Presentation on theme: "Peter Winch firstname.lastname@example.org Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria control Peter Winch email@example.com."— Presentation transcript:
1Peter Winch firstname.lastname@example.org Improving treatment of childhood diarrhea in sub‐Saharan Africa in the age of malaria controlPeter WinchDepartment of International HealthSocial and Behavioral Interventions Program
2What I do Topics: Maternal and child health Newborn care in the home Malaria, diarrhea, pneumonia treatment at the community levelWater and sanitationCountries where I work currentlyMali, Tanzania, Bangladesh, Nepal
3Influences and methods Medical anthropologyLinguisticsEpidemiologyMethodsFormative research: Qualitative and quantitative research to design intervention contentProcess evaluation/process learningOutcome evaluation
4Overview Under-five mortality in sub-Saharan Africa Explanations for high under-five mortalityGlobal health practice and under-five mortalityExample: Evaluation of introduction of zinc for diarrhea in Tanzania
6Total numbers of deaths in children under-5 years of age (millions) 1970Sub-Saharan Africa3.1Middle East and North Africa1.3South Asia5.4East Asia and Pacific5.0Latin America and Caribbean1.2Entire World16.7SSA proportion19%Source: UNICEF State of the World’s Children Report 2009
7Total numbers of deaths in children under-5 years of age (millions) 19701990Sub-Saharan Africa3.14.3Middle East and North Africa1.30.6South Asia5.44.2East Asia and Pacific5.01.6Latin America and Caribbean1.20.5Entire World16.711.4SSA proportion19%38%Source: UNICEF State of the World’s Children Report 2009
8Total numbers of deaths in children under-5 years of age (millions) 197019902008Sub-Saharan Africa220.127.116.11Middle East and North Africa18.104.22.168South Asia22.214.171.124East Asia and Pacific5.01.60.8Latin America and Caribbean126.96.36.199Entire World16.711.48.8SSA proportion19%38%50%Source: UNICEF State of the World’s Children Report 2009
9Direct causes of <5 mortality sub-Saharan Africa % of deathsPneumoniaDiarrhoeaMalariaMeaslesHIV/AIDSNeonatal causesInjuries
10Causes of <5 mortality in Africa % of deathsPneumonia21%Diarrhoea16%Malaria18%Measles5%HIV/AIDS6%Neonatal causes26%Injuries2%Malnutrition is important contributing factor in a large proportion of these deathsSource: J Bryce et al. Lancet 2005; 365:
11Under-five mortality rates per 1000 live births 197019902008Sub-Saharan Africa236184144Middle East and North Africa1937743South Asia19712476East Asia and Pacific1205428Latin America and Caribbean1225223Entire World1429065SSA:World Ratio1.72.02.2Source: UNICEF State of the World’s Children Report 2009
12Under-five mortality in sub-Saharan Africa: Observations Very high50% of under-five mortality now occurs in sub-Saharan AfricaRates have been decreasing, but more slowly than in other world regions
13Countries with top <5 mortality rates in the world (2008) CountryUnder-five mortalityAfghanistan257Angola220Chad209Somalia200Democratic Republic of the Congo199Guinea-Bissau195Mali194Sierra LeoneNigeria186Central African Republic173Source: UNICEF State of the World’s Children Report 2009
14Top <5 mortality rates in Africa CountryUnder-five mortalityAngola220Chad209Somalia200Democratic Republic of the Congo199Guinea-Bissau195Mali194Sierra LeoneNigeria186Central African Republic173Burkina Faso169Source: UNICEF State of the World’s Children Report 2009
15Why do some countries have higher under-five mortality?
16Possible explanations HIV/AIDSMalariaStatus and health of womenDevelopment trapsI 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 rateAdult HIV prevAngola2202.1%Chad2093.5%Somalia2000.5%DR Congo199--Guinea-Bissau1951.8%Mali1941.5%Sierra Leone1.7%Nigeria1863.1%Central African Republic1736.3%Burkina Faso1691.6%Source: UNICEF State of the World’s Children Report 2009
18HIV/AIDS as explanation for high under-five mortality rates HIV/AIDS definitely contributes to under-five mortalityNot a good explanation for national-level variationsCountries with highest HIV prevalence e.g. South Africa, Namibia, Swaziland, Botswana have relatively low under-five mortality
19Higher under-five mortality rates Higher HIV prevalence rates
21Malaria as an explanation Important cause of under-five mortalityWidespreadAt best a partial explanation for national-level variation in under-five mortality
22Possible explanations HIV/AIDSMalariaStatus and health of womenDevelopment traps
23Status and health of women Country<5 Mortality RateTotal Fertility RateContraceptive prevalence rateLifetime risk of Maternal MortalityAngola2205.86%1 in 12Chad2096.23%1 in 11Somalia2006.415%DR Congo1996.021%1 in 13Guinea-Bissau1955.710%Mali1945.58%1 in 15Sierra Leone5.21 in 8Nigeria1865.31 in 18CAR1734.819%1 in 25Burkina Faso1695.917%1 in 22Source: UNICEF State of the World’s Children Report 2009
24Status and health of women Countries with highest under-five mortality also haveHigh maternal mortalityHigh fertility ratesLower rates of female literacyScore poorly on other measures of women’s status
25Development trapsPaul Collier describes a number of development traps in his recent book “The Bottom Billion”, e.g.Being landlockedConflict and poor post-conflict transitionResource curse: Overwhelming dependence on one single natural resource
26Development traps Angola 220 N Y Chad 209 Somalia 200 DR Congo 199 Country<5 Mortality RateLand-lockedConflict or post-conflictResource curseAngola220NYChad209Somalia200DR Congo199N (Y)Guinea-Bissau195Mali194Sierra LeoneNigeria186CAR173Burkina Faso169Source: UNICEF State of the World’s Children Report 2009
27Recap: ExplanationsWide range of explanations, acting at different levels and through different mechanismsIdeally Global Health practice should take stock of these explanations, and address them in strategies to improve health in Africa
28What is Global Health, and what is it doing about under-five mortality in Africa?
29Some 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
30Why under-five mortality in Africa is a Global Health priority Concern for equity and justiceHalf of the world’s under-five mortality occurs in sub-Saharan AfricaPreventive measures relatively inexpensive
31Global Health response to under-five mortality in Africa Disease-specific control programsHIV/AIDSMalariaMaternal and child health programsResearchTrainingProduct developmentVaccines, drugs, mosquito nets etc.
33Diarrhea in Sub-Saharan Africa About 700,000 of the 4.4 M deaths in under-five children each yearHighest mortality between 6 and 24 months of agePeriod of weaningChild starting to eat solid food, crawl and walkThis increases exposure to diarrheal pathogens in the environment
34Diarrhea: What can we do? PreventionVaccines e.g. Rotavirus vaccineWater and sanitation, handwashingManagement of sick childrenOral rehydration therapy10-14 day treatment with zincContinued breastfeeding, feeding, fluids
35Prevent dehydration thru increased appropriate home fluids & ORS Continued feeding during & increased feeding after episodeRecognize signs of dehydration for early care-seeking-”new ORS” &/or other medical treatmentGive children zinc supplements for days
37Zinc treatment for diarrhea Shown to:Reduce under-five mortalityReduce duration and severity of diarrheaPrevent new cases of diarrhea in the months following the treatment
38Dispersible 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)
39Evaluation of introduction of zinc for diarrhea in Tanzania
40Categorical (Disease-specific) control programs in Tanzania Presidential Malaria Initiative (PMI)President’s Emergency Program For AIDS Relief (PEPFAR)Global Fund for AIDS, Tuberculosis and MalariaTrachoma eradicationFilariasis eradicationComing soon: Obama administration’s initiative on maternal and child health
41Management of children with diarrhea in Tanzania What is happeningDiarrhea not seen as a serious conditionAntibiotics routinely given for simple diarrheaChildren with fever and diarrhea treated for malaria onlyWhat we wantIncreased careseeking for diarrheaChildren treated with zinc and ORS rather than antibioticsChildren with fever and diarrhea treated with antimalarial, zinc and ORS
42Zinc 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 ADDOsDetailing by drug company representativesVisit health facilities and ADDOsTalks on zinc and ORS
48Zinc introduction in Tanzania: Public sector Official public sector launching ceremonyProcurement and distribution of zinc and ORS to health facilitiesRefresher training of health workers in Integrated Management of Childhood Illnesses (IMCI)Assess all problems of sick childProvide treatments for all problemsCounseling and follow-up
49Key elements in IMCI counseling Greet the parentState the diagnosisState the treatments, explain what each one is forExplain how to give the treatmentsAsk parent if she/he understood
50Zinc introduction in Tanzania Next slide: Intervention Impact ModelFirst step in planning an evaluationSummarizes how all the pieces of the intervention are supposed to fit together to achieve an impact
51Decreased diarrhoea-related morbidity and mortality Advocacy and policy dialogue for introduction of zinc and low-osmolarity ORSTraining & orientationDistrict health officialsPersonnel in health facilitiesADDO shopsBehavior change communicationPublic sector launchMass media communicationCounselling of parentsAvailability of essential drugsZincORSAntimalarialsAntibioticsProvision of quality careHealth facilitiesADDO shops, pharmaciesHousehold behaviorsPrompt careseeking for children with diarrhoea, fever, respiratory symptomsAdministration of 10 days of zinc to children with diarrhoeaPreparation and administration of ORS to children with diarrhoeaAdministration of 3 days of ACT (ALu) to children with both diarrhoea and feverAvoid antibiotics for uncomplicated diarrhoeaDecreased diarrhoea-related morbidity and mortality
52Combination therapy for malaria ArtemetherRapid-acting with short half-lifeLumefantrineLonger-acting with long half-lifeThe combination is called ALu in Tanzania, Coartem elsewhere
53Objectives (summary)Assess adequacy and consequences of training by district health teams and short orientation on diarrhoea case management by drug company representativesExamine 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 introducedEvaluate administration in the home of treatments to sick children with diarrhoea alone or with other symptoms such as feverAssess reactions of health workers and parents to introduction of zinc and low osmolarity ORS
54Study sites Morogoro Rural District, Morogoro Region Same District, Kilimanjaro Region
55Methods Sample size 1. Observation in first-level health facilities 9 2. Observation of prescription practices for children under age 5 in first-level facilities563. Follow-up interviews with caregivers of children under age 5 with diarrhoea previously seen at first-level facility984. Qualitative interviews with caregivers of children under age 5 with diarrhoea previously seen at first-level facility325. Qualitative interviews with health workers in first-level health facilities216. Interviews with representatives of pharmaceutical companies that conduct training sessions on zinc sulphate2
56Data 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
57Drug availability Zinc sulphate was widely prescribed All 9 government health facilities and private shops had both zinc and ORS in stockALu was in stock in 7 out of 9 government health facilities and all ADDO shops visited
58Private sector orientation sessions and detailing In Morogoro Rural District many ADDO shop owners recalled receiving a training or briefing from a Shelys representativeIn 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 anyoneDrug reps talked about ORS and zinc, then went on to talk about antibiotics and other drugs we don’t want to promote
59Zinc and ORS prescription for children with diarrhea DistrictMorogoro DistrictSame DistrictSample size2225Zinc tablets (20mg)20 (90.1%)25 (100.0%)ORS sachets9 (40.9%)12 (48.0%)Zinc AND ORS together8 (36.4%)13 (52.0%)
60Zinc 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 childrenPrescription of ORS was not universal for children presenting with diarrhoeaChildren presenting with both diarrhoea and fever, or both diarrhoea and vomiting, were much more likely to be prescribed ORSPrescription 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
61Antimicrobial prescription for children with diarrhea DistrictMorogoro DistrictSame DistrictSample size2225Cotrimoxazole8 (36.4%)13 (52.0%)Tetracycline0 (0.0%)1 (4.0%)Erythromycin4 (18.2%)3 (12.0%)AmoxicillinMetronidazole1 (4.5%)2 (8.0%)Any antimicrobial13 (59.1%)16 (64.0%)
62Antimalarial prescription for children with diarrhea + fever DistrictMorogoro DistrictSame DistrictSample size1516Zinc13 (86.7%)16 (100.0%)Artemether-Lumefantrine (ALu)6 (40.0%)1 (6.3%)Quinine1 (6.7%)2 (12.5%)Any antimalarial6 (40%)Any zinc AND any antimalarial4 (26.7%)
63Antimalarial prescription for children with diarrhea + fever ALu was the antimalarial most frequently prescribedFor children presenting with diarrhea and fever, treatments for diarrhea were prescribed much more than treatments for malariaOf 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 antimalarialTesting 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.
64Counseling 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).
65Items 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?
66Counseling of parents of children with diarrhea by health workers Prescribing practiceZinc tabletsFreq (%)ORSALuNumber of times this treatment was prescribed472720Health worker states that prescription must be completed40 (85.1%)19 (70.4%)19 (95.0%)Health worker describes what problem the prescribed drug is for25 (53.2%)4 (14.8%)13 (61.9%)Health worker makes an effort to determine if caretaker understands46 (97.0%)5 (18.5%)20 (100%)Mean score on 18-point scale of counselling quality +/- SD10.8 +/- 3.67.8 +/- 4.211.6 +/- 3.7
67Administration of zinc in the home N = 68 caregivers of children prescribed zinc sulphate
68Administration of ALu in the home N = 44 caregivers of children prescribed ALu
70Strengths and weaknesses of private sector involvement Increases access to products in remote areasMore variety of products availableGreater reach of orientation sessionsDifferent forms of products cause confusionDrug reps having competing priorities: Promote sales and collaborate with public health objectivesSome drug reps don’t discuss, just drop off materials
71Malaria and diarrhea: Coordination problems Malaria programs don’t include diarrhea in their trainingMany public service announcements about malaria treatment, nothing about diarrheaBetter drug administration for ALu than zincZinc introduction was more recent, so now providers treating fever + diarrhea with zinc only, previously they treated with the antimalarial drug only
72Difficulties 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.
73Investigators and funding Ifakara Health Institute: Selemani S Mbuyita, Ahmed M Makemba, Idda KinyongeJohns Hopkins Bloomberg School of Public Health: Ashley I. Bennett, Peter J. Winch, Rolf D. KlemmFundingTanzania Mission of the U.S. Agency for International Development, under the terms of Award No. GHS-A (Global Research Activity Cooperative Agreement).
74AcknowledgementsDr. 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.