REDUCING DIARRHEA IN CHILDREN AND CONTROLLING DENGUE VECTOR AEDES

AEGYPTI IN RURAL SCHOOLS IN TWO MUNICIPALITIES IN COLOMBIA.

HEALTHY SCHOOLS: HEALTH-ABSENTEEISM

Results

Sandra Lucía Vargas, María Inés Matiz , Neal Alexander, Víctor Alberto Olano, Juan Felipe

Jaramillo, Diana Sarmiento, Audrey Lenhart, Thor Axel Stenström, Razak Seidu, Hans J.

Overgaard

Diarrhea and dengue are both highly endemic

throughout Latin America and the Caribbean.

Diarrhea is a leading cause of morbidity and

one of the 10 most important in terms of mortality in Colombia,

with an estimated prevalence of 13% in children <5 years old.

Brazil, Venezuela, México, and Colombia have the

highest number of dengue cases in the Americas.

INTRODUCTION

Source: SIVIGILA-INS

0

5

10

15

20

25

30

35

40

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

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ort

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Source: Así vamos en salud

Dengue. Colombia 1990-2010Mortality rate for diarrhea. Colombia

1990-2010

DENGUE AND DIARRHEA IN COLOMBIA

Origin of dengue cases in Colombia

ORIGINDENGUE SEVERE DENGUE

2012 2013 2012 2013

Head Municipal 80.6% 83% 74.2% 80%

Populated Center 9% 8.6% 14% 11.4%

Dispersed Rural 10.4% 8.4% 11.8% 8.6%

Fuente: Instituto Nacional de Salud. Vigilancia y Control en Salud Pública.

Informe Evento dengue . 2012 y 2013.

OBJECTIVES

Investigate whether interventionsagainst diarrhea and denguewill significantly reduce:

The incidence of diarrheal illness in school children.

The number of absence episodes and length of those

due to these illnesses.

2×2 factorial cluster randomized controlled trial

TRIAL DESIGN

Interventions

Dengue

Inte

rve

nti

on

s

Dia

rrh

ea

+ -

+DIADEN

(8 schools)

DIA

(8 schools)

-DEN

(9 schools)

CONTROL

(9 schools)

LOCATION AND RECRUITMENT OF PARTICIPANTS

Characteristic Anapoima La Mesa

Height and temperature 700msnm y 26°C 1200msnm y 22°C

Rural area population 2013 7383 (57,2%) 13559 (44,5%)

Rural unsatisfied basic needs 2005 36,4% 36,8%

FLOW CHART OF SCHOOL AND PUPIL SELECTION

Rural schools for eligibility

Control

Allocated (n= 9 schools)

Median size: 28 pupils

Average: 23 pupils

Schools lost to follow-up: 0

Children lost to follow-up: 0

No. of pupils: 473No. of schools: 8Median size: 62

Range: 80

Intervention dengue y Diarrhea (DIADEN)

Allocated (n= 8 schools)

Median size: 16 pupils

Average: 25 pupils

Schools lost to follow-up: 0

Children lost to follow-up: 1

No. of pupils: 425No. of schools: 8Median size:38

Range:123

Intervention dengue (DEN)

Allocated (n= 9 schools)

Median size: 18 pupils

Average: 19 pupils

Schools lost to follow-up: 0

Children lost to follow –up: 1

No. of pupils: 454No. of schools: 10Median size: 38,5

Range: 84

Intervention diarrhea (DIA)

Allocated (n=9 schools)

Median size: 20 pupilsAverage: 29 pupils

Schools lost to follows-up: 1

Children lost to follow-up: 0

No. of pupils: 543 No. of schools: 8Median size:45

Range:203

Allocated

Schools excluded due to size, i.e. colegios (> 100 pupils; > 5 grades)

(n= 6)

Follow-up

Enrollment

Final analysis

Randomized

(n=35)

DATA COLLECTION METHODS

Daily record of absences by

professor

The teacher establishes the reason

for absence

Weekly collection of records

Phone call to the family to establish the

reason for absence

Home visit to children who could not establish the reason for

absence

• Rates of absence attributed to each diseases were calculated at the school level, in terms of both numbers of episodes and of numbers of days.

• Rates were calculated per year based on a school year of 185 days.

• These school-level rates were the response variable for a factorial analysis of covariance described by Overgaard et al (2012).

• The explanatory variables were:

a) whether or not the school received the dengue interventions, b) whether or not the school received the diarrhea interventions,

and c) municipio, by which the randomization was stratified.

Analysis

CHARACTERISTICS OF THE STUDY POPULATION

VARIABLE ARM

DIA

n=543

DENGUE

n=454

DIADEN

n=425

CONTROL

n=473

Gender: Male

Female

52,7%

47,3%

56,8%

43,2%

55,5%

44,5%

56%

44%

Years old

Average ± SD

Mínimum

Maximum

8,2±2,2

4

16

7,9±2,2

3

15

7,9±2,1

4

14

8,1±2,3

4

15

Nutricional diagnosis 2012n= 207 n= 152 n= 172 n= 180

Chronic malnutrition 2012

(Low height for age)11,6% 10,5% 10,5% 13,3%

Nutricional diagnosis 2013n= 230 n= 196 n= 158 n= 202

chronic malnutrition 2013

(Low height for age)8,7% 10,2% 8,9% 12,4%

DEMOGRAPHIC CHARACTERISTICS AND NUTRITIONAL STATUS OF SCHOOLCHILDREN

VARIABLE ARM

DIA

n=120

DENGUE

n= 91

DIADEN

n=103

Control

n=82

Sewerage coverage 15,0% 7,7% 3,9% 7,3%

Waste collection 22,5% 17,6% 9,7% 9,8%

Aqueduct coverage 74,2% 63,7% 27,2% 73,2%

Don’t count with sanitary service 17,5% 26,4% 30,1% 17,1%

Highest education level reached by

the head of the household: primary72,5% 76,9% 77,7% 74,4%

Average habitants per home 4,7 4,1 4,7 5,1

SOCIO-ECONOMIC CHARACTERISTICS OF HOUSEHOLDS FROM SCHOOLCHILDREN

SCHOOL ABSENTEEISM

Episodes absenteeism:

Absence of the student throughout the school day or

part of this.

New episode of absence:

When there is a difference of at least three days without absences for the same reason

(illness, travel, etc.) between the last day of absence and a new one.

EPISODES ABSENTEEISM

ABSENTEEISM EPISODES

EpisodesAbsenteeism

4836 (61,6%)

Number of students

La Mesa 1108 (58,5%)

Teacher and other

2929 (60,6%)

Phone Call

1907 (39,4%)

EpisodesAbsenteeism

3014 (38,4%)

Number of students

Anapoima 787 (41,5%)

Teacher and other

1894 (62,8%)

Phone Call1120 (37,2%)

SAKE OF ABSENCE REPORTING THROUGH PHONE CALL

INFORMANT TOTAL %

Mother64,2

Father 23,1

Grandparents 8,1

Stepfather 1,8

Uncles 1,7

Othet1,0

ABSENCE FOR ANY REASON – NUMBER OF EPISODES

Absencereason

CONTROL DEN DIA DIADEN

Any reasonepisodes/year

5,2 5,5 5,0 4,4

Any reasondays/year

8,6 8,9 8,2 6,2

Any diseaseepisodes/year

1,3 1,2 1,2 1,2

Any diseasedays/year

2,6 2,2 2,1 2,1

REASON CONTROL % DEN % DIA % DIADEN % TOTAL %

Disease 24,6 21,4 24,5 28,4 24,7

Lack of incentive 13,2 13,8 10,0 8,6 11,6

Travel 12,4 14,3 13,7 11,7 13,2

Medical / dental appointment 9,7 12,5 15,2 18,1 13,7

Bad weather 8,9 8,2 8,4 6,7 7,6

Others 7,8 4,0 3,3 4,4 4,4

Family commitments 4,8 6,7 5,6 4,8 5,5

Sick mother 3,6 2,9 1,9 2,2 2,7

Had no one to send 2,9 1,2 1,2 1,5 1,7

Caring home / brothers 2,7 3,6 1,5 1,7 2,4

Uniform 2,3 1,0 1,2 1,2 1,5

No date 1,9 2,7 3,3 3,1 2,7

Calamity 1,5 0,6 1,2 1,1 1,1

Indiscipline 1,2 0,6 0,1 0,3 0,6

distance / route 1,2 1,4 2,7 1,2 1,7

family problem 1,0 2,0 1,7 2,6 1,8

Económic 0,2 0,5 0,1 0,1 0,2

REASON SCHOOL ABSENTEEISM

ABSENTEEISM DUE TO ILLNESS

CONTROL27 %

DEN21 %

DIA29 %

DIADEN23 %

0

10

20

30

40

50

60

70

80

CONTROL DEN DIA DIADEN

Pe

rce

nt

ANAPOIMA LA MESA

DISTRIBUTION OF EPISODES OF ABSENCE DUE TO ILLNESS

0,0%20,0%40,0%60,0%80,0%

Masculino Femenino

0,0%

10,0%

20,0%

30,0%

0 1 2 3 4 5

7,9±2,5 7,4±2,3 7,9±2,3 7,4±2,2

DISTRIBUTION OF EPISODES OF ABSENCE DUE TO ILLNESS

Grade school Gender

YEARS OLD

CONTROL DEN DIA DIADEN

Episode: diarrhoea-day is one where a

subject experiences three or more loose

or watery stools in 24 hours or any number

of loose or watery bloody stools.

The length of the illness episode will be defined as

the number of days between the first and last day of

absence.

New episode of absence due to diarrhea: Three

consecutive diarrhoea-free days

has been proposed as an international

standard

EPISODES OF DIARRHEA ABSENTEEISM

ABSENCE DUE TO DIARRHEA – NUMBER OF EPISODES

Rat

ed

iarr

thea

epis

od

es/y

ear

ABSENCE DUE TO DIARRHEA – NUMBER OF DAYS

Dia

rrea

day

s/ye

ar

-

0,02

0,04

0,06

0,08

0,10

0,12

0,14

CONTROL DEN DIA DIADEN

DIARRHEA 2012 DIARRHEA 2013

Rat

ed

iarr

thea

epis

od

es/y

ear

E. Coli drinking water % (n)SchoolsRange

Incidence rate/year

Ausent 55,9 (19) 0,03-0,49

Low 26,5 (9) 0,02-0,37

Medium 8,8 (3) 0,18-0,35

High 5,9 (2) 0,04-0,05

Arm Log10 E. Coli drinking water % schoolsAverage rate

diarrhea/yearC High 11,1 ,053

Ausent 44,4 ,029

Low 44,4 ,127

Total ,075

DEN High 11,1 ,041

Ausent 33,3 ,108

Low 22,2 ,223

Medium 22,2 ,184

NA 11,1 ,000

Total ,131

DIA Ausent 75,0 ,068

High 12,5 ,351

Medium 12,5 ,299

Total ,133

DIADEN Ausent 66,7 ,173

Low 25,0 ,038

Total 8 ,139

Probable dengue cases will be defined accordingto WHO criteria and surveillance protocol for dengue in Colombia. They should have consulted the health service and physician-diagnosed.

Probable dengue case no warning signs:

Febrile illness acute (<7 days) observed in two or more of the following manifestations: headache, retro-orbital pain, myalgia, arthralgia or rash.

EPISODES OF DENGUE ABSENTEEISM

ABSENCE DUE TO DENGUE – NUMBER OF EPISODES

Rat

ed

en

gue

ep

iso

des

/yea

r

ABSENCE DUE TO DENGUE – NUMBER OF DAYS

de

ngu

e d

ay/y

ear

Perc

ent

9

0,000

0,005

0,010

0,015

0,020

0,025

0,030

0,035

0,040

0,045

0,050

CONTROL DEN DIA DIADEN

DENGUE 2012 DENGUE 2013

Rat

ed

en

gue

ep

iso

des

/yea

r

40

,7

37

,0

35

,1

39

,2

10

,4

10

,8

6,9

14

,3

6,6

8,8

8,5

7,5

6,4

8,3

6,7 7,3

5,8 6

,9 7,8

6,6

6,0

3,4

5,6 5,9

5,5

7,6

6,3

5,7

CONTROL D EN D IA D IA D EN

Resfriado Fiebre Diarrea Estómago/vómito Otros Cefalea Trauma

REASONS OF ABSENCE DUE TO ILLNESS AND SYMPTOMS

• The interventions don’t have an effect on diarrhea and dengue incidence. There were no statistically significantly differences between the four study groups in terms of diarrhea and dengue incidence among the school children.

• The main reason for absenteeism was illness. The most frequent symptoms were cold, fever, diarrhea, stomach pain and vomiting.

• Absenteeism rates for diarrhea were higher in the DIADEN arm.

• There was low infestation of Aedes aegypti in rural area and also low incidence rates for dengue. Nevertheless we have to be aware of the presence of entomological risks factors that can favor the transmission of the virus.

• The benefits of a water intervention to improve the quality depend on sanitation and hygiene conditions.

CONCLUSIONS

Ministerio de la Protección Social, Universidad de Antioquia, Facultad Nacional de Salud Pública: Análisis de la situación de salud en Colombia 2002–2007. Bogotá: Tomo IV "Situación de salud de la infancia"; 2010 [http://www.minproteccionsocial.gov.co/Documentos%20y%20Publicaciones/ASISTomo%20IV–Situaci%C3%B3n%20de%20salud%20de%20la%20infancia.pdf].

Profamilia Colombia: Encuestas Nacionales de Demografia y Salud (ENDS).

Bogotá:; 2010 [http://www.profamilia.org.co/encuestas/Profamilia/Profamilia/

images/stories/PDF-capitulos/Capitulo-10.pdf].

Pan American Health Organization: Health situation and trends - summary.

Washington, DC: PAHO; 2012 [http://www.paho.org/english/dd/ais/cp_170.

htm].

REFERENCES

• Dane. Estimaciones de población 1985-2005 y proyecciones de población 2005-2020. Colombia. Disponible en: http://www.dane.gov.co/index.php/poblacion-y-demografia/proyecciones-de-poblacion

• Dane. Necesidades básicas insatisfechas NBI. Resultados Censo 2005. Colombia. http://www.dane.gov.co/index.php/estadisticas-sociales/necesidades-basicas-insatisfechas-nbi

• Baqui AH, Black RE, Yunus M, Hoque AR, Chow- dhury HR, Sack RB. Methodological issues in diar- rhoeal diseases epidemiology: definition of diar-rhoeal episodes. Int J Epidemiol1991;20:1057-63.

• World Health Organization: Dengue - Guidelines for diagnosis, treatment, prevention and control. Geneva: WHO; 2009.

• Ministerio de la Protección Social. Instituto Nacional de Salud. Protocolo de la vigilancia y control del dengue. Colombia: 2010.

REFERENCES

Sandra Lucía Vargas Cruz

vargassandra@unbosque.edu.co