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
• Malaria, diarrhea, pneumonia
treatment at the community level
– Water and sanitation
 Countries where I work currently
– Mali, Tanzania, Bangladesh, Nepal
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
 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
Under-five mortality in
sub-Saharan Africa
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
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
1990
4.3
0.6
4.2
1.6
0.5
11.4
38%
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
1990
4.3
0.6
4.2
1.6
0.5
11.4
38%
2008
4.4
0.4
2.8
0.8
0.2
8.8
50%
Direct causes of <5 mortality
sub-Saharan Africa
Cause
Pneumonia
Diarrhoea
Malaria
Measles
HIV/AIDS
Neonatal causes
Injuries
% of deaths
Causes of <5 mortality in Africa
Cause
% 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: 1147-52
Under-five mortality rates per
1000 live births
1970
Sub-Saharan Africa
236
Middle East and North Africa 193
South Asia
197
East Asia and Pacific
120
Latin America and Caribbean 122
Entire World
142
SSA:World Ratio 1.7
Source: UNICEF State of the World’s Children Report 2009
1990
184
77
124
54
52
90
2.0
2008
144
43
76
28
23
65
2.2
Under-five mortality in subSaharan 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)
Country
Under-five mortality
Afghanistan
Angola
Chad
Somalia
Democratic Republic of the Congo
Guinea-Bissau
Mali
Sierra Leone
Nigeria
Central African Republic
Source: UNICEF State of the World’s Children Report 2009
257
220
209
200
199
195
194
194
186
173
Top <5 mortality rates in Africa
Country
Under-five mortality
Angola
Chad
Somalia
Democratic Republic of the Congo
Guinea-Bissau
Mali
Sierra Leone
Nigeria
Central African Republic
Burkina Faso
Source: UNICEF State of the World’s Children Report 2009
220
209
200
199
195
194
194
186
173
169
Why do some countries have higher
under-five mortality?
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
Country
Angola
Chad
Somalia
DR Congo
Guinea-Bissau
Mali
Sierra Leone
Nigeria
Central African Republic
Burkina Faso
<5 mortality rate
220
209
200
199
195
194
194
186
173
169
Source: UNICEF State of the World’s Children Report 2009
Adult HIV prev
2.1%
3.5%
0.5%
-1.8%
1.5%
1.7%
3.1%
6.3%
1.6%
HIV/AIDS as explanation for
high under-five mortality rates
 HIV/AIDS definitely contributes to underfive 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
Higher
underfive
mortality
rates
Higher HIV
prevalence
rates
Malaria as an explanation
 Important cause of under-five mortality
 Widespread
 At best a partial explanation for nationallevel variation in under-five mortality
Possible explanations




HIV/AIDS
Malaria
Status and health of women
Development traps
Status and health of women
Country
Angola
Chad
Somalia
DR Congo
Guinea-Bissau
Mali
Sierra Leone
Nigeria
CAR
Burkina Faso
<5
Mortality
Rate
220
209
200
199
195
194
194
186
173
169
Total
Fertility
Rate
5.8
6.2
6.4
6.0
5.7
5.5
5.2
5.3
4.8
5.9
Contraceptive
prevalence
rate
6%
3%
15%
21%
10%
8%
8%
15%
19%
17%
Source: UNICEF State of the World’s Children Report 2009
Lifetime risk
of Maternal
Mortality
1 in 12
1 in 11
1 in 12
1 in 13
1 in 13
1 in 15
1 in 8
1 in 18
1 in 25
1 in 22
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
 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 traps
Country
Angola
Chad
Somalia
DR Congo
Guinea-Bissau
Mali
Sierra Leone
Nigeria
CAR
Burkina Faso
<5
Mortality
Rate
220
209
200
199
195
194
194
186
173
169
Landlocked
N
Y
N
N (Y)
N
Y
N
N
Y
Y
Conflict or
postconflict
Y
Y
Y
Y
Y
N (Y)
Y
N (Y)
Y
N
Source: UNICEF State of the World’s Children Report 2009
Resource
curse
Y
Y
N
N (Y)
N
N
Y
Y
Y
N
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
What is Global Health, and what
is it doing about under-five
mortality in Africa?
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
 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
 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 Africa
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?
 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
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
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
+ 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)
Evaluation of introduction of
zinc for diarrhea
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
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
 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
Private sector:
What we don’t want
The alternative: ADDO shops
Accredited Drug Dispensing Outlets
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
 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
 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
Advocacy and policy dialogue for introduction of zinc and low-osmolarity ORS
Availability of
essential drugs
•Zinc
•ORS
•Antimalarials
•Antibiotics
Training & orientation
•District health officials
•Personnel in health facilities
•ADDO shops
Provision of quality care
•Health facilities
•ADDO shops, pharmacies
Behavior change
communication
•Public sector launch
•Mass media
communication
•Counselling of
parents
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
 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)
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
Study sites
 Morogoro Rural District, Morogoro Region
 Same District, Kilimanjaro Region
Methods
1. Observation in first-level health facilities
2. Observation of prescription practices for children
under age 5 in first-level facilities
3. Follow-up interviews with caregivers of children
under age 5 with diarrhoea previously seen at firstlevel facility
4. Qualitative interviews with caregivers of children
under age 5 with diarrhoea previously seen at firstlevel facility
5. Qualitative interviews with health workers in firstlevel health facilities
6. Interviews with representatives of pharmaceutical
companies that conduct training sessions on zinc
sulphate
Sample
size
9
56
98
32
21
2
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
 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
 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 diarrhea
District
Sample size
Zinc tablets
(20mg)
ORS sachets
Zinc AND ORS
together
Morogoro
District
22
20 (90.1%)
Same
District
25
25 (100.0%)
9 (40.9%)
8 (36.4%)
12 (48.0%)
13 (52.0%)
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
Antimicrobial prescription for
children with diarrhea
District
Morogoro
District
Sample size
22
Cotrimoxazole
8 (36.4%)
Tetracycline
0 (0.0%)
Erythromycin
4 (18.2%)
Amoxicillin
0 (0.0%)
Metronidazole
1 (4.5%)
Any antimicrobial 13 (59.1%)
Same
District
25
13 (52.0%)
1 (4.0%)
3 (12.0%)
1 (4.0%)
2 (8.0%)
16 (64.0%)
Antimalarial prescription for
children with diarrhea + fever
District
Sample size
Zinc
ArtemetherLumefantrine (ALu)
Quinine
Any antimalarial
Any zinc AND any
antimalarial
Morogoro
District
Same
District
1 (6.7%)
6 (40%)
4 (26.7%)
2 (12.5%)
2 (12.5%)
2 (12.5%)
15
13 (86.7%)
6 (40.0%)
16
16 (100.0%)
1 (6.3%)
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
 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
Does the dispenser …
Does the caretaker …
1 say which disease/problem the drug is 9
give first dose to child in front of
for?
dispenser?
2 say anything at all about the dose of theDoes the dispenser …
drug?
10. make any attempt to see if the
3 say how many times to take the drug
caretaker understands the instructions?
each day?
11. ask if the caretaker knows how many
4 say how many days to take the drug?
days to give drug?
5 explain that all the oral tablets must be 12. ask if the caretaker knows how many
finished to complete the course of
times a day to give drug?
treatment even if the child appears to 13. ask if the caretaker knows how many
get better?
tablets to give each time?
6 give the first dose of the tablet to the 14. look at caretaker when talking to
child?
her/him?
7 show a tablet and say how many tablets 15. nod when caretaker says something?
to take each time?
16. use harsh language or get irritated?
8 ask caretaker to show how much tablet 17. ask caretaker if the explanation is clear?
to give?
18. ask caretaker if she/he has any
questions?
Counseling of parents of
children with diarrhea
by health workers
Prescribing practice
Zinc tablets ORS
Freq (%)
Freq (%)
Number of times this treatment was 47
27
prescribed
Health worker states that
40 (85.1%) 19 (70.4%)
prescription must be completed
Health worker describes what
25 (53.2%) 4 (14.8%)
problem the prescribed drug is for
Health worker makes an effort to
46 (97.0%)
5 (18.5%)
determine if caretaker understands
Mean score on 18-point scale of
10.8 +/- 3.6 7.8 +/- 4.2
counselling quality +/- SD
ALu
Freq (%)
20
19 (95.0%)
13 (61.9%)
20 (100%)
11.6 +/- 3.7
Administration of zinc in the home
N = 68 caregivers of children prescribed zinc sulphate
Administration of ALu in the home
N = 44 caregivers of children prescribed ALu
Observations/conclusions
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
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
 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
– 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
 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.