Address by Minister Botha on the Situation with Diarrhoea in the Province

Introduction:
The policies employed within the province from community to tertiary hospital level for the prevention and management of diarrhoea is in line with international best practice.

The city and provincial health departments have a comprehensive diarrhoea seasonal plan that is enacted before the season starts. A multi-disciplinary team involving the city and province meets to plan for each season and monitors the implementation of the agreed plan. Extensive efforts go into ensuring that the health services are ready to fast track cases and to provide the most appropriate levels and quality of healthcare. At the same time, the city environmental health officials scale up their monitoring of health hazards, namely access to safe water, sanitation and solid waste removal. This is accompanied by educational projects to contain and minimise risks of exposure and spread of diarrhoea.

Some Facts and Figures about Diarrhoea Disease:
Diarrhoea disease and its tragic consequences in young children are not unique to the Western Cape - it is the second leading cause of death in children under five years' old worldwide - second only to pneumonia - with about 1.5 million children dying each year, 80% aged less than two years.

Diarrhoea due to infection is widespread throughout developing countries.

It is a leading cause of malnutrition in children under five years' old.

What makes this all the more tragic is the fact that it is both readily preventable and treatable through simple public health measures.

Nutrition and Diarrhoea Disease in Developing Countries:
Children under three years' old experience on average three episodes of diarrhoea every year. Each episode deprives the child of the nutrition necessary for growth. As a result, diarrhoea is a major cause of malnutrition, and malnourished children are more likely to fall ill from diarrhoea. Children who are malnourished or have impaired immunity are most at risk of life-threatening diarrhoea.

The Causes of Diarrhoea Disease:
Diarrhoea is usually a symptom of an infection in the intestinal tract, either bacterial, viral or parasitic, most of which are spread by faeces-contaminated water. Water contaminated with human faeces, for example, from sewage, septic tanks and latrines, is of particular concern, but animal faeces also contain microorganisms that can cause diarrhoea. Infection is more common when there is a shortage of clean water for drinking, cooking and cleaning. Worldwide, around 1 billion people lack access to improved water and 2.5 billion have no access to basic sanitation. Over 90% of children in the Western Cape have an adequate supply of drinking water and access to adequate sanitation (SA Child Gauge, 2009/2010).

Diarrhoea disease can also spread from person to person, aggravated by poor personal hygiene. Contaminated food is another major cause of diarrhoea when it is prepared or stored in unhygienic conditions. Water can contaminate food during irrigation.

How Diarrhoea Disease Leads to Severe Illness and Sometimes Death in Young Children:
Diarrhoea disease leaves children's bodies without the water and salts that are necessary for survival. Most children who die from diarrhoea actually die from severe dehydration and fluid loss. The most severe threat posed by diarrhoea is dehydration. During a diarrhoea episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools, vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced. Death can follow severe dehydration if body fluids and electrolytes are not replenished, either through the use of oral rehydration salts (ORS) solution or through an intravenous drip.

Treatment of Diarrhoea Disease:
Diarrhoea disease is readily treatable. Key measures include the following:

1. Rehydration with quite a simple mixture of clean water, salt and sugar, which can be prepared safely at home.
2. Zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume.
3. The continuous intake of nutrient-rich foods - including breast milk - during an episode.
4. Consult a health worker if there are signs of dehydration.

Prevention of Diarrhoea Disease:
Key measures to prevent diarrhoea, focusing particularly on upstream determinants, include:

1. Access to safe drinking water.
2. Improved sanitation.
3. Exclusive breastfeeding for the first six months of life.
4. Good personal and food hygiene.
5. Health education about how infections spread.
6. Rotavirus vaccination.

What is the Situation in the Western Cape and What is Being Done about It?
It is important to realise that, while diarrhoea can kill, the majority of cases of diarrhoea disease are mild, managed at home and never come to the attention of healthcare practitioners.

In any 12-month period the province sees around 45 000 to 50 000 children aged five years or less with diarrhoea. The monthly total ranges from around 2 000 to around 7 000, and it characteristically peaks in March and is at its lowest in August - September. There has not been any noticeable drop in the absolute number of children with diarrhoea in the 24-month period reviewed here in the Western Cape.

There does seem to be a downward trend of diarrhoea cases that were dehydrated at presentation - from 20% of cases to 15%. Possible reasons for this may include improved awareness amongst the children's caregivers, such that they are being better managed at home and brought to health facilities earlier. It may also be related to the majority of these children having received the rotavirus vaccine.

Cases Admitted to Hospitals, Referred to Specialist Facilities and ICUs, and Deaths:
Between 2009 and 2012, there has been a progressive decline in admissions to hospital due to diarrhoea. The most accurate data comes from the Metro District where over 60% of children live: the reduction here is approximately 25%.

The in-hospital mortality rate for diarrhoea during the peak season has decreased from 1.2 to about 0.5 per 1 000 admissions between 2009 and 2011. The on-record number of deaths for 2010/2011 is 86 - much lower than in 2009. In 2010/2011 - 16 778 cases were treated, which is an improvement over the previous year, 17 205.

The decline in deaths is greater than the decline in admissions, suggesting that children in general are not as sick when they reach the hospitals. Part of this is due to improvements in preventing illness due to HIV, but improvements in early identification and treatment and rotavirus vaccination have also contributed to this halving of the rate.

In terms of community-based deaths, it is not possible to gather real-time data but data from the Metro District suggests a rapid decline between 2009 and 2011.

The Department's Response to Diarrhoea Disease:
The department realises that childhood and infantile diarrhoea disease is a multi-factorial problem and as such needs a multi-pronged response, which involves not only the Health Department but the Departments of Education, Social Development, Housing, Agriculture and others.

The Department of Health Focuses Its Efforts on:
Implementing and monitoring evidence-based policies for the management of diarrhoea in children - the so-called Integrated Management of Childhood Illness or IMCI policies. These algorithms, which are now taught at our medical schools, nursing schools and other training institutions, empower healthcare workers to recognise the danger signs of serious childhood illness and take appropriate action before complications set in. They standardise the treatment regimens used for diarrhoeal disease and include measures such as the use of zinc, the aim being that every child with diarrhoea has access to the best evidence-based management available. They can and should be used by all health workers, from paediatric professors to community health workers.

Promoting exclusive breastfeeding for the first six months of life: A number of major related projects have been underway for some years in the province on this score, including the Baby Friendly Hospital Initiative and the Breastfeeding Restoration Project. Linked to this is the current focus on Early Childhood Development, which includes attention given to adequate nutrition of toddlers and young children attending crèches. Also linked to this is the drive to give supplemental Vitamin A to all infants and young children in the province. Baby Friendly Hospital Initiative facilities increased from three in 2003 to 18 facilities (excluding two private facilities) in 2011/2012.

Vitamin A supplementation was introduced in 2005 as a strategy to improve immunity and growth in children aged less than five years. Improvements in the coverage for children aged less than one year have been observed. Annualised vitamin A coverage data for children aged less than one year currently reflect 80% for 2011/2012.

Working with our partners in local government to improve the relevant aspects of environmental health, specifically access to safe drinking water, better sanitation, better personal hygiene, better food hygiene, and health education for parents and other community members about what causes diarrhoea disease and how it spreads. These activities are conducted throughout the province, but are focused on diarrhoeal disease "hotspots", which are detected through monitoring of routinely reported as well as other data, at provincial, district and sub-district level. In this regard we need to commend the efforts of environmental health practitioners in many towns and cities across the province who work in difficult circumstances to help accomplish the above objectives.

Vaccination:
Two of the vaccines which are available without charge from the provincial immunisation program are able to reduce the incidence of diarrhoeal disease. These include the measles vaccine and the rotavirus vaccine. The latter vaccine was introduced in 2009 in line with national policy. It does not prevent all diarrhoea - as is evident - but has been shown both in South Africa and elsewhere in the world to reduce significantly the amount of severe diarrhoea with dehydration, of the sort which leads to admission and complications. We are of the opinion that the introduction of the rotavirus vaccine in the province is at least partly responsible for the reduction in the percentage of children with diarrhoea who are dehydrated at presentation, the reduction in the numbers of children admitted with diarrhoea and the reduction in the number of diarrhoea deaths, year on year, as shown above.

Ensuring Access:
This includes providing primary healthcare facilities within reach of every child's family, where staff is familiar with the recognition and management of diarrhoeal disease. We have expended significant energy in ensuring that all primary level facilities in the province have an oral rehydration corner where infants and young children presenting with diarrhoea can be orally rehydrated and observed until such time as they are judged well enough to go home. Ensuring access also means providing reliable transport for up-referral where necessary, and adequately staffed and equipped referral facilities where complicated cases can be managed. It means ensuring that when an outbreak occurs suitable beds are available to admit children who need it.

Challenges:
There are significant challenges in preparing for and combating periodic diarrhoea disease outbreaks, even when they are more or less predictable. One of these is the influx of families and children from outside the province, including from areas where immunisation coverage is suboptimal, and some areas where vaccines such as rotavirus vaccine are simply not available. Linked to this is the phenomenon of families moving from one area to another within the province in search of seasonal work, particularly in the rural districts of the province.

Way Forward:
The department will continue to use the Provincial Child Health Monitoring and Response Unit, under the chairpersonship of the DDG: District Health Services and Programmes, to conduct Diarrhoea Disease surveillance, enable logistic unblocking and affect a rapid response to any diarrhoea disease outbreaks which do occur. We shall continue to use the seasonal approach (child health season and diarrhoea disease season) to focus our diarrhoea disease prevention and health promotion efforts. The augmentation of district based outreach / specialist teams will further assist these efforts. Lastly, we shall continue in our efforts to increase coverage with all vaccines, but specifically rotavirus vaccine, to as high a level as possible in the province, and particularly in known diarrhoea "hotspots".

Conclusion:
The department takes as its starting point the position that all diarrhoea deaths are preventable and that every single diarrhoea death needs to be fully investigated for avoidable factors so that remedial steps may be taken where appropriate. We believe that we have all the tools at our disposal to significantly reduce the burden of diarrhoea disease that the strategy which we are employing is the right one and that with perseverance the trends we are observing will continue.