How Zinc helps in Diarrhea

Zinc: An Introduction

Zinc is a micronutrient incorporated in integrated management of neonatal and childhood illness program of Nepal for management of diarrheal diseases. Micronutrients are those substances which are required in small amount for proper growth, development and functioning of our body. Zinc supports normal growth and development during pregnancy, childhood and adolescence. It helps in keeping up metabolism, cellular growth and immune function.

Reasons of Zinc Deficiency

1. Inadequate Dietary Intake
   
   When we don’t include diverse types of food in appropriate amount in our daily meal, there is high possibility of micronutrient deficiency including zinc.

2. Increased faecal loss of zinc due to repeated gastrointestinal infections
   
   Children in developing regions suffer from diarrheal diseases or gastrointestinal infections frequently causing loss of vital elements required to our body.

WHO recommendation

WHO have recommended zinc tablet to decrease the severity of diarrheal episode. Children above the age of two months are prescribed following doses of zinc when suffered with diarrhea.

- 20 mg zinc tablet per day for 10-14 days for children with acute diarrhea and

- 10 mg per day for infants under six months’ old

How does zinc help in diarrheal episode?

Although basic mechanism by which zinc helps curtailing the severity of diseases is still under investigation, yet it has proven to inhibit toxin-induced cholera, and decrease the severity and frequency of diarrhea by

- improving absorption of water and electrolytes

- improving regeneration of the intestinal epithelium

- increasing the levels of brush border enzymes

- boosting the immune response

By Pramila Rai

Vaccines Types and Storage

Type of vaccines

Currently available vaccines protect us from diseases caused by selective pathogens: bacteria and virus. Vaccines are usually categorized based on the constituents of the vaccines.

1. Inactivated/ killed vaccine: Those vaccines containing killed pathogens or particles are killed/Inactivated vaccines. Even though they are killed, they can trigger immune reactions, hence protects from the targeted diseases in the future. e.g. IPV

2. Live Vaccines: Vaccines consisting of live strain of pathogens are live vaccines, however, they are attenuated or weakened to reduce their virulence or infectivity. They are not capable enough to cause disease but triggers immune response for future protection.

3. Toxoid vaccines: Some of the disease conditions are caused by toxins produced by the microorganisms rather than pathogens themselves. Eg. The symptoms of tetanus is caused by the toxins such as tetanspasmin, produced by the clostridium tetani. Those toxoid vaccines contain the treated toxins of the disease causing pathogens which trigger the immune system to produce antitoxins.

4. Subunit and Conjugate vaccines: Subunit and Conjugate vaccines contain only the certain components of the pathogens, for example vaccine against Hepatitis B virus contains antigens (protein structure) of the hepatitis b virus that incite the immune reactions against Hepatitis B virus. Some Subunit vaccines are produced with genetic engineering. Conjugate vaccines are unique and effectively powerful as the part of the pathogens are combined with carrier protein making them more effective.

Vaccine Types and Storage

Vaccine	Targeted disease	Form	Type	Storage
Bacillus Calmatte Guerin (BCG)	Tuberculosis	Lyophilized powder , multi dose vial, requires reconstitution with diluent	Live attenuated ( They are live but weakened to reduce their infectivity or virulence)	2 to 8 °C (As this is freeze-dried, hence recommended to store at -20C but no longer recommended)
DPT-HB-HIB	Diphtheria, Pertussis,Tetanus, Haemophilus influenza, Hepatitis B	Liquid, multi-dose vial	Combination of diphtheria toxoid, inactivated pertussis, tetanus toxoid, Antigen (HBsAg)	2 to 8 °C (Don’t freeze)
OPV	Polio	Liquid, multi-dose vial	Live attenuated vaccine	Should be frozen at -14 °C in primary vaccine center but could be stored at 2 to 8 °C
IPV	Polio	Liquid, single dose vial/ multi-dose vial	Inactivated vaccine	store at 2 to 8 °C, don't freeze
Pneumococcal conjugate vaccine (PCV)	Diseases caused by Streptococcus Pneumoniae	Clear Liquid Suspension	Conjugate vaccine	store at 2 to 8 °C
MR (Measles-Rubella)	Measles and Rubella	Lyophilized powder, Requires reconstitution	Live attenuated	store at 2 to 8 °C
JE (Japanese Encephalitis)Vaccine	Japanese Encephalitis	Lyophilized powder, requires reconstitution, single-dose vial/ multi-dose vial	Live attenuated (Chengdu SA-14-14-2 strain)	store at 2 to 8 °C, should be used within 30 minutes of reconstitution
Td (Tetanus, diphtheria) Vaccine	Tetanus and Diphtheria	Liquid suspension	Toxoid Vaccine	store at 2 to 8 °C

BCG

BCG is the abbreviated form of Bacillus Calmette Guerin. This vaccine is given for developing immunity against tuberculosis. In this vaccine, the strain of tuberculosis bacteria is live and attenuated, hence they are harmless and doesn’t cause disease but are active enough to induce immune reactions. This produces necessary antibodies and memory cells to protect against future potential tuberculosis infection.

DPT-HB-Hib

DPT stands for diphtheria, pertussis, tetanus. Previously, DPT vaccine contained only the antigens for DPT that protects against diseases, diphtheria (known as “Bhyagute rog” in Nepali), pertussis (known as “Lahare khoki” in Nepali), tetanus (known as “Dhanustankar” in Nepali). However, the vaccine is now pentavalent and protects the five diseases including Haemophilus influenza type b and Hepatitis B. Haemophilus influenzae is one of the common causes of the pneumonia in children in Nepal. It can also cause ear infections, meningitis.

Polio vaccines

There are two types of polio vaccines: Oral polio vaccine (OPV) and Inactivated polio vaccine (IPV). Inactivated (Killed) polio vaccine (IPV), containing killed pathogens, is developed by Dr. Jonas Salk. Albert Sabin is the developer of non-killed i.e. live oral polio vaccine which contains strains of weakened live polio viruses. When I had confusion regarding name of developers of live and killed vaccines, I used to remember by the work ‘k’ in Salk so he is the developer of killed polio vaccine and IPV is given by intramuscular route whereas live vaccine is administered by oral route.

MR vaccine

MR stands for measles and rubella. Previously, only measles vaccine was given to the Nepalese children. Later, Rubella has also been added to the EPI schedule of Nepal and MR vaccine is given subcutaneously at the age of nine months. MR vaccines protects children from diseases Measles and Rubella.

Pneumococcal vaccine

Pneumococcal vaccine is given to develop immunity against infection of streptococcus Pneumoniae.

Td Vaccine

Recently, Td Vaccine is prescribed to prenatal mother in Nepal. Td stands for Tetanus and the diphtheria. This vaccine contains chemically treated toxoids of tetanus and diphtheria that triggers the immune system to prepare for future potential toxin exposure.

JE vaccine

JE vaccine is given against the Japanese encephalitis. Japanese encephalitis is a mosquito borne (spread by mosquito bite) viral disease caused by infection of JE virus. Live JE vaccine is given in Nepal at the age of 12 months

It is always essential to check the manufacturer’s guide about storage and transport. Even though all the vaccines provide some level of protection against specific diseases, they are not free of adverse reactions so, it’s very important to inform vaccine recipients of all the anticipated adverse reactions. Here in my experience in USA, when I had to take the vaccines for compliance of vaccination as recommended by the university, I was given pamphlets related to vaccines and its adverse reactions and consented for the vaccinations and their unwanted reactions (a part of defensive medicine.).
See the immunization schedule of Nepal

By Pramila Rai

Nutritional status of children and Anthropometric measurement!!

Background

Nutrition is key to life. “In fact people are pack of nutrients and they need all the nutrition since the formation of embryo to become a mature human. They need nutrition to keep on restoring depleted nutrition throughout the life.” This makes maternal, childhood, adult nutrition equally important throughout the life course of human.

How does Nutrition affect the Health?

If you don’t get adequate and essential nutrients, physical and mental growth will be delayed through various mechanisms, causes many diseases and even leads to death. The foremost mechanism is direct nutritional deficiency diseases such as deficiency of Vitamin A causes night blindness; imbalance of protein and carbohydrate results in PEM malnutrition, obesity; Iodine deficiency causes mental retardation, goiter. There are number of disease conditions that are directly related to the nutrition deficiencies. Such diseases are also responsible for other chronic disease such as cardiovascular diseases, diabetes.

Figure: Factors affecting Nutrition and its impact on health

Lack of nutrition also reduces immunity thereby making our body susceptible to many opportunistic infectious microorganisms. As for example, in a healthy people, tuberculosis could be in dormant phase but once the immunity or defense system of our body is disturbed, TB pathogen can become active and manifest TB disease. Viral infections are especially immunity relative and immunocompromised people suffer bouts of seasonal influenza or diarrheal diseases compared to people with strong immunity.

Anthropometric measures to measure the nutritional status of children

Anthropometry is the study of measurement of body parts. Nutritional status can be measured by various indicators such as mid arm circumference, BMI, height for age, weight for height, weight for age etc. However, the last three aforementioned indicators are used frequently.
Height for age: children should have comparable height for their age just like other children in their age group. If their height is below two standard deviations of that age group, then it is considered less height for age showing inadequate nutritional status. Having short gesture for age is also known as stunting. stunting is usually taken as sign of long term, chronic nutritional deprivation
Weight for height : Having short gesture or height for weight is also known as wasting. wasted children have short gesture for weight.If their weight for height is below two standard deviations of that age group, then it is considered less weight for height showing inadequate nutritional status. Low weight for height is an indicator of acute undernutrition
Weight for age : Similarly, this is one of the commonest and easiest way to measure the nutritional status of the children. children should have comparable weight for their age just like other children in their age group. If their weight is below two standard deviations of that age group, then it is considered low weight for age showing inadequate nutritional status. This combines information about linear growth retardation and weight for height

Indicators in NDHS Nepal Demographic and Health Survey 2016

According to NDHS 2016, 36 % of the children are stunted or have short gesture for that age group, 10% of the children are wasted or have lower weight for height and 27% under five children are underweight or have weight low for their age. These show Progress from the early years.

What are the reasons of Nutritional deficiency in Nepal?

I would like to describe the causes of nutritional deficiencies based on socio-ecological model.

• Policy: Certainly, Nepal is a developing country and significant fraction of people live under the poverty and very far from the light of development and education. The policy helps to shape the investment in different section of the programmes and population.
  
• Society, organization and culture: The culture, tradition and some taboos prevalent in the society, and organization equally affects the nutritional level of the population. Certain tradition like early weaning of female child, taboos prohibiting some foods during pregnancies, gender discrepancy in nutrition etc affect the nutrition of the children.
  
• Family level factors: socioeconomic status of the family, trade off of investment in other things vs nutrition also affects the family's importance in nutrition. This also depends upon the over all understanding of importance of nutrition.
  
• Individual level factors: Education of parents, other family members, occupation, knowledge about the nutrients, balanced diet and preparation, handling of the foods also affect the nutrition of the children
  
• International support: International support has tremendous influence over the policy and programmes and current programs like SUAAHARA project is funded by USAID. Many UNITED NATIONS organization have focussed in improving child nutrition in Nepal and all over the world affected by malnutrition.

By Pramila Rai

Birth Preparedness and Complication readiness

Case Scenario

“In a rural area of Nepal, a woman is due to childbirth and she lives almost 5-6 hours far from the health care center. She belongs to low middle income socio-economic class. she is not aware of danger signs of pregnancy. Her family members think that childbirth is simply a natural process of giving birth and there is no necessity of special precaution because they gave birth to their children at home without anyone’s attendance from generation to generation. They know there is ambulance service but they don’t know the contact details of the ambulance service. The woman, her husband and other family members are not aware of any danger signs of childbirth. She starts getting contraction and pain but her mother in law is very sure that she delivers baby without any events. Her labor progresses, but instead of head, the cord prolapses. The outcome is yet unknown”

In above scenario, what are the conditions that can lead to adverse events of maternal and child morbidities, deaths?

1.  She is not institutionalized for the childbirth.
2.  They don’t have enough money saved for childbirth
3. They don’t have vehicle even if they want to take her to health care center in case of   emergency. She might reach the health center after golden hours.
4. They even don’t know when should they be contacting health care workers
5. They haven’t identified the people, who can donate blood if needed
6. They will take very long time to identify the complications, arrange money, vehicles and to decide which health center, they will be going.

What could have done to make sure healthy childbirth?

1. Birth Preparedness and complication readiness!!: definitely an answer among many others.

What is Birth Preparedness and complication readiness?

Whenever we study measures that effectively helped to reduce maternal mortalities and neonatal mortalities, we encounter the phrase ‘birth preparedness and complication readiness’. Birth preparedness package is simply a set of planning strategies that better assist the process of giving birth to a child to make child bearing process safe, appropriate, affordable, and accessible. Though birth preparedness is equally important to everyone, this concept is much more relevant and emergent for the developing world, where the childbirth is taken for granted and maternal death and newborn death during the child bearing process are high. It is proactive step to preclude maternal and newborn complications and mortalities. This strategy includes preparation of family, who are expecting child with counseling for preparing anticipated funds for delivery of baby, vehicles for transportation, probable hospital and health care providers, warm clothes for both baby and mother, blood donors in case of need, educational materials regarding danger signs of pregnancy, childbirth and postpartum period. In a birth preparedness package, counselling and educational materials are provided to the couple and family informing all the preparation.

How it impacts?

It helps in tackling three delays, identified to be main causes of maternal and newborn deaths. Birth preparedness obviates delay in seeking, delay in reaching and delay in receiving the care at the time of birth. For example, in the aforementioned case scenario, there is a high possibility that the family members would take a longer time to identify that the prolapse of cord is a danger sign of the childbirth that may cost child’s life and even if they identify the danger signs, they will take longer time to arrange money, vehicle or if they don’t have any transportation facilities, it will take even days to reach health care facility and health care providers. These delays may cause mother’s morbid conditions, death, and fetal death.

A woman or a family is considered to be prepared for birth and tackling tentative complications if they arrange estimated money, identify blood donors, transportation mechanism, know danger signs of pregnancy, childbirth and postpartum, identify health care providers and health care center.

Promoting Birth Preparedness and complication readiness is one of the three major strategies of safe motherhood and newborn health program of Nepal, others being Aama Surakshya Program and expansion of 24-hour emergency obstetric care services at public health facilities. These strategies have been successful in decreasing the maternal mortality rate of Nepal.

Child Health in Nepal

The burden of child mortality is still high in Nepal. After all even only one death is 100 percent death for a family. After much prioritization and investment in child health programmes such as nutrition, immunization, management of child hood illnesses, and maternal and newborn survival programs, still the progress we made is far from expectation. Biannual distributions of Vitamin A and Albendazole, Iodine fortification of salt, Iron fortification in the wheat flour, Routine immunization, mop up and supplementary immunization activities and many other activities have helped in achieving improved child health in Nepal.

“Children sometimes used to vomit intestinal worms in the past but due to pills of medicines, children at our home are not suffering with intestinal worms” iterated a female community health volunteer of Prastoki of Duhabi municipality. so, We can make the guess of child health status even with such statement.

We can glance into the Child mortality rate of Nepal to understand status of child health in Nepal. Nevertheless, the program achievements are equally important to understand progress in child health status. Even though we have achieved tremendous progress in decreasing child mortality. Now, large proportion of babies dies before completing their first month of their life as we can see the number of neonatal death remaining stagnant and poses challenge to the current health system.

 Trend of Child mortality Rates in Nepal

Mortality Rates	1990 MDG Baseline		1996 NFHS	2001 NDHS	2006 NDHS	2011 NDHS	2015 MDG target
Under 5 mortality rate		162	118	91	61	54	54
Infant mortality rate		108	78	64	48	46	34
Neonatal mortality rate		46	50	43	33	33	16

Some terminologies:

Neonatal mortality: the probability of dying within first month of life.

Post-neonatal mortality: the probability of dying after first month of life up to one year of age. Infant mortality minus neonatal mortality gives post-neonatal mortality.

[Infant mortality – neonatal mortality = post-neonatal mortality]

Infant mortality: the probability of dying within first year after birth.

Child mortality: the probability of dying between exact ages one and five years.

Under-five mortality: the probability of dying up to the age of five from the day of birth

Some of the development in Child health policies, plans and programmes

Time Frame	Activities
1959	Establishment of shree panch Indra Rajya Laxmi Devi prasuti Griha (Maternity Hospital) Family planning services by Family planning association of Nepal
1965	Family planning policy FP/MCH project First MCH clinic was established in 1965 under Bir Hospital Premises.
1968	Family planning and MCH project had 4 regional offices
1970	Kanti Hospital as children hospital
1977/78	Inception of EPI
1978	PHC Alma Ata
1990	Ratified the convention on the rights of the child
1995	National Council for children
1998	Safe motherhood program IMCI (Integrated management of childhood illnesses) National Plan of Action on Nutrition
2004	National Nutrition policy and strategy, 2004 National neonatal health strategy 2004
2005	Infant and Young Child Feeding strategy
2006	National safe motherhood and newborn health long term plan (2006-2017)
2012	Multi-sector Nutrition Plan 2013-2017
2012	National Plan of Action for Children, Nepal 2004/05-2014/15

To understand child health status, it is equally crucial to evaluate the children, who are survived. Their survival should be accompanied by healthy childhood and better future. Thus the aim of child health programme should not be limited to decreasing deaths but the well being of the children and better opportunity in a safe, secure world.

Targets and indicators directly related to Child health in Sustainable development goals:

Targets and Indicators	2017	2020	2022	2025	2030
Goal 2: Target 2.2 By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and addressing the nutritional needs of adolescent girls, pregnant and lactating women and older persons
2.2a Prevalence of underweight children <5 years	24.64	19.19	15.55	10.09	1
2.2b Prevalence of stunted children <5yrs	30.58	23.75	19.20	12.38	1
2.2c Prevalence of wasted children <5 yrs	9.37	7.44	6.15	4.22	1
2.2d Proportion of population below minimum level of dietary energy consumption	18.71	14.63	11.90	7.81	1
2.2e prevalence of anaemia among women of reproductive age	31.47	24.44	19.75	12.72	1
2.2f prevalence of anaemia among children <5years of age (%)	37.56	29.13	23.50	15.06	1
Goal 3: Target 3.2 By 2030, end preventable deaths of newborns and children under 5 years of age
3.2a Neonatal mortality rate (per 1000 LB)	17	14	11.3	8.5	1
3.2bUnder-five mortality rate (per 1000 LB)	28	23	18.4	13.8	1

*sources: National Planning Commission, Government of Nepal. Sustainable Development Goals 2016-2030. National (Preliminary) Report. 2015