one service provider trained in IMNCI Nutrition Indicator Target Result Status Under 5 Stunting Prevalence 23% 25.5% Underweight prevalence Less 10% 5.8% Proportion of Children Seen at Facility who are underweight 0.71% Wasting prevalence Less than 5% 2.0% Proportion of Children Seen at Facility who are wasted Overweight Prevalence Less than 11% 9.0% Proportion of Children Seen at Facility who are overweight 0.88% Coverage of Vitamin A supplementation 90% 68.0% (MICS 2010) Coverage of Vitamin A supplementation 78% (HMIS, 2015) Exclusive Breastfeeding 50% 63.8% (MICS 2014) Low Birth Weight 6% 8.0% (MICS 2014)

10 CHAPTER 1: Introduction

11 There are a number of underlying and direct causes that impact child mortality in Swaziland from ill health, to interrelated causes like poverty, vulnerability, lack of education, and poor health care services. The following report will review the current child health status of children in Swaziland using clinical and program level data. Swaziland is currently facing a burden of both communicable and non-communicable diseases that have an impact on the health status of children. Overall mortality rates for children have improved in the last few years; according to MICS 2014 survey, with the exception of neonatal mortality rates, the country has seen an improvement in child mortality indicators. SWAZILAND DEMOGRAPHICS Crude Birth Rate (per 1 000) 30,88 Total Births Male Births Female Births Sex ratio at birth 1,03 Total Deaths Male Deaths 9677 Female Deaths 9565 Total Population Percent ,40% Age Dependency Ratio 72 Population density (per sq. km) National 64,5 Hhohho 88 Manzini 88,7 Shiselweni 55,5 SWAZILAND CHILD MORTALITY, , MICS SURVEYS 104 per thousand Neonatal mortality rate (0-1 month) Post-neonatal mortality rate (1-12 months) Infant mortality rate (0-12 months) Child mortality rate (13-59 months) Under-five mortality rate (0-59 months) Figure 1: Child Mortality Status, Infant Mortality Rate (IMR), has improved from 79 deaths per 1,000 in 2010 to 50 deaths per 1,000 in Under- Five Mortality Rate (U5MR) has also improved from 60 deaths per 1,000 to half in 2014 with 30 deaths per 1,000. The improvement in mortality rates among children can be attributed to an increase in the number of interventions targeting children across various sectors. Within the health sector, the public health unit has specific programs that address the needs of children including the Integrated Management of Childhood Illnesses (IMNCI), Expanded Program on Immunization (EPI), Nutrition Program, and many others. The need to focus on children is enshrined in the National Health Sector Strategic Plan II, that has a focus on life course approach to health care in Swaziland. It is in this line that child welfare is a core element of clinical service delivery in Swaziland. Page 2

12 Prior to 2010, the major contributors to child mortality in Swaziland was AIDS, which accounted for 49% of all deaths. According to the 2015 Swaziland HIV Estimates and Projections Report, this has been declining since Overall AIDS deaths have declined from a high of 1,815 deaths in children in 2005 to 695 in AIDS deaths in Swaziland created a social issue of OVC (Orphan and Vulnerable Children). The Government of Swaziland has focused heavily on interventions to curb the increase in the number of child headed households, including introduction of social grants, and ensuring free primary education in the country. All these interventions have resulted in improved child status. The nutritional status of children has been proven to be linked with mortality and morbidity of children under 5 in developing countries. In Swaziland the 2010 MICS reported that almost 1 in 3 children in the country was stunted (31%). In 2014 the figure for stunting stood at 1 in 4 children (25, 5%). NUTRITIONAL STATUS OF CHILDREN UNDER 5, MICS, Underweight Prevalence Stunting Prevalence Wasting Prevalence Overweight Prevalence Figure 2: Nutritional Status of Children Under 5 in Swaziland, According to MICS (2014), there are almost six percent (5.8%) moderately or severely underweight children under five years and about two percent (1.6%) are classified as severely underweight. Overall, 25.5 percent of children are stunted or too short for their age and two percent are wasted or too thin for their height. Stunting has a negative effective on the development of children. Page 3

13 CHAPTER 2: Program Background

14 2.1 Expanded Program on Immunizations The Swaziland Expanded Programme on Immunization was launched in November 1980 following a lameness survey conducted in 1979 with main focus of controlling vaccine preventable diseases. The Immunization Programme has made remarkable strides among which include improvement in vaccination coverage from 25 per cent in 1982 to 82 per cent by 1989, attainment of Universal Child Immunization in 1990, considerable reduction in morbidity and mortality from vaccine preventable diseases and longer inter-epidemic periods for measles from 2 years in the 1980s to 4 5 years in the 1990s. The main focus of the EPI programme is to increase vaccination coverage for children and women of childbearing age as a priority public health intervention towards the major goal of reduction of infant and child morbidity, mortality and disability due to Vaccine Preventable Diseases (VPD) in children of less than five years. The Programme has additional goals and objectives to: Maintain polio free certification standards; accelerate the elimination of measles and; Elimination of Maternal and Neonatal Tetanus. Immunization services are offered at no cost as part of the PHC services in all public health facilities. However, these services are also offered in private health institutions owned by faith based NGOs and private individuals for which fees are charged. Regrettably, not all private hospitals and clinics do submit monthly reports on immunizations performed to MOH. The National EPI policy recommends the following immunization schedule for children and woman of childbearing age, which the private sector follows the same schedule as in the draft policy. Table 1: Schedule for EPI antigens Antigens Number of doses Administered at BCG and Birth dose-opv0 1 Birth/First contact DPT-Hib-HepB (Penta-vaccine) 3 6 weeks, 10 weeks and 14 weeks OPV 5 6 weeks, 10 weeks, 14 weeks, 5 years and 10 years Measles 1 9 months 2 18 months DT boosters 2 5 years and 10 years TT for women in Child bearing age (12-49 years) 5 First contact; 4 weeks after; 6 m. after; 1 year after; 1 year after respectively Routine EPI and the disease control initiatives are considered as the cornerstones of the programme. To this effect, supplementary vaccination activities have been implemented in the context of strengthening routine EPI services and to minimize vaccine preventable diseases. The programme has adopted two main strategies to provide immunization services namely: Routine Immunization through fixed and outreach points and Supplementary Immunization Activities (SIAs). Page 5

15 The Swaziland Expanded Programme on Immunization shall provide efficient, equitable, high quality immunization plus (integrated) services to every child, adolescent and adult population to ensure that they are protected against vaccine preventable diseases thus promoting longevity and wider health system strengthening. VISION MISSION GOAL The Swaziland Expanded Programme on Immunization is committed to promotion of the health of children and beyond through provision of integrated quality immunization services at all service delivery points. To Reduce Morbidity and Mortality Due To Vaccine Preventable Diseases SPECIFIC OBJECTIVES Increase immunisation coverage of antigens to >80 / 90% by the end of the year 2010 Provide quality, potent and adequate vaccines to all consumers at all delivery points. Sustain quality performance indicators for polio eradication and measles/nnt elimination. Intensify disease surveillance activities for Acute flaccid paralysis, measles, neonatal tetanus and Heamophilus influenza type B (Hib) Enhance prevention of the spread of HIV/AIDS and Hepatitis B through safe injection practices. Introduce new vaccines e.g. Retro virus, Hib and Pneumococcal conjugate vaccine. Strengthen supportive supervision 2.2 Integrated Management of Childhood Illnesses A large proportion of childhood morbidity and mortality in developing countries are caused by five conditions mainly diarrhea, pneumonia, measles, malnutrition and malaria and HIV/AIDS the latter has watered down our efforts. These diseases are preventable yet they contribute to the high infant morbidity and mortality. In Swaziland the infant mortality rate 85/ 1000 live births and the child mortality rate is 120/1000 live births. An integrated strategy was needed to address the overall health of children for the following reasons: Most children present with signs and symptoms of more than one condition thus more than one diagnosis may be necessary. Health workers need to be prepared to assess the signs and symptoms of all the most common conditions, not simply those of present illness. Page 6

16 When a child has several conditions treatments for those conditions may need to be combined. Health workers need to be prepared to treat conditions when they occur in combination. Care needs to focus on the child as a whole and not just the condition/disease affecting the child. Other factors that affect the quality of care delivered to children such as drug availability. Organization of the health system, referral pathway, services and community behavior are best addressed through integrated strategy. The IMNCI was introduced as a strategy that provides comprehensive and continuous care of sick children. In Swaziland IMNCI came into existence in the year 1996 after realizing that children were dying from preventable diseases such as diarrhea, pneumonia, measles, malnutrition, neonatal, injuries and others. In the past Management of sick children was diseases specific and it was easy to miss other illnesses. IMNCI targets the major killer diseases and the approach are simply and effective. It has 3 components: 1. Clinical case management includes capacity building of health workers currently each health facility has one trained nurse in IMNCI. This will assist in improving quality care to sick children and reduce mortality 2. Strengthening of health system-policy issues for effective implementation. 3. Community- IMNCI: Promotes appropriate care seeking behavior, improved nutrition and preventive care and adherence to treatment. GOAL Reduce infant morbidity and mortality in children under five years of age and promote their survival, growth and development. OBJECTIVES To improve the quality of Health care provided to children in order to significantly reduce morbidity and mortality due to common childhood diseases among children under five by the full implementation of IMNCI To educate communities on home management of diseases and on disease prevention To strengthen health system by ensuring that policies pertaining to child health are in place Swaziland Nutrition Program The Swaziland National Nutritional Council (SNNC) The SNNC was established by an Act of Parliament in 1945 and is mandated to promote food and nutrition activities and to advise the government accordingly. The Swaziland National Nutrition Council seeks to improve the nutrition and health status of the nation for all vulnerable groups at all levels of society by providing effective, comprehensive, decentralized, coordinated, sustainable and enabling environment for the provision of food and nutrition services in Swaziland. Vision: The vision for Swaziland National Nutrition Council is to achieve optimum nutrition, health status and food security of the Swazi nation by Mission Statement: To improve the nutrition and health status of the nation for all vulnerable groups at all levels of society by providing effective, comprehensive, decentralized, coordinated, sustainable and enabling environment for the provision of food and nutrition services in Swaziland. The key intervention areas are: Infant and Young Child Feeding Integrated Community based Growth Monitoring and promotion, Integrated Management of Acute Malnutrition in Children and Adults Nutrition & HIV, Prevention and Control of Micronutrients deficiencies and Nutrition Surveillance Page 7

17 CHAPTER 3: Immunization Coverage for Children

18 Globally, immunization prevents three million child deaths each year, and the World Health Organization (WHO) estimates that 20% of remaining under-five deaths approximately 1.7 million deaths annually could be prevented with existing vaccines. Nearly 30% of all non-neonatal, under-five deaths are still preventable through immunization. Success in reducing vaccine-preventable mortality has been dramatic, but it cannot be taken for granted. For example, approximately one million new-borns died of tetanus 30 years ago compared to about 70,000 last year a 93% reduction. However, this achievement must be maintained and built upon every year to further lower neonatal mortality from the disease. And while vaccination coverage in some countries now exceeds 80%, coverage is not the only metric. Before they are exposed to disease, women and new-borns must be reached by both potent vaccines and high-quality services in a timely, safe, effective, acceptable and affordable manner, enabling them to return to complete all their doses Routine Immunization Routine immunization coverage has slightly decreased from 88% DPT-HepB-Hib3 in 2014 to 82.6% in MCV1: 81.5% in 2015 has slightly increased from 78% in 2014 and OPV3: 80.7% was achieved cumulatively; January to December This represents a total of 82.6% fully immunized children. The improvement in coverage is also observed in MCV1 which is a proxy for Millennium Development Goal (MDG) 4 reached the set performance target of 80%. A more or less constant coverage has been observed over the last nine months, even though we still experience incompleteness of reporting by health facilities as well as interrupted immunization services through planned outreach sites in some regions. See figure 1 below Trends on Routine Immunization by region, 2015 ANNUALIZED DPT3, MEASLES AND POLIO 3 ADMINISTRATIVE COVERAGE BY REGION, 2015 % Hhohho Manzini Lubombo Shiselweni DPT Measles Polio Figure 3: Annualized DPT3, Measles and Polio 3 administrative coverage Measles Measles case based surveillance has been implemented since 1998 and with all measles surveillance indicators have been achieved in A Non Measles Febrile Rash Illness (NMFRI) of 170.9/100,000 has been achieved in A total of 759 suspected measles cases were notified with 615 (81%) having lab samples and results available for 100%. Among the cases that were serologically investigated 41(5.4%) were rubella IgM positive and 303 measles IgM positive. Page 9

19 MEASLES 3 COVERAGE, NATIONAL % HHOHHO 88% 94% 86% 89% 131% 82% 78% % 86% 81% 82% 76% LUBOMBO 84% 80% 86% 81% 79% 73% MANZINI 98% 84% 89% 240% 79% 72% SHISELWENI 111% 100% 96% 91% 94% 96% All four regions have notified at least 1 suspected case/100,000 population. The measles incidence was 25.9/100,000 population reflecting high occurrence due to the measles outbreak experienced since November 2009 resulting from low immunity of the population against measles over years. NUMBER OF MEASLES VACCINES ADMINISTERED, ,000 60,000 50,000 40,000 30,000 20,000 10, Measles 1 28,882 26,746 27,801 41,749 26,376 25,019 Booster 29,060 23,010 25,326 24,462 25,325 23,657 Total 57,942 49,756 53,127 66,211 51,701 48,676 Figure 4: Number of Measles Vaccines Administered, DT3 Figure 5 below shows DT3 immunization coverage by region from the 2010 to The Shiselweni region has consistently outperformed all the regions since The DT3 immunization coverage in Shiselweni has been above 80% during the period shown, maintaining a coverage above the national coverage. The year 2013 was the lowest coverage for Hhohho and Manzini regions, with 2010 being the lowest for Lubombo and Shiselweni regions. One key thing to notice in all regions is that there is inconsistency in increasing the coverage of DT3, which is something the program can improve on (ensuring consistency of documentation). Page 10

20 DT3 IMMUNIZATION COVERAGE BY REGION, % HHOHHO LUBOMBO MANZINI SHISELWENI NATIONAL Figure 5: DT3 Immunization Coverage by Region, Figure 6 below shows number of DPT3 vaccines administered national from the year 2010 to From the year 2010 (n=25,323) to 2011 (n=28,288) there is an increase in the number of vaccines administered, then a slump from 2012 (n=27,948) until 2013 (n=25,045), then increases again to 27,771 in the year In the year 2015, vaccines administered decreased again to 25,753 vaccines administered. The year with the highest number of vaccines administered was 2011 were 28,288 vaccines were administered. NUMBER OF DPT3 VACCINES ADMINISTERED, ,000 25,323 28,288 27,948 25,045 27,771 25,753 20,000 10, Number of DPT3 Figure 6: Number of DPT3 Vaccines Administered, Polio 3 Figure 7 below shows OPV 3 (polio vaccine) coverage by region for the year The only region that reported a coverage above the national coverage was the Shiselweni region with a coverage of 94% though it was the region with the lowest number of vaccines administered. The Hhohho region reported a coverage of 81% which was the same as the national coverage and also was the region with the highest number of vaccines administered (n=7,636). Page 11

21 OPV 3 (POLIO VACCINE) COVERAGE BY REGION, ,000 25,000 20,000 15,000 10,000 5, % 7,636 Hhohho 76% 76% 7,561 5,441 Lubombo Manzini 94% 5,135 Shiselweni 25,773 81% NATIONAL 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0 OPV 3 (POLIO VACCINE) OPV 3 (%) Figure 7: OPV 3 (Polio Vaccine) Coverage by region, Rota Vaccinations Figure 8 below shows the number of rota 1 and 2 vaccinations by region for the year In all regions, except for the Hhohho region, the number of rota vaccination 1 is slightly more than rota vaccination 2 administered, just like it is nationally. The Hhohho region reported the highest number of rota vaccinations administered for both 1 and 2 with 3,838 and 3,842 respectively. NUMBER OF ROTA 1 AND 2 VACCINATIONS BY REGION, ,000 12,000 10,000 12,484 12,150 8,000 6,000 4,000 2,000 3,838 3,842 2,301 2,272 3,693 3,512 2,652 2,524 0 Hhohho Lubombo Manzini Shiselweni NATIONAL Figure 8: Number of Rota 1 and 2 Vaccinations by Region, 2015 Page 12

22 Deworming in Swaziland Figure 9 below shows Albendazole 1st dose coverage at ANC for the year 2015 by region. The Lubombo region reported the highest coverage with 89%, whilst the Manzini region reported the highest number of vaccines administered with 6,656 vaccines at 1st ANC. ALBENDAZOLE 1ST DOSE COVERAGE BY ANC VISIT, ,000 25,000 20,000 15,000 10,000 5, % 8,614 6,436 Hhohho 28,008 89% 77% 73% 78% 8,682 5,225 6,656 4,673 5,487 4,025 Lubombo Manzini Shiselweni NATIONAL 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0 Number of ANC Number of First ANC % Covered Figure 9: Albendazole 1st Dose Coverage by ANC Visit, 2015 Figure 10 below shows the number of albendazole vaccinations for deworming administered by region for the year The Manzini region recorded the highest number of vaccinations administered for albendazole 2nd and 3rd for the first and second trimesters with 6,869 and 3,272 vaccines administered respectively. 30,000 NUMBER OF ALBENDAZOLE VACCINATIONS FOR DEWORMING ADMINISTERED BY REGION, ,000 20,000 20,086 15,000 10,000 5, ,984 2,749 Hhohho 6,869 3,992 2,443 3,272 3,241 1,323 Lubombo Manzini Shiselweni 9,787 Grand Total Albendazole 2nd/3rd Trimester1 Albendazole 2nd/3rd Trimester2 Figure 10: Number of Albendazole Vaccinations for TB administered by region, 2015 Page 13

23 Vitamin A Coverage Figure 11 below shows the number of vitamin A, 1st dose and follow-up dose administered in the year 2015 by region. Manzini region reported the highest count of 1st dose administered (n=9,167), with the Hhohho region being the highest with vitamin A follow-up dose (n=36,336). NUMBER OF VITAMIN A DOSES ADMINISTERED BY REGION, , , ,000 80,000 60,000 40,000 20,000 7,711 36,336 5,737 23,930 9,167 29,313 6,347 21,806 28,962 0 Hhohho Lubombo Manzini Shiselweni NATIONAL 1st Dose Vitamin A Follow-up Figure 11: Number of Vitamin A doses administered by region, Vaccines Supply, Quality and Management The Government of Swaziland procures all EPI vaccines and injection equipment. Currently, the national vaccine forecast is done by EPI and vaccines are ordered once with a planned split quarterly shipment through Central Medical Stores. The Central Vaccine Stores (CVS) manages the distribution of vaccines to five (5) regional vaccine depots. Stock out of DT and TT was reported for six weeks in A computerized stock management system is in place at national level, strengthening of the system is inevitable to ensure consistency throughout the levels Cold Chain Following the last cold chain assessment in 2011 and the EVMA in 2013; observations showed that most of the refrigerators in the system were due for replacement and most health facilities were using refrigerators that are not WHO/UNICF compliant. This situation compromised the quality of vaccines in 2015, hence Government and World Bank procured 187 units of cold chain equipment, which will be distributed based on the expansion and replacement plan developed in July 2015 following a cold chain inventory assessment. Page 14

24 CHAPTER 4: Health Data on Management of Childhood Illnesses

25 IMNCI Program core mandated is to build capacity to all service providers who care for sick children in the country. IMNCI services are accessed in all health facilities that are dealing with sick children under five years. The program has been conducting training of service providers on case management of the illnesses that are a threat to the lives of the under-fives. These diseases contribute to the high under five mortality rates that is diarrhea, accounting to 10% and pneumonia 9%. Currently nurses trained on IMNCI are 650/3000 in the country. We need to accelerate trainings to improve quality of services provided in the health facilities, through sharpening of nurse s skills in assessing sick children especially because nurses come out of pre-service without IMNCI yet after training they are placed in facilities, where there are no doctor and this compromises service delivery. We rely on trained health care workers in identification, classifying and treating of diseases in children. Educating communities and preventing diseases is the key to improve early seeking behavior by the communities before sick children develop complications. The approach used by IMNCI is in case management is integration, holistic and looks beyond the reason the mother/ caregiver brought the sick child to the facilities Health Data on Management of Childhood Illnesses Below in figure 12, under 1 mortality by year is shown from 2009 to From the year 2010 (n=534), a downward trend is observed until 2013 (n=204). A slight increase is observed in 2014 (n=248) and in 2015 an all-time low of 200 deaths is observed of under 1s. Figure 12: Under 1 Mortality by Year Page 16

26 Figure 13 below shows under 1 admissions and death rates by region. In the figure Hhohho region has the highest admission of under 1(n=1124) though Shiselweni shows to have the highest death rate of 9.0%. The Manzini had the most deaths of under 1 with 91 infants who were admitted dying in the region. Figure 13: Under 1 Admissions and Death Rates by Region , % 39 Hhohho % 20 Lubombo 1, % 91 Manzini 9.0% Shiselweni 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0 Number of Admission Number of Deaths % of deaths Below in figure 14 under 1 mortality by region for the years 2009 to The Manzini region is amongst the two highest deaths by region during the specified period except for the years 2013 and Figure 14: Under 1 Mortality by Year by Region HHOHHO LUBOMBO MANZINI SHISELWENI Total Page 17

27 Under 1 Death by Sex Figure 15 below shows the proportion of under 1 deaths by sex. The proportion is relatively the same with male infants having a slightly higher proportion with 52% compared to 48% for females. Looking at the trend from 2009 to 2015, consistently the male infant deaths is higher than female infant death except for 2013 and 2014 were slightly more female (n= 101 and 129 respectively) under 1 deaths compared to males (n= 100 and 115 respectively). Figure 15: Proportion of deaths by sex, under NUMBER OF UNDER 1 FACILITY DEATHS, female Male Contribution to Under 1 Year by Condition. The following graph below shows the leading causes of death amongst under 1s nationally. Not surprising the leading cause of death for under 1s is the same as the leading cause of death amongst under 5s, other noneinfective gastroenteritis and colitis(n=37) LEADING CAUSES OF DEATHS FOR UNDER 1, 2015 Other and unspecified aneamis Kwashiokor Septicaemia Pulmonary Tuberculosis Respiratory Distress Syndrome Bronchopneumonia, organism unspecified Viral Pneumonia Pneumonia, Organism unspecified Other and unspecified Protein - Calorie malnutrition Intrauterine Hypoxia and Birth asphyxia Acquired Immune Deficiency Syndrome Other and Ill-Defined conditions originating in the.. Infections specified to the Perinatal period Disorders relating to short Gestation and High... Other non-ifective Gastroentritis and colitis Page 18

28 Contribution of Diseases to Mortality The diagram below shows leading causes of death by proportion for under 1 in Slightly more the half of the deaths for under 1s are other than the options offered (this reiterates the need to improve our data collecting systems) and not far off in second is other none-infective gastroenteritis and colitis with 37.17%. LEADING CAUSES OF DEATH BY PROPORTION FOR UNDER 1, 2015 Other Nonifective Gastroenteritis and Colitis Disorders Relating to Short Gestation and High Birthweight 50, 23% 37,17% Infections specific to the perinatal period Other and ill-defined conditions originating in the perinatalperiod Acquired Immune Deficiency Syndrome Intrauterine Hypoxia and Birth Asphyxia 4, 2% 4, 2% 5, 2% 5, 2% 5, 2% 7, 3% 7, 3% 12, 5% 8, 4% 10, 5% 10, 5% 10, 5% 10, 5% 20, 9% 20, 9% Other and Unspecified Protein - Calorie Malnutrition Pneumomia, Organism Unspecified Viral Pneumonia Bronchopneumonia, Organism Unspecified Respiratory Distress Syndrome Pulmonary Tuberculosis Septicaemia Kwashiorkor Other and Unspecified Aneamias Other The table below shows the leading cause of death for under 1 distributed by regions for All regions reported other none-infective gastroenteritis and colitis as the highest contributor except for the Shiselweni region which reported disorders relating to short gestation and high birthweight (n=12). Diagnosis Description HHOHHO LUBOMBO MANZINI SHISELWENI Total Other None-infective Gastroenteritis and Colitis Disorders Relating to Short Gestation and High Birthweight Infections specific to the perinatal period Acquired Immune Deficiency Syndrome Other and Unspecified Protein - Calorie Malnutrition Pneumomia, Organism Unspecified Viral Pneumonia Bronchopneumonia, Organism Unspecified Respiratory Distress Syndrome Pulmonary Tuberculosis Septicaemia Kwashiorkor Page 19

29 Under 1 Status of Health In terms of under 5 mortalities, the majority of deaths occur before the child has turned 1 years old. Figure 16 shows proportion contribution of under 1 deaths to under 5 mortality for the years 2009 to The figure shows that as from 2013 the percentage contribution to under 5 mortalities by under 1 s has been decreasing from 39% in 2013 to 29% in Figure 16: Proportion contribution of Under 1 deaths to Under 5 Mortality % 75% 76% 71% 61% 67% 71% 28% 25% 24% 29% 39% 33% 29% Under 1 Mortality Under 5 Mortality Admissions by Region Swaziland is implementing a primary health care model that is decentralized across the regions. In-patient admissions are however centred on the major referral hospitals. The age between 0-1 years present a number of challenges for child mortality, and timely and effective services are required. TOTAL NUMBER OF UNDER 1 ADMISSIONS BY REGION, 2015 MANZINI HHOHHO LUBOMBO 583 In 2015, a total of 3588 children under the age of 1 were admitted into health facilities in Swaziland. The most admissions occurred in Hhohho with 1124 admissions, and Lubombo had the lowest number of admissions. GRAND TOTAL SHISELWENI 767 Page 20

30 Top 10 leading causes of admissions for under 1s in 2015 In 2015 the leading cause of admissions for children under the age of 1 was non-infective gastroenteritis. Figure 17: Top 10 leading causes of admissions for under 1s in 2015 TOP 10 LEADING CAUSES OF ADMISSIONS FOR UNDER 1, 2015 Other and unspecified Protein - Calorie malnutrition Other Diseases of Respiratory system Acquired Immune Deficiency Syndrome 75 Other Perinatal Jaundice Viral Pneumonia Bronchopneumonia, organism unspecified Disorders relating to short Gestation and High birthweight Pneumonia, Organism unspecified Infections specified to the Perinatal period Other non-ifective Gastroentritis and colitis Page 21

31 Top causes of admissions by region The following table analyses top causes of admissions by region for the year 2015 as well as the proportion the region has of a specific condition. Out of the 75 AIDS related admissions, 77.33% (n=58) of the cases were seen in the Manzini region. Diagnosis Description HHOHHO LUBOMBO MANZINI SHISELWENI Total Other Non-Infective % % % % % Gastroenteritis and Colitis Infections specific to % % % % % the perinatal period Pneumonia, % % % % % Organism Unspecified Disorders Relating to % % % % % Short Gestation and High Birthweight Bronchopneumonia, % % % % % Organism Unspecified Viral Pneumonia % % % % % Other Perinatal % % % % % Jaundice Acquired Immune % % % % % Deficiency Syndrome Other Diseases of % % % % % Respiratory System Other and % % % % % Unspecified Protein - Calorie Malnutrition Intestinal Infections % % % % % Due to Other Organisms Bronchiectasis % % % % % Asthma % % % % % Kwashiorkor % % % % % Page 22

32 Under 5 Mortality in Facilities Effective management of childhood illnesses resulted in the reduction of under 5 mortalities in children. As figure 3 illustrates below child mortality rates have decreased significantly from (11.3%, n=721) in 2009 to (4.1%, n=283) in This represents a drop of 7.2 percentage points. This was from a total of 6,252 admissions. Figure 18: Total Number of under 5 deaths in facilities NUMBER OF UNDER 5 DEATHS IN FACILITIES Under 5 mortality rate by sex The figure shows the mortality rate for under 5 s by sex. Both male and female under 5 mortality rates have seen a steady decline since 2009 with the only exception being male under 5 mortalities in 2012 when it increased by (0.6%). Whilst the female under 5 mortality rate has been higher in previous years than the males, that gap has significantly closed in 2015 as illustrated below in figure 19. Figure 19: Under 5 Mortality Rates in Health Facilities by Sex Female Male Page 23

33 Although the mortality rate for under 5 deaths for females was higher, the number of actual deaths was higher for males than females. The mortality rate for males is lower as they had higher admissions into facilities in each year than females. Figure 20: Number of Under 5 Deaths in Facilities by Sex female Male Death by region Regional deaths of under 5 children have continued to decline in recent years. With the exception of male under 5 children from Manzini, all regions and sexes experienced a drop in under 5 deaths from Figure 21: Number of Under 5 Deaths in Facilities by Region and Sex Hhohho - Female Hhohho - Male Lubombo - Female Lubombo - Male Manzini - Female Manzini - Male Shiselweni - Female Shiselweni - Male Page 24

34 Causes of Death for Under 5 in Swaziland Figure 22 shows the leading causes of death for Under 5 in Health Facilities in Swaziland Despite other noneinfective gastroenteritis and colitis with 51 deaths, infection specific to perinatal period and disorders relating to short gestation and high birthweight are the leading causes of death for under 5 with each registering 21 deaths even though it is disorders relating to short gestation and high birthweight with a higher proportion (7%) in figure 11 below. Figure 22: Leading Causes of Under 5 Deaths 2015 Respiratory Distress Syndrome 7 28 Kwashiokor 7 27 Septicaemia 8 Pulmonary Tuberculosis 8 Bronchopneumonia, organism unspecified 9 Viral Pneumonia 9 Pneumonia, Organism unspecified 10 Other and unspecified Protein - Calorie malnutrition 11 Intrauterine Hypoxia and Birth asphyxia 11 Acquired Immune Deficiency Syndrome 13 Other and Ill-Defined conditions originating in the.. 18 Infections specified to the Perinatal period 20 Disorders relating to short Gestation and High Other non-ifective Gastroentritis and colitis Figure 23: Proportion Causes of Death for Under 5 in Swaziland 2015 Other Nonifective Gastroenteritis and Colitis Disorders Relating to Short Gestation and High Birthweight 34% 18% Other and Unspecified Protein - Calorie Malnutrition Other and ill-defined conditions originating in the perinatalperiod Acquired Immune Deficiency Syndrome 7% Pneumomia, Organism Unspecified Intrauterine Hypoxia and Birth Asphyxia 6% Bronchopneumonia, Organism Unspecified Viral Pneumonia 2% 2% 2% 3% 3% 3% 3% 4% 4% 4% 5% Pulmonary Tuberculosis Septicaemia Kwashiorkor Respiratory Distress Syndrome Gastrointestinal Haemorrhage Other Page 25

35 Leading causes of death by sex, 2015 Figure 24 below shows the leading causes of death by sex in Both sexes reported other none-infective gastroenteritis and colitis as their leading cause of death with males reporting 25 deaths and females reporting 16 deaths from this condition. Figure 24: Leading Causes of Under 5 Deaths by Sex 2015 Respiratory Distress Syndrome Kwashiokor Septicaemia Pulmonary Tuberculosis Viral Pneumonia Bronchopneumonia, organism unspecified Intrauterine Hypoxia and Birth asphyxia Pneumonia, Organism unspecified Acquired Immune Deficiency Syndrome Other and Ill-Defined conditions originating in the.. Other and unspecified Protein - Calorie malnutrition Infections specified to the Perinatal period Disorders relating to short Gestation and High... Other non-ifective Gastroentritis and colitis female Male Admissions of Under 5 by Region and Sex The table below shows 2015 admissions disaggregated by sex and region. The table shows that the highest admissions in each region were male patients. Significantly Manzini had a high number of recorded patients whose sex was unknown at 385. Table 1: Under 5 Admissions by Sex and by Region 2015 Female Male Unknown Total HHOHHO LUBOMBO MANZINI SHISELWENI Total Source: HMIS, April 2016 Page 26

36 Causes of Under 5 admissions Figure 26 shows Leading causes of admissions for under 5 by diagnosis for the year The highest leading cause of admission is other none-infective gastroenteritis and colitis (n=1499) followed by pneumonia, organism unspecified (445). Figure 26: Leading Causes of under 5 Admissions 2015 Other and unspecified Protein - Calorie malnutrition Acquired Immune Deficiency Syndrome 133 Viral Pneumonia 140 Other Diseases of Respiratory system Gastrointestinal Haemorrhage Asthma Bronchopneumonia, organism unspecified Infections specified to the Perinatal period 258 Pneumonia, Organism unspecified 445 Other non-ifective Gastroentritis and colitis Despite other none-infective gastroenteritis and colitis the leading causes of under 5 admissions is different for each region. Hhohho reported Gastrointestinal Haemorrhage(n=156), Lubombo reported Pneumonia, Organism Unspecified(n=256), Manzini reported Infections specific to the perinatal period(n=188) and Shiselweni Bronchopneumonia, Organism Unspecified(n=77). Page 27

37 Figure 26: Leading Causes of under 5 Admissions 2015 Hhohho Lubombo Manzini Shiselweni Other Nonfictive Gastroenteritis and Colitis Pneumonia, Organism Unspecified Infections specific to the perinatal period Bronchopneumonia, Organism Unspecified Asthma Gastrointestinal Haemorrhage Other Diseases Of Respiratory System Viral Pneumonia Acquired Immune Deficiency Syndrome Other and Unspecified Protein - Calorie Malnutrition Epilepsy Other and ill-defined conditions originating in the perinatal period Intestinal Infections Due To Other Organisms Disorders Relating to Short Gestation and High Birthweight Burn Unspecified Acute Upper Respiratory Infections Of Multiple or Unspecified Site Kwashiorkor Other Perinatal Jaundice Bronchiectasis 3 76 Bronchitis Not Specified as Acute or Chronic Page 28