Kenya: plan to halve infant diarrhoea prevalence

Kenya has set its sights on halving the prevalence of infant diarrhoeal disease – which kills dozens of children daily – within five years, using new treatments and by boosting preventive measures.

Every Kenyan child under five has an average of three episodes of diarrhoea annually, according to the 2008 Demographic and Health Survey.

Hon Beth Mugo, EGH, MP

“With 86 children dying every day, diarrhoea is the third leading cause of death among under-fives in Kenya. It is unacceptable, but we can stop this!” said Beth Mugo, Minister for Public Health and Sanitation, at the 31 March 2010 launch in Nairobi of national policy guidelines.

The new guidelines, she said, complemented the government’s Child Survival and Development Strategy with a package of interventions based on using a new type of oral rehydration salts (ORS) containing lower concentrations of glucose and salt; zinc supplements to reduce the frequency of episodes; selective use of antibiotics; and encouraging prevention through breastfeeding.

“With exclusive breast feeding, vitamin A supplementation, strengthened routine childhood immunization, proper hygiene and access to improved water supplies, we can curb the number of deaths,”said David Okello, country representative of the World Health Organization (WHO).

“We are also looking forward to solutions such as PATH’s rotavirus vaccines. With 730,000 doses distributed this year, we could really make a difference for all the children of Kenya,” said Annah Wamae, head of the Department of Child Health at the ministry.

According to the WHO, vaccination is the only preventive method for diarrhoeal disease cases caused by rotavirus, the most severe form of diarrhoea. In Kenya rotavirus causes 7,500 deaths each year.

At the launch, Sanjiv Kumar, the UN Children’s Fund Kenya (UNICEF) chief of health, announced a financial support package worth US$850,000 by the end of 2010. Aimed at control and management of diarrhoeal disease in Kenya, Kumar added that the focus of the funding was to scale up oral rehydration therapy to cover the whole country; train health staff in new enhanced diarrhoeal guidelines; and to support communication to promote appropriate household behaviours.

Calling for more resources from partners to implement child health programmes, Mugo said resources allocation would be increased to include training of health personnel on control and management of diarrhoeal diseases, strengthening of health systems and programmes aimed at empowering communities to control diarrhoeal diseases.

“The rate of exposure to diarrhoea and waterborne diseases in this country is extremely high because of the high fluoride content in groundwater and the poor wastewater treatment,” James Gesami, Assistant Minister for Public Health and Sanitation, told IRIN.

“In 2010, no single town in Kenya has a sustainable water supply,” he added. “We can’t do much about quantity, but when it comes to quality, the Ministry of Health is working together with USAID and other partners to set up a strategy that will include the protection of springs ready by 2015.”

Training parents

The new guidelines include training parents in home-based care to under-fives to help them recognize the symptoms of dehydration.

This follows the health ministry’s recognition that about 30 percent of children with diarrhoeal diseases are not getting any oral rehydration salts or fluids. Home therapy will include information about recommended fluid intake to prevent dehydration at the onset of diarrhoea as well as feeding, including breastfeeding, during and after diarrhoea.

“Together with our partners, we can save thousands of lives. A coordinated approach involving already proven prevention and treatment methods is the way to do it,” said Olivia Yambi from UNICEF.

Source: IRIN, 01 Apr 2010

South Africa, Cape Town: basic services needed to save babies

Toddler Sanele Qaqa should have been running around his home by now. Instead, his family is grieving his death, which could have been prevented. Sanele, the youngest of six children, died in March [2009], just two weeks ahead of his second birthday.

[...] A shocking 37 city children younger than five died of diarrhoea in February, March and April [2009] – deaths that could easily have been avoided. In 2005, more than 100 children, most of them from poverty-stricken areas, died, statistics show.

But health officials are making headway in the war on this disease. According to the Department of Health, the main contributors to the death rate are lack of access to potable water, and inadequate sanitation, sewerage services, and hygiene practices. The deaths earlier this year were largely concentrated in informal settlements where access to clean water was limited.

[Cape Town] has said that although it spends R10-million a year installing sanitation infrastructure, it is costing it R60m a year to repair infrastructure that has been damaged.

Broken toilets, stagnant pools of dirty water and human waste are common in informal settlements. These are the conditions in which disease thrives.

[Sanele Qaqa died on 28 March 2009, two days after falling ill]. One week earlier, on March 17, one-year-old Unabantu Mali died, tied to the back of his grandmother, as she made the two-hour walk home after allegedly being turned away from three health-care centres at which she had sought help for the boy, who had diarrhoea. A probe later cleared the facilities of wrongdoing.

Sanele was one of 3 586 children admitted to hospital for diarrhoea in the past year. Provincial health department spokeswoman Faiza Steyn said there was no accurate picture of deaths from diarrhoea that occurred outside hospitals.

[...] Of the 37 children who died, four had malnutrition and 12 were HIV-positive. Dehydration was the direct cause of the deaths of 14 of the children, said Steyn.

[...] According to Jaco Muller, of the City of Cape Town’s water and sanitation department, the capital expenditure for these services was R23m, while operating expenditure was R80m. The city has 223 informal settlements. The number of toilets needed was 27 052. In May, there were 2 078. The required number of standpipes providing potable water was 5 148, compared with the 4 402 that were in place.

“If all families were to have ready access to clean potable water, the risk of contamination would be considerably reduced,” said Steyn. “The risk would be further reduced if water was stored in clean containers that were cleaned regularly.”

While 37 deaths in three months is high, the mortality rate has improved since 2005, when more than 100 children in the metropole died. The provincial and city health departments have tried to curb the number of deaths through, among other things, awareness campaigns.

From April 1, [2010], a new vaccine is to be introduced that can reduce the incidence and severity of diarrhoea.

Source: Esther Lewis and Lavern De Vries, Cape Argus / Mercury & Independent Online, 05 Oct 2009

South Africa: Rotavirus vaccination programme delayed

South Africa’s introduction of a rotavirus vaccine will be launched at the earliest on 1 August 2009, after a three-month delay in its registration by the Medicines Control Council (MCC). About four-fifths of rotavirus infections occur in Africa and Asia; it is the leading cause of severe, dehydrating diarrhoea in children younger than five years, and is blamed for the deaths of between 140,000 and 150,000 children annually in Africa and 500,000 globally.

In the developing world, diarrhoeal diseases account for 20 percent to 25 percent of deaths among children aged under five years. According to a 2005 World Health Organization report on rotavirus vaccine research, infection occurs in 25 percent to 40 percent of children hospitalized with diarrhoeal illness in Africa.

[...] Most of the world’s children – 95 percent – will have suffered a rotavirus infection by the time they are between three and five years old, but in Africa this has usually happened by the time a child reaches the age of two. Peak incidence occurs in children aged between 6 months and 18 months, and the younger the child the higher the risk posed by the rotavirus. [C]hildren were usually infected numerous times, but the first infection was almost always the most severe, becoming milder with each subsequent bout.

The vaccine was designed to protect against the first infection, and would also alleviate the burden of hospitalization in already stretched health infrastructure.

Infections of the highly contagious rotavirus occur seasonally in South Africa, usually during the winter months from late March to August.

Reasons for delay

[A]ccording to reports the company awarded the tender to supply the vaccine had discontinued manufacture of the powder form registered by the MCC, and was only available as a liquid, which had not been registered. The vaccine had to be re-registered by the MCC, which took place in March [2009].

Madagascar: education hampered by lack of clean water

Because most schools in Madagascar have no access to running water, lack of hygiene and sanitation have become a major problem for children. Many pupils fall sick regularly, are unable to attend classes and hence don’t perform well at school.

Although government has promised to improve sanitation within its education system, programmes are yet to be implemented. To speed up the process, a national network of more than 150 non-governmental organisations, Diorano Wash, has launched a clean water initiative in 400 Malagasy schools that enables children to wash their hands at least once a day.

“[The water shortage] results from the fact that the country’s school construction programme did not take into account the required infrastructure. Funding for new schools did not include money to install running water,” said Diorano Wash national coordinator Herivelo Rakotondrainibe.

Lack of clean water is a problem in both urban and rural areas on the island, according to Rakotondrainibe, but the more rural the school, the more difficult it is to find sanitary conditions. In many rural schools, children are therefore instructed to bring a bottle of water each morning, which they use to wash, drink and for ablutions.

[...] According to a 2002 study by the Antananarivo-based National Institute of Statistics, more than half of under-five-year-olds die of diarrhoea in Madagascar, mainly caused by lack of sanitation. [...] According to an official survey of hygiene at Malagasy schools in February 2009, only 18 percent of the country’s 111 school districts have access to drinking water at their educational facilities. Only 30 percent have toilet facilities, while pupils in the rest of the schools have to defecate in nature.

[...] A 2009 National Institute of Statistics study confirmed that lack of access to drinking water directly relates to the percentage of children missing school, particularly due to diarrhoea. About 3.5 million school hours are lost each year in Madagascar, the study found, calculating that of the 2.5 million school-going pupils those who fall ill need about three days to recover.

Numerous schools in Madagascar have now started to educate their pupils about the importance of hygiene and sanitation. Ilafy Primary School, for example, introduces the topic of basic hygienic behaviour, such as washing of hands before meals, from Grade 1. Having soap to clean their hands properly is yet another problem, however. “The school district provides some soap, but it is never enough for all schools,” lamented [Aimée Rasoanirina, one of the school's teachers].

[..] “Elected political representatives have promised us a system of water supply, but so far their promises have not been kept,” said Landy Rasoatavy, a mother of three from Ilafy. She says she boils water for her children every morning, because their only source of water is a polluted river.

Until government implements sanitation systems in the country’s schools, teachers and pupils will continue to rely on initiatives, like Diorano Wash, which are dependent on funding from international donors. UNICEF and USAID have so far spent $4 million on school hygiene programmes in Madagascar.

But the country’s current political crisis might be an obstacle to a swift implementation of existing sanitation policies. Madagascar has been led by a transitional government under ex-Antananarivo mayor and former disc jockey Andry Rajoelina since Mar. 17, after former president Marc Ravalomanana was toppled. Newly appointed Minister of Water, Niry Lanto Randriamahazo, is yet to announce a strategy to improve the supply of clean drinking water in schools.

Related web site: WASH in Schools

Source: Fanja Saholiarisoa, IPS, 13 May 2009

Tanzania, Dar es Salaam: seeking low-cost solutions to sanitation crisis

In 2006, Jenna Davis and Alexandria Boehm of Stanford University, were awarded a two-year Environmental Venture Projects grant from Stanford’s Woods Institute for the Environment to find solutions to the problem of diarrhoea-related deaths among children in Africa.

The focus of the study is Dar es Salaam, the largest city in Tanzania. Historically, residents of the peri-urban communities surrounding Dar have relied on water from surface sources or shallow wells that are in close proximity to household pit latrines. “That means when people defecate, the waste stays under the house,” said Davis, an assistant professor of civil and environmental engineering and a fellow at the Woods Institute. “As a result, those shallow wells are very vulnerable to microbial contamination.”

To address the situation, city water and sanitation officials have drilled a series of bore wells that tap into clean aquifers deep below the surface. High-quality water is then pumped into storage tanks connected to sets of four to six taps. “Most of the water from the bore wells meets the World Health Organization guidelines for E. coli bacteria in drinking water,” said Boehm, an assistant professor of civil and environmental engineering. “Concentrations are typically less than 1 bacterium per 100 milliliters water.”

For a little money, residents can go to the taps and carry clean water back to their homes. Many people use the bore-well water for cooking and drinking. But so far, there has been little improvement in their overall health. City water officials want to know why and have turned to the Stanford team for answers.

In the summer of 2008, Davis, Boehm and a team of Stanford students and postgraduates traveled to Dar to study 300 households over a 10-week period. The research team hired Tanzanian enumerators to conduct surveys and interact directly with the households. The enumerators visited each household four times. On the first visit, they collected behavioral information, primarily from female heads of households (“the mothers”), and tested stored water and the hands of family members for indicators of fecal contamination.

Approximately 7,000 water and hand samples were collected during the study. Laboratory analysis revealed very high levels of bacterial contamination on the hands and in the stored drinking water of study participants, even though the deep bore-well water collected at the source was generally of good quality.

“There appears to be something in the transport and storage that is contaminating the water,” Davis explained. “It’s probably happening when people use their fecal-contaminated hands to scoop water out of their home containers. Another possibility is that the stored water containers used for fetching water are not cleaned regularly.”

A major challenge facing many households is distance. Some homes are 200 yards from the clean tap water, and a typical water container weighs 44 pounds when full. “We know that when people haul water from a distance, the first thing they do is drink it, then they cook, and then they wash their kids, themselves and sometimes their animals,” Davis said. “So they may not have enough water for adequate personal hygiene.”

For the second round of visits, the researchers separated the households into four groups. Each group was given generic information about how germs are spread through the five F’s—feces, flies, field, food and fingers. “We used pictures showing several ways to prevent the spread of germs, such as boiling or chlorinating the water,” Davis explained. “One of the four groups received only the generic information. A second cohort got the generic information plus the results of their water test. The third cohort got the generic information and their hand test results. The fourth group got everything—generic information, the water test results and the hand test results. The idea builds on basic health behavior-change theory: The more tailored and less generic the message is, the more effective it should be at motivating change.”

The preliminary results were surprising. Groups that received hand data or water data alone seemed to have a more positive response than households that got both hand and water test results. “It turns out that more is not better,” Davis said. “Even though we spent an equal amount of time discussing water-related strategies and hand hygiene-related strategies, there was a bigger behavioral change on the hand hygiene side than on the water side.”

The researchers are in the process of finalizing the survey data from their Environmental Venture Project. Meanwhile, in September 2008, Davis and her colleagues were awarded a three-year National Science Foundation grant to expand the number of households and the length of the study. “We’re aiming for a full year, which would allow us to monitor behaviors in both the dry and wet seasons,” she said. Data collection will begin in mid-2009, and the results could lead to low-cost solutions that reduce the incidence of diarrhea for tens of millions of children in sub-Saharan Africa and throughout the developing world.

Other members of the Stanford research team are Gary Schoolnik, professor of medicine and of microbiology and immunology; Abby King, professor of health research and policy and of medicine; and Cynthia Castro, research associate at the Stanford Prevention Research Center.

Source: Mark Shwartz, Stanford University News, 22 Apr 2009

Zambia: sanitation backlog to blame for high child mortality

Dehydration caused by severe diarrhoea is a key cause of infant deaths in Zambia, a country with one of the highest child morality rates in the world, according to a new report by Zambia’s health department. This will not change until government makes a major effort to improve access to clean water and sanitation throughout the country, health experts say.

The Zambia Demographic and Health Survey (ZDHS) report, released in early April [2009], shows that 119 out of 1,000 children don’t reach their fifth birthday. Diarrhoea accounts for one fifth of all deaths among children under five. [...] According to the Lusaka-based Central Statistical Office (CSO), not even 60 percent of the population have access to adequate sanitation and safe water.

Ivy Mutwale, programme officer at Civil Society for Poverty Reduction (CSPR), a national anti-poverty advocacy network of more than 140 organisations, believes access to clean drinking water and sanitation could be enhanced if government implemented its Fifth National Development Plan (FNDP) 2006-2011. “CSPR calls on government to seriously consider increasing the [budget] allocation to the sector. Allocations have reduced in recent years. This shows a lack of [effort] to ensure a healthy and productive population,” said Mutwale.

Although adequate policies and strategies have been developed, there has been little implementation. The National Water Policy of 1994, for example, recognises that all water supply strategies should have components on sanitation, health and hygiene education. However, government is yet to put the policy framework into practice. In his budget speech earlier this year, Minister of Finance and National Planning, Situmbeko Musokotwane, admitted that despite the fact that clean water and sanitation have been identified as a key investment area of the FNDP, government has not set aside an adequate budget to tackle the problem.

Government has allocated $38.3 million to the National Rural and Urban Water Supply Programme to improve current infrastructure and extend services to under-served areas, particularly in peri-urban sites. It has further set aside $1.8 million to improve the country’s drainage systems.

This is far too little, experts complain. Dr Chrispin Mphuka, economist at the University of Zambia, estimates in a 2005 study called The Cost of Meeting Millennium Development Goals (MDGs), that Zambia would need to spend $42.7 million a year to bring its water and sanitation systems up to scratch.

[...] Prudence Phiri, sister-in-charge at Kagoro rural health centre in Katete district, about 500 kilometres outside of Lusaka, confirms that diarrhoea occurs frequently due to lack of sanitation and clean water. If running water is unavailable, villagers use water from streams for washing, laundry and cooking, she says. What makes matters worse is that few parents bring their sick children for treatment to the local clinic. Only 60 percent of Zambian children suffering from diarrhoea receive medial attention, according to the ZDHS.

“We have two major problems,” explained nurse Phiri. “The first is that we just have one river where the villagers draw water. The second is that most villagers believe in traditional medicine [to treat diarrhoea].” As a result, many children die of diarrhoea-related dehydration. “In the last few years, we have intensified education campaigns, advising the mothers to boil drinking water and seek medical attention at the clinic [to prevent] dehydration,” she says. But behaviour change is slow.

Health department child health specialist, Dr Penelope Kalesha, says it has been a challenge for government to improve access to safe drinking water and sanitation, while at the same time making diarrhoea treatment available to as many mothers as possible.

Source: Kelvin Kachingwe, IPS News, 23 Apr 2009

Kenya: Long rains raise fears of new cholera cases

New cases of cholera are being recorded amid fears of an increase in the spread of the disease as the long rains start. Already, cases have been reported in 17 districts, according to a senior health official. “At least 176 cases of acute watery diarrhoea [AWD] have been reported in Kipsing [north of the eastern district of Isiolo]; of these, at least three have tested positive for cholera,” Shahnaaz Sharif, the director of public health and sanitation, told IRIN. “Some 1,097 AWD cases have been reported nationally since late 2008, of which 137 have tested positive for cholera,” he said.

[...] “Because of the current drought, residents are using untreated water from boreholes that just three months ago had been submerged,” Titus Mung’ou, Kenya Red Cross Society (KRCS) communications manager, told IRIN, adding that limited latrine coverage and cross-border interaction had fuelled the spread.

Mung’ou expressed concern that the spread of the disease would be exacerbated should the rains bring floods. In late 2008, floods submerged hundreds of latrines and contaminated water sources in the northeast, with cases of diarrhoea reported.

High water-table levels in some of the affected areas increased the risk of contamination, he said.

The province of Nyanza is also facing its third outbreak of cholera since December 2007, with the districts of Kisumu East and West, Nyando, Rachuonyo, Homa Bay, Migori, Suba and Rongo affected, according to KRCS. Cases have also been reported in Kakamega, in Western Province, and Athi River, near Nairobi.

Mung’ou said the outbreak in Kisumu East was due to the contamination of water sources by municipal and residential waste and a lack of proper drainage. Seepage from latrines into wells was also a risk factor in the Nyanza region.

KRCS and Ministry of Health teams are carrying out water purification and trucking in affected areas.

Source: IRIN, 01 Apr 2009

Somalia: acute watery diarrhoea kills dozens in Galgadud

Dozens of people have died in central Somalia’s Galgadud region after an outbreak of acute watery diarrhoea (AWD), medical personnel said on 23 December 2008. The worst-affected area is in and around the town of Balambale [where] 16 people have been confirmed to have died [of whom] 12 were children under five.  [In November, at least 100 people were reported to have died after an AWD outbreak in Abudwaaq, in Galgadud].

So far 139 cases of AWD had been registered in Balambale, said Mahamud Mohamed Isturaye, the district medical coordinator, adding [that there were] reports that some [more] people had died in surrounding villages. He said AWD had broken out after heavy rains, which contaminated water in wells and barkads (water catchments). UNICEF had provided oral rehydration salts (ORS), he added.

[Isturaye]  said medical workers had urged people to keep their children away from contaminated water and to separate the sick from the healthy. “Unfortunately, we do not have chlorine to put in the water points, especially the barkads,” he said.

Source: IRIN, 23 Dec 2008

Somalia: Dozens die in diarrhoea outbreak

At least 100 people have died in the past four weeks after an outbreak of acute watery diarrhoea (AWD) in and around the town of Abudwaaq, in Galgadud region of central Somalia, medical sources said on 18 November.

The outbreak was blamed on contaminated water drawn from wells and “barkads” (water catchments).

[...] Hassan Bulhan, a leader of a youth group carrying out awareness campaigns in the town, said a taskforce had been set up two weeks ago to deal with the outbreak and a campaign mounted to warn people against drinking water that has not been chlorinated.

Source: IRIN, 18 Nov 2008

Kenya: Acute diarrhoea reported in western region

At least 34 cases of acute watery diarrhoea (AWD) have been reported in the Rift Valley town of Nakuru in the western region, a senior health official has said.

[...]

The cases were attributed to the contamination of a spring in the Mbaruk area in the district.

Intervention measures included supplying the residents with clean water, a ban on the hawking of food in the area [...] and health and hygiene education.

Health officials were waiting for laboratory results to confirm whether the AWD was cholera.

Meanwhile, an outbreak of cholera in the western district of Kisumu East [attributed to seepage from latrines, which contaminated wells] has still not been brought under control.

Read more: IRIN, 3 Jul 2008