Increasing coverage of pediatric diarrhea treatment in high-burden countries

Abstract

Background Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc. Methods We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions. Results Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21–23%) to 48% (95% CI = 47–50%) and program states in Nigeria, from 38% (95% CI = 32–40%) to 55% (95% CI = 51–58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies. Conclusions Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.

Mapping geographical inequalities in oral rehydration therapy coverage in low-income and middle-income countries, 2000–17

“…We found that of the 526 800 diarrhoeal deaths (95% UI 485 300-568 900) estimated to have occurred in 2017 in children younger than 5 years across the 94 LMICs included in our analysis, an estimated 299 900 deaths (274 000-324 300) could be attributable to lack of treatment with ORS. We also estimated that increase in ORS coverage during the study period prevented an additional 52 In a sensitivity analysis, we found that, while the geographical patterns in deaths averted remained largely unchanged, the absolute number of averted deaths changed substantially in some places (appendix 1 pp 82-83). Reducing the percentage of diarrhoeal deaths that could be averted with ORS from 69% to 35% reduced the total number of deaths attributable to lack of ORS Dark grey grid cells were classified as barren or sparsely vegetated and had fewer than ten people per 1 km × 1 km grid cell; light grey countries were not included in these analyses.…”

“…49 In addition, promoting zinc use has shown a secondary effect of increasing ORS use in some places; 50,51 thus comprehensive approaches to overcome challenges to uptake and scaling up of coverage are warranted. 52 Future work could investigate how missing data affect estimates of ORS coverage and how to account for this, as well as how to incorporate differences between urban and rural populations into the analysis. In addition, we did not map ORS availability, but rather the prevalence of its use, and future studies could map availability distribution patterns.…”

Access to oral rehydration solution and zinc supplementation for treatment of childhood diarrhoeal diseases in Sudan

“…Some high-burden countries have established successful scale-up programmes to increase coverage and access rates of ORS and zinc supplementation among target population groups [8,24]. Paediatric diarrhoeal treatment rates in Kenya increased from 0.8 to 15% in 5 years after permission was given to dispense zinc supplements over-the-counter and government procurement was shifted to co-packaged ORS and zinc.…”

“…Paediatric diarrhoeal treatment rates in Kenya increased from 0.8 to 15% in 5 years after permission was given to dispense zinc supplements over-the-counter and government procurement was shifted to co-packaged ORS and zinc. These policies created a competitive market for ORS and zinc supplements and enhanced healthcare provider practices in the management of diarrhoeal diseases [24].…”

Progress in the use of ORS and zinc for the treatment of childhood diarrhea

“…The CHAI interventions included improving knowledge about appropriate treatment for caregivers via schools and community health workers and for providers via education and mentorship as well as drug detailing. Extensive work was needed to increase the availability of affordable ORS and zinc products and establish a functional supply chain, as well as assist with policies, such as approving zinc as an over-the-counter medicine and adding it to the national essential medicines list [17]. An important strategic activity in these countries was the change from separate ORS and zinc products to a co-packaged product, particularly in the public sector [15].…”