1. SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’Hanlon Health Consulting Inappropriate pediatric diarrhea treatment: Challenges in Nepal, Benin, and Madagascar Kathryn Banke, Ph.D. Abt Associates June 16, 2011

2. Overview USAID-funded Social Marketing Plus for Diarrheal Disease Control: Point-of-Use Water Disinfection and Zinc Treatment (POUZN) Project Pediatric diarrhea and diarrhea treatment POUZN zinc programs Methods Main findings/results: Pediatric diarrhea treatment practices Zinc ORS/ORT Antibiotics Antidiarrheals Next steps

3. Pediatric diarrhea 2 nd leading cause of death in children under 5 years (15%) At least 1.3 million deaths per year Dehydration is most immediate cause of death Source: Black et al. Lancet 2010; 375:1969-1987Lancet 2010; 375:1969-1987

4. Zinc for treatment of uncomplicated pediatric diarrhea 1985-2003: Field research findings Reduced duration and severity of diarrhea when zinc taken for 10-14 days Protective effect: reduced incidence in following 2-3 months May 2004: WHO/UNICEF issue revised recommendation for treatment of uncomplicated pediatric diarrhea: Zinc for 10-14 days PLUS low-osmolarity oral rehydration solution (ORS)/ oral rehydration therapy (ORT)

5. POUZN zinc programs (1) Nepal Public sector pilots: 2006 POUZN (w/MOHP) public/private sector program in Kathmandu: Jan-Aug 2007 POUZN in 30 districts (out of 75 total): April- August 2008 Local manufacturer partnerships, BCC campaign, 8000 providers trained Benin Public/private pilot (2 departments): April 2008 National launch through health centers and pharmacies: July 2008 8/12 departments initially Remaining 4 departments by 2009

6. POUZN zinc programs (2) Madagascar  MOH launched limited public sector zinc program in 2006; expanded to 90/111 districts with BASICS/UNICEF support  ViaSur (ORS + zinc) launched April 2009 (rural communities)  Hydrazinc (ORS + zinc) launched December 2009 (commercial)

7. Household survey details NepalBeninMadagascar DatesAug-Sept 2008Nov 2009March-April 2010 No. of Households355029121200 No. of children421138541200 No. with diarrhea2893071000 Age range0-59 months 6-59 months DesignCross-sectional Cross-sectional; programs vs. comparison

8. Household survey methods Structured questionnaire Diarrhea treatment practices Exposure to messages and media Knowledge, perceptions related to diarrhea and zinc Administered to caregivers of children under 5 Nepal & Benin: youngest & next-youngest (if any) child in house (0-59 months) Madagascar: youngest child in house (6-59 months) Weighted analysis (complex sampling designs)

9. Zinc and ORS/ORT use

10. Among zinc users, zinc with ORS/ORT use high; correct zinc use for 10 days still needs attention Note: analysis restricted to respondents who used zinc for diarrhea episode in past 2 weeks

11. Antibiotics and antidiarrheals are inappropriate and potentially harmful for uncomplicated diarrhea Antibiotics should only be used if blood in stools Inappropriate use of antibiotics will not improve diarrhea Antibiotics may have side effects and can lead to development of antibiotic resistance Benefits of antidiarrheals do not outweigh the risks Antidiarrheals may mask symptoms and delay treatment Antidiarrheals not appropriate for children under 5

12. Caregivers use other treatments, regardless of zinc/ORS promotion and marketing

13. Inappropriate use of antibiotics Proportion of children given antibiotics that had blood in the stools: Madagascar: 19% Nepal: 20% Benin: 28%

14. Providers continue to sell/recommend inappropriate treatments even when contraindicated Mystery client survey results Nepal: 82% recommended an antidiarrheal; 3% gave an antibiotic; 10% provided other pills/syrups Madagascar: 46% inappropriately recommended antibiotics 33% inappropriately recommended antidiarrheals Benin Few recommended antibiotics alone (2% in public clinics/6% in pharmacies) or antidiarrheals alone (2% in public clinics/20% in pharmacies) 84% of public clinics and 52% of pharmacies recommended OraselZinc plus either an antibiotic or anti-diarrheal

15. Qualitative data from providers and caregivers Madagascar caregivers: Used to treating with antibiotics rather than new zinc product Benin providers: Zinc not as effective as antidiarrheals – does not stop diarrhea immediately and requires 10 days to accrue benefits

16. Next steps Conduct additional research with providers to identify reasons for recommending inappropriate treatments Explore provider incentives Modify program messages for caregivers and providers in new program countries Develop/implement new provider training strategies

17. Millennium Development Goal #4 Between 1990 and 2015: reduce, by two-thirds, the under-five mortality rate

18. SHOPS is funded by the U.S. Agency for International Development. Abt Associates leads the project in collaboration with Banyan Global Jhpiego Marie Stopes International Monitor Group O’Hanlon Health Consulting Kathryn_banke@abtassoc.com www.shopsproject.org