Tuesday, December 04, 2007

Kageno Child Health Initiative: Our Vision for the Future of Child Health Care in the Kageno Communities

“Every [child] has the right to the highest attainable standard of health.”

“The right to health not only encompasses access to health care, but also the underlying determinants of health, such as safe water, adequate sanitation, a healthy environment, health-related information, and freedom from discrimination.”-UN Committee on Economic, Social and Cultural Rights, General Comment 14.

Key Objectives:
 Address all aspects of child mental and physical health and development
 Utilize local people and local resources for long-term sustainability
 Direct outside projects towards education and development, rather than short-term direct involvement in patient care
 Start with Kageno nursery school children and grow as Kageno grows to encompass older children, adults
 Initiate record-keeping system to monitor magnitude of problems, efficacy of interventions
 Provide orphans with the same access to resources as those children whose parents will ensure they have access
 Do whatever it takes


Model:
Following the Partners In Health Model of doing “whatever it takes”, this initiative will seek to address all aspects of child mental and physical health and development through a primary, secondary, and tertiary prevention approach. Primary prevention involves providing conditions which promote wellbeing and prevent disease from ever being contracted. Secondary prevention involves screening and early detection of those at risk for disease to ensure proper early intervention before the disease advances. Tertiary prevention involves detecting those with disease and ensuring they have access to adequate treatment and care. This model not only works to prevent disease, but to promote well-being, encompassing the belief that “health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right” –Declaration of Alma-Ata.

The major issues facing the well-being of children in the Suba District of Kenya are outlined below with proposed interventions following this model.

Issues:
I. Malnutrition: Adequate nutrition is essential to healthy physical and mental growth and development. In the Suba District, kwashiorkor (due to protein deficient diet) and marasmus (due to protein and calorie deficient diet) are rampant amongst children. Many children receive one or fewer meals per day, and this often consists of ugali or porridge, both of which are very low in protein and micronutrient content. Orphans are at particular risk for malnutrition, and families who take in multiple orphans have the increased stress of providing food for a large household. Without proper nutrition, these children may have stunted growth, abnormal brain development, and a weakened immune system leaving them susceptible to infection. Micronutrient deficiencies, including iron, vitamin A, and vitamin D can lead to anemia, blindness, and deficient bone development, respectively. In addition, hunger is a distraction to education in the many children struggling to pay attention to class with an empty stomach.
a. Primary Prevention:
i. Meals program: One hot meal per day is currently provided free of charge for all Kageno school children. The food is purchased locally or grown on site, and local women are employed for preparation. This meal needs to be protein and micronutrient rich, fortified with supplements if necessary. .
ii. Vitamin A administration: Children will receive vitamin A supplements with their immunization schedule as outlined by WHO guidelines.
iii. Nutrition Education: Teachers will provide parents with nutrition education on local sources of high protein foods: such as fish, beans, and lentils (which often have comparable price to ugali and porridge). Information on how to grow protein rich foods in home gardens will be provided.
b. Secondary Prevention:
i. Growth Charting: Teachers will chart the height and weight of each Kageno student 4 times a year on growth charts. They will be educated on how to identify children at risk for malnutrition.
ii. Targeted feeding program: Those children identified as at risk for malnutrition will be assessed by the Kageno nurse and will receive a home visit by the runner, who will assess the family situation. Families who meet criteria will receive food support with nutritious staples, such as beans and lentils.
iii. Orphan feeding program: Families who have taken in orphans will receive additional food support to ensure 3 nutritious meals per day to their family.
c. Tertiary Prevention:
i. Kwashiorkor/ Marasmus Treatment Plan: Those children assessed by the nurse to have a diagnosis of kwashiorkor or marasmus will be placed on specific diets to treat their malnutrition. They will receive increased calorie meals fortified with micronutrients and their progress will be followed weekly by the Kageno nurse.

II. Acute Diarrheal Disease: Diarrheal disease leading to dehydration is one of the leading causes of morbidity and mortality amongst children in the Suba district. Most children drink directly from Lake Victoria which is contaminated with human and animal waste. This leads to frequent bouts of diarrhea, as well as epidemics of diarrhea due to cholera and typhoid. Children are especially susceptible to dehydration from diarrhea, which can be easily treated through oral rehydration, or IV hydration, if severe.
a. Primary Prevention:
i. Access to Clean Drinking Water: Kageno provides clean, filtered drinking water to the local community free of charge.
ii. Access to Latrines: Kageno provides sanitary latrines to decrease the spread of fecal-oral microbes contributing to diarrhea.
iii. Health Education: Teachers will incorporate lessons on hygiene, water sanitation, and latrine use to school-age children. Teachers will also provide health education to parents on clean water, recognition of diarrhea and treatment with oral rehydration.
b. Secondary Prevention:
i. Identification of Students with Diarrhea: Teachers will be educated on recognizing signs of dehydration and symptoms of diarrhea. They will identify those students with active diarrhea for ORT, and those with dehydration will be referred to the Kageno nurse for evaluation.
ii. Oral Rehydration Therapy: Oral rehydration packets will be available at the school as well as the clinic. Children identified to be having diarrheal symptoms and/or mild dehydration will be sent home with ORT packets and instructions for use.
c. Tertiary Prevention
i. Referral for IV Hydration: Those students determined to be moderately to severely dehydrated will be transported to Mbita Health Center to receive IV fluids.
ii. Reporting of Cholera Outbreaks: During outbreaks of acute diarrhea, the nurse will be responsible for reporting the epidemic to local health officials for early intervention.

III. Parasitic Infection: Parasitic infections, such as schistosomiasis, amoebaeiasis, giardiasis, and intestinal worms, are endemic to the Lake Victoria Region. They are most commonly contracted through fecal-oral spread, through soil-foot transmission, or undercooked food. Due to the drinking of water directly from the lake, which is known to be contaminated with schistosoma, amoeba, and giardia, many children are chronically infected with these parasites. Most children walk barefoot over the beaches contaminated with human and animal waste, leading to chronic infections with soil-transmitted helminthes. These infections are a major cause of malnutrition, and can cause a variety of other health effects including bloody diarrhea, bladder cancer, and organ failure.
a. Primary Prevention:
i. De-worming and Schistosomiasis Prophylaxis: Per WHO guidelines, students will receive prophylactic albendazole and praziquantel twice per year. This will be distributed by teachers according to dosing height poles.
ii. Provision of Shoes: Each Kageno student will receive a pair of locally made akala shoes to prevent the transmission of soil transmitted helminthes.
iii. Clean Water and Latrines: As described above
iv. Health Education: Teachers will provide health education to students on hygiene, clean water, and latrines.
b. Secondary Prevention:
i. Identifying Students with Parasitic Infections: Teachers will receive education on the signs and symptoms of parasitic infections. They will refer identified students to the Kageno nurse. In addition, the growth charting will identify students with malnutrition due to parasitic infection.
c. Tertiary Prevention:
i. Anti-parasitic Treatment: The Kageno nurse will conduct stool or urine studies on those students with symptoms of parasitic infection. Anti-parasitic medication will be provided and the student will be followed until asymptomatic.

IV. Malaria: The Lake Victoria region has one of the highest incidences of malaria in the world. Mosquitoes active only during the night transmit the disease from person to person, therefore children not sleeping under nets are at high risk of contracting the disease. It is not uncommon for people in the Lake Victoria area to contract malaria more than once per month. While most adults recover after several days of fever, malaria is a leading cause of death in children. Children are susceptible to cerebral malaria, a condition that can lead to convulsions, coma, and death. In addition, malaria leads to school absence and fatigue from anemia.
a. Primary Prevention
i. Mosquito Nets: Insecticide treated mosquito nets will be distributed to each Kageno student. Instructions will be given on its use to parents.
ii. Health Education: Parents will be educated on recognizing the signs and symptoms of malaria, and to bring their children to the Kageno clinic whenever they are febrile.
b. Secondary Prevention
i. Identification of Febrile Children: Teachers will identify all febrile children and refer them to the Kageno nurse for evaluation. All students absent from school for more than one day will receive a home visit from the runner, who will ensure that children missing school for illness will receive proper treatment at an early stage.
c. Tertiary Prevention
i. Anti-malarial Treatment: The Kageno nurse will evaluate all febrile children and provide Coartem for those suspected of having malaria. The children will be examined for anemia and receive iron supplements if needed. The runner will do a home visit to ensure the child is sleeping under an insecticide treated mosquito net.
ii. Referral of Advanced Disease: Those children with symptoms of advanced malaria will receive transportation to the Mbita Health Center for IV treatment and supportive therapy.

V. HIV: The Suba District of Kenya has an HIV prevalence of over 40%, one of the highest in Kenya and all of East Africa. The migratory nature of workers in the fishing industry and the practices of jaboya, or fish-for-sex trade, contribute greatly to the spread of HIV in this area. Local cultural practices of polygamy and wife inheritance are likewise contributors. Women and children share the most difficult plight, often orphaned or widowed by HIV, with no way to financially support themselves. Prenatal care is lacking, leading to preventable transmission of HIV from mother to child. In the cases where transmission to the child has been prevented during birth, HIV is often spread perinatally through breastfeeding, due to the lack of available infant formula. Few children are ever tested for HIV and therefore most HIV positive children are undiagnosed and untreated.
a. Primary Prevention
i. Mother to Child Transmission: Kageno VCT provides HIV testing for all expectant mothers and can refer HIV positive mothers. Prevention of mother to child transmission (PMTCT) programs are conducted by IMC Suba, which provides counseling and treatment.
ii. Health Education: Teachers will provide age-appropriate HIV education to students, stressing prevention and stigma-breaking activities.
b. Secondary Prevention
i. Identification and Testing of At-Risk Children: Children with parents who have died at a young age or have disclosed their HIV positive status will be tested for HIV at the Kageno VCT, with permission from their guardians.
ii. Provision of formula to HIV positive mothers: Infant formula will be provided free of charge to all HIV positive women for the duration of infancy. Women can access this resource through the Kageno HIV support groups or VCT office.
c. Tertiary Prevention
i. HIV treatment: HIV positive children will be referred to the FACES Mbita office which provides anti-retroviral treatment and opportunistic infection treatment. Transportation will be provided by Kageno and oversight of care will be performed by the Kageno nurse.

VI. Tuberculosis: Tuberculosis is one of the most common opportunistic infections associated with HIV. It is transmitted through the coughing of respiratory droplets, and most readily spread when people are living in cramped one room living quarters, such as the majority of residences in the Suba District. Tuberculosis primarily affects the lungs and causes wasting, however it can manifest as involvement of nearly any organ system. Children, especially of TB positive parents, are very susceptible to TB. Treatment involves long-term multi-drug therapy, but is very effective at eradicating the disease and preventing transmission.
a. Primary Prevention
i. Treatment of Affected Parents: TB education will be provided to parents of Kageno students. They will be educated on signs and symptoms and informed of the treatment available through the IMC Mbita office TB program.
b. Secondary Prevention
i. Home Modification for Children of Parents with Active TB: The runner will help coordinate home modification to separate rooms in those homes of parents with active TB.
ii. Prophylactic Treatment of Children with High-Risk TB Exposure: The Kageno nurse will provide isoniazid prophylactic therapy in children with in-home exposure to someone with active TB.
iii. TB testing in High-Risk Children: Children with in-home TB exposure, or signs and symptoms of TB infection will receive transportation to Sindu for chest X-ray and AFB testing.
c. Tertiary Prevention
i. Treatment of Children with Active TB: Children with active TB will receive directly observed therapy (DOTS) through the Kageno nurse, who will receive medications from IMC Suba.

VII. Immunizable Diseases: In the Suba District, outbreaks of immunizable diseases, such as measles, are frequent. Immunizations are provided by the government, however many children on the islands of Lake Victoria are not reached by these efforts. Recordkeeping is poor, and participation is voluntary, with no effort made to track down unimmunized children.
a. Primary Prevention
i. Immunization of 100% of Children: Vaccinations provided by the government will be administered by the Kageno nurse to all Kageno students. The following vaccines will be administered: polio, measles, mumps, rubella, diphtheria, pertussis, tetatanus, BCG, HPV, hepatitis B, hepatitis C, HIB, pneumococcus, rotavirus
ii. Recordkeeping: Kageno records will be kept in addition to the government records held by families, to provide a permanent reliable source of information on Kageno student vaccinations.
b. Secondary Prevention
i. Identification of Unimmunized Children in the Community: The runner will be responsible for going door-to-door throughout the community and ensuring that 100% of the children are up to date on their immunizations. This will help to provide herd immunity to the children in the community.
c. Tertiary Prevention
i. Treatment of Immunizable Disease: Students with signs and symptoms of immunizable disease will be referred to the nurse for medication and vaccination. Appropriate isolation measures will be taken and cases will be recorded.
ii. Reporting of Local Outbreaks: The Kageno Nurse will be responsible for reporting local outbreaks of immunizable disease to local health officials to ensure early intervention.

Personnel:
 Kageno Teachers: Provide health education to students and parents. Track student growth charts, identify students at risk for malnutrition and disease, and refer these students to the Kageno nurse.
 Kageno nurse: Diagnose and treat students referred from teachers for malnutrition and disease. Monitor students referred to outside organizations for treatment. Oversee vaccination program.
 Runner: Track students missing from school. Door-to-door monitoring of immunizations. Home visits for at risk patients. Oversee home remodeling TB program. Transport children to referral centers.

Forums:  Student Health Day: deworming, schistosomiasis treatment, height and weight charting, vaccinations, distribution of nets, shoes.
 Educational Curriculum: incorporate age-appropriate health education into daily curriculum
 Parent’s Day: health education provided for parents by teachers.
 Home Visits: conducted by runner to homes of at risk students. Door to door monitoring of immunization status.
 Kageno Clinic: Kageno nurse provides individualized care of students referred
 Partner Sites: FACES (Family Aids Care and Education Services) provides anti-retroviral therapy, IMC (International Medical Corps) provides prevention of mother to child transmission program, TB DOTS program.