Control of Diarrhea Diseases 

1          BACKGROUND

Recognizing diarrhea diseases as one of the major public health problems among children under five in Nepal, the National Control of Diarrhea Diseases Program (NCDDP) has been accorded high priority status by GON and is an integral part of Primary Health Care.

Improvement in diarrhea case management has been used as a primary strategy for the reduction of mortality due to diarrhea among children under five years of age.  Standard diarrhea case management are provided in the health institutions by establishing Oral Rehydration Therapy (ORT) corners in all Hospitals, Primary Health Care Centers, Health Posts and Sub Health Posts throughout the country.  All health facilities and community health volunteers serve as the primary health service providers in the treatment of Diarrhea with Oral Rehydration Solutions (ORS) which is free of cost.

1.1       OBJECTIVES

The main objective of the National Control of Diarrhea Diseases Program (NCDDP) is to reduce mortality due to diarrhea and dehydration (from the estimated 30,000 deaths per year in the past) to a minimum, and to reduce morbidity from 3.3 episodes per child per year to a minimum.

1.2       TARGETS

1.2.1    To reduce the under-five mortality rate due to diarrhea by 50 percent by 2005/2006;

1.2.2    To reduce the under-five morbidity rate due to diarrhea by 20 percent by 2005/2006;

1.2.3    To increase the accessibility of Oral Rehydration Solution (ORS) to 100 percent of the population by 2005/2006;

1.2.4    To raise public awareness about the correct preparation and use of Oral Rehydration Solution in the treatment of diarrhea, and increase use of ORS by 20 percent by 2005/2006; and

1.2.5    To increase the proportion of caretakers that provides ORT for children with diarrhea to 40 percent by 2005/2006.

 

1.3       Indicators

Main Indicators	Numerator and Denominator
1.             Morbidity rate due to diarrhea	Total diarrhea new cases in specified time                         x 1000
	Target population (under-fives)
2.             Mortality rate due to diarrhea	Total number of diarrhea-related deaths                            x 1000
	Target population (under-fives)
3.             Case fatality rate from diarrhea	Total diarrhea deaths per year                                             x 1000
	Total diarrhea new cases in same period

 

 

1.4       STRATEGIES

 

General Strategies

• 4.1        Establish functioning ORT Corners and replenish ORT Corner sets in each health facility in order to educate mothers/caretakers, to demonstrate proper ORS preparation, and to treat children suffering from diarrhea;
• 4.2    Increase access to Oral Rehydration Solution packets through FCHVs, SHPs, HPs, PHCCs, hospitals and commercial outlets;
• 4.3    Raise public awareness;
• 4.4        Promote specific preventive measures through communication and information activities;
• 4.5    Involve Community Health Workers including the volunteers (VHWs, MCHWs and FCHVs), District Development Committee (DDC) and VDC members, local NGOs and local decision-makers;
• 4.6    Apply an integrated child health package including the CDD, EPI, Nutrition, Acute Respiratory Infection (ARI) and Malaria programs; and
• 4.7    Emphasize program management at all health facilities.

 

Strategies for Tenth Five Year Plan

• 4.8    Train all levels of health workers including VHWs/MCHWs/FCHVs/community leaders;
• 4.9    Orient community opinion leaders, VDC members, faith healers;
• 4.10 Supply Oral Rehydration Solution to all health institutions;
• 4.11 Supply Oral Rehydration Solution to all FCHVs;
• 4.12  Develop health education materials (including development and printing of IEC materials) to be used by mothers, FCHVs, and through channels of radio and TV communication;
• 4.13  Promote supervision and monitoring at all levels; and
• 4.14  Promote “Knowledge, Attitude and Practice” (KAP) on CDD among health workers, mothers and FCHVs

2          ANALYSIS OF ACHIEVEMENTS BY MAJOR ACTIVITIES

2.1       ACTIVITIES CARRIED OUT IN FY 2062/63 (2005/2006)

2.1.1    Planning

• District-level planning and orientation was conducted for District Health Officers (DHOs), Public Health Officers (PHOs), and other health personnel including DDC members and local decision makers in Sankhuwasabha, Sindhuli, Udayapur, Gorkha, Parbat, Kapilvastu, Surkhet and Jumla districts.

2.1.2    Supply of ORS

• 2,500,000 sachets ORS purchased and distributed to the districts.

2.1.3    Communication and Training Materials

• Revised and finalized training materials and printed through WHO and GoN.

2.1.4    Transportation

• Supply of IEC materials regarding CDD to districts as requested.

2.1.5    Monitoring and Supervision

• Supervision from center and region to districts accomplished
• Supervision from district to PHCC, HP/SHP as per schedule done

2.1.6    Epidemic Control

• Financial support to all districts provided where epidemic occurred

 

2.2              TARGETS vs. ACHIEVEMENT, FY 2062/63 (2005/2006)

S. No.	Activities	Unit	Targets	Achievement	Targets vs. Achievement (percent)
1.	Purchase of ORS	Pkts.	2,500,000	2,500,000	100
2.	Printing of IMCI Register	Pcs.	1,500	1,500	100
3.	Printing of Mothers’ Card	Sheets	10,000	10,000	100
4.	Printing of CB-IMCI Training Materials	Pcs.	2,800	2,800	100
5.	CB-IMCI Drugs	freq	1	1	100
6.	Counselling Service (CB-IMCI Program for 10 Districts)	freq	2	2	100
7.	Treatment of <5 Diarrhea Cases	Cases	628,573	739,915	100

Source: HMIS/MD & IMCI Section/CHD, DoHS

 

As can be seen from the above table, all CDD targets were achieved satisfactorily during FY 2062/63. The overall achievement was 100 percent.

 

Table 2c.1       ORS Supply, Three-Year Comparison, FY 2060/61 to 2062/63

Year	Targets	Achievement	Achievement percent
2060/61                                2003/2004	2,000,000	2,000,000	100%
2061/62                                2004/2005	2,000,000	2,000,000	100%
2062/63                                2005/2006	2,500,000	2,500,000	100%

Source: IMCI Section/CHD, DoHS

 

Table 2c.1 shows the trend of Oral Rehydration Solution supply to the districts from FY 2060/61 to 2062/63.  The CDD program provided ten packets of ORS to each FCHV according to the CDD National Policy. Those ten packets were replenished whenever FCHVs used all on treatment of diarrhea in under-five children. During the FY 2060/61, 2061/62 and 2062/63 the target vs. achievement was 100 percent.  Figure 2c.3 and Table 2c.1 for FY 2062/63 is based on the report received from the Finance Section, DoHS.

2.3              ANALYSIS OF SERVICE STATISTICS

Table 2c.2 below shows the decreasing trend in the number of diarrhea visits for the last two years compared to FY 2060/61.  In FY 2062/63, the total number of diarrhea visits decreased remarkably in comparison to FY 2060/61 and 2061/62. Diarrhea deaths in FY 2062/63 have decreased by 66.4% in comparison to FY 2061/62 and 57.7% to 2060/61. The national reported incidence of diarrhea per 1,000 among children under five years also decreased in FY 2062/63 in comparison to FY 2060/61 and 2061/62. The reported incidence of diarrhea at the regional level also decreased in all the development regions. At national level, the case fatality rate has decreased significantly (0.11/1,000) in the FY 2062/63 compared to FY 2060/61 and 2061/62. The reason for this decreasing trend in the visits for diarrhea, deaths and incidence and case fatality rate may be due to rapid expansion of CB-IMCI Program.

 

Table 2c.2       Incidence of Diarrhea, by Region, FY 2060/61 to 2062/63

Indicators	Year		Region					National
			EDR	CDR	WDR	MWDR	FWDR
Total <5 Populationfor CDD/ARI	2062/63		796,079	1,202,989	725,133	524,860	384,625	3,633,687
Total diarrheaVisits	2060/612061/622062/63	2003/04 2004/05 2005/06	234,206 230,320 221,757	253,588 249,003 229,268	121,327 128,644 113,459	103,451 106,297 104,234	74,522 71,072 71,197	787,094 785,336 739,915
Total diarrheaDeaths	2060/612061/622062/63	2003/04 2004/05 2005/06	23 24 11	50 56 20	26 20 3	63 107 39	32 37 9	194 244 82
Incidence ofdiarrhea /1,000<5 yrs. Popn.	2060/612061/622062/63	2003/04 2004/05 2005/06	302 294 279	216 209 191	171 179 156	202 205 199	199 187 185	222 219 204
Case Fatality Rate/ 1,000<5 yrs. Popn.	2060/612061/622062/63	2003/04 2004/05 2005/06	0.1 0.1 0.05	0.2 0.2 0.09	0.2 0.2 0.03	0.6 1.0 0.37	0.4 0.5 0.13	0.2 0.3 0.11

Source:  HMIS/MD, DoHS

 

Figure 2c.4 shows the three-year trend of reported diarrhea incidence per 1,000 under-five children.  At the national level during FY 2062/63, incidence of diarrhea decreased slightly, (204 per 1,000) compared to FY 2060/61 and 2061/62. At regional level also diarrhea incidence has decreased in all regions in FY 2062/63 in comparison to FY 2060/61 and 2061/62.

 

Figure 2c.5 shows the three-year trend of reported diarrhea deaths. In FY 2062/63 the total number of diarrhea deaths decreased by 66.4% in comparison to FY 2061/62 and by 57.7% compared to FY 2060/61. Similarly, at regional level also the diarrhea deaths decreased by more than 50 percent in comparison to FY 2060/61 and 2061/62. Amongst the five development regions the highest number of diarrhea deaths occurred in the MWDR (39) followed by CDR (20) and the lowest number occurred in the WDR (3) in FY 2062/63.

 

Table 2c.3       Classification of Dehydration, by Region, FY 2060/61 to 2062/63

Indicators	Year		Region					National
			EDR	CDR	WDR	MWDR	FWDR
Total cases	2060/612061/622062/63	2003/04 2004/05 2005/06	234,206 230,320 221,757	253,588 249,003 229,268	121,327 128,644 113,459	103,451 106,297 104,234	74,522 71,072 71,197	787,094 785,336 739,915
No Dehydration Cases	2060/61	2003/04	110,764 47.3%	146,966 58.0%	80,141 66.1%	63,918 61.8%	47,726 64.0%	449,515 57.1%
	2061/62	2004/05	114,888 49.9%	155,256 62.4%	88,256 68.6%	66,137 62.2%	46,449 65.4%	470,986 60.0%
	2062/63	2005/06	127,884 57.7%	154,586 67.4%	81,938 72.2%	68,062 65.3%	48,660 68.3%	481,130 65.0%
Some Dehydration Cases	2060/61	2003/04	118,086 50.4%	100,715 39.7%	38,760 31.9%	34,921 33.8%	24,812 33.3%	317,294 40.3%
	2061/62	2004/05	111,610 48.5%	89,176 35.8%	38,038 29.6%	35,144 33.1%	22,876 32.2%	296,844 37.8%
	2062/63	2005/06	91,701 41.4%	72,407 31.6%	30,199 26.6%	33,113 31.8%	21,297 29.9%	248,717 33.6%
Severe Dehydration Cases	2060/61	2003/04	5,356 2.3%	5,907 2.3%	2,426 2.0%	4,612 4.5%	1,984 2.7%	20,285 2.6%
	2061/62	2004/05	3,822 1.7%	4,571 1.8%	2,350 1.8%	5,016 4.7%	1,747 2.5%	17,506 2.2%
	2062/63	2005/06	2,172 1.0%	2,275 1.0%	1,322 1.2%	3,059 2.9%	1,240 1.7%	10,068 1.4%

Source: HMIS/MD, DoHS

 

Table 2c.3 shows the classification of dehydration by region over the last three years. CDD reactivation, CBAC, and IMCI programs had positive impact on the skill and knowledge of health workers, enabling them to better identify various categories of classifications and treat them appropriately.  Because of their better skill and knowledge, more cases are gradually being classified as ‘No Dehydration’ and less cases as ‘Some Dehydration’.  Also because of increased awareness among caretakers, cases of diarrhea in children are brought to health facilities at an earlier stage. At the national level cases of ‘Severe Dehydration’ has gradually declined (2.6 percent, 2.2 percent and 1.4 percent) during the three fiscal years.  This decline in severe dehydration is observed in all regions in comparison to FY 2060/61 and 2061/62.

 

Table 2c.4       Treatment of Diarrhea Diseases, by Region, FY 2060/61 to 2062/63

Indicators	Year		Region					National
			EDR	CDR	WDR	MWDR	FWDR
Total cases	2060/612061/622062/63	2003/04 2004/05 2005/06	234,206 230,320 221,757	253,588 249,003 229,268	121,327 128,644 113,459	103,451 106,297 104,234	74,522 71,072 71,197	787,094 785,336 739,915
Treated withORS	2060/612061/622062/63	2003/04 2004/05 2005/06	192,352 188,410 176,215	233,303 230,052 212,912	114,664 121,641 107,050	88,973 89,188 89,267	67,968 64,540 63,727	697,260 693,831 649,171	88.6% 88.3% 87.7%
Treated withIV fluid	2060/612061/622062/63	2003/04 2004/05 2005/06	5,637 4,266 2,599	6,309 5,645 3,404	3,863 4,017 2,527	5,810 6,185 4,306	2,812 2,730 1,449	24,431 22,843 14,285	3.1% 2.9% 1.9%

Source:  HMIS/MD, DoHS

 

Table 2c.4 shows that, at the national level over the three fiscal years, treatment by IV fluid is gradually decreasing, whereas the percentage of ORS treatment in all three fiscal years remained almost the same. In FY 2062/63 1.4 % of cases were diagnosed as severe dehydration where as 1.9% were treated by IV Fluid. But this has been gradually improving over the years.

Figure 2c.6 shows a consistent seasonal variation in total diarrhea visits over the last three years.  Increases in diarrhea incidence starts from the month of Falgun and continues till Jestha, and then starts declining gradually. This sort of seasonal variation was observed during the last three fiscal years.

2.4       Recommendations

Based on field experience, the following strategies are to be improved and should be continued for a successful and effective implementation of program.

1. A) Strategies to be modified
   1. IMCI approach
   2. Extension of community-based IMCI to FCHV and VDCs

• Decentralized planning to promote district-level commitment and a feeling of program ownership and responsibility for effective program implementation

1. Central level facilitators should be made available for each district-level training as well as for community-level program monitoring
2. Focus on program management without neglecting case management
3. B) Strategies to be improved
4. Training allowances for VHWs, MCHWs, and FCHVs to be revised according to the level of status and allocated in central-level budget planning

• FCHVs to be supervised/recognized by all levels to maintain high motivation
• Motivation and follow-up mechanisms to be developed for VDCs to support FCHVs

 

3 PROBLEMS/CONSTRAINTS AND ACTIONS TO BE TAKEN

S. No.	Problems/constraints	Action to be taken	Responsibilities	Deadline
3.1	Inadequate ORS in some districts	Increase budget for ORS for some districts.	CHD	As soon as possible
3.2	Inadequate budget for epidemics of diarrhea.	Strict management and discipline over proper use of epidemic budget and increase budget.	DHO/RHD and CHD	As soon as possible

 

4          TARGETS FOR FY 2063/64 (2006/2007)

S. No.	Activities	Unit	Annual Targets	Budget Rs.’000
1	ORS purchase	Pkts.	2,500,000	11,000
2	Treatment of <5 diarrhea cases	Cases	628,573	1,177

Source: IMCI Section/CHD, DoHS

Note:    For detailed, district-specific data and analysis on this program/project, please refer to the annexes in this document.