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Peter Winch pwinch@jhsph.edu Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control Peter Winch pwinch@jhsph.edu.

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Presentation on theme: "Peter Winch pwinch@jhsph.edu Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control Peter Winch pwinch@jhsph.edu."— Presentation transcript:

1 Peter Winch pwinch@jhsph.edu
Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control Peter Winch 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
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)
1970 Sub-Saharan Africa 3.1 Middle East and North Africa 1.3 South Asia 5.4 East Asia and Pacific 5.0 Latin America and Caribbean 1.2 Entire World 16.7 SSA proportion 19% Source: UNICEF State of the World’s Children Report 2009

7 Total numbers of deaths in children under-5 years of age (millions)
1970 1990 Sub-Saharan Africa 3.1 4.3 Middle East and North Africa 1.3 0.6 South Asia 5.4 4.2 East Asia and Pacific 5.0 1.6 Latin America and Caribbean 1.2 0.5 Entire World 16.7 11.4 SSA proportion 19% 38% Source: UNICEF State of the World’s Children Report 2009

8 Total numbers of deaths in children under-5 years of age (millions)
1970 1990 2008 Sub-Saharan Africa 3.1 4.3 4.4 Middle East and North Africa 1.3 0.6 0.4 South Asia 5.4 4.2 2.8 East Asia and Pacific 5.0 1.6 0.8 Latin America and Caribbean 1.2 0.5 0.2 Entire World 16.7 11.4 8.8 SSA proportion 19% 38% 50% Source: UNICEF State of the World’s Children Report 2009

9 Direct causes of <5 mortality sub-Saharan Africa
% of deaths Pneumonia Diarrhoea Malaria Measles HIV/AIDS Neonatal causes Injuries

10 Causes of <5 mortality in Africa
% of deaths Pneumonia 21% Diarrhoea 16% Malaria 18% Measles 5% HIV/AIDS 6% Neonatal causes 26% Injuries 2% Malnutrition is important contributing factor in a large proportion of these deaths Source: J Bryce et al. Lancet 2005; 365:

11 Under-five mortality rates per 1000 live births
1970 1990 2008 Sub-Saharan Africa 236 184 144 Middle East and North Africa 193 77 43 South Asia 197 124 76 East Asia and Pacific 120 54 28 Latin America and Caribbean 122 52 23 Entire World 142 90 65 SSA:World Ratio 1.7 2.0 2.2 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)
Country Under-five mortality Afghanistan 257 Angola 220 Chad 209 Somalia 200 Democratic Republic of the Congo 199 Guinea-Bissau 195 Mali 194 Sierra Leone Nigeria 186 Central African Republic 173 Source: UNICEF State of the World’s Children Report 2009

14 Top <5 mortality rates in Africa
Country Under-five mortality Angola 220 Chad 209 Somalia 200 Democratic Republic of the Congo 199 Guinea-Bissau 195 Mali 194 Sierra Leone Nigeria 186 Central African Republic 173 Burkina Faso 169 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
Country <5 mortality rate Adult HIV prev Angola 220 2.1% Chad 209 3.5% Somalia 200 0.5% DR Congo 199 -- Guinea-Bissau 195 1.8% Mali 194 1.5% Sierra Leone 1.7% Nigeria 186 3.1% Central African Republic 173 6.3% Burkina Faso 169 1.6% 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

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

22 Possible explanations
HIV/AIDS Malaria Status and health of women Development traps

23 Status and health of women
Country <5 Mortality Rate Total Fertility Rate Contraceptive prevalence rate Lifetime risk of Maternal Mortality Angola 220 5.8 6% 1 in 12 Chad 209 6.2 3% 1 in 11 Somalia 200 6.4 15% DR Congo 199 6.0 21% 1 in 13 Guinea-Bissau 195 5.7 10% Mali 194 5.5 8% 1 in 15 Sierra Leone 5.2 1 in 8 Nigeria 186 5.3 1 in 18 CAR 173 4.8 19% 1 in 25 Burkina Faso 169 5.9 17% 1 in 22 Source: UNICEF State of the World’s Children Report 2009

24 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

25 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

26 Development traps Angola 220 N Y Chad 209 Somalia 200 DR Congo 199
Country <5 Mortality Rate Land-locked Conflict or post-conflict Resource curse Angola 220 N Y Chad 209 Somalia 200 DR Congo 199 N (Y) Guinea-Bissau 195 Mali 194 Sierra Leone Nigeria 186 CAR 173 Burkina Faso 169 Source: UNICEF State of the World’s Children Report 2009

27 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

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

29 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

30 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

31 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.

32 Diarrhea in Sub-Saharan Africa

33 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

34 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

35 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 days

36

37 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

38 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)

39 Evaluation of introduction of zinc for diarrhea in Tanzania

40 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

41 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

42 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

43 Private sector: What we don’t want

44

45

46 The alternative: ADDO shops

47 Accredited Drug Dispensing Outlets

48 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

49 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

50 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

51 Decreased diarrhoea-related morbidity and mortality
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

52 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

53 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

54 Study sites Morogoro Rural District, Morogoro Region
Same District, Kilimanjaro Region

55 Methods Sample size 1. Observation in first-level health facilities 9
2. Observation of prescription practices for children under age 5 in first-level facilities 56 3. Follow-up interviews with caregivers of children under age 5 with diarrhoea previously seen at first-level facility 98 4. Qualitative interviews with caregivers of children under age 5 with diarrhoea previously seen at first-level facility 32 5. Qualitative interviews with health workers in first-level health facilities 21 6. Interviews with representatives of pharmaceutical companies that conduct training sessions on zinc sulphate 2

56 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

57 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

58 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

59 Zinc and ORS prescription for children with diarrhea
District Morogoro District Same District Sample size 22 25 Zinc tablets (20mg) 20 (90.1%) 25 (100.0%) ORS sachets 9 (40.9%) 12 (48.0%) Zinc AND ORS together 8 (36.4%) 13 (52.0%)

60 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

61 Antimicrobial prescription for children with diarrhea
District Morogoro District Same District Sample size 22 25 Cotrimoxazole 8 (36.4%) 13 (52.0%) Tetracycline 0 (0.0%) 1 (4.0%) Erythromycin 4 (18.2%) 3 (12.0%) Amoxicillin Metronidazole 1 (4.5%) 2 (8.0%) Any antimicrobial 13 (59.1%) 16 (64.0%)

62 Antimalarial prescription for children with diarrhea + fever
District Morogoro District Same District Sample size 15 16 Zinc 13 (86.7%) 16 (100.0%) Artemether-Lumefantrine (ALu) 6 (40.0%) 1 (6.3%) Quinine 1 (6.7%) 2 (12.5%) Any antimalarial 6 (40%) Any zinc AND any antimalarial 4 (26.7%)

63 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.

64 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).

65 Items in counseling index
Does the dispenser … Does the caretaker … say which disease/problem the drug is for? give first dose to child in front of dispenser? say anything at all about the dose of the drug? Does the dispenser … make any attempt to see if the caretaker understands the instructions? say how many times to take the drug each day? ask if the caretaker knows how many days to give drug? 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? 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? give the first dose of the tablet to the child? look at caretaker when talking to her/him? show a tablet and say how many tablets to take each time? nod when caretaker says something? use harsh language or get irritated? ask caretaker to show how much tablet to give? ask caretaker if the explanation is clear? ask caretaker if she/he has any questions?

66 Counseling of parents of children with diarrhea by health workers
Prescribing practice Zinc tablets Freq (%) ORS ALu Number of times this treatment was prescribed 47 27 20 Health worker states that prescription must be completed 40 (85.1%) 19 (70.4%) 19 (95.0%) Health worker describes what problem the prescribed drug is for 25 (53.2%) 4 (14.8%) 13 (61.9%) Health worker makes an effort to determine if caretaker understands 46 (97.0%) 5 (18.5%) 20 (100%) Mean score on 18-point scale of counselling quality +/- SD 10.8 +/- 3.6 7.8 +/- 4.2 11.6 +/- 3.7

67 Administration of zinc in the home N = 68 caregivers of children prescribed zinc sulphate

68 Administration of ALu in the home N = 44 caregivers of children prescribed ALu

69 Observations/conclusions

70 Strengths and weaknesses of private sector involvement
Increases access to products in remote areas More variety of products available Greater reach of orientation sessions 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

71 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

72 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.

73 Investigators and funding
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 (Global Research Activity Cooperative Agreement). 

74 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.


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