An Evaluation of Diarrheal Diseases and Acute Respiratory Infections Control Programmes in a Delhi Slum

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1 49 Original Article An Evaluation of Diarrheal Diseases and Acute Respiratory Infections Control Programmes in a Delhi Slum Neeru Gupta 1, S.K. Jain, Ratnesh, Uma Chawla, Shah Hossain and S. Venkatesh National Institute of Communicable Diseases and 1 Division of Reproductive Health & Nutrition, Indian Council of Medical Research, New Delhi, India. [Received February 20, 2006; Accepted February 21, 2007] ABSTRACT Objective. Effective early management at home level and health seeking behavior in case of appearance of danger signs are key strategies in Acute respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) where majority of episodes are selflimiting and viral in origin. Integrated Management of Childhood illnesses (IMNCI) also envisages that family and community health practices especially health care seeking behaviors are to be improved to reduce childhood morbidity, mortality and cost of admissions to hospitals. Thus, a study was undertaken at an urban slum area Gokul Puri in Delhi, among under-5 children with the aim to assess the magnitudes of ARI and ADD. Methods. A Cross-sectional survey was conducted in this urban slum of Trans-Yamuna, covering 1307 under-5 children for five days starting from 9 th of August, Survey team consisted of 14 FETP Participants (WHO Fellows) from India, Nepal, Myanmar, Bhutan and Sri Lanka. A pre-tested, house-hold tally marking form was used to interview the caretakers/mothers. History of episodes of ARI and/or ADD in the last two weeks was asked. Health care practices including use of ORS & home available fluids in diarrhea, continued feeding during diarrhea, awareness of danger signs of ARI & ADD and medical advice sought were asked of those mothers whose children had such an episode. Results. 191 (14.6 %) of 1307 children surveyed, had an attack of ARI in the preceding two wk. The common symptoms of ARI cases were mild running nose (78%), cough (76.4%) and/or fever (45.5%). Only 8 (4%) had fast breathing. One or more danger signs were known to 80% (152/191) of mothers and an equal number (80%) of mothers had sought treatment. ARIs are mostly mild or self limiting but only 16% of caretakers perceived so and doctors also prescribed medicines. The attack rate of Acute Diarrheal Diseases was 7.73% in the study and ADD s annual adjusted morbidity rate was 1.69 episodes per child per year. Though nearly three-fourth of mothers (71.3%) had reported to be seeking medical advice (which is not needed in mild episodes of diarrhea) the ORS use was 38.6%, use of Home available fluids (HAF) was 42% and continued feeding was 50% during the ADD episode and awareness of at least two danger signs was present in 34%. Conclusion. Though aware of danger signs of ARI, care takers were still seeking medical advice for mild cases of ARI and doctors were prescribing drugs. Correct home based management e.g. use of ORS, continued feeding etc. was deficient in the community. Knowledge of danger symptoms was low and medical advice was being sought and drugs were being prescribed for ADD, too. [Indian J Pediatr 2007; 74 (5) : ] guptan@icmr.org.in Key words : Evaluation; ARI; ADD; Health seeking behavior; Morbidity rate; Incidence Every year some 12 million children in developing countries die before they reach their fifth birthday, many during the first year of life. Seven in ten of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhea, measles, malaria or malnutrition Correspondence and Reprint requests : Dr. Neeru Gupta, F-8/17, Krishna Nagar, Delhi or a combination of these conditions. 1 Infectious diseases like Acute Respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) continue to be major scourges in childhood. Globally, Acute respiratory infections (ARI) and Acute Diarrheal Diseases (ADD) constitute 19% and 17% of mortality respectively in this age-group. 2 Therefore, United Nations millennium development goals (MDGs) is committed to the two-third reduction of childhood mortality by 2015 from 1990 levels. The Child Mortality is declining steadily over the past few decades 471

2 50 Neeru Gupta et al in India, South east Asian Region as well as globally. 3,4 The Diarrheal Diseases Control Program (DDC) in India was launched in 1978 which was joined by National Oral Rehydration Therapy (ORT) Program in , wherein focus shifted to strengthening case management of diarrhea for children under age of five yr. Subsequently, these and ARI control programme (initiated in ) became part of Child Survival and Safe Motherhood Programme in 1992 and Reproductive and Child Health (RCH) Programme in 1997 and WHO proposed Integrated Management of Neonatal and Childhood illnesses (IMNCI) in 2005 in RCH -2. Through these programmes child mortality (as per Sample Registration System, Registrar General of India) has declined from 57.3 in 1972 to 20 in Though mortality has declined still the morbidity is very high. National Family Health survey (NFHS) -2 found that 19 percent of children under age three in India suffered from ARI (cough accompanied by short rapid breathing) at some time during the two-wk prior to the survey. Same number (19%) of children also suffered from episode of diarrhea in that recall period. 5 Consequently, the IMNCI component of RCH-2 is addressing these two illnesses in a major way. IMNCI is concentrating on health care practices of community and skills of health care workers as their prime strategies. Slums are vulnerable sections of the population, hence they assume importance in recognition of the principle of equitable distribution of health. Thus, a study was undertaken at an urban slum, namely, Gokul Puri in Delhi, among under-5 children. This study aimed to assess the extent of ARI and ADD in this age group by obtaining two week incidence rates and to study the treatment seeking behaviors of the caretakers for these two illnesses. These will identify the gaps in awareness and practices in the community and hence evaluate the bottlenecks and reasons for impediments in the fight against the two diseases particularly in this slum community. MATERIALS AND METHODS A Cross-sectional Descriptive Study was conducted at Gokulpuri, an urban slum of Trans-Yamuna area, Delhi expecting to cover a sample size of about 1400 under 5 children (sample size calculations are given below) in Gokulpuri. Study was carried out from 9 to 13 August Survey team consisted of 14 FETP Participants (WHO Fellows) from India, Nepal, Myanmar, Bhutan and Sri Lanka. Survey was conducted by means of a house-hold tally marking form, which was adapted from Evaluate service Coverage module (Child Survival and Safe Motherhood Programme, Ministry of health and Family Welfare, Government of India, 1992). The form was translated and pre-tested by role-play method. 472 Calculation of sample size Sample size calculations were based on incidence of diarrrrhea/ari episodes in two weeks in 100 children, sample size was calculated. Assuming 3 episodes of diarrhea or ARI/child/yr making it 300 episodes/100 children/year and a recall period of two wk (i.e. 26 times of 2-wk/yr), the incidence or attack rate of diarrhea/ari calculated was 11.53%. Thus assuming an incidence of 11.53% and 15% as permissible relative error the sample size calculated for 95% confidence limits was 1408 or 1400 (approx). Considering 12 % of the population comprised of under-5 children the survey population was calculated as 1400/12 x 100 = 11,666 = 12,000 (approx). Sampling was done by means of purposive Quota sampling (a rapid survey method). The population of Gokulpuri is approximately 19,000. The locality was divided in five sectors and one team comprising of twothree members each, went to cover around one-fifth of sample each, i.e children in each sector. Interviews of the caretakers of the under-five children were performed. Age of child in months and sex were recorded. Histories of ARI and/or ADD (definitions given below) in the last two wk were taken (according to NFHS 5, two-week recall period is thought to be most suitable for ensuring that there will be an adequate number of cases to analyze and that recall errors will not be too serious). Questions on awareness and health care practices were also asked of the mothers/caretakers whose children were suffering from respective illnesses in the two weeks preceding the survey. These included use of ORS, use of home available fluids in diarrhea, continued feeding during diarrhea, awareness of danger signs of ARI & ADD and medical advice sought by mothers. Deaths due to ARI or ADD or any other cause in the preceding one year in the community were also noted down. Inclusion criteria All children who have not completed 5 yr (upto 4 yr and 364 days) of age on the date of study were included in the study. Exclusion criteria Children whose families had not been residing in the community for the past 3 mth and children of families who were visiting their relatives were excluded from the study. Definitions followed were Acute respiratory infections: ARI included both upper and lower respiratory tract infections and were taken as any acute episode of running nose (cold), cough, ear discharge, hoarseness of voice, breathing difficulty or fast breathing with/without fever or chest indrawing.

3 51 An Evaluation of Diarrheal Diseases and Acute Respiratory Infections Control Programmes in a Delhi Diarrhea: Acute diarrheal diseases included passage of 3 or more loose watery motions or a single large watery motion in a day with/without bloody stools, vomiting or dehydration. In infants the mothers judgment that the child was passing more frequent liquid stool was taken as correct. Statistical analysis was done manually since the forms were household tally-marking forms. The calculations were done by means of number and percentages. Statistical test for difference in proportions (Chi-square) was applied wherever required. Attack rates (two weekly incidences) and number of episodes per child per year were also determined for two diseases in the community. RESULTS Gokulpuri is an urban slum located across the Yamuna river in the North East of the National Capital Region of Delhi covering an area of approximately 1 square km and is subdivided into four blocks and a Jhuggi Jhopdi colony. The population of Gokulpuri is approximately Its residents comprised of persons who are daily wage earners or pursuing small time businesses. Most of the houses have a water tap supplying municipal water to be used for domestic purposes other than drinking. Water for drinking is being collected either from a central cemented water tank located in the block, where water is being supplied by Municipal Corporation Department or from a tube well situated in the locality. There are common public toilets for defecation. Open drains were also present to drain waste water. The survey was conducted during monsoon period when it was raining off and on. A total of 1307 children of age below five yr were surveyed. 191 (14.6 %) of these children had an attack of ARI in the two weeks preceding the survey. ARI morbidity rate per child (annual rate) in this survey was found to be episodes per child per yr. The rate was TABLE 1. Age Wise Distribution of ARI and ADD Cases (n=1307) significantly higher in infants. ARI was found to be significantly associated with the age of the children (Table 1). Gender differences were too small to be statistically significant. The common symptoms of ARI cases recorded were running nose (149/191,78%) followed by cough (146/191, 76.4%) and fever (87/191, 45.5%). Only 8 (4%) had fast breathing. One or more danger signs viz. high grade fever, rapid breathing, difficult breathing, chest indrawing, child looking sick, refusal to feeds were known to 80% (152/191) of mothers of these children. Equal number (80%) of mothers had sought treatment for ARI. Half of mothers (49%) took the child to private doctors for treatment for ARI, while only one-third (31%) consulted a Government doctor, and one-fifth (20%) did not consult any doctor at all. Most of those caretakers who did not consult any medical personnel (31/191, 16%), thought the ARI episode was mild or self limiting. Three mothers (1.5%) used home remedy and 2 mothers (1.0%) could not afford treatment monetarily. Doctors prescribed syrups to 91.4% (139/152) of children and/or tablets to 32.2% (49/152) children while 18 (11.8%) children were given injections. The attack rate of Acute Diarrheal Diseases was found to be 7.73% in the study (Table 1). In Gokulpuri survey, the younger children had significantly higher incidence e.g. infants had significantly higher attack rate at 12.2 % due to ADD as compared to children 1 to 5 years age who had attack rate of 6.7 %. ADD was significantly associated with the age of children (Table 1). No significant gender differences were observed. The caretakers of those under-fives who reported diarrhea two weeks preceding the survey, were enquired about how they would recognise the danger symptoms of diarrhoea. More than half (55%) considered passing of many stools to be a danger symptom, and the other responses received were fever, bloody stools, persistent vomiting or when the child refuses to eat or drink. 17% caretakers could not identify any such symptom. Nearly half (47.5%) of mothers of these children went to Age groups (yrs) Total children surveyed Number of children afflicted by Attack Rate (in %)* Annual Adjusted episodes/ ARI ADD ARI ADD Child/year** ARI*** ADD 0 - < < < *Two weekly incidence per 100 children. **Two weekly incidence per child/ seasonal correction factor, where seasonal correction factor is Average No. of afflicted cases reporting to dispensary in two weeks in that season (half of monthly reporting) / Average Total No. of cases reporting to the dispensary in the past years. *** Since the cases reporting to dispensary (n) in month of August are only 2 and the proportion p of dispensary cases out of total afflicted cases in the population is only ~0.003 (~2/700, with an attack rate of 14.6 per 100 under-five children in a population of approx underfives), the inferences may be statistically invalid because for proportion, n is considered to the large if np 8 and n(1-p)

4 52 Neeru Gupta et al TABLE 2. Estimation of Month-wise ARI and ADD Morbidity Rates (two Weekly Incidences per 100 Children in Gokulpuri*). Months ADD Cases Seasonal Calculated/ ARI Cases Seas. Calculated or in last 3 years correction estimated two in dispensary Corr. estimated ARI (X) coming to factor weekly incidence factor two weekly Gokulpuri (X/2 Y) of ADD per 100 incidence** Dispensary children January February March April May June July August (actual also (actual also 7.7 per 14.6per children) children) September October November December Total (Y) *Estimated Two weekly incidence for the month (per 100 children) =Annual (adjusted) no. of episodes per child per year X seasonal correction factor X 100 ** The inferences may be invalid for ARI, as stated in Table 1 and is limitation of the study. government doctors and one third (30.7%) sought treatment from private practitioners and around a quarter (27.7%) did not seek any medical advice. Nearly, three-fourth of mothers (71.3%) sought medical advice. Less than two-fifth (38.6%) used ORS, 42% used of Home available fluids (HAF) and continued feeding rate was 50% during the ADD episode and awareness of at least two danger signs was present in only one third (34%). It was also recorded that less than one-third (29%) of caretakers were unaware of ORS or its usefulness in diarrhea while 16% caretakers still gave Sugar Salt Solution to their children during diarrhoea episodes contrary to expectations. DISCUSSION National Family Health Survey-2 ( ) was one major survey that had evaluated the impact and effectiveness of these two programmes and bottlenecks in their effective implementation. Attack rate of ARI among under-5 in the Gokulpuri slum was found to be 14.6%. NFHS-2 gave an attack rate of 16.9% in Delhi in children below three yr of age 5. Our case definition differed from NFHS, which had made a mandatory inclusion of fast breathing in the case definition (in other words, their definition of ARI was WHO criteria of pneumonia rather than all ARIs). The morbidity in terms of episodes per yr in Gokulpuri was episodes per child per yr. This morbidity rate has to be interpreted with caution (Table 1 and 2). Various other Indian studies have measured the morbidity in terms of episodes and revealed that ARIs primarily affect under five children, who may suffer 2 6 episodes per child per yr. 6,7&8 Though most of the mild ARIs i.e. running nose and cough are viral in origin and are self-limiting but only 16% perceived it as mild and self-limiting and only 1.5% mothers tried home remedies. In the present survey majority of mothers (80%) sought treatment. In NFHS -2 Survey also, 64.0% suffering from ARI sought medical treatment 5. The ADD morbidity rate in the under five children was episodes per child per year (Table 1). Other Indian household surveys which reported diarrhoea episodes in 6-47 mth to be per child per year and under three yr as The higher incidence in these studies may be because of younger ages of study groups and the fact that settings were rural. Another study in urban area of Kolkata had shown lower average episode rates of 1.4 and 1.6 in under-fives residing in multi-storeyed buildings and slum area respectively. 11 The average episode rate of ADD for infants was higher than the rate among children 1 5 yr (episodes per child per yr). (Table 1). S. Lal in his longitudinal study also found that number of episodes of diarrhea reduced as the children grew up. 10 The attack rate of Acute Diarrheal Diseases was 7.73% in the study which was much less compared to other studies and was also less than National Family Health Survey 2 carried out in India, which reported prevalence of ADD in under three children to be 19% within a recall period of 2 weeks. 5,10,12 The difference in the prevalence may be also due to the fact that we took all under-fives whereas other surveys were conducted in younger age groups. In this survey too infants had significantly higher attack rate of 12.2 % due to ADD as compared to children 1 to 5 yr age who had attack rate of 6.7%. Moreover, NFHS-2 gives only attack rates without specifing the 474

5 53 An Evaluation of Diarrheal Diseases and Acute Respiratory Infections Control Programmes in a Delhi month of survey and the seasonal variations may be implicated in the differences observed. Though nearly three-fourth of mothers (71.3%) reported to have sought medical advice the ORS use was 38.6%, use of Home available fluids (HAF) was 42% and continued feeding was 50% during the ADD episode and awareness of at least two danger signs was 34%. The aim of ORT is to replace fluid and necessary electrolytes in the body and save the child from dehydration but 71% of those mothers who were not administering ORS, were aware of ORS but still did not use. In the same manner, NFHS -2 also reports that 62% of mothers with births preceding three yr of the survey knew about ORS packets but much less number (only 27%) of the children who suffered from diarrhea two weeks preceding the survey, in this age group, were treated with a solution made from ORS packets. 5 Oral rehydration therapy (ORS+HAF) was being given by 80% of mother during diarrheal episodes but Cold drinks (given by 16% of mothers) are so sugary and have such a high osmolality that it will cause osmotic diarrhea and such high osmolality solution should not be used during diarrhea. One-fifth (20%) of children were not given any fluid to drink in our study whereas in NFHS-2, more than half (52%) of the children did not receive any of the various types of oral rehydration therapy when sick with diarrhea. 5 Thirty four percent of these caretakers were aware of two or more danger symptoms which is similar to NFHS figures that reported 37% for India and 33% for Delhi. 5 Not only ORS use was low but at the same time, around two-fifths (38%) of those who consulted doctors were also advised to take some medicines. None of these children who were advised medicines had bloody stools. Generally, use of antibiotics and other antidiarrheal drugs is not recommended for treatment of chilhood diarrhea. 5 In NFHS also, 68% of diarrhea children were treated with either syrup, pill or injections suggesting poor knowledge of proper treatment of diarrhea not only among mothers but also among health care providers. 5 According to a cross-sectional study among the private practitioners in Chennai that analysed 403 prescriptions by 40 physicians 79.9% of children with common illnesses of ARI and ADD were prescribed antibiotics. 13 During past one year 9 deaths took place giving a Child mortality rate of 6.9 per thousand children. In the past one yr two-third (6/9, 66.7%) of deaths in the community were either associated with ADD (4/9, 44.5%) or ARI (2/9, 22.2%) and cause was not known in rest of the one-third deaths. Since the sample size was too small to calculate the disease-specific mortality rates of ARI and ADD, therefore, these mortality rates are not interpreted. Not only there is significant morbidity and mortality the cost incurred due to admissions to health care services is considerable. In India 30-35% of pediatric hospital admissions are for acute respiratory infections (ARI). 14 Diarrheal diseases cause a heavy economic burden on health services as well, because one third of total pediatric admissions are due to diarrheal diseases and 17% of all deaths in indoor pediatric patients are diarrhea related. 15 CONCLUSION Mothers were seeking medical advice for all types of ARI despite their awareness of danger signs. Most of mothers were seeking medical advice for ADD too, but ORS use (despite their awareness for ORS) and continued feeding practices were deficient. Awareness of two danger signs in diarrhea was present in only one-third of caretakers. There were lacunae in the knowledge of home based management for these illnesses among the caretakers. More medical advice was sought which might have been unnecessary. RECOMMENDATIONS Prevention of Diarrheal diseases and ARI goes in nutrition, sanitation, housing, hygiene etc. but since these are socio-economic development goals and may be long term, the immediate step is effective early management at home level and health seeking behavior in case of appearance of danger signs. Integrated Management of Childhood illnesses also envisages that family and community health practices especially Health care seeking behaviors are to be improved to reduce childhood morbidity, mortality and cost of admissions to hospitals. Early use of ORS and home available fluids will decrease the need for intravenous therapy and hence unnecessary load on health care services and would diminish the cost of treatment. Recognition of danger signs would also lead to seeking timely medical advice and reduce mortality too. Present survey indicated that there is a need to make efforts to impart knowledge on home based management of mild cases of ARI and ADD and to educate them on recognition of danger signs and when to seek health advice. This may be done through intensive and sustained Information, Education and Communication activities. Now, New ORS is becoming available that has lower sodium content (75mosml/l) and total osmolality (245mosml/l) compared to previous ORS and is safer to use during diarrheal episodes in children. Unnecessary medicines prescribed by doctors during ARI and ADD creates a need to do a detailed study into their attitudes and prescription patterns and reorient the doctors in the rational drug use and standard case management during these common illnesses as suggested in Integrated Skill Training for IMNCI. 475

6 54 Neeru Gupta et al Acknowledgements This study was funded by World Health Organization and was a part of training of WHO Fellowship called Field Epidemiology Training Programme. This course is being conducted by NICD. Survey Team: DSL Karma, Nepal; Narain Thapa, Nepal; Tarun Paudel, Nepal; Kunal Chatterjee, Armed Forces, India; Somenath Karmakar, India; Neeru Gupta, India; Sona Pradhan, Bhutan; Subhasis Debbarma, Tripura; Kamal Riyang, Tripura; K.P.Debnath, Tripura; KT Lepcha, Sikkim; Maya Sarkar, West Bengal; Tun min, Myanmar; HGS Navratne, Srilanka. REFERENCES 1. Management of childhood illness in developing countries: Rationale for an integrated strategy. IMCI Information. WHO, & UNICEF. WHO/CHS/CAH/98.1A: Rev.1; 1999:1. 2. Major causes of death among children under 5 uears of age and neonates in the world, (Available from: health/integr.htm). 3. Claeson M, Eduard R. Bos, Mawji T, Pathmanathan I. Reducing child mortality in India in the new millennium. Bull World Health Organ 2000; 78(10) : Health situation in South-East Asia Region. (Available from: 5. National Family Health Survey ( ). International Institute of Population Sciences. Oct, 2000:216, 218, Chhabra P, Garg S, Mittal SK, Chhabra SK. Risk factors for acute respiratory infection in underfives in a rural community. Indian J Matern and Child Health 1997; 8 (1) : Acharya D, Prasanna KS, Nair S, Rao RS. Acute respiratory infection in children: a community based longitudinal study in south India. Indian J Public Health 2003; 47 (1) : Sharma AK, Reddy DC, Dwivedi RR. Descriptive epidemiology of acute respiratory infections among under five children in an urban slum area. Indian J Public Health 1999; 43 (4) : Anand K, Sundaram KR, Lobo J, Kapoor SK. Are diarheal incidence and malnutrition related in under five children? A longitudinal study in an area of poor sanitary conditions. Indian Pediatr 1994; 31(8) : Lal S. Surveillance of acute diarrhoeal diseases at village level for effective home management of diarrhoea. Indian J Public Health 1994; 38(2) : Chakraborty AK, Das JC. Comparative study of incidence of diarrhea among children in two different environmental situations in Calcutta. Indian Pediatr 1983; 20(12) : Bhatia V, Swami HM, Bhatia M, Bhatia SP. Attitude and practices regarding diarrhoea in rural community in Chandigarh. Indian J Pediatr 1999; 66(4) : Bharathiraja R, Sridharan S, Chelliah LR, Suresh S, Senguttuvan M. Factors affecting antibiotic prescribing pattern in pediatric practice. Indian J Pediatr 2005; 72(10) : Sethi GR. Environment and acute respiratory infections. ICCW News Bull 1992; 40(3-4) : Park K. Acute diarrhoeal diseases. In Park s Textbook of Preventive and Social Medicine. Fifteenth Edition. M/S Banarsi Das Bhanot Publishers, Jabalpur (India); 1997: Abhaya Indrayan Sanjeev B. Sarmukaddam. Gausian Conditions. In Marcel Dekker, ed. Medical Statistics. Inc. Publishers. New York (U.S.A.); 2001: