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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

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
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
influences and methods
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
overview
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
total numbers of deaths in children under 5 years of age millions
Total numbers of deaths in children under-5 years of age(millions)

Source: UNICEF State of the World’s Children Report 2009

total numbers of deaths in children under 5 years of age millions7
Total numbers of deaths in children under-5 years of age(millions)

Source: UNICEF State of the World’s Children Report 2009

total numbers of deaths in children under 5 years of age millions8
Total numbers of deaths in children under-5 years of age(millions)

Source: UNICEF State of the World’s Children Report 2009

causes of 5 mortality in africa
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

under five mortality rates per 1000 live births
Under-five mortality rates per 1000 live births

Source: UNICEF State of the World’s Children Report 2009

under five mortality in sub saharan africa observations
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
countries with top 5 mortality rates in the world 2008
Countries with top <5 mortality rates in the world (2008)

Source: UNICEF State of the World’s Children Report 2009

top 5 mortality rates in africa
Top <5 mortality rates in Africa

Source: UNICEF State of the World’s Children Report 2009

possible explanations
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
5 mortality rates and estimated adult hiv prevalance
<5 mortality rates and estimated adult HIV prevalance

Source: UNICEF State of the World’s Children Report 2009

hiv aids as explanation for high under five mortality rates
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
slide19

Higher under-five mortality rates

Higher HIV prevalence rates

malaria as an explanation
Malaria as an explanation
  • Important cause of under-five mortality
  • Widespread
  • At best a partial explanation for national-level variation in under-five mortality
possible explanations22
Possible explanations
  • HIV/AIDS
  • Malaria
  • Status and health of women
  • Development traps
status and health of women
Status and health of women

Source: UNICEF State of the World’s Children Report 2009

status and health of women24
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
development traps
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
development traps26
Development traps

Source: UNICEF State of the World’s Children Report 2009

recap explanations
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
some key tenets fried et al lancet 2010
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
why under five mortality in africa is a global health priority
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
global health response to under five mortality in africa
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.
diarrhea in sub saharan africa33
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
diarrhea what can we do
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
slide35
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
zinc treatment for diarrhea
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
dispersible zinc tablets
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)

categorical disease specific control programs in tanzania
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
management of children with diarrhea in tanzania
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
zinc introduction in tanzania private sector
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
zinc introduction in tanzania public sector
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
key elements in imci counseling
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
zinc introduction in tanzania
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
slide51

Advocacy and policy dialogue for introduction of zinc and low-osmolarity ORS

  • Training & orientation
  • District health officials
  • Personnel in health facilities
  • ADDO shops
  • Behavior change communication
  • Public sector launch
  • Mass media communication
  • Counselling of parents
  • Availability of essential drugs
  • Zinc
  • ORS
  • Antimalarials
  • Antibiotics
  • Provision of quality care
  • Health facilities
  • ADDO shops, pharmacies
  • Household behaviors
  • Prompt careseeking for children with diarrhoea, fever, respiratory symptoms
  • Administration of 10 days of zinc to children with diarrhoea
  • Preparation and administration of ORS to children with diarrhoea
  • Administration of 3 days of ACT (ALu) to children with both diarrhoea and fever
  • Avoid antibiotics for uncomplicated diarrhoea

Decreased diarrhoea-related morbidity and mortality

combination therapy for malaria
Combination therapy for malaria
  • Artemether
    • Rapid-acting with short half-life
  • Lumefantrine
    • Longer-acting with long half-life
  • The combination is called ALu in Tanzania, Coartem elsewhere
objectives summary
Objectives (summary)
  • Assess adequacy and consequences of training by district health teams and short orientation on diarrhoea case management by drug company representatives
  • Examine quality of care for children presenting with diarrhoea, diarrhoea and fever and diarrhoea and acute respiratory infections in health facilities where zinc and low-osmolarity ORS introduced
  • Evaluate administration in the home of treatments to sick children with diarrhoea alone or with other symptoms such as fever
  • Assess reactions of health workers and parents to introduction of zinc and low osmolarity ORS
study sites
Study sites
  • Morogoro Rural District, Morogoro Region
  • Same District, Kilimanjaro Region
data collection in health facilities
Data collection in health facilities
  • During the study period, all (1-3 per facility) health workers with responsibility for seeing sick children as outpatients were observed in clinical consultation with sick children presenting with diarrhea with or without fever.
  • One interviewer was stationed with the health workers dispensing medications and a second interviewer identified children with diarrhea whose care is to be observed
drug availability
Drug availability
  • Zinc sulphate was widely prescribed
  • All 9 government health facilities and private shops had both zinc and ORS in stock
  • ALu was in stock in 7 out of 9 government health facilities and all ADDO shops visited
private sector orientation sessions and detailing
Private sector orientation sessions and detailing
  • In Morogoro Rural District many ADDO shop owners recalled receiving a training or briefing from a Shelys representative
  • In Same District representatives only visited the drug shops to drop off supplies of pamphlets describing how to use the medication, but didn’t talk to anyone
  • Drug reps talked about ORS and zinc, then went on to talk about antibiotics and other drugs we don’t want to promote
zinc and ors prescription for children with diarrhea60
Zinc and ORS prescription for children with diarrhea
  • Only 3 out of 47 cases of diarrhoea had diarrhoea alone.
  • Prescription of zinc tablets was nearly universal: 45 out of 47 children
  • Prescription of ORS was not universal for children presenting with diarrhoea
  • Children presenting with both diarrhoea and fever, or both diarrhoea and vomiting, were much more likely to be prescribed ORS
  • Prescription of ORS is NOT associated with a diagnosis of dehydration made by the health worker. Only 5 of the 12 children diagnosed with dehydration received ORS
antimalarial prescription for children with diarrhea fever63
Antimalarial prescription for children with diarrhea + fever
  • ALu was the antimalarial most frequently prescribed
  • For children presenting with diarrhea and fever, treatments for diarrhea were prescribed much more than treatments for malaria
  • Of the 22 cases of malaria diagnosed by the health worker among 31 children presenting with diarrhoea and fever, only 5 (22.7%) were prescribed an antimalarial
  • Testing for malaria was not performed as part of this study, so we cannot determine how many of the cases receiving a diagnosis of malaria were parasitemic.
counseling of parents by health workers
Counseling of parents by health workers
  • Overall counselling quality was assessed through an 18-point additive scale for each of the three treatments: zinc, ORS and ALu.
  • Counselling quality was highest for ALu (Mean of 11.6 points out of 18), followed by zinc (mean of 10.8 points) and ORS (mean of 7.8 points).
items in counseling index
Items in counseling index

Does the dispenser …

  • say which disease/problem the drug is for?
  • say anything at all about the dose of the drug?
  • say how many times to take the drug each day?
  • say how many days to take the drug?
  • explain that all the oral tablets must be finished to complete the course of treatment even if the child appears to get better?
  • give the first dose of the tablet to the child?
  • show a tablet and say how many tablets to take each time?
  • ask caretaker to show how much tablet to give?

Does the caretaker …

  • give first dose to child in front of dispenser?

Does the dispenser …

  • make any attempt to see if the caretaker understands the instructions?
  • ask if the caretaker knows how many days to give drug?
  • ask if the caretaker knows how many times a day to give drug?
  • ask if the caretaker knows how many tablets to give each time?
  • look at caretaker when talking to her/him?
  • nod when caretaker says something?
  • use harsh language or get irritated?
  • ask caretaker if the explanation is clear?
  • ask caretaker if she/he has any questions?
strengths and weaknesses of private sector involvement
Strengths and weaknesses of private sector involvement

Strengths

Weaknesses

Different forms of products cause confusion

Drug reps having competing priorities: Promote sales and collaborate with public health objectives

Some drug reps don’t discuss, just drop off materials

  • Increases access to products in remote areas
  • More variety of products available
  • Greater reach of orientation sessions
malaria and diarrhea coordination problems
Malaria and diarrhea: Coordination problems
  • Malaria programs don’t include diarrhea in their training
  • Many public service announcements about malaria treatment, nothing about diarrhea
    • Better drug administration for ALu than zinc
  • Zinc introduction was more recent, so now providers treating fever + diarrhea with zinc only, previously they treated with the antimalarial drug only
difficulties with promoting management of multiple symptoms
Difficulties with promoting management of multiple symptoms
  • Communities need to be made aware of the need for zinc, ORS and ALu in combination for children presenting with fever and diarrhoea, where appropriate depending on local rates of malaria prevalence and policies on malaria rapid testing.
  • Such messages may vary by region, and should be coordinated with plans for introduction of rapid testing for malaria.
investigators and funding
Investigators and funding
  • Investigators
    • Ifakara Health Institute: Selemani S Mbuyita, Ahmed M Makemba, Idda Kinyonge
    • Johns Hopkins Bloomberg School of Public Health: Ashley I. Bennett, Peter J. Winch, Rolf D. Klemm
  • Funding
    • Tanzania Mission of the U.S. Agency for International Development, under the terms of Award No. GHS-A-00-03-00019-00 (Global Research Activity Cooperative Agreement). 
acknowledgements
Acknowledgements
  • Dr. Neema Rusibamayila of the Ministry of Health and Social Welfare;
  • Dr. Nemes Iriya of the World Health Organization Tanzania country office;
  • Ráz Stevenson, Malia Boggs, Neal Brandes, Esther Lwanga and Emily Wainwright of the United States Agency for International Development;
  • Bongo Mgeni, Christian Winger, Nadra Franklin and Camille Saade of the Academy for Educational Development and the A2Z project;
  • Council Health Management Teams, health personnel and study participants in Morogoro and Same Districts.