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Nicaragua ORT ProjectNicaragua ORT Project

Imelda Medina, M.D.Imelda Medina, M.D.

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UN Millennium Development Goals

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The UN Millennium Development Goals

Global partnership to reduce extreme poverty. Established on September 2000, deadline 2015. Address:

Basic human rights-the rights of each person on the planet to health, education, shelter, and security.

Extreme poverty in its many dimensions: Income poverty Hunger Disease Lack of adequate shelter Exclusion-while promoting gender equality Education Environmental sustainability

http://www.unmillenniumproject.org/goals/index.htm

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What they are Goal 1: Eradicate Extreme Hunger and Poverty Goal 2: Achieve Universal Primary Education Goal 3: Promote Gender Equality and Empower

Women

Goal 4: Reduce Child Mortality Goal 5: Improve Maternal Health Goal 6: Combat HIV/AIDS, Malaria and other dis

eases

Goal 7: Ensure Environmental Sustainability Goal 8: Develop a Global Partnership for Develop

ment

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Our Focus Let’s start with…

Goal 4: Reduce Child Mortality

Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate

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EDUCATION

Evidence shows that information, not in the hands of experts, but in the hands of the population, leads to changes in behavior, health improvement and decrease in mortality.

Education and Prevention play an essential role.

Low income, Social Growth and Good Health: A History of twelve countries. New England Journal of Medicine, 2008

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HEALTH

Worldwide over 10 million children under 5 years of age are dying each year.

What interventions are appropriate for reducing these deaths?

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HEALTH

Two main causes of Morbidity and Mortality in children 5 and less than 5 y/o

Malnutrition Acute gastroenteritis (Diarrhea)

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HEALTHMalnutrition

MALNUTRITION Major underlying factor Complicates the clinical presentation EDUCATION is essential

10World Health Organization data 2001 (from Global Health Council http://www.globalhealth.org)

Leading Causes of Death in Children Under 5 years of age

Perinatal (22%)Perinatal (22%)

All other causes All other causes (29%)(29%)

HIV / AIDS HIV / AIDS (4%)(4%)Diarrhea Diarrhea

(12%)(12%)

Measles (5%)

Malaria Malaria (8%)(8%)

Pneumonia Pneumonia (20%)(20%)

MalnutritionMalnutritionunderlying factor underlying factor

(60%)(60%)

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HEALTHMalnutrition Consequences

Child with Spina Bifida and Hydrocephalus

(Folic acid deficiency during pregnancy)

High Prevalence of Prematurity

Child with Myelomeningocele (Folic acid deficiency during pregnancy)

Protein, Calories, Vitamins deficiencies

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HEALTHAcute gastroenteritis

Acute gastroenteritis (Diarrhea) remains a common illness among infants and children worldwide. In the United States, acute diarrhea accounts for >1.5

million outpatient visits, 200,000 hospitalizations, and approximately 300 deaths/year (CDC report year 2003).

In developing countries, diarrhea is a common cause of mortality among children aged <5 years, with approximately 2 million deaths annually (CDC MMWR 2003).

Diarrhea dehydration is one of the main causes of death in children under the age of five (Ahmad OB et al 2000; Sakisaka K 2006), and often (almost 50% of these cases) are complicated by malnutrition (Rutstein SO 2000).

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HEALTH Acute gastroenteritis’ primary morbidity and

mortality arises from dehydration and electrolyte losses associated with untreated diarrhea (CDC MMWR 2003; Greenough WB-The Lancet 1995).

Fortunately, this can effectively be prevented by the adequate use of Oral Rehydration Therapy (ORT), which includes rehydration and maintenance fluids with oral rehydration solutions (ORS), combined with continued age-appropriate nutrition (CDC MMWR 2003).

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Interventions by cause - Diarrhea

Exposure to diarrhea

Diarrhea

SurviveDie

Breastfeeding

Complementary feeding

Treatment

Zinc

Future: rotavirus vaccine

Vitamin AAntibiotics for dysentery

Oral rehydration therapy

Zinc

Water/San/Hygiene

Prevention

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HEALTH

Oral Rehydration Therapy A simple solution of

water, salt and sugar saves millions of young lives.

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HEALTHHow ORT works

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Oral Rehydration Therapy

"The discovery that sodium transport and glucose transport are coupled in the small

intestine so that glucose accelerates absorption of solute and water (is)

potentially the most important medical advance of this century."

The Lancet (British Scientific Journal)

5th August, 1978

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HEALTH

Treatment can begin at home if primary caretakers: are educated about the disease understand adequate ORT preparation/use are trained to recognize signs of illness or treatment

failure that necessitate immediate medical intervention (CDC MMWR 2003).

ORT is simple and allows management of uncomplicated cases of diarrhea at home, regardless of etiologic agent (CDC MMWR 2003).

Thus, early intervention can significantly diminish complications, hospitalizations and deaths.

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HEALTH ORT preparation

It can be prepared from commercially available ORS packets

Mix a packet in a liter of previously boiled water.

By using home ingredients to make a standard homemade solution.

The recipe includes 5 cups of clean potable water, 1 teaspoon of salt and 8 teaspoons of sugar.

Education plays a significant part on the safe and efficient use of ORT, otherwise serious errors and complications can occur (Meyers A et al 1997).

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Action Plan

Work towards the achievement of the UN’s Millennium Development Goal #4: To reduce child mortality.

Assume the UN’s Millennium Villages working plan.

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Action Plan Cont. UN MILLENNIUM VILLAGES WORKING

PLAN We will empower those who need us the most

living in impoverished “villages/barrios” so they can transform themselves and meet the Millennium Development Goals.

In order to do so, we will work in partnership with governments and other committed organizations, to provide affordable and science-based solutions to help people lift themselves out of extreme poverty.

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Our Plan

We will Improve and Establish the most effective Sustainable Distribution System for Oral Rehydration Therapy (ORT) of Acute Gastroenteritis, and Ensure its continuous Excellent Performance in Nicaragua.

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Action Plan We will provide continuous Education and ORT treatment

for gastroenteritis through an existing distribution system in Managua, working in liaison with a small clinic, base houses in the communities and health promoters.

We will establish similar systems in other areas of much need in Nicaragua with the help of local organizations. Our goal is to eventually implement our system at a national level.

Promote mental health and unity with families in the communities through fun activities.

Carry out infrastructure restoration as well as the establishment of hygiene measurements important for malnutrition and infectious diseases prevention.

Action Plan cont. Four important components that will ensure sustainability –

FAMILIAS UNIDAS

FUND RAISING ACTIVITIES AND GRANT WRITING IN THE US AND NICARAGUA

To provide ORT packets to the families

PARTICIPATION Pre-Clinical and Public Health/Research Continuous involvement with the ORT project in educational and other

activities

PARTNERSHIP WITH LOCAL ORGANIZATIONS LOS CHAVALITOS CLINIC OTHER (S)

EDUCATION We will teach Families and Community Leaders how to prepare treatment at

home with home-made ingredients. Educate about the disease and associated co-morbidities among other important topics.

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Action Plan Target population:

Children 5 and less than 5 yrs old living in underserved villages (“barrios”) of Nicaragua.

Target population goal is about 5,000 children

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Action Plan Distribution system

Initially established by Dr. Imelda Medina in 1999

Currently our system in Managua is working with 8 base houses in the communities, providing a total of about 300 ORT packets monthly with an average of 3000-4000 salts per year. In addition, we provide some medicines such as Paracetamol. The salts are distributed by "brigadistas de salud" (health promoters) in charge of the base houses, who also refer children to the clinic.

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Action Plan

Distribution system Still active (since 1999) which shows

it's importance to serve the needs of the population and our ability to ensure a project’s sustainability.

However, the services are not enough to cover the basic needs of our pediatric population.

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Action Plan DISTRIBUTION SYSTEM

We will provide the base houses with Oral Rehydration Therapy salts so they serve as a source of distribution to the population.

Two ways we will provide ORT to the population:

1. ORT Packets ($0.32 each). Each child will need at least 2 packets on day 1 of the

disease.

2. Teach parents how to correctly prepare them with ingredients at home.

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Action Plan DISTRIBUTION SYSTEM

ORT PACKETS COST

Taking into consideration that the total number of children 5 and less than 5 years old in these communities is approximately 4,444, the most frequent times per year they get sick is 3, and that we will provide them with two packets during the first day of the disease, each packet costing $0.32, we will need $8,532.48 annually to help the communities or at least 26,666 packets of WHO ORT solution per year, about 2,000 packets/month (note the large gap from the current annual supply).

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Action Plan DISTRIBUTION SYSTEM

We will Educate the population about the disease and conduct workshops about the adequate preparation of the solution at home for cases when the packets are not available.

Establish additional base houses to cover all areas in need in the country and ensure excellent performance so that families can have resources close to their home and receive ORT treatment in a timely manner.

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