Inappropriate pediatric diarrhea treatment: Challenges in Nepal, Benin, and Madagascar
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Transcript of Inappropriate pediatric diarrhea treatment: Challenges in Nepal, Benin, and Madagascar
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SHOPS is funded by the U.S. Agency for International Development.Abt Associates leads the project in collaboration withBanyan GlobalJhpiegoMarie Stopes InternationalMonitor GroupO’Hanlon Health Consulting
Inappropriate pediatric diarrhea treatment: Challenges in Nepal, Benin, and Madagascar
Kathryn Banke, Ph.D.Abt Associates
June 16, 2011
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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
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Pediatric diarrhea
• 2nd 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; 375:1969-1987
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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)
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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
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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)
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Household survey details
Nepal Benin Madagascar
Dates Aug-Sept 2008 Nov 2009 March-April 2010
No. of Households 3550 2912 1200
No. of children 4211 3854 1200
No. with diarrhea 289 307 1000
Age range 0-59 months 0-59 months 6-59 months
Design Cross-sectional Cross-sectional Cross-sectional; programs vs. comparison
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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)
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Zinc and ORS/ORT use
7382
74
15
31
4
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20
40
60
80
100M
adag
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Nep
al 2
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Ben
in 2
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in p
as
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we
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inc
or
OR
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RT
ORS/ORT
Zinc
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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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nepal Benin Madagascar
Pe
rce
nta
ge
(%
) o
f re
sp
on
de
nts
Used zinc with ORS/ORT
Used zinc for at least 10days
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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
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Caregivers use other treatments, regardless of zinc/ORS promotion and marketing
0%
10%
20%
30%
40%
50%
60%
70%
Nepal Benin Madagascar
Pe
rce
nta
ge
(%
) o
f re
sp
on
de
nts
Antibiotics
Antidiarrheals
Unknown pill orsyrup
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Inappropriate use of antibiotics
Proportion of children given antibiotics that had blood in the stools:• Madagascar: 19%• Nepal: 20%• Benin: 28%
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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
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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
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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
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Millennium Development Goal #4
• Between 1990 and 2015: reduce, by two-thirds, the under-five mortality rate
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SHOPS is funded by the U.S. Agency for International Development.Abt Associates leads the project in collaboration withBanyan GlobalJhpiegoMarie Stopes InternationalMonitor GroupO’Hanlon Health Consulting
www.shopsproject.org