Fulll chapter of national diarroheal control programme in nepal

BY - M O N I K A R I JA L
N I S H A AC H A RYA
N I S H M A C H AU D H A RY
PA D M A R A I
PA B I T R A G U R U N G
Control of diarrheal disease in
Nepal
1

DIFINITION
Diarrhoea is defined as passing of liquid or watery
stools usually at least 3 times in a 24 hours period.
However,it is the recent change in consistency of
stools rather than the number of stools that is more
important.
2

TYPES
 Acute watery diarrhoea:
 Which lasts several hours to days.
 The main danger is dehydration, weight loss also
occurs if feeding is not continued.
 The pathogens usually cause acute diarrhoea is
V.cholerae,or E.coli as well as Rotavirus
3

Cont..
 Acute bloody diarrhoea:
 Which is also called dysentry.
 The main dangers are damage of intestinal
mucosa, sepsis, and malnutrition , other
complication including dehydration, may also
occur.
 Most common cause is Shigella.
4

Cont..
Persistent diarrhoea:
Which lasts 14 days or longer.
The main danger is malnutrition and serious non-
intestinal infection,dehydration may also occur.
Persons with other illness, such as AIDS, are more
likely to develop persistent diarrhoea.
5

Cont…
Diarrhoea with severe malnutrition:
The main dangers are severe systemic infection,
dehydration, heart failure,and vitamin and mineral
deficiency
6

Disease Diarrhea of control programme
 Started by W.H.O in the year 1978.
 After the 1985/86 oral rehydration programme
,the DDCP has shifted its focus on strengthening
case management of diarrhea under 5yrs
childeren.
 Research on the causes prevention and treatment
of disease is also being incorporated in this
programme. from 1992-1993 the programme has
become a part of child survival 7 safe
motherhood programme.(CSSM).
8

Cont…
 CSSM programme is became part ofRCH
(reproductive & childhealth)
programme in 1997.
 In RCH programme ,policy of IMCI was
adopted
 Since 2003 –DDCP included in IMCI which
includes….
- Neonates of 0-7 days
- Incorporating national guidelines in
diarrhoea, ARI, Malaria, Anaemia, Vit A,
supplementation 7 immunizations
9

In nepal
 Nepal recorded high under-five mortality averaging about
170 annual deaths per 1000 in the early 1980s, and on
2009 reports 61 per 1000.
 WHO-supported programmes for the control of
diarrhoeal diseases and respiratory infections started
during the 1980s and reduced child mortality.
 A community-based national programme to control
diarrhoeal diseases was launched in 1982
10

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;
11

Strategies for Tenth Five Year Plan
 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
12

National Control of Diarrhoeal
Disease Programme (NCDDP)
13

BACKGROUND
 Diarrhoeal diseases as one of the major public
health problems among children under five years
of age in Nepal .
 NCDDP has been accorded high priority status by
Government of Nepal and is an integral part of
primary health care .
 Improvement in diarrhea case management has
been used as primary strategy for the reduction
of mortality due to diarrhoea among children
under five years of age .
14

CONTD………
 Standard diarrhea case management will be
provided in the health institutions by
establishing Oral Rehydration Therapy (ORT)
corners in Hospital , PHCC , Health posts and
Sub health posts throughtout the country.
 All health facilities and Community health
volunteers will serve as the primary health
providers in the treatment of Diarrhoea with
oral Rhydration Solutions (ORS).
15

OBJECTIVES
To reduce mortality and morbidity due to diarrhea and
dehydration.
TARGETS
To reduce the under five mortality rate due to diarrhea
by 50% by 2007/2008.
To reduce the under five morbidity rate due to
diarrhea by 20%.
16

CONTD………..
To increase the accessibility of oral Rehydration
solution (ORS ) to 100% of the target population.
To raise public awareness regarding the correct
preparation and use of ORS in the treatment of
diarrhea by 20% .
To increase the proportion of caretakers that
provides ORT for children with diarrhea to 40% .
17

STRATEGIES
 Establish functioning ORT corners in each health
facility in order to educate mothers / caretakers
to demonstrate proper ORS preparation and to
treat children suffering from diarrhoea .
 Increase access to oral rehydration solution
packets and Zinc tablets through FCHV , SHP , HP
,PHCC ,Hospitals & commercial outlets .
 Raise public awareness .
19

CONTD…………..
 Promote specific preventive measures through
communication and information activities .
 Involve community health workers ( VHW and
MCHW ) including the volunteers ( FCHV ) , District
Development Committee ( DDC ) and VDV members ,
local NGOs and local decision makers .
 Apply an integrated child health package including
the CDD , EPI ,Nutrition , Acute Respiratory
Infection (ARI) and Malaria programme
management at all health facilities .
20

CONTD………..
 Emphasize programme management at all
health facilities .
21

SPECIFIC STRATEGIES
 Train all levels of health workers including
VHW / MCHW /FCHV / Community leaders .
Orient community opinion leaders , VDC
members , faith healers .
Supply ORS to all health institutions and FCHVs
.
 Supply Zinc tablets to all health institutions
and FCHV of Zinc programme implemented
districts .
22

CONTD……….
 Develop and print health education materials
to be used by mothers , FCHVs and broadcast
through mass media .
 Promote supervision & monitoring at all levels .
23

ACTIVITIES CARRIED OUT IN FY 2062/63
(2005/2006)
 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.
24

(2005/2006)
 Supply of ORS
 2,500,000 sachets ORS purchased and distributed to
the districts.
 Communication and Training Materials
 Revised and finalized training materials and printed
through WHO and GoN.
 Transportation
 Supply of IEC materials regarding CDD to districts as
requested.
25

(2005/2006)
 Monitoring and Supervision
 Supervision from center and region to districts
accomplished
 Supervision from district to PHCC, HP/SHP as per
schedule done
 Epidemic Control
 Financial support to all districts provided where epidemic
occurred
26

Achievements of 2062/2063
 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.
27

Cont…
 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
28

Achievements
 The 377 770 diarrhoea episodes reported in a total
under-five population of 1, 798 ,668 in districts with
interventions represented 0.21 episodes per child per
year.
 In the 42 districts without interventions, the 3,03, 049
episodes reported in a total under-five population of
1 ,873 ,982 represented 0.16 episodes per child per year .
29

Cont…
 In districts with interventions the proportion of diarrhoea
episodes with some dehydration (110 956/377 770,
29.4%) was significantly lower than in districts without
interventions.
 The proportion of diarrhoea episodes with severe
dehydration was lower in districts that received
interventions(3108/377 770, 0.8%) than in those without
interventions (4465/303 049, 1.5%).
30

Cont…
 Between 2004 and 2007 more districts were included in
the programme. during this period the proportions of
diarrhoeal episodes with some dehydration or severe
dehydration nationwide,
 The national case fatality rates for acute diarrhoea,
showed a significant trend towards a decrease.
31

IMCI
 IMCI strategy was developed by WHO in
collaboration with UNICEF , Government Nepal
decided to introduce it in June 1995 in Nepal.
 It is a curative, preventive and promotive
strategy aimed at reducing the death, severity of
illness and disability which contributes to
improve growth and development of under
5children.
32

CONT……
 Nepal is almost the first two countries in SEARO
region to start IMICI(another country being
Indonesia) It was initially implemented in
mahottari and nawalparasi districts.
 By the year 2066, it is implemented in all districts,
since then training started from health
facility(HP/SHP) to the community
level(VHW/MCHW and FCHV).
33

CBIMCI
 The community based ARI and CDD(CBAC)
program was merged in to IMCI in 1999 and was
named the CBIMCI.
 New born care component included in CB-IMCI
IN 2004 and name given as CB-NCP.
 Integrated package of CBIMCI and CBNCP was
implemented as IMNCI from2071/72
34

VISION
 Contribute to survival, health growth and
development of under five years children of
Nepal.
 Sustain the achievement of MDG4 beyond
2015.
35

GOAL
 To reduce morbidity and mortality among
children under- five due to pneumonia,
diarrhea, malnutrition, measles and malaria.
36

TARGET
 To reduce neonatal mortality from the current rate of
33/1,000 live births to 17/1,000 live births by 2015.
 To reduce neonatal morbidity among infants less than 2
months of age.
37

OBJECTIVES
 Reduce frequency and severity of illness and
death related to ARI, Diarrhoea, Malnutrition,
 Measles and Malaria.
 Contribute to improved growth and
development.
38

STATEGIES
The following strategy have been adopted by
CB-IMCI program.
1.Improving knowledge and case management
skill of health service providers.
2.Improving overall health systems.
3.Improving family and community practices.
39

Major Activities regarding Diarrhea
Management of Diarrheal Diseases
 Diarrhea is still a leading killer disease in Nepal. CB‐IMCI
program intensely focuses on
 management of diarrheal diseases among the under‐five
year’s children. Standard diarrhea case
 management with Oral Rehydration Therapy (ORT,
continued feeding and Zinc tablet have been
40

Cont..
 providing in the health institutions. All health facilities
and community health volunteers have been
 serving as the primary health service providers in the
treatment of diarrhoea with low osmolar oral
41

Cont….
 Rehydration Solutions (ORS) and Zinc supplementation.
 The targets of important components of the CB‐IMCI
program were achieved by 100 percent in
 three consecutive fiscal years (Annex 1.1).
42

Zinc Supplementation
 Zinc tablet in the treatment of diarrhea was introduced in
FY 2062/63 as a pilot program in two
 districts of Nepal (Rautahat and Parbat). The scaling up of
the program was completed in 2066/67.
43

Achievements
Diarrhoea
 IMCI program has imparted positive impact on the skills
and knowledge of health workers, enabling
 Them for better identification, classification and
treatment of diarrhoeal diseases. Health workers
 classify diarrhoeal cases as 'No Dehydration', 'Some
Dehydration', 'Severe Dehydration' and Dysentry
2
44

Cont..
 according to the treatment protocol of CB‐IMCI.
 The reported number of total new diarrhoeal cases
(health facility plus community) and classification
 a total of 1,809,205 diarrhoeal cases were reported.
 The national incidence of diarrhoea per 1,000 under‐five
years' children has increased slightly from 500/1000 in FY
2067/68 to 528/1,000 in 2068/69,
45

Cont..
 At the national level cases of 'Severe Dehydration' has
decreased slightly to 0.2 percent in FY 2068/69 from 0.4
of FY 2066/67 and 2067/68. Severe dehydration has
decreased considerably in all the regions except WDR.
 In FY 2068/69 the diarrhoeal deaths increased by 2
percent from that of number 44 of FY 2067/68.
 However, it is still 51 percent lower than that of FY
2066/67.
2
46

Treatment of diarrhoeal diseases, FY2066/67 to
2068/69
Indicators Year National level
Total Cases (HF +
Community Level)
2066/67 2,034,892
2067/68 1,735,844
2068/69 1,809,205
Zinc + ORS 2066/67 970,598 (47.7)
2067/68 1,524,871 (87.8)
2068/69 1,594,044 (88.9)
Treated with IV Fluid 2066/67 6,650 (0.3)
2067/68 6,027 (0.3)
2068/69 9,116 (0.5)
Note: Numbers in parenthesis are percentages. Source:
HMIS
47

CASE MANAGEMENT PROCESS
1.Assess the child or young infant
2.Classify conditions and identify treatment
actions according to colour- coded treatment
charts where;
Pink Red; urgent referral
Yellow ; treatment at outpatient facility
48

CASE MANAGEMENT PROCESS
Green ; home management
3.Identify treatment
4.Treat the child or refer
5. Counsel the mother
6.Give follow-up care
49

DIARRHEAL DISEASES
Defination ;
Diarrhoea is defined as the
passage of loose , liquid or watery stool
more than three times in 24hours.
TYPES OF DIARRHOEA
1.Acute diarrhea
2.Chronic diarrhea
50

CONT…..
1.ACUTE DIARRHOEA;
Acute diarrhea as an
attack of sudden onset, which usually last 3-7
days, may last up to 10-14 days.
About 10% of acute diarrheal episode become
chronic persistent diarrhea.
51

CONT……………
2.Chronic diarrhea;
If diarrhea last for more
than 2 weeks and may vary from day to day ,
is termed as chronic diarrhea.
It is usually associated with malabsorption
syndrome , chronic inflammatory bowel
disease and food allergies.
52

CB-IMNCI
 CB-IMNCI is an integration of CB-IMCI and CB-NCP
Programs as per the decision of MoH on 2071/6/28
(October 14, 2014).
 This integrated package of child‐survival intervention
addresses the major problems of sick newborn such as
birth asphyxia, bacterial infection, jaundice, hypothermia,
low birthweight, counseling of breastfeeding.
 It also maintains its aim to address major childhood
illnesses like Pneumonia, Diarrhoea, Malaria, Measles
and Malnutrition among under 5 year’s children in a
holistic way.
55

Facility-Based Integrated Management of Childhood
and Neonatal Illnesses
 The Facility-Based Integrated Management of Neonatal
and Childhood Illnesses(FB-IMNCI)package has been
designed specially to address childhood cases referred
from peripheral level health institutions to higher
institutions.
 This package addresses the major causes of childhood
illnesses including Emergency Triage
 and Treatment (ETAT) and thematic approach to common
childhood illnesses towards diagnosis and
 treatment especially newborn care, cough, diarrhoea,
fever, malnutrition and anemia.
56

Goal
 Improve newborn and child survival and healthy growth
and development.
58

Targets
 Reduction of Under-five mortality rate (per 1,000 live
births) to 28 by 2020
 Reduction of Neonatal mortality rate (per 1,000 live
births) to 17.5 by 2020
59

Objectives
 To reduce neonatal morbidity and mortality by promoting
essential newborn care services
 To reduce neonatal morbidity and mortality by managing
major cause to fullness
 To reduce morbidity and mortality by managing major
causes of illness among under 5 years children
60

Strategies
 Quality of care through system strengthening and referral
services for specialized care
 Ensure universal access to health care services for new
born and young infant
 Capacity building of frontline health workers and
volunteers
 Increase service utilization through demand generation
activities
 Promote decentralized and evidence-based planning and
programming
61

Major interventions
 • Newborn SpecificInterventions
 o Promotion of birth preparedness plan
 o Promotion of essential new born care practices and
postnatal care to mothers and newborns
 o Identification and management of non‐breathing babies
at birth
 o Identification and management of pre termand low
birth weight babies
 o Management of sepsis among young infants (0‐59days)
including diarrhoea
62

Cont…
• Child SpecificInterventions
 Case management of children aged between2 ‐59 months for
5 major childhood killer
 diseases
(Pneumonia,Diarrhoea,Malnutrition,MeaslesandMalaria)
• Cross-CuttingInterventions
 Behaviour change communications for healthy pregnancy,
safe delivery and promote personal
 hygiene and sanitation
 Improved knowledge related to Immunization and Nutrition
and care of sick children
 Improved interpersonal communication skills of HWs and
FCHVs
63

Major Achievements
Classification of diarrhoeal cases by province 2074/75
 CB-IMNCI program has created enabling environment to
health workers for better identification,
 classification and treatment of diarrhoeal diseases.
 As per CB-IMNCI national protocol, diarrhoea has been
classified into three categories: ‘No Dehydration’, ‘Some
Dehydration’, and ‘Severe Dehydration’.
64

 In FY 2074/75, a total of 1,148,238diarrhoeal cases
were reported outof which about one third (33%)were
reported from health facilities and ORC and rest two
third (67%) by FCHV.
 Among registered cases in Health Facilities and
PHC/ORC more thanthree fourth (83%) were classified
as having no dehydration, about one fifth (16.7%) some
dehydration.
 Severe dehydration remained below 1% across all
provinces and in national level.
65

Cont..
 incidence of diarrhoea per thousand under age 5 children
was 385 in FY2074/75, being highest at Karnali (709)
followed by Sudur Pachhim (648).
 Similar trend was seen in the previous fiscal year. Further,
the lowest incidence was in province 3 (262).
66

Cont..
 Total diarrhoeal death in health facility and PHC/ORC was
47 which increased by 42% than the last fiscal year.
 Case fatality rate across all the provinces was below 1 per
thousand.
67

Treatment of diarrhoea cases by province (FY
2074/75)
 In FY 2074/75, the proportion of diarrhoeal cases treated
with ORS and Zinc as per IMNCI national protocol at
national level was 95.2% which was slightly higher than
that of previous year (92.14%).
 Highest proportion was seen in Sudur Pachhim (98.82%)
and lowest in province 1 (89.76%).
68

Roles and responsibilities of
community health nurse in
management of diarrheal
disease
69

ROLES OF FCHVS IN MANAGEMENT OF DIARRHEAL
DISEASE
1. Educator :-
 Provide community based education on prevention of
diarrheal disease
 Educate mothers on use of ORS during diarrhea
 Increase awareness on diarrheal disease and its impact
71

2. MOTIVATOR :-
 Motivates on increasing family and community
participation in prevention and management of
diarrheal disease
 Motivates use of local health care services during
episodes of diarrhea
72

3. Facilitator:-
 Provide ORS packet and zinc supplement where ever
needed
4. Change agent :-
 Demonstrates healthy behavior by mothers , community
people to manage diarrheal disease and follow up to see
the changed behavior
73

Roles of Family Health Nurse
1. Health educator :-
 Provide education on how to prepare ORS and when to
visit to hospital
 Assess the child and educate the family on management
protocol by CBIMNCI and inform on importance of
treating diarrhea
 Provide education related to personal hygiene , balance
diet , hand washing etc
74

2. PLANNER:-
 Pre planning is necessary for timely control and managing
diarrhea
 She assess the client affected with diarrhea and their
source of infection i.e. drainage system, latrine, personal
habit cultural aspect etc
 Encourages use of local resources available .
75

COMMUNITY HEALTH NURSE IN PRIMARY HEALTH
CARE SETTING
1. Health care provider :-
 Physical examination for sign of dehydration and its
severity and symptoms of diarrhea
 Assess the intake of fluids and dietary pattern
 Provide intravenous therapy as per protocol
 She also emphasizes on diarrheal disease prevention ,
health promotion and maintenance and rehabilitation
76

2. Motivator :-
 She can motivate the people for intake of balanced diet
 She can motivate people for a healthier way of life by
increasing interest to adopt healthy life style
 Motivates community people to promote and maintain
their own health
77

3. Counselor:-
 She provides counseling service on use of safe water , use
of latrines and importance of hand washing
4. co-ordinator :-
A PHC nurse can use inter-sectoral and multi-sectoral co-
operation for maintenance of positive health habits and
health awareness
78

5. EVALUATOR :-
 She can evaluate the effectiveness of education ,
treatment therapy and health habits adopt by the society
 She can plan follow up visits and identify the obstacles to
determine further plan in managing diarrheal disease
79

Evaluator cont..
 Evaluates the effectiveness of nursing care seeking
assistance and knowledge as necessary
 Contributes to support , direction and teaching or training
of professionals in management of diarrhea
80

6. Facilitator :-
 She can help bring new health
policies and facilities given by
government ( act as channel or
bridge)
81

Role of public health nurse
1. Management :-
 Undertakes a comprehensive and accurate nursing
assessment of client with diarrhea using suitable
assessment tool
 Contributes in care planning involving the community in
which clients are affected and ensures delivery of
health policies , plan at proper area
82

2. Professional responsibility:-
 Respect cultural aspect of client and ensure the same by
others while practicing nursing
 Maintain infection control principle
 Attends regular clinical supervision
 Evaluate environmental safety, hazard identification and
risk assessment related to diarrheal disease
83

3. inter-professional health care and quality
improvement
 Collaborates and coordinates care with other health
professionals to ensure a delivery of quality service
concerned with diarrhea
 Attends relevant community meetings and forums
 Maintain and documents information necessary for
continuity of care and recovery from diarrhea
84

At central level
 Collect epidemiological data from whole national level
 Formulating drafts , policies and forwarding them to
ministry of Health.
 Executing the formulated plans and policies regarding
Diarrhea , its management, sources and interventions.
85

References
 Source :_ control of diarrhoeal disease,Nepali R., (2011) ,
from webocreation
 Source :- Community-based interventions for diarrhoeal
diseases and acute respiratory infections in Nepal,
Bulletin of the World Health Organization 2010 by
Ghimire M.
 DOHS annual report 2068/2069
 Dohs annual report 2074/75
 Dohs annual report 2067/68
 Dohs annual report2066/2067
87

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