Nicaragua ORT Project
Imelda Medina, M.D.

1
UN Millennium Development Goals

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The UN Millennium Development Goals
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Global partnership to reduce extreme poverty.
Established on September 2000, de...
What they are
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Goal 1: Eradicate Extreme Hunger and Poverty
Goal 2: Achieve Universal Primary Education
Go...
Our Focus
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Let’s start with…
 Goal

4: Reduce Child Mortality

Reduce by two-thirds, between 1990 and 2015,
the under-f...
EDUCATION


Evidence shows that information, not in the hands of
experts, but in the hands of the population, leads to
ch...
HEALTH
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Worldwide over 10 million children under 5
years of age are dying each year.



What interventions are appropri...
HEALTH


Two main causes of Morbidity and Mortality in
children 5 and less than 5 y/o
Malnutrition
 Acute gastroenteriti...
HEALTH
Malnutrition
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MALNUTRITION
Major underlying factor
 Complicates the clinical presentation
 EDUCATION is essenti...
Leading Causes of Death in Children
Under 5 years of age
Perinatal (22%)

Pneumonia
(20%)
Malnutrition
underlying factor
(...
HEALTH
Malnutrition Consequences
Child with Spina Bifida and Hydrocephalus
(Folic acid deficiency during pregnancy)

Child...
HEALTH
Acute gastroenteritis


Acute gastroenteritis (Diarrhea) remains a common illness among infants and
children world...
HEALTH


Acute gastroenteritis’ primary morbidity and mortality
arises from dehydration and electrolyte losses
associated...
Interventions by cause - Diarrhea
Prevention

Treatment

Breastfeeding
Water/San/Hygiene

Exposure to
diarrhea

Complement...
HEALTH


Oral Rehydration
Therapy


A simple solution of
water, salt and sugar saves
millions of young lives.

15
HEALTH
How ORT works

16
Oral Rehydration Therapy
"The discovery that sodium transport and glucose
transport are coupled in the small intestine so ...
HEALTH


Treatment can begin at home if primary caretakers:


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are educated about the disease
understand adequate ORT...
HEALTH


ORT preparation


It can be prepared from commercially available ORS packets




By using home ingredients to...
Action Plan
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Work towards the achievement of the UN’s
Millennium Development Goal #4: To reduce
child mortality.



Ass...
Action Plan Cont.
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UN MILLENNIUM VILLAGES WORKING
PLAN
We will empower those who need us the most living
in impoverished...
Our Plan


We will Improve and Establish the most
effective Sustainable Distribution System
for Oral Rehydration Therapy ...
Action Plan


We will provide continuous Education and ORT treatment for gastroenteritis
through an existing distribution...
Action Plan cont.
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Four important components that will ensure sustainability – FAMILIAS UNIDAS
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FUND RAISING ACTIVITIE...
Action Plan
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Target population:
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Children 5 and less than 5 yrs old living in
underserved villages (“barrios”) of Nica...
Action Plan


Distribution system


Initially established by Dr. Imelda Medina in 1999

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Currently our system in Manag...
Action Plan


Distribution system


Still active (since 1999) which shows it's importance
to serve the needs of the popu...
Action Plan


DISTRIBUTION SYSTEM


We will provide the base houses with Oral Rehydration Therapy salts so
they serve as...
Action Plan


DISTRIBUTION SYSTEM


ORT PACKETS COST


Taking into consideration that the total number of children 5 an...
Action Plan
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DISTRIBUTION SYSTEM

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We will Educate the population about the disease and conduct
workshops about the ad...
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References
AAP. (2006). Rec...
References (cont.)
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Goenjian AK, Molina L, Steinberg AM, Fairbanks LA, Alvarez ML, Goenjian HA,...
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Nicaragua ort project presentation

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Nicaragua ort project presentation

  1. 1. Nicaragua ORT Project Imelda Medina, M.D. 1
  2. 2. UN Millennium Development Goals 2
  3. 3. The UN Millennium Development Goals    Global partnership to reduce extreme poverty. Established on September 2000, deadline 2015. Address:  Basic human rights-the rights of each person on the planet to health, education, shelter, and security.  Extreme poverty in its many dimensions:        Income poverty Hunger Disease Lack of adequate shelter Exclusion-while promoting gender equality Education Environmental sustainability http://www.unmillenniumproject.org/goals/index.htm 3
  4. 4. What they are         Goal 1: Eradicate Extreme Hunger and Poverty Goal 2: Achieve Universal Primary Education Goal 3: Promote Gender Equality and Empower Women Goal 4: Reduce Child Mortality Goal 5: Improve Maternal Health Goal 6: Combat HIV/AIDS, Malaria and other diseases Goal 7: Ensure Environmental Sustainability Goal 8: Develop a Global Partnership for Development 4
  5. 5. Our Focus  Let’s start with…  Goal 4: Reduce Child Mortality Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate 5
  6. 6. EDUCATION  Evidence shows that information, not in the hands of experts, but in the hands of the population, leads to changes in behavior, health improvement and decrease in mortality.  Education and Prevention play an essential role.  Low income, Social Growth and Good Health: A History of twelve countries. New England Journal of Medicine, 2008 6
  7. 7. HEALTH  Worldwide over 10 million children under 5 years of age are dying each year.  What interventions are appropriate for reducing these deaths? 7
  8. 8. HEALTH  Two main causes of Morbidity and Mortality in children 5 and less than 5 y/o Malnutrition  Acute gastroenteritis (Diarrhea)  8
  9. 9. HEALTH Malnutrition  MALNUTRITION Major underlying factor  Complicates the clinical presentation  EDUCATION is essential  9
  10. 10. Leading Causes of Death in Children Under 5 years of age Perinatal (22%) Pneumonia (20%) Malnutrition underlying factor (60%) All other causes (29%) Malaria (8%) Measles (5%) Diarrhea (12%) HIV / AIDS (4%) World Health Organization data 2001 (from Global Health Council http://www.globalhealth.org) 10
  11. 11. HEALTH Malnutrition Consequences Child with Spina Bifida and Hydrocephalus (Folic acid deficiency during pregnancy) Child with Myelomeningocele (Folic acid deficiency during pregnancy) High Prevalence of Prematurity Protein, Calories, Vitamins deficiencies 11
  12. 12. HEALTH Acute gastroenteritis  Acute gastroenteritis (Diarrhea) remains a common illness among infants and children worldwide.  In the United States, acute diarrhea accounts for >1.5 million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths/year (CDC report year 2003).   In developing countries, diarrhea is a common cause of mortality among children aged <5 years, with approximately 2 million deaths annually (CDC MMWR 2003). Diarrhea dehydration is one of the main causes of death in children under the age of five (Ahmad OB et al 2000; Sakisaka K 2006), and often (almost 50% of these cases) are complicated by malnutrition (Rutstein SO 2000). 12
  13. 13. HEALTH  Acute gastroenteritis’ primary morbidity and mortality arises from dehydration and electrolyte losses associated with untreated diarrhea (CDC MMWR 2003; Greenough WB-The Lancet 1995).  Fortunately, this can effectively be prevented by the adequate use of Oral Rehydration Therapy (ORT), which includes rehydration and maintenance fluids with oral rehydration solutions (ORS), combined with continued age-appropriate nutrition (CDC MMWR 2003). 13
  14. 14. Interventions by cause - Diarrhea Prevention Treatment Breastfeeding Water/San/Hygiene Exposure to diarrhea Complementary feeding Oral rehydration therapy Zinc Vitamin A Diarrhea Antibiotics for dysentery Zinc Die Future: rotavirus vaccine Survive 14
  15. 15. HEALTH  Oral Rehydration Therapy  A simple solution of water, salt and sugar saves millions of young lives. 15
  16. 16. HEALTH How ORT works 16
  17. 17. Oral Rehydration Therapy "The discovery that sodium transport and glucose transport are coupled in the small intestine so that glucose accelerates absorption of solute and water (is) potentially  the most important medical advance of this century." The Lancet (British Scientific Journal) 5th August, 1978 17
  18. 18. HEALTH  Treatment can begin at home if primary caretakers:    are educated about the disease understand adequate ORT preparation/use are trained to recognize signs of illness or treatment failure that necessitate immediate medical intervention (CDC MMWR 2003).  ORT is simple and allows management of uncomplicated cases of diarrhea at home, regardless of etiologic agent (CDC MMWR 2003).  Thus, early intervention can significantly diminish complications, hospitalizations and deaths. 18
  19. 19. HEALTH  ORT preparation  It can be prepared from commercially available ORS packets   By using home ingredients to make a standard homemade solution.   Mix a packet in a liter of previously boiled water. The recipe includes 5 cups of clean potable water, 1 teaspoon of salt and 8 teaspoons of sugar. Education plays a significant part on the safe and efficient use of ORT, otherwise serious errors and complications can occur (Meyers A et al 1997). 19
  20. 20. Action Plan  Work towards the achievement of the UN’s Millennium Development Goal #4: To reduce child mortality.  Assume the UN’s Millennium Villages working plan. 20
  21. 21. Action Plan Cont.  UN MILLENNIUM VILLAGES WORKING PLAN We will empower those who need us the most living in impoverished “villages/barrios” so they can transform themselves and meet the Millennium Development Goals.  In order to do so, we will work in partnership with governments and other committed organizations, to provide affordable and science-based solutions to help people lift themselves out of extreme poverty.  21
  22. 22. Our Plan  We will Improve and Establish the most effective Sustainable Distribution System for Oral Rehydration Therapy (ORT) of Acute Gastroenteritis, and Ensure its continuous Excellent Performance in Nicaragua. 22
  23. 23. Action Plan  We will provide continuous Education and ORT treatment for gastroenteritis through an existing distribution system in Managua, working in liaison with a small clinic, base houses in the communities and health promoters.  We will establish similar systems in other areas of much need in Nicaragua with the help of local organizations. Our goal is to eventually implement our system at a national level.  Promote mental health and unity with families in the communities through fun activities.  Carry out infrastructure restoration as well as the establishment of hygiene measurements important for malnutrition and infectious diseases prevention. 23
  24. 24. Action Plan cont.  Four important components that will ensure sustainability – FAMILIAS UNIDAS  FUND RAISING ACTIVITIES AND GRANT WRITING IN THE US AND NICARAGUA   PARTICIPATION     LOS CHAVALITOS CLINIC OTHER (S) EDUCATION   Pre-Clinical and Public Health/Research Continuous involvement with the ORT project in educational and other activities PARTNERSHIP WITH LOCAL ORGANIZATIONS   To provide ORT packets to the families We will teach Families and Community Leaders how to prepare treatment at home with homemade ingredients. Educate about the disease and associated co-morbidities among other important topics.
  25. 25. Action Plan  Target population:  Children 5 and less than 5 yrs old living in underserved villages (“barrios”) of Nicaragua.  Target population goal is about 5,000 children 25
  26. 26. Action Plan  Distribution system  Initially established by Dr. Imelda Medina in 1999  Currently our system in Managua is working with 8 base houses in the communities, providing a total of about 300 ORT packets monthly with an average of 3000-4000 salts per year. In addition, we provide some medicines such as Paracetamol. The salts are distributed by "brigadistas de salud" (health promoters) in charge of the base houses, who also refer children to the clinic. 26
  27. 27. Action Plan  Distribution system  Still active (since 1999) which shows it's importance to serve the needs of the population and our ability to ensure a project’s sustainability.  However, the services are not enough to cover the basic needs of our pediatric population. 27
  28. 28. Action Plan  DISTRIBUTION SYSTEM  We will provide the base houses with Oral Rehydration Therapy salts so they serve as a source of distribution to the population.  Two ways we will provide ORT to the population:  1. ORT Packets ($0.32 each).  Each child will need at least 2 packets on day 1 of the disease.  2. Teach parents how to correctly prepare them with ingredients at home. 28
  29. 29. Action Plan  DISTRIBUTION SYSTEM  ORT PACKETS COST  Taking into consideration that the total number of children 5 and less than 5 years old in these communities is approximately 4,444, the most frequent times per year they get sick is 3, and that we will provide them with two packets during the first day of the disease, each packet costing $0.32, we will need $8,532.48 annually to help the communities or at least 26,666 packets of WHO ORT solution per year, about 2,000 packets/month (note the large gap from the current annual supply). 29
  30. 30. Action Plan  DISTRIBUTION SYSTEM  We will Educate the population about the disease and conduct workshops about the adequate preparation of the solution at home for cases when the packets are not available.  Establish additional base houses to cover all areas in need in the country and ensure excellent performance so that families can have resources close to their home and receive ORT treatment in a timely manner. 30
  31. 31.                                                References AAP. (2006). Recommended Childhood and Adolescent Immunization Schedule United States. from http://www.cispimmunize.org/IZSchedule_2006.pdf BBC. (2001, 30 July 2001). Timeline: Nicaragua. Retrieved 30 July 2001, 2001, from http://www.hartford-hwp.com/archives/47/397.html Beachy, B. (2006, 01/30/2006). The IMF debt relief sham: swindling the sick. The counterpunch. sick. counterpunch. Blakely, T., Hales, S., Kieft, C., Wilson, N., & Woodward, A. (2005). The global distribution of risk factors by poverty level. Bull World Health Organ, 83(2), 118-126. 83(2), Boelen, C. (2003). [World Health Organization strategies "Towards Unity for Health" and the social responsibility of medical schools]. Sante Publique, 15 Spec No, 137-145. No, Bower, H. (1998). Sackings and strikes paralyse Nicaraguan health care. Bmj, 316(7138), 1115. 316(7138), Braveman, P. (2006). Health disparities and equity: concepts and measurement. Annu Rev Public Health, 27, 167-194. 27, Braveman, P., & Gruskin, S. (2003). Poverty, equity, human rights and health. Bull World Health Organ, 81(7), 539-545. 81(7), Caldera , N. (2005). General debate of the 60th session of the united nations general assembly: Ministry of Foreign Affairs of the Republic of Nicaragua. assembly: CIA. (2006). The World Factbook-Nicaragua. from http://www.cia.gov/cia/publications/factbook/geos/nu.html CISAS. (2003). Nicaragua health in the poverty reduction strategy., from http://www.cisas.org.ni/pdf/ercerp%20english%20trans%20con%20anexos.pdf Goyder, E. C., Blank, L., Ellis, E., Furber, A., Peters, J., Sartain, K., et al. (2005). Reducing inequalities in access to health care: developing a toolkit through action research. Qual Saf Health Care, 14(5), 336-339. 14(5), Maclure, R. S., M. (2004). Children’s rights and the tenuousness of local coalitions : a case study in Nicaragua. Journal of Latin American Studies 36, 85–108, 36, 85-108. 36, MINSA. (2005). Nicaragua national development plan 2005. Retrieved. from http://siteresources.worldbank.org/INTPRS1/Resources/Nicarauga_PRSP-November2005.pdf. 2005. http://siteresources.worldbank.org/INTPRS1/Resources/Nicarauga_PRSP-November2005.pdf. Nicaragua - A Country Study. (1993). from http://www.country-data.com/cgi-bin/query/r-9203.html Oberhelman, R. A., Guerrero, E. S., Fernandez, M. L., Silio, M., Mercado, D., Comiskey, N., et al. (1998). Correlations between intestinal parasitosis, physical growth, and psychomotor development among infants and children from rural Nicaragua. Am J Trop Med Hyg, 58(4), 470-475. 58(4), Oliver, A., & Mossialos, E. (2004). Equity of access to health care: outlining the foundations for action. J Epidemiol Community Health, 58(8), 655-658. 58(8), Ostlin, P., Braveman, P., & Dachs, N. (2005). Priorities for research to take forward the health equity policy agenda. Bull World Health Organ, 83(12), 948-953. 83(12), PAHO. (2001). Resumen sobre desigualdades en salud Nicaragua (Summary on inequalities in health Nicaragua). Washington, DC: Pan American Health Organization. Nicaragua). PAHO. (2005). Nicaragua: Health sistuation analysis and trends summary: Pan American Health Organization. summary: Shelby, K. (2006, Februray, 2006). Health sector strike in Nicaragua enters fourth month. from http://www.provadenic.org/Website%20Upload%20Files/Health%20Sector%20Strike%20in%20Nicaragua%20(updated%203-16-06).pdf UNDP-CISAS. (2002). El desarrollo humano en Nicaragua 2002 (Human development report 2002): United Nations Development Programme. 2002): UNDP. (2005). Human development report 2005: United Nations. 2005: Wikipedia. (2006). History of Nicaragua.Unpublished manuscript. Nicaragua.Unpublished Worldbank. (2002). Nicaragua Country Assistance Strategy: World Bank. Strategy: WorldBank. (2003). Nicaragua poverty assessment: raising welfare and reducing vulnerability (No. 26128-NI). WorldBank. (2004). Nicaragua country brief: development progress: World bank group. progress: WorldBank. (2006). Nicaragua at a glance. : Worldbank. Salinas, Abraham MD, MPH Nicaragua: Country Profile Social Justice and Health. 2006 Unpublished Crockford, Peter M, MD, FACP, FRCPC. Why is the Third World the Third World. April 2006 WHO 2006 Social Determinants of Health. http://www.who.int/features/galleries/2006/year_review/en/index.html Oberhelman RA, Guerrero ES, Fernandez ML, Silio M et al. Correlations between intestinal parasitosis, physical growth, and psychomotor development among infants and children from rural Nicaragua. American Journal of Tropical Medicine and Hygiene, 58 (4), 1998, pp. 470-475 Tellez A, Morales W, Rivera T et al. Prevalence of intestinal parasites in the human population of Leon, Nicaragua.. Acta Tropica 66 (1997) 119-125 WHO (2007) Partners for Parasite Control. http://www.who.int/wormcontrol/documents/key_articles WHO (2007) Micronutrients deficiences. http://www.who.int/nutrition/topics/vad/en Mora JO, Gueri M, Moral OL. Vitamin A deficiency in Latin America and the Caribbean: An overview. Pan American Journal of Public Health, Volume 4, Number 3, September 1998, pp. 178186 (9) Villamor E and Fawzi WW Effects of Vitamin A supplementation on immune responses and correlation with clinical outcomes. Clinical Microbiology Reviews July 2005, p. 446-464 Stephensen CB. Commentary: A hypothesis concernng vitamin A supplementation, vaccines, and childhood mortality. International Journal of Epidemiology 2003; 32:828-829 WHO (2006) Vitamin A Deficiency..http://www.childinfo.org/areas/vitamina/priority.php WHO launches international programme to combat childhood blindness. The Lancet. Vol 359. June 29, 2002 Health in the Americas, 1998 Edition, Volume II. Nicaragua Perfiles Nutricionales por paises-Nicaragua. May 2001 FAO, Rome, Italy. WHO (1998) Distribution of vitamin A during national immunization days WHO (2005) WHO Global Database on Vitamin A. Nicaragua http://www3.who.int/whosis/mn/mn_vitamina/html/NIC.htm EPI Newsletter. Expanded program on immunization in the Americas. Immunize and Protect your children. Vol XXV, Number 1. February 2003. Personal Interviews with Dr. Miguel Angel Guevara (Lactantes Director), Dra. Marina Morales (Neonatology Director) , Dra. Maria Carolina Cantarero (Pediatrics Neurosurgery Director ) Nicaraguan National Children’s Hospital Manuel de Jesus Riveral “La Mascota.” July 30 th, 2008 31
  32. 32. References (cont.)              Goenjian AK, Molina L, Steinberg AM, Fairbanks LA, Alvarez ML, Goenjian HA, Pynoos RS. Posttraumatic stress and depressive reactions among Nicaraguan adolescents after hurricane Mitch. Am J Psychiatry . 2001 May;158(5):788-94. Caldera T, Palma L, Penayo U, Kullgren G. Psychological impact of the hurricane Mitch in Nicaragua in a one-year perspective. Soc Psychiatry Psychiatr Epidemiol . 2001 Mar;36(3):108-14. Hume F, Summerfield D. After the war in Nicaragua: a psychosocial study of war wounded ex-combatants. Med War . 1994 Jan-Mar;10(1):4-25. Summerfield D, Toser L. 'Low intensity' war and mental trauma in Nicaragua: a study in a rural community. Med War . 1991 Apr-Jun;7(2):84-99. (Am J Clin Nutr. 2007 Nov;86(5):1278-85) Li Y, Zhang J. Serum concentrations of antioxidant vitamins and carotenoids are low in individuals with a history of attempted suicide. Nutr Neurosci. 2007 Feb-Apr;10(1-2):51-8. http://www.unmillenniumproject.org/goals/index.htm http://www.childinfo.org 32

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