Childhood DiarrhoeaRegional Situation

Dr Rajesh Mehta MD

Regional Adviser, Newborn-Child-Adolescent Health

WHO-SEARO

15-17 Oct 2019 Regional NCH Meeting 1

119

84

5356

44

2934

28

20

0

20

40

60

80

100

120

140

U5MR IMR NMR

Dea

ths

per

100

0 liv

e b

irth

s

SEAR (1990-2018)

1990 2010 2018

93

65

37

57

40

23

39

29

18

0

20

40

60

80

100

120

140

U5MR IMR NMR

Dea

ths

per

100

0 liv

e b

irth

s

World (1990-2018)

1990 2010 2018

Child mortality reduction (1990-2018)SEAR’s performance is better than the World

58% reductionAARR=3.1

71.4% reductionAARR=4.4

67% reductionAARR=3.8

62% reductionAARR=3.4

55% reductionAARR=2.8

51% reductionAARR=2.5

*1990 and 2019 data from UNIGME Report 2019 and 2010 data from UNIGME Report 201115-17 Oct 2019 Regional NCH Meeting 2

If we maintain the

AARR for 2010-2018,

SEAR will achieve

U5MR <25

NMR<12 before 2030

AIDS0%

Congenital

15%

Diarrhoea6%

Injury7%

Intrapartum

12%Malaria

0%

Measles1%

Meningitis

1%

Pneumonia

13%

Preterm21%

Sepsis7%

Tetanus0%

Other17%

2018

15-17 Oct 2019 Regional NCH Meeting 3

Diarrhoeal diseases

(postneonatal)

14%

Measles

1%

HIV/AIDS

2%

Other

13%

Injuries (postneonatal)

3%

Noncommunicable diseases

(postneonatal)

4%

Pneumonia

(postneonatal)

13%

Neonatal deaths

40%

Malaria

9%

Causes of Under-Five Mortality2008

Key facts (2017)•Diarrhoeal disease is the second leading cause of death in children: 525 000 deaths / year•1.7 billion cases of childhood diarrhoealdisease every year.

Almost 0.5 million dying between 1 month and 5 years of age

Neonatal deaths

60%

Post-neonatal deaths

40%

HIV/AIDS 1%

Diarrhoeal diseases

20%

Measles 5%

Meningitis/encephalitis

4%Acute respiratory infections

28%

Prematurity 4%

Birth asphyxia and birth trauma

1%

Other Group 1 12%

Congenital anomalies

6%

Other NCDs 9%

Injuries 10%

Causes of post-neonatal deaths

Acute respiratory infections and

diarrhea are the two biggest killers…!!

21 July 2011 WHO-SEARO 5

Much of diarrhoea is preventable and treatable Protect, prevent and treat

Protect

Exclusive breastfeeding –Complementary feeding

Adequate nutrition

Zinc & Vit. A supplementation

Safe water and sanitation

Prevent

Hand washing

Vaccination against pertussis, measles, and rotavirus

Treat

Improved care seeking

Case management at the health facility and community level

Provision of low osmolarity ORS, zinc,

Treat co-morbidities, Malnutrition

Reduce diarrhoea

morbidity and mortality

Interventions are well-known, however, coverage remains low!

15-17 Oct 2019 Regional NCH Meeting 6

ChildhoodNewborn/postnatalPre-pregnancy Pregnancy Birth

Treatment for diarrhea: ORS and Zinc

3845

15 18

42

10

40

77 74

51

36

75

62

37

54

73 70

0102030405060708090

100

Proportion of children under 5 years with diarrhea receiving ORS and zinc

Proportion of children under 5 years with diarrhea receiving ORS

Source: Recent DHS/MICS (Bangladesh 2014; Bhutan 2012; DPRK 2017; India 2016; Indonesia 2017; Maldives 2016-17; Myanmar 2016; Nepal 2016; Sri Lanka 2016; Thailand 2016; Timor-Leste 2016)

34

59 63

76

0102030405060708090

100

Last DHS Current DHS Last DHS Current DHS

Children under age 5 withdiarrhoea given ORS

Children under age 5 withsuspected pneumonia

taken to facility

Common illness treatment

Rotavirus vaccine: Completed dose coverage among one year-olds is 24% in 2018

97

14

46

0

10

20

30

40

50

60

70

80

90

100

Percentage of children who received 3 doses of PCV vaccine

2016 2015 2014 2013 2012 2011 2010

Introduced

PartiallyIntroduced

PartiallyIntroduced

NOTIntroduced

NOTIntroduced

NOTIntroduced

NOTIntroduced

NOTIntroduced

Address diarroea and pneumonia together

15-17 Oct 2019 Regional NCH Meeting 9

21 July 2011 WHO-SEARO 10

Management Strategy: Integrated and Continuum • Integrated approach: Protect, prevent and treat diarrhoea

• Community level: Community Case Management by trained community health workers

• First level care: IMCI

• Referral care at hospitals

Multi-sectoral approach: Water, sanitation

• Complete Assessment• Treatment: ORS & Zinc + Continue feeding + When to Return• Prevention: Nutrition counseling, WASH, Vaccine

21 July 2011 WHO-SEARO 11

SEAR: Community-based Case Management

Authorization of most peripheral CHW in SEAR:

• Diarrhea management:• ORS and Zinc: Bangladesh, DPR Korea, India, Myanmar, Nepal, Timor Leste

• ORS not Zinc: Bhutan and Indonesia

• Pneumonia management (antibiotics use): BAN, IND, NEP

• Management of both Diarrhea and Pneumonia: BAN, IND, NEP

Training: IMCI based training in most countries

WHO-UNICEF CHW package is available

21 July 2011 WHO-SEARO 12

SEAR: Facility Based Management

• First level:• IMCI/IMNCI is being implemented in all member states except Thailand

• Scale: • Maldives, Nepal and Timor: 100% districts

• Bangladesh, India, Myanmar: 50 -75% districts

• Bhutan, DPR Korea: < 50% districts

• Referral level: All member states• WHO Pocket book is the basis

• Challenges: Scale and quality of care

Addressing health system constraints

• Is healthcare infrastructure adequate?: First level and Referral health facilities and Transport; Community services

• Health workforce: Numbers, Distribution, Skill-Mix and Competencies, Motivation, Supportive Supervision

• Essential supplies

• Suboptimal quality of care

• Poor measurement and monitoring (Health Information System) –Accountability

• Engagement with Community: Demand and utilization of services and accountability

15-17 Oct 2019 Regional NCH Meeting 13

Rajasthan

Tripura

Mizoram

Manipur

Nagaland

Arunachal PradeshSikkim

Jammu & Kashmir

Uttar Pradesh

West Bengal

Haryana

Uttarakhand

ChandigarhPunjabHimachal Pradesh

Bihar

Dadra and Nagar Haveli

Puducherry

Tamil Nadu

KeralaLakshadweep

Goa

Karnataka

Meghalaya

Maharashtra

Assam

Daman and Diu

Gujarat Madhya Pradesh

ChhattisgarhOrissa

Jharkhand

Andaman & Nicobar Islands

Andhra Pradesh

BMGF

DFID

NIPI

UNFPA

UNICEF

USAID

Focus on :

• Rural and Urban Poor• Tribal & Minority groups• Hard to Reach Areas• Girl Child

184 High Priority Districts (HPDs) across 29 States

India: Strategy focuses on High Priority Districts

Integrated approach: Protect, prevent and treat diarrhoea

• Community level: Community Case Management by trained community health workers

• First level care: IMCI

• Referral care at hospitals

India’s Intensified Diarrhoea Control Fortnight (IDCF): Campaign Launched in 2014

..with the objective to kick-start diarrhoea control efforts

WEEK 1

1. ORS distribution &

counselling - home visits

by ASHA

2. Establishment of ORS-

Zinc Corners

3. Hand washing

demonstration and

practice in schools

1. Breastfeeding initiation

immediately or within 1

hour

2. IYCF demonstration and

counselling sites

3. Medical management of

under nourished children

at health facility

WEEK 2

1. Capacity building for

IDCF implementation

2. Intensive Awareness

generation

3. Multisectoral

involvement –AWCs,

Schools PRI, etc.

COMMON ACTIVITIES

FOR WEEK WISE THEME

Increase in Coverages

Source: Bangladesh DHS 2014 and 2017, Bhutan MICS 2010 and 2016, DPRK MICS 2016, India NFHS 3 and 4 (2015-2016), Indonesia DHS 2012 and 2017, Maldives 2011 and 2017, Myanmar 2011 and 2016, Nepal DHS 2014 AND 2016, Sri Lanka DHS 2017, Thailand MICS 2010 and 2016, Timor Leste DHS 2010 and 2016.

SEAR- Annual Births (2015-2020) from WPP, 2017 revision weighted coverage for last round of DHS compared with current.

8174

26

35

84

5045

51

67 70

34

84 86

60

36

91

6861

54

7470

59

0

10

20

30

40

50

60

70

80

90

100

BangladeshBhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor

LesteSEAR

Under 5 with Diarrhoea given ORS

Last DHS Current DHS

Increase between 2005 and 2016

15-17 Oct 2019 Regional NCH Meeting 17

Should we aim for Zero Mortality from

Diarrhoea

•Protect

•Prevent

•Treat