Sub-Saharan Africa


Sub-Saharan Africa: Rotavirus vaccine clinical trials
PATH is evaluating the efficacy of rotavirus vaccines among impoverished populations in Africa, conducting clinical trials in Kenya, Ghana, Malawi, Mali, and South Africa in collaboration with manufacturers Merck & Co., Inc., and GlaxoSmithKline. Results will be available in 2009, and the World Health Organization will review the data toward making a universal recommendation on the use of rotavirus vaccines. 
Sub-Saharan Africa: Revitalizing diarrheal disease case management
Using the introduction of zinc for diarrhea treatment as a catalyst, USAID/BASICS has been working in a number of countries to revitalize diarrheal disease case management. In collaboration with Management Sciences for Health, A2Z, and USAID, and building on earlier work by Johns Hopkins University School of Public Health in Tanzania, USAID/BASICS developed a tool to assess country readiness for zinc introduction. The tool was first used in Madagascar, and adapted for Indonesia, DR Congo, and Senegal. It has also been shared with Uganda, Rwanda, Afghanistan, and Malawi. The tool covers case assessment, classification, and treatment; extension of diarrhea case management to community health workers; communication approaches and tools; logistics issues, including registration of zinc, as well as supply of both zinc and low osmolarity oral rehydration salts (ORS); and data for monitoring and evaluation.
Challenges surrounding the acquisition of zinc by countries have been a primary obstacle for rapid revitalization of diarrhea case management. Still, Madagascar and DR Congo are making substantial progress with scale-up in spite of limitations in commodity availability. In both countries, more than 20 percent of districts are already covered. Moreover, DR Congo is planning a national launch of its diarrhea case management revitalization program.

Public demonstrations on administering a life-saving intervention

Diarrhea is a leading cause of child death in Burundi, accounting for 18 percent of deaths among children under five. Population Services International (PSI)/Burundi has been distributing oral rehydration solution through commercial outlets in Burundi under the brand Orasel since 2004 as part of a USAID-funded project to reduce childhood morbidity and mortality.

Despite these efforts, a nationally representative baseline survey of female caregivers of children under five conducted in 2006 showed that just 20 percent of caregivers had administered Orasel to their child during the child’s latest diarrhea episode. Although knowledge of the role of dehydration in causing death was nearly universal, less than one-third of caregivers felt capable of preparing and administering Orasel to a child.

Based on these findings, PSI/Burundi implemented a variety of strategies to increase Orasel use, including conducting public demonstrations on how to prepare and use it, disseminating print and radio messages about the benefits of Orasel, and changing the taste from a bitter flavor to an orange flavor. In the follow-up survey in 2007, use of Orasel among all caregivers had increased to 30 percent. Among those who were highly exposed to the PSI campaign, 75 percent had treated their child with Orasel during the child’s last diarrhea episode.

Caregivers highly exposed to the campaign also showed significant increases in knowledge of signs of diarrhea, dehydration, and self-efficacy for Orasel use—from 28 percent at baseline to 88 percent at follow-up. Further, 86 percent of highly exposed caregivers reported having discussed Orasel use with others. These findings suggest that social marketing of ORS and skills-building administration of the intervention can improve ORS use among caregivers.

For more information: Population Services International (PSI). Burundi : Etude TRaC Pour Evaluer L’Utilisation de Orasel Chez Les Femmes Ayant Des Enfants Des Moins de 5 Ans. Deuxième Passage. 2008.

Contributed by PSI


Photo credit: Amy Gottlieb

Healthy competition leads to reduction in diarrhea

The World Wildlife Fund (WWF) in partnership with Johnson & Johnson began working in Cameroon to provide training and tools for residents in Lobeke National Park to construct latrines in their communities. A friendly competition between villages led to rapid construction across a region where sufficient sanitation is nearly non-existent. As a result, the Salapoumbé Private Catholic Hospital in southeastern Cameroon reported that cases of childhood diarrhea admitted to the hospital dropped significantly in the course of a few months after the latrines were introduced. Building on this success, funds were extended to the hospital to create an additional water source, thereby providing clean water to its patients, as well as general residents.

Contributed by World Wildlife Fund



Photo credit: PATH/Gareth Bentley

Mass media educates mothers

In 1977, diarrhea-related dehydration was responsible for the deaths of nearly half of the infants in Egypt. To address this, the National Control of Diarrheal Disease Project of Egypt was formed to inform mothers of small children about the appropriate treatment for diarrhea and to promote the use of locally produced oral rehydration solution (ORS) to treat dehydration. The project trained health care workers on the optimal treatment for diarrhea-related dehydration and reached mothers through television and other mass media programming, which led to almost universal awareness among Egyptian mothers and a four-fold increase in the distribution of ORS. From 1982 to 1987 diarrhea-related child deaths fell 82 percent and deaths from diarrhea among older children fell 62 percent.

Contributed by Center for Global Development

Expanding community-based water health centres throughout West Africa

In the village of Pokuase, Ghana, women and children collect dirty water from nearby lakes and streams for their families to drink. Without access to reliable sources of safe drinking water, waterborne diarrheal disease and illness is rampant.

Safe Water Network is working with WaterHealth International to demonstrate the potential of community-based Water Health Centres as a model that can be brought to scale to provide safe, reliable, and affordable drinking water to people in greatest need. With the Centres, water is sourced from streams or rivers, purified, and then provided to patrons for a user fee of approximately five cents per 20 litres.

The community response and demand around the initial Water Health Centres has exceeded forecasts, and preparations are now underway to initiate an expansion plan to build additional Water Health Centres throughout Ghana and beyond into West Africa.

Safe Water Network’s priority is to materially reduce the widespread human suffering caused by lack of access to safe drinking water, of which diarrheal disease is the most pressing concern. Understanding that there are many factors that must be addressed to achieve optimal health outcomes, Safe Water Network is testing a water dispenser program to help prevent recontamination after the water is collected from the Centres.

Additionally, Safe Water Network is sponsoring an independent health impact study by Johns Hopkins University’s Bloomberg’s School of Public Health to assess the health, behavior, and water collection and storage profiles of 600 households across six communities.

Contributed by Safe Water Network 

Kenya: Hygiene

Kenya: Integrated approach

Kenya: Nutrition

Kenya: ORS

Kenya: Water and sanitation

Community capacity building on hygiene and prevention of waterborne diseases

To realize adequate community awareness and sensitization in Kenya, the Rural Integrated Community Organization (RICO), the Ministry of Health, and specialized partners developed Information, Education and Communication (IEC) strategies. The IEC materials contained messages against negative cultural beliefs about the transmission of waterborne diseases and unhygienic practices.

The materials targeted community members and were behavior-change oriented, not just limited to awareness-raising. The residents of the Bukalama and Muyala villages learned the importance of good hygiene practices, proper latrine use, the dangers of acute diarrhea, and the importance of oral rehydration salts and how ORS can be accessed.

Contributed by RICO


Identifying gaps and providing education

In 2009, PATH launched a pilot program in Kenya’s Western Province aimed at building awareness of new diarrheal disease control interventions. Workshops with parents and providers helped PATH, health officials, and local physicians evaluate current practices and knowledge gaps. The needs identified through these workshops informed follow-up training for providers and community members on diarrheal disease control interventions.

As Elijah Mbiti from the Ministry of Public Health and Sanitation said upon closing the inaugural gathering, "The work on diarrhea does not end here. The work goes on."

On March 31, 2010, the Government of Kenya stepped out as a regional leader in the renewed fight against diarrhea—unveiling an updated national diarrheal disease control policy.  The policy, which highlights traditional and new interventions like ORS, breastfeeding, zinc, hygiene, and forthcoming interventions including rotavirus vaccines, shows Kenya’s commitment to addressing diarrheal disease through a comprehensive approach.

Contributed by PATH


Vitamin A supplementation in Kenya

Palkamau calls out to his neighbours in the Kayaba area of Nairobi, Kenya’s Mukuru slum. With a megaphone in hand, he roams through the streets and alleys. He’s lived in the area since 1978 and, in 1986, joined the Kayaba Community Health Workers project as a volunteer. He is now the project’s Chairperson.

It’s been a busy week for Palkamau and his fellow volunteers. For five days they’ve been active in their community, encouraging caregivers to bring their children to the temporary health post for the week-long campaign for measles vaccination and vitamin A supplementation campaign.

Thanks to its powerful ability to boost the immune system, vitamin A is a critical micronutrient for the survival and physical health of children exposed to disease. Supplementation in populations who are at risk of vitamin A deficiency can reduce childhood mortality by an average of 23 percent. Vitamin A can help the body fight deadly infections such as measles and has been proven to not only reduce the duration of diarrhea episodes but also to reduce diarrhea severity and complications. Vitamin A supplementation is critical if Kenya is to reach its Millennium Development Goals, including reducing child deaths.

Mercy has come to the health post with her son Stephen, who is just six months old. “I am looking for the vitamin A,” she says. Stephen is not yet old enough for the measles vaccination but will receive his first dose of vitamin A. Mercy is told that Stephen should get doses every six months until he is five to protect him from disease.

The vitamin A supplements are donated by the Micronutrient Initiative, an Ottawa-based organization supported by the Canadian International Development Agency (CIDA). The Micronutrient Initiative supplies more than 75 percent of the world’s need for vitamin A, working with governments and agencies such as UNICEF in a concerted effort to achieve universal coverage of vitamin A supplementation in children aged six to 59 months. Bottles of vitamin A supplements bearing the Canadian flag, are found in countless health posts and hospitals around the world.

Palkamau continues his efforts to get parents and children into the health post. “I know most of the people around here so I know who has brought their children to the post and who has not,” he explains. “Many of the parents here are working so we must keep at it throughout the week so their children can be protected.”  Palkamau is just one of the millions of everyday heroes around the world working to help the children in their communities survive and thrive, with a little long-distance help from Canada.

Contributed by the Micronutrient Initiative


Revitalizing ORT corners and reprioritizing diarrheal disease in Kenya

In 2009, PATH reinvigorated efforts to bring back oral rehydration therapy, or ORT, corners to defeat diarrheal disease. An ORT “corner” is a small area set aside from a crowded waiting room in a clinic or hospital, where mothers can immediately access oral rehydration solution (ORS) and clean water to begin to rehydrate children suffering from severe diarrhea. In this small room furnished simply with benches, plastic containers, spoons, and cups, mothers replenish their children’s lost fluids sip by sip; health workers educate them about hygiene and sanitation, prevention, and treatment of diarrhea at home; and they learn about proper nutrition, including zinc treatment, for infants and young children.

In the 1980s, ORT corners in health facilities were instrumental in global health efforts to reduce the number of child deaths in Kenya and other parts of Africa and Asia.  In the two decades that followed, however, international aid shifted to other threats like HIV/AIDS and malaria.  Many believed the diarrheal disease burden was under control.  Unfortunately, with this shift in focus diarrhea death rates that were on the decline began to stagnate, and diarrhea remains a leading killer of children, particularly in sub-Saharan Africa and Asia. In fact, in Africa diarrhea is the number one cause of child death.

PATH partnered with Kenya’s Ministry of Public Health and Sanitation and the Department of Child and Adolescent Health to bring the ORT corners back to health facilities and raise community awareness about diarrheal disease and simple prevention and treatment solutions.  Access to ORT corners in local clinics reduces the need to refer mothers and their children to higher level facilities that are often miles and hours away. It also prevents the senseless deaths of children who die simply because they are not able to see a doctor in time. The partners have seen a real impact in a very short amount of time.  Since the Kenya project’s inception:

- Over 44,000 mothers received information about diarrhea management from community health workers, women’s health programs, health providers, village health meetings, and ORT corners.

- 430 nurses and clinical officers, 480 community health workers, and 55 pediatricians received training in clinical management of diarrhea.

- 20,000 ORS packets and 2,500 blister packs of zinc were distributed.

- Nearly 40 ORT corners were established, with an additional 20 planned by April 1, 2011.

- The Government of Kenya launched a new diarrheal disease control policy that highlights traditional and new interventions like ORS, breastfeeding, zinc, hygiene, and forthcoming interventions including rotavirus vaccines.

Contributed by PATH


Provision of safe drinking water

After conducting a needs assessment, the Rural Integrated Community Organization (RICO) identified two villages in Kenya (Muyala and Bukalama) that were in dire need of safe drinking water. Each community selected a site for a new borehole that would provide access to clean drinking water. Communities provided resources such as bricks, sand, and labor for construction. RICO hired contractors to drill boreholes and tested water quality. Water Committees were formed and trained to maintain, repair, and clean the boreholes.

These initiatives led to a reduction of diarrheal diseases by approximately 50 percent in the two villages, leading to improved health.

Contributed by RICO


Improved health, door-to-door

Safe Water and AIDS Project (SWAP) is an NGO operating in Western Kenya with the aim to reduce diarrheal diseases and to improve general health and income of HIV support groups and other community self-help groups. SWAP visits the groups and introduces them to a variety of safe water treatment and health products.

The groups are engaged as vendors of these products and sell door to door, during home-based care and community meetings, and at community kiosks and pharmacies. SWAP offers training on safe water and business skills and links the groups to microfinance services. The field officers routinely  visited the groups to offer business counseling, restock them with new supplies, and provide microfinance services.

As of 2009, more than 700 groups are vending and 4,000 vendors registered with microfinance services, with over 2,500 loans disbursed. The growth of the project allowed SWAP to decentralize its activities and open two provincial offices and nine satellite offices throughout the districts in Western Kenya. SWAP activities have demonstrated a tremendous impact on individuals, self help groups, and the entire community:

- Reduced stigma and discrimination because HIV support group members become useful members of society.

- Improved income of group members.

- Increased access to microfinance services.

- Improved health of HIV self-help group members and their families.

- Increased access to water treatment and other health products in the communities.

- Improved health of the community at large due to affordable access to treated water. (A study is - currently in progress to measure the health impact.)

- No stigma attached to water programs, so easy access to homes and entry point for HIV programs.

Contributed by Safe Water and AIDS Project (SWAP)

Madagascar: Sanitation

Madagascar: Water

Dispelling myths saves lives of children and their families

For generations of Madagascans, the prospect of using a latrine meant confronting superstitions and changing traditions—not an easy task. When children learn from an early age that squatting over a pit can induce a miscarriage or that excrement does not belong in the same ground that holds their deceased family members, education to dispel these myths is just as important as the actual latrines themselves.

Only 7.5 percent of the rural population in Madagascar has access to adequate sanitation, according to WaterAid. But residents of Mangarivotra are trying to change attitudes toward latrines. In a village where only a few residents are literate, the message about clean sanitation through the use of latrines is communicated by a series of puppet shows.

Young puppeteers use community performances to teach children about how the latrines will keep them healthy. On a hot afternoon in Mangarivotra, a 300-strong crowd of mostly children watched a series of domestic dramas: one puppet got diarrhea from contaminated water; another was berated by his wife for defecating near the river; and a puppet couple was overjoyed by a new latrine.

Today, the latrines are so popular in some areas, security guards have begun monitoring toilet factories.

Contributed by WaterAid


Improving child survival through safe water interventions

In Madagascar, some 75 percent of the population does not have access to clean drinking water, and diarrheal diseases are one of the major causes of morbidity and mortality for children under five.

However, Madagascar has demonstrated tremendous success in reducing both under-five and infant mortality. From 1992 to 2004, there was a 50 percent decrease in the prevalence of diarrhea and a doubling of the percentage of those with diarrhea who received either oral rehydration salts (ORS) or a homemade solution. These successes can be attributed in part to highly effective public health interventions by the Government of Madagascar, donors, and nongovernmental organization partners such as Population Services International (PSI).

Since 2000, PSI/Madagascar, in collaboration with CARE and the US Centers for Disease Control and Prevention, produced, marketed, and distributed a sodium hypochlorite solution under the brand name Sûr'Eau for point-of-use treatment of drinking water. In 2005, some 700,000 bottles of Sûr'Eau were sold, enough to treat up to one billion liters of water. Funding from USAID and UNICEF has allowed national expansion of this vital program. PSI/Madagascar currently distributes a full range of high-quality maternal and child health products at affordable prices, including diarrheal disease prevention and treatment tools.

Contributed by PSI

Malawi: Policy

Malawi: Integrated approach

Malawi: Water and sanitation


Charting the course for integrated diarrhea control in Malawi

In May 2010, Malawi hosted the All-African Environmental Health Congress in Lilongwe. There, government stakeholders, academics and NGOs came together to discuss how better to control diarrheal disease, the second leading cause of child death in the country.

Diarrhea causes approximately 11 percent of deaths in children under five in Malawi. One of the poorest nations in the world, Malawi is a mostly rural, land-locked country tucked between larger neighbors Mozambique, Tanzania, and Zambia. Safe drinking water and sanitation are scarce, and much of the population has no access to health care. In addition to diarrhea, the country also struggles with better-known and better-funded diseases such as HIV/AIDS, malaria, and tuberculosis. As a consequence, more common, easily preventable, and easily treated causes of childhood morbidity and mortality can lose critical airtime and attention in the national policy debate.

A group of committed stakeholders wanted to raise the priority of diarrhea, and they decided to start at the level of policy and political will. Over the course of the year, a committed group of stakeholders from across sectors and departments engaged in a process of dialogue and policy analysis that produced a roadmap for policy change and reprioritization of diarrheal disease control in the country. Read about what the group found and their recommendations for the way forward here


Documenting uptake of safe water solutions in tandem with antenatal care

In 2007 the US Centers for Disease Control and Prevention (CDC) reported remarkable uptake of the liquid chlorine water treatment product, WaterGuard, when the product was provided and marketed by Population Services International (PSI) as part of a free hygiene kit at antenatal clinics in Malawi. At baseline, only 2% of the program participants had used WaterGuard. Nine months later, 61% of the participants were using WaterGuard and 55% reported having purchased the product. Among friends and relatives of program participants, confirmed water treatment increased from 2% at baseline to 25% at follow-up.

PATH recently supported the CDC to learn whether women from the original study were still treating their water, three years after the intervention. The CDC found that 26% of the original participants had confirmed use of WaterGuard and 54% used either WaterGuard and/or a chlorine solution distributed for free by the Ministry of Health. These encouraging results suggest that pregnant women and new mothers may be excellent targets for ongoing and future efforts to increase household water treatment behavior in developing countries.

Contributed by PATH


Clean water, better school attendance

The negative consequences of contaminated water extend far beyond health issues such as diarrheal disease. For example, in Malawi contaminated drinking water and the diarrheal disease it causes led to children missing many days of school.

The Midzemba ADP Schools Safe Water Project, a partnership between Procter and Gamble’s Children’s Safe Drinking Water Program, World Vision, and Population Services International/Malawi, worked to reduce diarrheal disease episodes and absenteeism in target area schools.

The projects implemented point-of-use water treatment in target schools using WaterGuard Wa Ufa (known as PUR in the United States). A small four-gram satchel of the powdered treatment has the capacity to clean ten liters of water by killing bacteria and viruses while removing solid materials in about 20 minutes. The partners provided the water disinfectant to participating schools, promoted complementary diarrheal disease intervention methods, including hand-washing with soap after using the restroom, and increased the number of pit latrines available to students.

The project led to a 90 percent reduction in diarrheal disease in target schools and a 57 percent reduction in school absences. Additionally, pit latrine coverage increased by 75 percent. Broader benefits were also realized in the general community. Children brought their improved hand-washing habits to their families, leading to a more than 50 percent decrease in diarrheal disease in this Malawi community.

Contributed by World Vision

Promoting WASH literacy in Nigeria

The Society for Water and Public Health Protection (SWAPHEP) organizes seminars, training workshops, campaigns, and poverty reduction activities as part of its WASH Literacy program. One of the key objectives of the program is to promote hygiene practices to reduce the incidence of diarrheal disease. The program targets women and children.

To mark the Global Handwashing Day 2009 in Nigeria, SWAPHEP organized campaigns and lectures in schools to teach that handwashing with soap and water after using the toilets, changing a baby’s diaper, and before touching food could save the lives of 3000 children daily from deaths caused by diarrheal disease. SWAPHEP partnered with the Independent Television and the Nigerian Television Authority Benin to educate the public. Visit SWAPHEP Picasa web album on to view the pictures of the event.

In addition, SWAPHEP initiated the WASH Enterprises Development training workshops in order to help people, particularly women, generate income from manufacturing soaps and other washing agents. The expected outcomes of this initiative are poverty reduction and reduction in incidence of diarrheal disease. The WASH program is not being used by SWAPHEP to advertise soaps made by wealthy multinationals. Instead, the organization will promote the soaps being manufactured by local women.

Contributed by the Society for Water and Public Health Protection

Improving water and sanitation in the aftermath of civil war

In 2006, Wherever the Need (WTN) was invited to visit a community in eastern Sierra Leone. The villagers of Gbongay, Pejeh Chiefdom, had suffered considerably both during and after the rebel war, depending on a local stream for drinking water after their hand pumps were stolen. With the funds of a generous donor, WTN supported the development of eco-sanitation units, wells, rainwater harvesting tanks, and a partial livelihood project for Pejeh Chiefdom.

Today, child mortality rates as a result of intestinal illness have considerably decreased. In addition, people are healthier and their livelihoods (beekeeping) are generating excellent income and creating secondary business. The river, previously polluted by open defecation, is cleaner; and the eco-sanitation toilets are beginning to yield their valuable fertilizer and compost, which is helping local crop growth. Above all, the people feel equal because they have discovered dignity. WTN wants to expand its work in Sierra Leone and is actively seeking partners and donors to bring a better future to the people of Pujehun Chiefdom.

Contributed by Wherever the Need

[Page] Why Defeat DD?

Each day, diarrhea kills more than 1,500 children under five. 90% of these child deaths happen in poor countries of Asia and Africa, where safe water, sanitation, and access to urgent medical care are limited.1 But this crisis can be solved: Diarrheal disease is preventable and treatable.

[Story] Success Story: Oral Rehydration Therapy (ORT) corners in Kenya

Two African children

PATH is working to reestablish oral rehydration therapy (ORT) corners in Kenya, where mothers can easily access lifesaving rehydration for sick children.

[Video] A Common Disease, A Promising Solution


No children should die of diarrhea and, with a coordinated package of proven interventions, they don't have to. Rotavirus vaccines are among the newest tools in the fight against diarrheal disease and the only way to prevent severe infection. Follow their trail as they show dramatic impact in Nicaragua and demonstrate their potential for saving young lives in Africa and Asia.

[Story] Success Story: Research to relieve burden

Dr. George Armah

Studies led by Dr. George Armah will have worldwide impact, but he looks to how they can make life better for his own community.

[Story] Success Story: New sanitation habits in Madagascar

Dispelling myths saves lives of children and their families.

For generations of Madagascans, the prospect of using a latrine meant confronting superstitions and changing traditions—not an easy task. When children learn from an early age that squatting over a pit can induce a miscarriage or that excrement does not belong in the same ground that holds their deceased family members, education to dispel these myths is just as important as the actual latrines themselves.

[Story] Success Story: Clean water, better school attendance

If you give students clean water, the entire community benefits in this Malawi community.

The negative consequences of contaminated water extend far beyond health issues such as diarrheal disease. For example, in Malawi, contaminated drinking water and the diarrheal disease it causes led to children missing many days of school.

[Story] Success Story: Songs keep kids healthy

Spreading healthy behaviors through simple songs that can be shared with families improves the health of the entire community.1

Maintaining good hygiene is a very serious issue in Tanzania, where cholera and diarrheal diseases frequently keep kids sick and away from school. However, school attendance has risen at Kisaki Primary School in Singida because the children are learning about good hygiene through song and sharing these songs with their families.

[Story] Success Story: Keeping infants healthy

Mother breastfeeding her child

Breast milk for young infants protect children from future illnesses.

In Lesotho, a common cultural practice is to wait until a newborn’s umbilical cord falls off to begin breastfeeding. When Mamorena Namane gave birth, she fed her child only water for the first seven days of his life. She noticed that her son was frequently ill and later learned that not beginning breastfeeding immediately could have put her baby at risk.

[Story] Success Story: ORS success in Burundi

Packet of oral rehydration salts (ORS)

Public demonstrations of how to administer a life-saving diarrheal disease intervention

Diarrhea is a leading cause of child death in Burundi, accounting for 18 percent of deaths among children under five. Population Services International (PSI)/Burundi has been distributing oral rehydration salts through commercial outlets in Burundi under the brand Orasel since 2004 as part of a USAID-funded project to reduce childhood morbidity and mortality.