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Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control

Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control . Peter Winch pwinch@jhsph.edu. Department of International Health Social and Behavioral Interventions Program. What I do. Topics: Maternal and child health Newborn care in the home

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Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control

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  1. Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control Peter Winch pwinch@jhsph.edu Department of International Health Social and Behavioral Interventions Program

  2. What I do • Topics: • Maternal and child health • Newborn care in the home • Malaria, diarrhea, pneumonia treatment at the community level • Water and sanitation • Countries where I work currently • Mali, Tanzania, Bangladesh, Nepal

  3. Influences and methods • Influences • Medical anthropology • Linguistics • Epidemiology • Methods • Formative research: Qualitative and quantitative research to design intervention content • Process evaluation/process learning • Outcome evaluation

  4. Overview • Under-five mortality in sub-Saharan Africa • Explanations for high under-five mortality • Global health practice and under-five mortality • Example: Evaluation of introduction of zinc for diarrhea in Tanzania

  5. Under-five mortality in sub-Saharan Africa

  6. Total numbers of deaths in children under-5 years of age(millions) Source: UNICEF State of the World’s Children Report 2009

  7. Total numbers of deaths in children under-5 years of age(millions) Source: UNICEF State of the World’s Children Report 2009

  8. Total numbers of deaths in children under-5 years of age(millions) Source: UNICEF State of the World’s Children Report 2009

  9. Direct causes of <5 mortality sub-Saharan Africa

  10. Causes of <5 mortality in Africa Malnutrition is important contributing factor in a large proportion of these deaths Source: J Bryce et al. Lancet 2005; 365: 1147-52

  11. Under-five mortality rates per 1000 live births Source: UNICEF State of the World’s Children Report 2009

  12. Under-five mortality in sub-Saharan Africa: Observations • Very high • 50% of under-five mortality now occurs in sub-Saharan Africa • Rates have been decreasing, but more slowly than in other world regions

  13. Countries with top <5 mortality rates in the world (2008) Source: UNICEF State of the World’s Children Report 2009

  14. Top <5 mortality rates in Africa Source: UNICEF State of the World’s Children Report 2009

  15. Why do some countries have higher under-five mortality?

  16. Possible explanations • HIV/AIDS • Malaria • Status and health of women • Development traps • I will take the 10 countries with highest under-five mortality rates as examples

  17. <5 mortality rates and estimated adult HIV prevalance Source: UNICEF State of the World’s Children Report 2009

  18. HIV/AIDS as explanation for high under-five mortality rates • HIV/AIDS definitely contributes to under-five mortality • Not a good explanation for national-level variations • Countries with highest HIV prevalence e.g. South Africa, Namibia, Swaziland, Botswana have relatively low under-five mortality

  19. Higher under-five mortality rates Higher HIV prevalence rates

  20. Malaria as an explanation • Important cause of under-five mortality • Widespread • At best a partial explanation for national-level variation in under-five mortality

  21. Possible explanations • HIV/AIDS • Malaria • Status and health of women • Development traps

  22. Status and health of women Source: UNICEF State of the World’s Children Report 2009

  23. Status and health of women • Countries with highest under-five mortality also have • High maternal mortality • High fertility rates • Lower rates of female literacy • Score poorly on other measures of women’s status

  24. Development traps • Paul Collier describes a number of development traps in his recent book “The Bottom Billion”, e.g. • Being landlocked • Conflict and poor post-conflict transition • Resource curse: Overwhelming dependence on one single natural resource

  25. Development traps Source: UNICEF State of the World’s Children Report 2009

  26. Recap: Explanations • Wide range of explanations, acting at different levels and through different mechanisms • Ideally Global Health practice should take stock of these explanations, and address them in strategies to improve health in Africa

  27. What is Global Health, and what is it doing about under-five mortality in Africa?

  28. Some key tenets(Fried et al. Lancet 2010) • Global health is public health. • Dedication to better health for all, with particular attention to the needs of the most vulnerable populations, and a basic commitment to health as a human right. • Belief in a global perspective on scientific inquiry and on the translation of knowledge into practice

  29. Why under-five mortality in Africa is a Global Health priority • Concern for equity and justice • Half of the world’s under-five mortality occurs in sub-Saharan Africa • Preventive measures relatively inexpensive

  30. Global Health response to under-five mortality in Africa • Disease-specific control programs • HIV/AIDS • Malaria • Maternal and child health programs • Research • Training • Product development • Vaccines, drugs, mosquito nets etc.

  31. Diarrhea in Sub-Saharan Africa

  32. Diarrhea in Sub-Saharan Africa • About 700,000 of the 4.4 M deaths in under-five children each year • Highest mortality between 6 and 24 months of age • Period of weaning • Child starting to eat solid food, crawl and walk • This increases exposure to diarrheal pathogens in the environment

  33. Diarrhea: What can we do? • Prevention • Vaccines e.g. Rotavirus vaccine • Water and sanitation, handwashing • Management of sick children • Oral rehydration therapy • 10-14 day treatment with zinc • Continued breastfeeding, feeding, fluids

  34. Prevent dehydration thru increased appropriate home fluids & ORS • Continued feeding during & increased feeding after episode • Recognize signs of dehydration for early care-seeking-”new ORS” &/or other medical treatment • Give children zinc supplements for 10-14 days

  35. Zinc treatment for diarrhea • Shown to: • Reduce under-five mortality • Reduce duration and severity of diarrhea • Prevent new cases of diarrhea in the months following the treatment

  36. Dispersible Zinc Tablets + Easily dissolves in a few drops of water or breast milk + Sweet, acceptable to young children + Blister-pack + 3 year shelf life + Not bulky or heavy so transport and storage costs are less + No ‘breakage” (unlike bottled syrup)

  37. Evaluation of introduction of zinc for diarrheain Tanzania

  38. Categorical (Disease-specific) control programs in Tanzania • Presidential Malaria Initiative (PMI) • President’s Emergency Program For AIDS Relief (PEPFAR) • Global Fund for AIDS, Tuberculosis and Malaria • Trachoma eradication • Filariasis eradication • Coming soon: Obama administration’s initiative on maternal and child health

  39. Management of children with diarrhea in Tanzania What is happening • Diarrhea not seen as a serious condition • Antibiotics routinely given for simple diarrhea • Children with fever and diarrhea treated for malaria only What we want • Increased careseeking for diarrhea • Children treated with zinc and ORS rather than antibiotics • Children with fever and diarrhea treated with antimalarial, zinc and ORS

  40. Zinc introduction in Tanzania: Private sector • Production of zinc tablets and ORS by local manufacturer (Shelys) • Upgrading of shops and training of shopowners so their shops become Accredited Drug Distribution Outlets (ADDO) • Introduction of zinc and ORS into ADDOs • Detailing by drug company representatives • Visit health facilities and ADDOs • Talks on zinc and ORS

  41. Private sector:What we don’t want

  42. The alternative: ADDO shops

  43. Accredited Drug Dispensing Outlets

  44. Zinc introduction in Tanzania: Public sector • Official public sector launching ceremony • Procurement and distribution of zinc and ORS to health facilities • Refresher training of health workers in Integrated Management of Childhood Illnesses (IMCI) • Assess all problems of sick child • Provide treatments for all problems • Counseling and follow-up

  45. Key elements in IMCI counseling • Greet the parent • State the diagnosis • State the treatments, explain what each one is for • Explain how to give the treatments • Ask parent if she/he understood

  46. Zinc introduction in Tanzania • Next slide: Intervention Impact Model • First step in planning an evaluation • Summarizes how all the pieces of the intervention are supposed to fit together to achieve an impact

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