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Improving treatment of childhood diarrhea in sub ‐ Saharan Africa in the age of malaria control Peter Winch Department of International.

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

1 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  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) 1970 Sub-Saharan Africa3.1 Middle East and North Africa1.3 South Asia5.4 East Asia and Pacific5.0 Latin America and Caribbean1.2 Entire World16.7 SSA proportion19% Source: UNICEF State of the World’s Children Report 2009

7 Total numbers of deaths in children under-5 years of age (millions) 19701990 Sub-Saharan Africa3.14.3 Middle East and North Africa1.30.6 South Asia5.44.2 East Asia and Pacific5.01.6 Latin America and Caribbean1.20.5 Entire World16.711.4 SSA proportion19%38% Source: UNICEF State of the World’s Children Report 2009

8 Total numbers of deaths in children under-5 years of age (millions) 197019902008 Sub-Saharan Africa3.14.34.4 Middle East and North Africa1.30.60.4 South Asia5.44.22.8 East Asia and Pacific5.01.60.8 Latin America and Caribbean1.20.50.2 Entire World16.711.48.8 SSA proportion19%38%50% Source: UNICEF State of the World’s Children Report 2009

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

10 Causes of <5 mortality in Africa Cause% of deaths Pneumonia21% Diarrhoea16% Malaria18% Measles5% HIV/AIDS6% Neonatal causes26% Injuries2% Source: J Bryce et al. Lancet 2005; 365: 1147-52 Malnutrition is important contributing factor in a large proportion of these deaths

11 Under-five mortality rates per 1000 live births 197019902008 Sub-Saharan Africa236184144 Middle East and North Africa1937743 South Asia19712476 East Asia and Pacific1205428 Latin America and Caribbean1225223 Entire World1429065 SSA:World Ratio1.72.02.2 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) CountryUnder-five mortality Afghanistan257 Angola220 Chad209 Somalia200 Democratic Republic of the Congo199 Guinea-Bissau195 Mali194 Sierra Leone194 Nigeria186 Central African Republic173 Source: UNICEF State of the World’s Children Report 2009

14 Top <5 mortality rates in Africa CountryUnder-five mortality Angola220 Chad209 Somalia200 Democratic Republic of the Congo199 Guinea-Bissau195 Mali194 Sierra Leone194 Nigeria186 Central African Republic173 Burkina Faso169 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 rateAdult HIV prev Angola2202.1% Chad2093.5% Somalia2000.5% DR Congo199-- Guinea-Bissau1951.8% Mali1941.5% Sierra Leone1941.7% Nigeria1863.1% Central African Republic1736.3% Burkina Faso1691.6% 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


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 Angola2205.86%1 in 12 Chad2096.23%1 in 11 Somalia2006.415%1 in 12 DR Congo1996.021%1 in 13 Guinea-Bissau1955.710%1 in 13 Mali1945.58%1 in 15 Sierra Leone1945.28%1 in 8 Nigeria1865.315%1 in 18 CAR1734.819%1 in 25 Burkina Faso1695.917%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 Country<5 Mortality Rate Land- locked Conflict or post- conflict Resource curse Angola220NYY Chad209YYY Somalia200NYN DR Congo199N (Y)Y Guinea-Bissau195NYN Mali194YN (Y)N Sierra Leone194NYY Nigeria186NN (Y)Y CAR173YYY Burkina Faso169YNN 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  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 1.Prevent dehydration thru increased appropriate home fluids & ORS 2.Continued feeding during & increased feeding after episode 3.Recognize signs of dehydration for early care-seeking-”new ORS” &/or other medical treatment 4.Give children zinc supplements for 10-14 days


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



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 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 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

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) 1.Assess adequacy and consequences of training by district health teams and short orientation on diarrhoea case management by drug company representatives 2.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 3.Evaluate administration in the home of treatments to sick children with diarrhoea alone or with other symptoms such as fever 4.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 facilities9 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 DistrictMorogoro District Same District Sample size2225 Zinc tablets (20mg) 20 (90.1%)25 (100.0%) ORS sachets9 (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 DistrictMorogoro District Same District Sample size2225 Cotrimoxazole8 (36.4%)13 (52.0%) Tetracycline0 (0.0%)1 (4.0%) Erythromycin4 (18.2%)3 (12.0%) Amoxicillin0 (0.0%)1 (4.0%) Metronidazole1 (4.5%)2 (8.0%) Any antimicrobial13 (59.1%)16 (64.0%)

62 Antimalarial prescription for children with diarrhea + fever DistrictMorogoro District Same District Sample size1516 Zinc13 (86.7%)16 (100.0%) Artemether- Lumefantrine (ALu) 6 (40.0%)1 (6.3%) Quinine1 (6.7%)2 (12.5%) Any antimalarial6 (40%)2 (12.5%) Any zinc AND any antimalarial 4 (26.7%)2 (12.5%)

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 … 1 say which disease/problem the drug is for? 2 say anything at all about the dose of the drug? 3 say how many times to take the drug each day? 4 say how many days to take the drug? 5 explain that all the oral tablets must be finished to complete the course of treatment even if the child appears to get better? 6 give the first dose of the tablet to the child? 7 show a tablet and say how many tablets to take each time? 8 ask caretaker to show how much tablet to give? Does the caretaker … 9 give first dose to child in front of dispenser? Does the dispenser … 10.make any attempt to see if the caretaker understands the instructions? 11.ask if the caretaker knows how many days to give drug? 12.ask if the caretaker knows how many times a day to give drug? 13.ask if the caretaker knows how many tablets to give each time? 14.look at caretaker when talking to her/him? 15.nod when caretaker says something? 16.use harsh language or get irritated? 17.ask caretaker if the explanation is clear? 18.ask caretaker if she/he has any questions?

66 Counseling of parents of children with diarrhea by health workers Prescribing practiceZinc tablets Freq (%) ORS Freq (%) ALu Freq (%) Number of times this treatment was prescribed 472720 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 +/- 3.67.8 +/- 4.211.6 +/- 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 Strengths  Increases access to products in remote areas  More variety of products available  Greater reach of orientation sessions 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

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  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).

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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