Times of India, May 2013
A pivotal clinical study of India's first indigenous rotavirus vaccine...
On a recent trip to Kenya’s Western Province, I witnessed how the Oral Rehydration Treatment (ORT) corner is becoming an important part of primary care services in that region.
While I was visiting one of the ORT corners in Kakamega, a shy young mother came in with her 4 month old baby. He had been having diarrhea for the past two days, and had stopped nursing. He was alternately fussy and listless. He had the classic signs of dehydration: sunken fontanel, skin torpor, he wasn’t tracking much, shed no tears when he cried.
The nurse in the ORT corner went into action. She had the mother wash her hands, reminding her how important it is to wash hands whenever you feed the baby, even if just nursing, and after changing diapers, and using the latrine. Then she mixed up a 500 ml container of ORS, showing the mother all the while how to do it using common household utensils and containers. She showed the mother how to position the baby so that she could spoon him the ORS. As the mother gave the baby spoonful after spoonful of ORS, she sat with the mother, talking about nutrition, what kind of foods are best and what she should expect as the child develops, and other symptoms to keep watch for, like fever and cough. She also explained how to set up a basic dish washing system in her home to effectively wash food utensils. The nurse reviewed the baby’s health card to make sure he was up on his immunizations, vitamin A, and to review his growth status.
I retuned an hour later, and if you have never witnessed the power of simple ORS, it is truly amazing. After only an hour, the baby was already bright eyed, looking around, even smiled a little. The little guy had consumed about two-thirds of the ORS, which is quite a lot, but he was clearly thirsty. The mother’s relief was palpable. The mother and baby would stay for another two hours or so during which time the nurse would continue to monitor the baby’s progress, and mix up a first dose of zinc treatment, instructing the mother on how to prepare it and emphasizing the importance of completing the full course. Because of the baby’s age, the mother was given five 20 mg tablets, to be split in half and administered each day for ten days. She was also given another packet of ORS for the next day. The nurse told me it is not uncommon to have 8 to 10 mothers and children in the ORT corner at one time. At another ORT corner that I visited in a small and overcrowded dispensary on the border with Uganda, the nurse told me they see 20 to 30 cases of diarrhea a day, and quickly run through their supplies of zinc and ORS. They had no zinc at the time of my visit.
The story does not end there, however. While the mother was giving her baby ORS, I went to talk to the nurse in the pediatric ward. She was to confirm what we had been hearing: that since our efforts to re-establish ORT corners began, there has been a steady decrease in hospitalization for diarrhea. Previously, in situations such as the one with the baby I just described, the only course would have been to admit him for an overnight stay, hooked up to an IV, at great expense to the mother. In addition, the mother would not likely have received the varied counseling and instruction.
In Western Province we are collecting the data on hospitalizations and referrals to other health facilities, as well as other measures of progress. We are assessing the impact of the ORT corners, and the community mobilization that is taking place to improve both diarrhea prevention and treatment practices in the homes and communities. We will be analyzing that data in the coming months to arrive at more conclusive results, and will share what we learn.
While in Kenya I was struck by the sheer dedication of the staff to overcome all obstacles. For example, another ORT corner that I visited was in a District Hospital that had no running water and no electricity, so even if they had water, there was no way to boil it. So, each day one of the nurses brings three, one liter bottles of water for mixing the ORS that she boiled at home.
On this same trip I attended a sub-location open forum on health. A sub-location is a geographic area, usually consisting of about 10 villages. The forum was presided over by the Assistant Chief, and in attendance were villagers and village elders, and several Community Health Volunteers trained by our program to educate communities on diarrhea prevention and treatment, and the importance of care seeking. Malaria and diarrhea have been their main focus this year. The villagers shared their interest in preventing diarrhea, since the nearest health facilities was 10 kilometers away, a tough journey on foot or bike on any day, but more so with a sick child. There are no cars. They explained to me their three priorities: protecting their water sources (springs) from contamination by floods, and human and animal waste; constructing quality latrines, since open defecation remains a huge problem; and continuing to educate one another on appropriate treatment. They expressed their appreciation to the Community Health Volunteers who have emphasized hand washing and care seeking. The villagers and asked me if we could furnish the Community Health Volunteers with ORS, so that it was more readily available in the village. This is something we would like to explore with the Ministry of Health. I visited one ORT corner that does give Community Health Volunteers ORS for use in the community, but this was an exception not the rule.
These communities know that prevention is the key to long term disease burden reduction. They are highly motivated to improve water and sanitation, knowing that it’s the root cause of more than just diarrheal disease, but other health issues as well. I was moved by their willingness and capacity to put the effort into improving their situation.
-- Evan Simpson is a Program Officer for PATH's Enhanced Diarrheal Disease Control Initiative