Author: Enzley, S.; Barros, F.; UNICEF NYHQ
A decade after the initiation of global activities in the control of diarrhoeal diseases, it was important to review the progress that had been achieved in reducing the morbidity and mortality associated with diarrhoeal diseases. To accomplish this, UNICEF commissioned five expert groups to conduct an in-depth review of published and unpublished literature.
Purpose / Objective
The objective of the present review was to summarize available information on diarrhoea morbidity and mortality, preventive strategies, case management and national programmes, from 1980 to 1992, for the Americas, South Asia, East Asia, Middle East and North Africa, and sub-Saharan Africa, and to propose recommendations to UNICEF.
The review process included computerized literature searches and contact with international agencies and with individual researchers in the regions. UNICEF also commissioned five expert groups to prepare a comprehensive regional report, which was presented in a meeting of interested parties at UNICEF New York in April 1993. Subsequently, these have been collated as a single global report.
Key Findings and Conclusions
Morbidity and mortality:
Diarrhoea remains a major cause of child morbidity and mortality globally. Nevertheless, in most countries, diarrhoea mortality has been falling over the past 10-20 years, as well as diarrhoea admissions to hospitals and the case-fatality rate. In some countries, the fall in the last decade has been up to 20 per cent per year. A number of local studies have attempted to document associations between reduction in diarrhoea mortality and improvements in case management or in preventive strategies conducted by the national control of diarrhoeal diseases (CDD) programmes. Although the role of national programmes is, in some cases, very clear, it is difficult to rule out alternative explanations for the observed decline.
The etiology of diarrhoea has been assessed in studies from many countries, but because of incomplete laboratory methodologies employed, and sampling from only hospital- or clinic-based patients, the results of such studies are often only partially valid. Cholera has become epidemic in some countries, and antibiotic resistance has spread to many organisms.
Little evidence is available on whether diarrhoea deaths were mostly due to acute watery diarrhoea, dysentery or persistent diarrhoea. Existing data suggest a large role for persistent episodes. Better management of acute watery diarrhoeas, dealing with bloody diarrhoea with appropriate antibiotics and proper feeding, are all critical components; this will also reduce persistent diarrhoea deaths.
Control of morbidity and mortality:
CDD programmes have concentrated principally on diarrhoea case management. Activities aimed at diarrhoea prevention have been implemented by other programmes. Breastfeeding duration varies according to region, being usually lower in urban areas. Exclusive breastfeeding, however, is low world-wide, due to the early introduction of water, herbal teas and weaning foods. These practices should be strongly discouraged, as they are importantly associated with diarrhoea morbidity and mortality.
Availability of adequate supplies of water, as well as cleanliness of available water, is particularly important for diarrhoea prevention. There has been much investment in the provision of water and adequate sanitation in some countries as a consequence of the cholera epidemic. These efforts have generally not been managed by diarrhoea programmes.
The impact that the provision of vitamin A may have produced on the morbidity and mortality from diarrhoea is difficult to ascertain. However, in some regions, mild, subclinical, vitamin A deficiency is present in an important part of the population and it is possible that its provision can have some effect on the current declining mortality observed in some areas.
Research carried out in different regions has also implicated the following risk factors in diarrhoea morbidity and mortality: low family income, low maternal education, low birth weight, malnutrition, lack of safe water and poor domestic and personal hygiene. Most, if not all of these associations, are likely to be causal. However, there have been very few specific intervention studies for establishing causality and for showing the feasibility of modifying these risk factors. Interventions to improve levels of family income and maternal education are long-term investments that fall outside the usual role of health services. Also, improving birth weights or nutritional status are difficult enterprises that have failed in most settings.
Case management of diarrhoea:
a) Home case management
Caretakers in most countries are familiar with ORT. Several studies have shown that mothers have elaborate conceptions of signs of diarrhoea severity, and use ORT according to this perception. Studies have demonstrated that early signs, such as vomiting and fever, allow the identification of a large proportion of those children who will develop dehydration later in the episode. If parents and caretakers can be taught to increase ORT use as well as recognize signs of severe diarrhoea and seek health care, it may be possible to achieve important reductions in mortality. Sustaining and achieving high levels of oral rehydration therapy continue to be a challenge.
It is clear from a large number of studies, however, that caretakers do not have adequate practices regarding ORT or ORS use. The majority of them do not mix ORS correctly, most commonly not adding sufficient volumes of water. Recommended home fluids are not used. In addition, most caretakers do not provide adequate volumes of fluid necessary for rehydrating a child. Also, caretakers still give to their children unnecessary and dangerous antibiotics and anti-diarrhoeal preparations.
b) Health facility case management
Health care providers have been the principal focus of training efforts of national programmes. Although trained health workers perform better than those without training, even the trained ones frequently do not assess or effectively treat children with diarrhoea. Further, they prescribe antibiotics more usually than ORS. Besides training, other situational factors, such as supervision and availability of materials and drugs, may play critical roles in supporting the quality of performance.
The importance of health care providers in the private sector needs to be taken into account. Private practitioners, drug sellers, pharmacists, traditional healers, all play a major role in the management of diarrhoea in children and can contribute to extend the reach of health care services on a national scale. In some countries, for example, traditional healers outnumber their biomedical counterparts by 100 to 1, and are the main sources of health care for many segments of the population.
National CDD programmes:
a) ORS production and logistics
A wide range of access to ORS is seen in the different regions, with critical shortages in some countries, as for example, Sudan. This may be due to decreased supply or increased demand or both. Reports also indicated that many facilities experienced stock-outs of ORS, while others had large supplies. Increasing quantities of ORS supply appear to be needed by national CDD programmes. To meet this need, many national programmes have worked with private firms or parastatal industries to locally produce ORS. However, concerns about effective quality control as well as costs have to be further reviewed.
Communication has been a critical programme component wherever progress has been seen. Development of sound communication strategies involving mobilization of the community and households in support of families, have all contributed to increasing ORT use rates and changing behaviour. Unfortunately, most countries do not give adequate attention and resources to information, education and communication. Communication expertise is often not used. But, where it has been - as in Mexico, Morocco, Brazil and Egypt - the positive changes are significant.
Training has been a major activity of essentially all national CDD programmes, but the coverage of training for both clinical and supervisory skills, varies widely. Decentralization of training beyond a few centralized Diarrhoea Training Units (DTUs) to smaller peripheral units has begun in many places. WHO has developed a distance learning course in which the individual health worker teaches himself with the aid of materials and feedback provided by the national programme. To overcome the problem of the small numbers of dehydrated patients available for hands-on training on ORT at peripheral treatment sites, WHO has also developed courses with simulated teaching cases for both teaching as well as assessing performance of participants.
d) Cost allocations
As activities of national programmes have expanded, budgetary resources have not kept pace. Allocation of costs is now an important consideration for national programmes. To help programme managers, WHO has developed costing guidelines for national programmes to assist in better defining how costs are being allocated, and how best to select the most cost-effective intervention options.
e) Measurement of progress
In order to track the changes over time in morbidity and mortality reduction targets as well as other programme management objectives, the WHO Global Programme for the Control of Diarrhoeal Diseases has promoted the use of 16 programme indicators, of which seven are being jointly monitored by UNICEF/WHO. With the exception of training coverage, which is an administrative estimate, the other programme indicators are collected from surveys of households or health facilities. However, some of the indicators, such as ORT use, are difficult to measure. UNICEF has recently developed the Multiple Indicator Cluster Survey, which gives important information on the use of oral rehydration therapy, continued feeding and increased fluids. This is a very useful instrument. Recent and reliable estimates on oral rehydration therapy are not available currently for most countries. However, all these data that are collected need to be effectively integrated into ongoing programme management and planning, or else it is costly misuse of scarce resources.
The benefits of research in guiding CDD programmes and solving problems are clear. Small surveys have been critical to identifying problems, while studies of epidemiology, etiology, the behaviours of caretakers and practitioners in response to diarrhoea, alternative methods of training and education, have all played a role in improving the effectiveness of CDD activities. Monitoring indicators need to be validated, and additional ones further developed as a priority area for research. The reason for the gap between knowledge and use of ORT needs to be better understood, as do factors that contribute to better programme planning and management.
Private Sector: Increase support of activities aimed at engaging the private sector in appropriate case management for diarrhoea, through collaboration with ORS and consumer goods (e.g. soap) manufacturers, and through efforts to reach private physician and non-physician practitioners, including unlicensed practitioners who care for diarrhoea patients.
Measurement and Targets: Develop measures and set targets for CDD-related behaviour, in particular ORT/ORS use, which reflect the different responses by caretakers and practitioners to children with mild versus severe dehydrating diarrhoea. Implement monitoring of preventive behaviours and programme activities, in addition to case management.
Research and Evaluation: Develop better monitoring indicators in order to allow data-based problem solving and planning, and targeting of sub-populations at higher risk for intensified CDD efforts.
Communications: Develop communication strategies to achieve/sustain high levels of oral rehydration therapy and timely care seeking. Increase the support in the region for audience, channel, and message research needed to make communications efforts effective; continue support for air time and other 'marketing' costs, recognizing that desired patterns of behaviour must continuously be defended against competing alternative behaviours by effectively varying marketing strategies and messages.
Integration and Decentralization: Seek, through evaluation and monitoring, a more appropriate balance between integration and independence of CDD programmes and efforts, so that effectiveness is not diminished by efforts to obtain greater efficiency. Similarly assess and balance, based on objective data, the tension between decentralization and central concentration of CDD activities and decision making.
Medical Education/Pre-Service Education: Encourage the use of the newly available WHO materials for medical, nursing, and pharmacist/drug seller pre-service education as the basis for enhanced activities in this area, to provide a foundation of appropriate practitioner behaviour for the future.
Prevention: Greater coordination is required for efforts aimed at the prevention of diarrhoea, especially water/hygiene/sanitation; exclusive breastfeeding; facilitating and tracking measles immunization; and communications efforts supporting prevention.
Training: Take steps to avoid wasting resources on ineffective training, by: eliminating ineffective training (determined by evaluation research), improving training methods, providing adequate time and appropriate materials for learning, supervising the quality of training activities while in process, and providing adequate post-training supervision to ensure implementation of the training.
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Health - CDD