Letters. Reaching Every District (RED) approach: a way to improve immunization performance

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1 Reching Every District (RED) pproch: wy to improve immuniztion performnce In their pper, Victor et l. 1 show tht child survivl interventions re inequitbly distributed within low- nd middle-income countries. Ares of gretest need were not prioritized, nd expnsion of these helth progrmmes in more difficult res hs tended to be delyed or postponed. In response, we wish to shre some results nd propose wy forwrd bsed upon experiences with immuniztion progrmmes. Immuniztion progrmmes round the world hve recognized nd strived to reduce inequity for mny yers. While Universl Child Immuniztion (UCI) of 80% coverge ws chieved in 1990, this merely emphsized the need to blnce the inequlities within nd between countries. Accordingly, severl pproches were dopted. The high risk pproch ws designed in the mid- 1990s to rech women in underserved res with tetnus toxoid immuniztion using cmpign-style pproch. 2 District level microplnning hs been the cornerstone of the polio erdiction nd mesles elimintion inititives, to mximize the delivery of vccines to ll districts, especilly underserved popultions. District-level coverge nd disese surveillnce dt re now routinely collected in most countries, with reporting of selected indictors to the globl level since In 2002, the Reching Every District (RED) pproch ws developed nd introduced by WHO, the United Ntions Children s Fund (UNICEF) nd other prtners in the GAVI Allince to improve immuniztion systems in res with low coverge. Fr from being progrmme, or seprte inititive, the pproch outlines five opertionl components tht re specificlly imed t improving coverge in every district: re-estblishment of regulr outrech services; supportive supervision: on-site trining; community links with service delivery; monitoring nd use of dt for ction; better plnning nd mngement of humn nd finncil resources. 3 The RED pproch encourges countries to use coverge dt to mke n nlysis of the distribution of unimmunized infnts, nd thereby prioritize districts with poor ccess nd utiliztion of immuniztion, while districts re encourged to mke microplns to identify locl problems nd dopt corrective solutions. Since 2003, 53 developing countries hve strted implementing RED to vrious degrees, mostly in Afric nd south nd south-est Asi. 4 All 53 countries belong to the groups of lower income nd lower-middle income countries, s per World Bnk clssifiction. In 2005, n evlution of 5 countries in Afric tht hd implemented RED found tht, in 4 of the 5 countries, immuniztion coverge hd incresed since the implementtion of RED, nd tht the proportion of districts with DTP3 (three-dose diphtheri, tetnus nd pertussis vccine) coverge bove 80% hd more thn doubled. 5 The number of unimmunized children in these 5 countries ws reduced from 3 million in 2002 to 1.9 million in Interestingly, the report notes tht outrech services, one of the five components of RED, were often used to deliver other interventions beyond immuniztion, such s Vitmin A, ntihelminthic drugs or insecticidetreted bed nets. This indictes tht implementtion of RED components my strt to hve n impct beyond immuniztion services lone. An nlysis of coverge dt supports the findings of the evlution in Afric. It shows tht in the 53 countries tht strted to implement RED between 2003 nd 2005, DTP3 coverge (s estimted by WHO nd UNICEF) incresed between 2002 nd 2005 in 34 (64%) countries, nd decresed in only 7 (13%). 6 Although these dt need to be interpreted with cution, since RED implementtion hs not been ntionwide in mny countries, they seem to indicte tht where RED is implemented, it cn help to reduce gps in immuniztion coverge. We gree with the suggestion of Victor et l. regrding the need for informtion systems nd trining. Most of the 53 countries we refer to hve functionl immuniztion informtion, logistics nd supply systems nd hve implemented district trining, often using funds from the GAVI Allince. Furthermore WHO, UNICEF nd other prtners t country nd regionl level hve been closely involved in guiding countries dopting the RED pproch to rech the unreched. We believe tht the RED pproch of district microplnning bsed upon locl dt using simple opertionl components nd supported by supply nd logistics hs the potentil for the successful delivery of other child helth interventions, especilly during outrech. Jos Vndeler, Julin Bilous b & Deo Nshimirimn c 1. Victor CG, Huicho L, Amrl JJ, Armstrong- Schellenberg J, Mnzi F, Mson E et l. Are helth interventions implemented where they re most needed? District uptke of the Integrted Mngement of Childhood Illness strtegy in Brzil, Peru nd the United Republic of Tnzni. Bull World Helth Orgn 2006;84: PMID: doi: /blt Anonymous. The high-risk pproch: the WHOrecommended strtegy to ccelerte elimintion of neontl tetnus. Wkly Epidemiol Rec 1996;71:33-9. PMID: Globl Immuniztion Vision nd Strtegy Genev: WHO nd UNICEF; Globl Polio Erdiction Inititive: 2005 nnul report. Genev: WHO, Rotry Interntionl, CDC, UNICEF; 2006 (WHO/Polio/06.02). Helth Section, Progrmme Division, UNICEF, New York, NY, United Sttes of Americ. b Deprtment of Immuniztion nd Biologicls, World Helth Orgniztion, 20 venue Appi, 1211 Genev 27, Switzerlnd. c Regionl Office for Afric (AFRO), World Helth Orgniztion, Brzzville, Republic of the Congo. Correspondence to Jos Vndeler (e-mil: vndelerj@who.int). Bulletin of the World Helth Orgniztion Mrch 2008, 86 (3) A

2 5. Report of evlution of Reching Every District pproch in five countries. Brzzville: WHO Regionl Office for Afric, 2005 [unpublished document]. 6. WHO vccine-preventble diseses: monitoring system: 2006 globl summry. Genev: WHO; 2006 (WHO/IVB/2006). Avilble from: Helth insurnce in sub- Shrn Afric: cll for subsidies De Allegri et l. 1 rightly describe low enrolment s principl problem relted to the functioning of community helth insurnce (CHI) in sub-shrn Afric. Furthermore, they identify set of importnt fctors ffecting the decision to enrol. Nonetheless, on reflection bout the evidence estblished by this pper nd relted reserch, I would like to suggest some dditionl considertions. First of ll, the described (nd not too surprising) fct tht the eductionl nd, importntly, the socioeconomic sttus of household ply predominnt roles in the decision of whether to enrol in helth insurnce is depicted by series of rticles 2 s well s severl systemtic rticle reviews. 3 Some of them re quoted by the uthors themselves. 4,5 Second, the consistency of this observtion nd the cler-cut cuse effect reltionship between socioeconomic well being nd the rediness to embrk on n expenditure (be it for helth insurnce or nything else) llow the conclusion tht welth is fundmentl predictive fctor for enrolment into helth insurnce. Third, if then poverty cn be understood s risk fctor for not embrking into helth insurnce, the discussion round n insurnce pproch for the poor should focus very much on the following three questions: Wht percentge of the popultion trgeted by the envisged or existing insurnce scheme re too poor to enrol on their own? By which kind of corrective mesures cn they be included? Wht consequences do these mesures hve for the finncil vibility of the scheme? Two recent nlyses from Ghn 6 nd Rwnd 7 suggest tht the cpcity of households to contribute finncilly is so wek tht the dul objectives of mobilizing significnt resources for helth on one side, nd of covering lrge percentge of the trgeted rurl popultion on the other, re mutully exclusive. Tht is to sy tht insurnce schemes requiring contribution of little more thn few US dollrs per yer re beyond the rech of the mjority, but they still do not llow the finncing of resonble (nd thus ttrctive) helth services! Furthermore, schemes chrging bout ten times such n mount re still ffordble by considerble minority of the popultion nd mximize resource mobiliztion in bsolute terms. This phenomenon is explined lrgely by the highly skewed distribution of welth in the settings studied (s expressed eqully by high Gini coefficient). This finding seems to be one of the min resons underlying the forementioned low enrolment rte scrutinized by De Allegri et l. In mny countries in sub-shrn Afric, helth insurnce schemes might find themselves in trgic sitution: Depending on the design, people re either unble to py for the schemes, or the schemes re unble to py for the envisged services. Therefore, it is suggested tht future reserch go beyond the identifiction of dditionl predictive fctors for helth insurnce enrolment. If helth insurnce is to cover broder popultion strt in sub-shrn Afric nd to ssure stisfctory helth services, schemes will require continuous nd long-term subsidies to bridge the gp between household cpcity to contribute finncilly nd the rel costs of helth cre. The development of pproches ddressing this dilemm should be considered s reserch priority. They might include inititives of north south risk pooling s between the Netherlnds nd Ghn. 8 This necessity is underpinned by the cpcity of helth insurnce to formlize socil protection nd to crete mrket between helth service providers nd their customers, simultneously lleviting poverty nd empowering communities. Yet, vilble evidence points out tht to ply these roles, helth insurnce needs subsidies. Andres Klk 1. De Allegri M, Kouyté B, Becher H, Gbngou A, Pokhrel S, Snon M. et l. Understnding enrolment in community helth insurnce in sub-shrn Afric: popultion-bsed csecontrol study in rurl Burkin Fso. Bull World Helth Orgn 2006;11: Musngo L, Dujrdin B, Drmix M, Criel B. Les profils des membres et non membres des mutuelles de snté u Rwnd: le cs du district snitire de Kbutre. Trop Med Int Helth 2004;9: PMID: doi: / j x 3. Preker AS, Crrin G, Dror D, Jkb M, Hsio W, Arhin-Tenkorng D. Effectiveness of community helth finncing in meeting the cost of illness. Bull World Helth Orgn 2002;80: PMID: Ekmn B. Community-bsed helth insurnce in low-income countries: systemtic review of the evidence. Helth Policy Pln 2004;19: PMID: doi: /hepol/czh Wlkens MP, Criel B. Les mutuelles de snté en Afrique sub-shrienne Ett de lieu et réflexion sur un gend de recherche. Wshington, DC: World Bnk; 2004 [Helth, Nutrition nd Popultion Discussion Pper]. 6. Arhin-Tenkorng D. Experience of community helth finncing in the Africn region. In: Helth finncing for poor people: resource mobiliztion nd risk shring. Wshington, DC: World Bnk; Schmidt JO, Myindo JK, Klk A. Thresholds for helth insurnce in Rwnd: who should py how much? Trop Med Int Helth 2006;11: PMID: doi: /j x 8. Improving socil protection for the poor: helth insurnce in Ghn The Ghn socil trust pre-pilot project. Genev: Interntionl Lbour Orgniztion; Anti-tuberculosis mediction side-effects constitute mjor fctor for poor dherence to tuberculosis tretment Two significnt issues tht require further clrifiction in Grner et l. s stimulting pper (Promoting dherence to tuberculosis tretment 1 ) re the impct of mediction side-effects on tretment dherence s well s how dherence to tuberculosis (TB) chemotherpy should be defined nd monitored. The tretment regimen recommended Helth Sector Coordintor, Germn Coopertion, GTZ, BP 59, Kigli, Rwnd. Correspondence to Andres Klk (e-mil: ndres.klk@gtz.de). B Bulletin of the World Helth Orgniztion Mrch 2008, 86 (3)

3 within the DOTS pproch is ssocited with significnt side-effects. Side-effects such s heptitis, dyspepsi, exnthem nd rthrlgi were responsible for termintion of therpy in up to 23% of ptients during the intensive phse. 2 Mediction side-effects were lso found to be significntly ssocited with defulting. 3 At Kyrgyzstn prisons, where the uthor worked s TB doctor in erly 2007, mediction side-effects were mong the most common resons for ptient non-ttendnce t DOTS clinics. The uthor observed similr non-ttendnce nd defulting trends mong community-bsed TB ptients in northern Nigeri during the 1990s. The side-effects profile of TB chemotherpy is mgnified in ptients with concurrent HIV tretment nd/ or prior history of heptitis, 4 nd those being treted with second-line drugs for multidrug-resistnt TB, during which s mny s 86% of ptents my develop mediction side-effects. 5,6 To minimize the dverse impct of mediction sideeffects in TB tretment dherence, it is importnt tht TB helth stff re dequtely trined on their recognition nd mngement. Such trining should include how to provide concise pretretment counselling to ptients on possible side-effects of tretment. 7 It is lso importnt tht medictions for mnging side-effects should be ordered concurrently with the ordering of nti-tb chemotherpy to fcilitte timely nd dequte tretment of such side-effects. The DOTS strtegy contins elements of dherence nd complince. While these terms were initilly used synonymously nd re still commonly used interchngebly in TB literture, they hve subtle but noteworthy significnt differences. The term dherence (or ptient-centred complince 8 ) refers to the extent to which ptients follow prescribed regimen. It implies more ctive nd collbortive involvement of ptients working with helth-cre providers in mnging their tretment. Adherence is currently preferred to complince in medicl literture s it portrys more respectful nd ctive role of the ptient in disese mngement. It cptures the incresing complexity of TB chemotherpy by chrcterizing ptients s independent, intelligent nd utonomous people who tke ctive nd voluntry roles in defining nd pursuing gols for their medicl tretment. The extent of tretment dherence my be fcilitted by positive or negtive ttributes relted to helth system, socil/fmily issues, personl fctors, nd drug fctors (e.g. mediction side-effects re negtive drug ttributes while fixed-dose combintion is positive drug ttribute in reltion to tretment dherence). Empowerment of people with TB, nd communities, through dvoccy, communiction nd socil mobiliztion s well s ptient nd community prticiption in TB cre re importnt in fcilitting tretment dherence using the DOTS pproch. 9 In exceptionl situtions, the DOTS pproch of fcilitting dherence might not chieve its objectives, since ptients need to mke themselves vilble for tretment nd re less likely to do so if they re imprisoned, suffer mediction side-effects or experience homelessness, drug ddiction, unemployment or lcoholism. 4,10 In Kyrgyzstn prisons, the prctice of selfdministered nti-tb tretment on weekends ws discontinued in Mrch 2007 due to repeted documented evidence tht mny ptients were trfficking their weekend TB medictions, despite concerted efforts imed t enhncing ptient empowerment nd peer support. The most cited definition of tretment complince is by Hynes the extent to which person s behviour (in terms of tking mediction following diets, or executing lifestyle chnges) coincides with medicl or helth dvice. 11 Complince my be used to describe the right of public helth uthorities to demnd dherence 1 such s by compelling ptients to tke TB chemotherpy using Public Helth Detention Orders. 12 Or it my be used s frmework to evlute dherence. For exmple, ptients who dhere to TB mediction s prescribed 95% of the time re sid to demonstrte high complince, while ptients who dhere for 40% of the time re sid to demonstrte low complince. The World Helth Orgniztion defines TB tretment defulter s ptient whose tretment ws interrupted for two consecutive months or more. It indictes closure of the current tretment, nd documents tht ptients complince hs been 0% for so long. As with HIV tretment, TB therpy requires high (> 90%) complince to fcilitte cure. Good dherence results in high complince nd bsence of tretment defult. Defult rte is crude pproch to dherence monitoring, since it does not relly revel why the ptient interrupted tretment for 2 or more consecutive months. Promptly implementing complince ssurnce mesures provide for better dherence monitoring thn defulter trcing, provided tht bseline complince level is set t which investigtion of the resons for poor dherence cn be undertken. Currently t the Kyrgyzstn prison TB project, we undertke investigtion of resons for poor dherence if ptient misses t lest two doses of nti-tb tretment in week. This ptient contct bseline period is in line with the mximum durtion of non-dherence tht will dversely impct on the efficcy of tretment. 13 Niyi Awofeso 1. Grner P, Smith H, Munro S, Volmink J. Promoting dherence to tuberculosis tretment. Bull World Helth Orgn 2007;85: PMID: doi: /blt Schberg T, Rebhm K, Lode H. Risk fctors for side-effects of isonizid, rifmpicin nd pyrzinmide in ptients hospitlized for pulmonry tuberculosis. Eur Respir J 1996;9: PMID: doi: / Tekle B, Mrim DH, Ali A. Defulting from DOTS nd its determinnts in three districts of Arsi zone in Ethiopi. Int J Tuberc Lung Dis 2002;6: PMID: Fry RS, Khoshnood K, Vdovichenko E, Grnsky J, Szhin V, Shpkovsky L, et l. Brriers to completion of tuberculosis tretment mong prisoners in St. Petersburg, Russi. Int J Tuberc Lung Dis 2005;9: PMID: Torun T, Gungor O, Ozmen I, Bolukbsi Y, Mden E, Bickci B, et l. Side effects ssocited with the tretment of multi-drug resistnt tuberculosis. Int J Tuberc Lung Dis 2005;9: PMID: School of Public Helth & Community Medicine, University of New South Wles, Sydney, NSW, Austrli. Correspondence to Niyi Awofeso (e-mil: niyi.wofeso@justicehelth.nsw.gov.u). Bulletin of the World Helth Orgniztion Mrch 2008, 86 (3) C

4 6. Leimne V, Riekstin V, Holtz TH, Zrovsk V, Skripconok L, Thorpe K, et l. Clinicl outcome of individulized tretment of multi-drug resistnt tuberculosis in Ltvi: retrospective cohort study. Lncet 2005;365: PMID: Self-study modules on tuberculosis: ptient dherence to tuberculosis tretment. Wshington, DC: Ntionl Center for HIV, STD nd TB Prevention, US Deprtment of Helth nd Humn Services; Avilble from: pdf 8. Conrd P. The mening of mediction: nother look t complince. Soc Sci Med 1985;20: PMID: doi: / (85) Building on nd enhncing DOTS to meet the TB-relted Millennium Development Gols. Genev: WHO: Avilble from: tb_2006_368.pdf 10. Khn MA, Wlley JD, Witter SN, Shh SK, Jveed S. Tuberculosis ptient dherence to direct observtion: results of socil study in Pkistn. Helth Policy Pln 2005;20: PMID: doi: /hepol/czi Hynes RB. Determinnts of complince: the disese nd the mechnics of tretment. In: Complince in Helth. Bltimore: Johns Hopkins University Press; Sennyke SN, Ferson MJ. Detention for tuberculosis: public helth nd the lw. Med J Aus. 2004;180: Frieden T. Wht is intermittent tretment nd wht is the scientific bsis for intermittency. In: Tomn s tuberculosis: cse detection, tretment nd monitoring. Genev: WHO; Response to opt-out pproch to prevent mother-to-child trnsmission of HIV I red with gret interest the pper on routine HIV testing for pregnnt women in Zimbbwe by Winfred Chndisrew et l. 1 The pper reported significnt increse in the cceptnce of PMTCT (preventing mother-tochild trnsmission) services such s HIV testing, counselling nd follow-up fter the introduction of routine HIV testing ( opt-out pproch). However, the conclusion tht the opt-out pproch for HIV testing ws opertionlly fesible nd cceptble to ll women, nd tht HIV-infected women reported reltively low levels of spousl buse nd other dverse socil consequences, seems to be overstted. Results from survey of the tested mothers indicted tht pproximtely 10% of those women who disclosed their test results still experienced negtive effects. These findings hrdly indicte low levels of spousl buse nd other dverse socil consequences in considertion of these women s personl sfety. It is necessry to evlute the optout pproch for HIV testing by compring the incidence of dverse effects with mothers who opted-in to HIV testing to conclude whether the benefit of the opt-out pproch outweighs the risk. More importntly, more ttention must be pid to the issue of domestic violence by prtners fter disclosure, since mny cses hve been reported in Africn countries. 2 4 In ddition, the uthors should show the percentge of those mothers who hd been tested nd counselled before the study period. As the mjority of mothers in the study were reportedly multipre, they might hve been tested for HIV in previous pregnncies. Mothers re-tested during the study re likely to hve experienced fewer negtive effects. Moreover, I would like to suggest tht the uthors provide more informtion on the role of the community mobiliztion ctivities conducted before the introduction of the opt-out pproch. Brriers nd predictors to HIV testing hve been investigted to improve the cceptnce of HIV testing in PMTCT services. 5,6 This reserch shows tht community ctivities ply n importnt role in clering some of the brriers to testing nd counselling services, therefore providing n entry point to prevention nd cre services including PMTCT. These ctivities, together with high-qulity counsellors, might hve contributed to incresing the cceptnce of HIV testing nd counselling nd to reducing its dverse effects. The contents of the community mobiliztion ctivities, including mle involvement, could be nlysed more nd shred with reders, so s to provide good model to commencing providerinitited HIV testing nd counselling (PITC) in other res. There hve been lot of rguments bout humn rights nd HIV testing. However, I would like to stress tht we need more good prctices with successful incresed uptke of PMTCT services nd miniml negtive impct, so s to provide prcticl ides for the dpttion of the WHO guidelines on PITC t country level. 7 The ctivities outlined in this study, especilly those conducted in the community, could help to provide such ides. Kzuhiro Kkimoto 1. Chndisrew W, Strnix-Chibnd L, Chirp E, Miller A, Simoyi M, Mhomv A, et l. Routine offer of ntentl HIV testing ( opt-out pproch) to prevent mother-to-child trnsmission of HIV in urbn Zimbbwe. Bull World Helth Orgn 2007;85: PMID: Biden F, Remes P, Biden R, Willims J, Hodgson A, Boelert M, et l. Voluntry counseling nd HIV testing for pregnnt women in the Kssen-Nnkn district of northern Ghn: is couple counseling the wy forwrd? AIDS Cre 2005;17: PMID: Medley A, Grci-Moreno C, McGill S, Mmn S. Rtes, brriers nd outcomes of HIV serosttus disclosure mong women in developing countries: implictions for prevention of motherto-child trnsmission progrm. Bull World Helth Orgn 2004;82: PMID: Mmn S, Mbwmbo JK, Hogn NM, Weiss E, Kilonzo GP, Swet MD. High rtes nd positive outcomes of HIV-serosttus disclosure to sexul prtners: resons for cutious optimism from voluntry counseling nd testing clinic in Dr es Slm, Tnzni. AIDS Behv 2003;7: PMID: doi: / B:AIBE d4 5. Bjunirwe F, Muzoor M. Brriers to the implementtion of progrms for the prevention of mother-to-child trnsmission of HIV: A crosssectionl survey in rurl nd urbn Ugnd. AIDS Res Ther 2005;2:10. doi: / Mmn S, Mbwmbo J, Hogn NM, Kilonzo GP, Swet M. Women s brriers to HIV-1 testing nd disclosure: chllenges for HIV-1 voluntry counselling nd testing. AIDS Cre 2001; 13: PMID: doi: / Guidnce on provider-initited HIV testing nd counselling in helth fcilities. Genev: WHO/ UNAIDS; Avilble from: who.int/publictions/2007/ _ eng.pdf Bureu of Interntionl Coopertion, Interntionl Medicl Center of Jpn, Toym , Shinjuku-city, Tokyo, Jpn. Correspondence to Kzuhiro Kkimoto (e-mil: k-kkimoto@it.imcj.go.jp). D Bulletin of the World Helth Orgniztion Mrch 2008, 86 (3)

5 Declines in cse mngement of dirrhoe mong children less thn five yers old In the Jnury 2007 Bulletin, Forsberg et l. present n elegnt nlysis of the trends in dirrhoe cse mngement using dt from ntionl Demogrphic nd Helth Surveys (DHS) from 1986 to They conclude tht despite globl efforts to promote pproprite dirrhoe mngement during this time, only slow progress hs been mde in the proportion of children treted with orl rehydrtion slts (ORS), recommended home fluids (RHF) or incresed fluids. The proportion of children given continued feeding during dirrhoe episodes ctully decresed. Forsberg et l. exmined trends in dirrhoe mngement over ll DHS surveys conducted from 1986 to Since the time horizon of their nlysis encompsses the lte 1980s nd erly 1990s, when ntionl nd globl Control of Dirrhoel Disese progrmmes were quite ctive, nd the period in the second hlf of the 1990s when these trnsitioned into Fig. 1. Percent chnge in use of orl rehydrtion therpy during the two most recent Demogrphic nd Helth Surveys, Mli, Colombi, Burkin Fso, Eritre, Mozmbique, Mlwi, Bngldesh, Peru, Hiti, Viet Nm, Egypt, Countries Rwnd, United Republic of Tnzni, Morocco, Nmibi, Ghn, Nepl, Nicrgu, Benin, Chd, Nigeri, Dominicn Republic, Ethiopi, Mdgscr, Zmbi, Jordn, Bolivi, Philippines, Senegl, Guine, Cmeroon, Ugnd, Indonesi, Keny, Chnge in ORT use for children < 3 yers of ge (%) Bulletin of the World Helth Orgniztion Mrch 2008, 86 (3) E

6 the Integrted Mngement of Childhood Illness progrmme, we believe tht the smll increses in ORS, RHF nd incresed fluids reported do not ccurtely represent the current trend in dirrhoe mngement. To inform future progrmmtic strtegies, we sought to determine the most recent trends in dirrhoe tretment by reviewing DHS dt on mngement of dirrhoe mong children < 3 yers old in the 34 countries tht conducted DHS survey between 2000 nd 2005 (vilble t: We clculted the bsolute difference between the percentge of children with dirrhoe who were reportedly given ORS, RHF or incresed fluids during the most recent DHS survey (2000 to 2005) nd the preceding DHS survey (1992 to 2000) nd found declines in the use of ORS, RHF or incresed fluids in 23 (68%) of 34 countries, rnging from < 1% (Rwnd) to 32% (Keny nd Nigeri) (Fig. 1). Eleven countries experienced declines greter thn 10%. Children with dirrhoe who re not given ORS, RHF or incresed fluids my be given the sme mount of fluids s when they re well, reduced mount of fluids or no fluids t ll. In surveys conducted in or fter 2000 in 43 countries, medin of 29% (rnge: 5 83%) of children ctully received reduced or no fluids during dirrhoe episode. Forsberg et l. report n nnul decrese of 0.64% for this indictor. However, of 32 countries where this indictor ws mesured during both of the most recent surveys, 27 (91%) experienced increses in the proportion of children < 3 yers old receiving reduced or no fluids during dirrhoe episodes, with increses rnging from < 1 to 64% (medin 10%). The medin nnul chnge in the proportion of children with dirrhoe receiving reduced or no fluids ws n increse of 1.4% (rnge: 2% 13%). Declines in use of rehydrtion seem to occur despite overll improvements in wreness of ORS. In the 40 countries hving DHS surveys in or fter 2000 nd in which this indictor ws mesured, medin of 89% (rnge: 46 98%) of mothers of children with dirrhoe knew bout ORS. Of 30 countries where this indictor ws mesured during both of the most recent surveys, 17 (57%) experienced increses in the proportion of mothers wre of ORS. The medin increse in the proportion of mothers wre of ORS ws 11% (rnge: < 1 33%). Our nlysis confirms Forsberg s finding of downwrd trend in the prctice of continued feeding during dirrhoe. In the 42 countries hving DHS surveys conducted in or fter 2000 nd in which this indictor ws mesured, medin of 52% (rnge: 37 67%) of children received reduced or no food during dirrhoe episode. Of 30 countries where this indictor ws mesured during both of the most recent surveys, 17 (57%) experienced increses in the proportion of children < 3 yers old receiving reduced or no food during dirrhoe episodes. The medin increse in the proportion of children with dirrhoe getting reduced or no food ws 8% (rnge: 2 31%). The decline in pproprite dirrhoe cse mngement t the household level is likely multifctoril. The well-deserved recent growth in ttention nd resources ccorded to diseses such s HIV/AIDS, tuberculosis nd mlri hs not been mtched for other leding cuses of childhood deth, including dirrhoe. 2 The shift wy from verticl, disese-specific public helth progrmmes during the pst decde towrds more integrted pproches, which hve been primrily implemented t helth fcilities nd mong helth-cre workers, my hve resulted in gps in promotion of bsic dirrhoe cse mngement t the community level. 3 As Forsberg et l. point out, incresed knowledge does not necessrily result in n improvement in prctices. Thus, efforts to increse pproprite dirrhoe mngement must concentrte on behviour chnge in the community nd household, trgeting vriety of cretkers involved in tretment decisions. To better understnd these chnges, we re undertking quntittive nd qulittive reserch to investigte the determinnts of dirrhoe tretment by cregivers nd helth-cre workers in Keny, which hs seen substntil reduction in use of rehydrtion therpy. We encourge collegues to undertke similr investigtions in other countries showing evidence of declines in pproprite dirrhoe mngement. We congrtulte Forsberg et l. for highlighting the lck of progress in dirrhoe cse mngement. Our dditionl findings underscore the disturbing fct tht dirrhoe mngement behviours re ctully worsening in some countries. These findings indicte the possibility of losing ground on orl rehydrtion therpy, one of the simplest nd most ffordble public helth innovtions of the pst century. Without swift corrective ction on multiple levels (community-bsed behviour chnge, ntionl nd globl funding nd policy), we my indeed see reversls in the drmtic decline in dirrhoe mortlity of the pst 20 yers, decline frequently ttributed to the dvent of orl rehydrtion therpy. 4 Renewed commitment to decresing the highly preventble nd tretble infnt nd child mortlity from dirrhoe, which remins t 2 million deths nnully, is long overdue. Pvni Klluri Rm, Misun Choi, b Luren S Blum, c Annh W Wme, d Eric D Mintz c & Alfred V Brtlett b 1. Forsberg BC, Petzold MG, Tomson G, Allebeck P. Dirrhoe cse mngement in low- nd middle-income countries n unfinished gend. Bull World Helth Orgn 2007;85:42-8. PMID: Rudn I, El Arifeen S, Blck RE, Cmpbell H. Childhood pneumoni nd dirrhoe: setting our priorities right. Lncet Infect Dis 2007;7: PMID: doi: /s (06) Bryce J, Victor CG, Hbicht JP, Blck RE, Scherpbier RW. Progrmmtic pthwys to child survivl: results of multi-country evlution of Integrted Mngement of Childhood Illness. Helth Policy Pln 2005;20:i5-17. PMID: doi: /hepol/czi Victor CG, Bryce J, Fontine O, Monsch R. Reducing deths from dirrhoe through orl rehydrtion therpy. Bull World Helth Orgn 2000;78: PMID: University t Bufflo, Bufflo, NY, United Sttes of Americ. b US Agency for Interntionl Development, Wshington, DC, USA. c Centers for Disese Control nd Prevention, Atlnt, GA, USA, nd Nirobi, Keny. d Ministry of Helth, Nirobi, Keny. Correspondence to Pvni Klluri Rm (e-mil: pkrm@bufflo.edu). F Bulletin of the World Helth Orgniztion Mrch 2008, 86 (3)