1. 1

2. THE PROBLEM
2

3. THE PROBLEM
3

4. THE PROBLEM
4

5. THE PROBLEM
5

6. Fluid Therapy for Diarrhea
1831-32 • Description of psysiologic
disturbances in diarrhea
• Use of intermittent saline
and alkali in cholera
1930-50s • Use of IV fluids
1950s • Use of ORS in United States
6

7. 7

8. Baltimore City Hospitals
Solution #1
• NA 62 m.Eq/L
•K 20 m.Eq/L
• CI 52 m.Eq/L
• Lactate 30 m.Eq/L
• Glucose 33 GM/L
8

9. Mass Accidental Salt
Poisoning in Infancy
A Study of a Hospital Disaster
9
Laurence Finberg et al: Jama: 184:April 20, 1963; 121-124

10. “The whole WHO Program may now be
safely endorsed for all kinds of diarrheal
dehydration in populations of infants and
children in developing regions, including
those analogous situations within the
United States, such as Indian
reservations.”
10
Editorial J of Ped, 1980:96:51

11. 11
New Eng J Med 306: May 6th 1982

12. THE SOLUTION (ORS)
12

13. 13

14. 14

15. 15

16. 16

17. 17

18. 18

19. 19

20. CONTROVERSY – 70’s and 980’s
Diarrhea Treatment
•To Feed or Not to Feed -
That is the Question
• Strong opinions on both
sides
20

21. E.A. Park (1924): “The habit of starving
an infant just because he has
frequent stools is fallacious and gives rise
to disastrous results…”
(quote provided by Chung, 1948)
21

22. The heresy of yesterday is
the gold standard of today.
22

23. Nelson, Textbook of Pediatrics, 11th
edition
… Usual dietary intake is
achieved, usually in 7 to 8 days.
23

24. “…half of what we
teach you here
is wrong –
Unfortunately,
we don’t know
which half…”
-Lisa Sanders,
-New York Times
24

25. Randomized Trial
Early Feeding
Vs
Delayed Feeding ( Standard Treatment)
Pediatrics 76; no 2 Aug 1985
25

26. Early Vs Delayed Feeding
Duration of Diarrhea
Group A Group B
26
* P<0.001 Pediatrics 76; no 2 Aug 1985

27. Clinical trials of early vs latter feeding for the
management of acute diarrhea
- No increase in complications
- Better nutritional outcomes
27
Carlos H. Lifschitz, Pediatric Gastroenterology and Nutrition in Clinical Practice. 2001

28. By mid-1980’s:
- ORS accepted all over the
world
- the benefits of Early Feeding
Firmly Established
28

29. Trends in ORT Use for Diarrhea
Countries with consecutive DHS data from 1990-2001
and 2001-2006
Total number Median Median (IQR)
of countries baseline annual change in
coverage coverage
Africa 21 34% -0.2% (-1.2% to 1.6%)
Asia 8 43% -0.4% (-0.3% to 2.0%)
29
Boschi-Pinto et al. 2009 J Health Popul Nutr 27(6):755-62

30. Annual change in ORT coverage between first
DHS (1990-2001) and second DHS (2001-2006)
30
Boschi-Pinto et al. 2009 J Health Popul Nutr 27(6):755-62

31. ORS use in India
State Percentage of children w/
diarrhea who received ORS
Meghalaya 65.1% Highest
performing
Tripura 58.1%
states
Himachal Pradesh 56.3%
Goa 50.6%
National Average 26.0% National Average
Nagaland 16.5% Lowest
performing
Rajasthan 16.5%
states
Assam 14.5%
Uttar Pradesh 12.5%
National Family Health Survey III 2005-2006

32. Barriers to ORS Implementation
• Reduced focus on diarrhea
• Reduced funding
• Integration with Integrated Management
of Childhood Illness (IMCI)
32

33. WHO - Constrained Resources
1987:
Full time staff for CDD - 25 to 30
Bi-annual budget - $20M
2012:
Full time staff for
Maternal/Newborn/Child/Adolescent
Health - 33
Bi-annual budget - $ 20 to 23M

34. Problems with Integration of
Diarrhea Programs with IMCI
• IMCI was an approach to training NOT
a Program
• Little Program Management
• No permanent staff
• No monitoring and evaluation
• No seat at the table for resources
• Mainly facility based
34

35. CDD Programs 1980’s
• CDD Programs had dedicated staff
• Each country had a National CDD
(NCDD) Program
• Dedicated Training Program
• Monitoring and evaluation
35

36. Barriers to Appropriate Case
Management
• Mixed messages re. Home Available
Fluids
• Supply issues
• Access
• Training
• Parentral perception:
- ORS does not stop diarrhea
- Preference for drugs 36

37. Barriers to coverage
• Preference for antimicrobial/anti-motility drugs to stop
diarrhea symptoms
• Inconsistent recommendations and recipes from
health workers, if ORS not given parents often
assume it’s not needed
• In rural communities cost, distance to health facilities,
belief in herbal remedies
37
Blum et al. Am J Trop Med Hyg 2011 85(6):1126-33

38. Strategies for preventing and Strategies for preventing and
treating pneumonia treating diarrhea
• Protection • Protection
– Breast feeding promotion – Breast feeding promotion
– Hand washing promotion – Hand washing promotion
– Zinc supplementation – Vitamin A and Zinc supplementation
– Adequate nutrition – Adequate nutrition
– Reduced indoor air pollution – Safe water and sanitation
• Prevention • Prevention
Many interventions and
– Vaccination
treatment strategies –are identical
• New: Pneumococcal, Hib
Vaccination
• New: Rotavirus
• Routine: Measles, pertussis • Routine: Measles
– HIV prevention – HIV prevention
• Treatment • Treatment
– Improve care seeking behavior – Improve care seeking behavior
– Community case management – Community case management
– Health facility case management – Health facility case management
– Antibiotics – Low-osmolarity ORS
– Zinc

39. Integration of Diarhea and
Pneumonia Control Programs
DOES IT MAKE SENSE?
39

40. Many interventions are available to prevent
diarrhea and pneumonia deaths…
However, uncoordinated implementation can
result in:
• Development of parallel structures and processes
• Duplication of efforts
• Conflicting messages to countries & communities
• Suboptimal results

41. Opportunities for Synergy: Expanded
Program for Immunization (Part 1)
• Provide simple interventions
 Vaccines
 Vitamin A supplementation
 Zinc supplementation
 ORS distribution and education
 Breastfeeding education
 Hand washing education DTP3 Coverage
<50%
50% -< 70%
70% -< 80%
• Challenges
80% - 90%
>90%
 Low coverage of current EPI vaccines
No data
 New vaccines may overburden already stressed system
 Adding additional interventions without additional support could
disrupt an otherwise effective system
UNICEF State of the Worlds Children, 2009

42. Opportunities for Synergy:
Community Case Management
• Provide basic services
 Treatment: Zinc and ORS for diarrhea, antibiotics for pneumonia
 Education: Hand washing / breastfeeding, ORS use
 Referral for severe disease
• Challenges
 Overburdening of responsibilities
 Health referral system weak
 Supervision and management difficult

43. Opportunities for Synergy:
Health Facility
• Can provide integration of all preventive and
treatment strategies
• Challenges
 Most facilities are overburdened and underfunded
 Can only reach those who seek and access care

44. Conditions necessary for successful
coordination of programs
•Clear WHO policy
Global Level •Clear strategies
•International funding and support
•Clear national policies
•Political commitment
National Level •Appropriate funding
•Improved management
•Strong supply procurement
•Health worker training
Local Level •Monitoring and evaluation
•Communication and feed back between
global, national, and local levels

45. Conclusions
OPPORTUNITIES CHALLENGES
• Combining strategies can • May over burden already under
reduce duplication of structures resourced programs
and effort
• Monitoring and evaluation will
• New treatment and prevention be difficult
strategies can reenergize efforts
• Successful programs may lose
• Old strategies can be packaged focus and identity
in new programs
• Suboptimal implementation
• Multiple, coordinated efforts will likely with out proper funding
increase impact and management
Engagement of private sector critical

46. Where am I?
You must be a researcher
Because what you told me is absolutely
correct but completely useless
Yes, how did you know?
You’re 30 metres above the
ground in a balloon
Yes. How did you know?
You must be a policy maker
Because you don’t know where you are or where
you’re going, and now you’re blaming me….