Diarrhea - We have the solution (ORS) - What is the problem?

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Diarrhea - We have the solution (ORS) - What is the problem?

  1. 1. 1
  2. 2. THE PROBLEM 2
  3. 3. THE PROBLEM 3
  4. 4. THE PROBLEM 4
  5. 5. THE PROBLEM 5
  6. 6. Fluid Therapy for Diarrhea1831-32 • Description of psysiologic disturbances in diarrhea • Use of intermittent saline and alkali in cholera1930-50s • Use of IV fluids1950s • Use of ORS in United States 6
  7. 7. 7
  8. 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. 9. Mass Accidental Salt Poisoning in Infancy A Study of a Hospital Disaster 9Laurence Finberg et al: Jama: 184:April 20, 1963; 121-124
  10. 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.” 10Editorial J of Ped, 1980:96:51
  11. 11. 11New Eng J Med 306: May 6th 1982
  12. 12. THE SOLUTION (ORS) 12
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  18. 18. 18
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  20. 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. 21. E.A. Park (1924): “The habit of starving an infant just because he hasfrequent stools is fallacious and gives rise to disastrous results…” (quote provided by Chung, 1948) 21
  22. 22. The heresy of yesterday isthe gold standard of today. 22
  23. 23. Nelson, Textbook of Pediatrics, 11th edition … Usual dietary intake isachieved, usually in 7 to 8 days. 23
  24. 24. “…half of what we teach you here is wrong – Unfortunately, we don’t know which half…” -Lisa Sanders, -New York Times 24
  25. 25. Randomized Trial Early Feeding VsDelayed Feeding ( Standard Treatment) Pediatrics 76; no 2 Aug 1985 25
  26. 26. Early Vs Delayed Feeding Duration of Diarrhea Group A Group B 26* P<0.001 Pediatrics 76; no 2 Aug 1985
  27. 27. Clinical trials of early vs latter feeding for the management of acute diarrhea - No increase in complications - Better nutritional outcomes 27Carlos H. Lifschitz, Pediatric Gastroenterology and Nutrition in Clinical Practice. 2001
  28. 28. By mid-1980’s:- ORS accepted all over theworld- the benefits of Early FeedingFirmly Established 28
  29. 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%) 29Boschi-Pinto et al. 2009 J Health Popul Nutr 27(6):755-62
  30. 30. Annual change in ORT coverage between first DHS (1990-2001) and second DHS (2001-2006) 30Boschi-Pinto et al. 2009 J Health Popul Nutr 27(6):755-62
  31. 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. 32. Barriers to ORS Implementation • Reduced focus on diarrhea • Reduced funding • Integration with Integrated Management of Childhood Illness (IMCI) 32
  33. 33. WHO - Constrained Resources1987:Full time staff for CDD - 25 to 30Bi-annual budget - $20M2012:Full time staff forMaternal/Newborn/Child/AdolescentHealth - 33Bi-annual budget - $ 20 to 23M
  34. 34. Problems with Integration ofDiarrhea 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. 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. 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. 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 37Blum et al. Am J Trop Med Hyg 2011 85(6):1126-33
  38. 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. 39. Integration of Diarhea andPneumonia Control Programs DOES IT MAKE SENSE? 39
  40. 40. Many interventions are available to preventdiarrhea and pneumonia deaths…However, uncoordinated implementation canresult in:• Development of parallel structures and processes• Duplication of efforts• Conflicting messages to countries & communities• Suboptimal results
  41. 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 systemUNICEF State of the Worlds Children, 2009
  42. 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. 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. 44. Conditions necessary for successful coordination of programs •Clear WHO policyGlobal Level •Clear strategies •International funding and support •Clear national policies •Political commitmentNational 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. 45. ConclusionsOPPORTUNITIES 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. 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 theground in a balloonYes. How did you know?You must be a policy makerBecause you don’t know where you are or whereyou’re going, and now you’re blaming me….

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