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

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

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

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)

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

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)

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

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)

Zinc and ORS/ORT use

7382

74

15

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ORS/ORT

Zinc

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

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(%

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Used zinc with ORS/ORT

Used zinc for at least 10days

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

Caregivers use other treatments, regardless of zinc/ORS promotion and marketing

0%

10%

20%

30%

40%

50%

60%

70%

Nepal Benin Madagascar

Pe

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(%

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Antibiotics

Antidiarrheals

Unknown pill orsyrup

Inappropriate use of antibiotics

Proportion of children given antibiotics that had blood in the stools:• Madagascar: 19%• Nepal: 20%• Benin: 28%

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

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

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

Millennium Development Goal #4

• Between 1990 and 2015: reduce, by two-thirds, the under-five mortality rate

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

Kathryn_banke@abtassoc.com

www.shopsproject.org