Community-Based Management of Pneumonia in Nepal

Background and Epidemiological Context

Evolution of the Program

1. ARI Program (1987) - Facility-Based Origin

2. Pilot Study in Jumla and Four Districts (Mid-1990s)

3. CB-IMCI Rollout (1997-2009)

4. CB-IMNCI (2014 onwards)

The FCHV Cadre

• Selection: Local women chosen by their communities
• Motivation: Non-financial - increased social status and community recognition. Many had personally lost children to pneumonia, making them highly motivated.
• Compensation: Standard government allowance only for training and review meetings; no regular salary
• Scale: Over 26,000 FCHVs and VHW/MCHWs were trained in CB-IMCI
• Literacy challenge: A large proportion of FCHVs were illiterate when the program began. Pictorial tools (color-coded respiratory rate timers, flip charts) were developed to overcome this.
• Trust: The established, accepted nature of FCHVs in communities was a critical success factor - communities already recognized and trusted them.

Clinical Classification of Pneumonia (CB-IMCI / CB-IMNCI)

• 2-12 months: ≥50 breaths per minute
• 1-5 years: ≥40 breaths per minute

Treatment Protocol

Original CB-IMCI (before 2014 WHO revision)

• Non-severe pneumonia (fast breathing): Cotrimoxazole-Pediatric (Cotrim-P) tablets, oral, 5-day course
• FCHVs provided this antibiotic at community level
• Severe pneumonia: Refer urgently; pre-referral benzylpenicillin at sub-health post

Revised Protocol (2014 WHO guideline, adapted in Nepal)

• Fast breathing pneumonia AND chest-indrawing pneumonia (without danger signs) are now both classified as "pneumonia" and treated with oral amoxicillin dispersible tablets (DT), 5 days
• Amoxicillin dosing by age/weight:
  • 2-12 months (4-<10 kg): 250 mg twice daily
  • 12 months - 3 years (10-<14 kg): 500 mg twice daily
  • 3-5 years (14-19 kg): 500 mg twice daily (or 1000 mg once daily)
• Severe pneumonia (any general danger sign, oxygen saturation <90%): Referral + injectable ampicillin/gentamicin or benzylpenicillin at hospital

Key Program Components

1. Training: Short intensive training (5-day Phase 1 + 2-day Phase 2) covering ARI/pneumonia assessment, diarrhea management, nutrition, and immunization
2. Respiratory rate counting: Using a 1-minute timer; automated devices trialed for accuracy (PMID: 31762072)
3. Drug supply: Cotrim-P (previously) and amoxicillin DT maintained at community level
4. Follow-up: Cases reassessed on day 3 - deterioration or non-improvement triggers referral
5. Referral system: Severe and very severe cases referred urgently; health facilities are the backstop
6. Mothers' groups: Community orientation through mothers' group meetings
7. Support and supervision: Periodic reviews, cold chain maintenance, resupply of drugs

Program Achievements

• Community-based management doubled pneumonia case detection and treatment compared to facility-only districts
• 69% of Nepal's under-five population had access to pneumonia treatment through community workers at program peak
• Case fatality rate for acute diarrhoea and proportion of severe pneumonia decreased significantly at national level
• Nepal achieved MDG 4 (50% reduction in under-5 mortality since 1990) - one of only five countries to do so
• Over 26,099 community health workers trained; 4,406 health workers trained
• Community members, traditional healers (6,308), and mothers' group members (352,628) oriented to support CB-IMCI

Challenges and Limitations

• Literacy: Many FCHVs were illiterate; required pictorial/color-coded job aids
• Geographic barriers: Severe weather and terrain still complicate referral and drug resupply
• Referral compliance: High non-compliance with referral advice remains a problem in LMICs generally
• Quality concerns: Assessment of CB-NCP in 2012 revealed quality of care issues with FCHWs/MCHWs for neonatal care, influencing the 2014 policy decision to limit FCHV curative roles
• Neonatal mortality: Progress in child mortality has been stronger than neonatal mortality; the SDG NMR target (<12/1000 live births) remains challenging
• Antibiotic stewardship: Transition from cotrimoxazole to amoxicillin needed re-training; monitoring antibiotic overuse remains ongoing

Nepal's Significance as a Global Model

Prevention and Control of Diarrheal Disease in Nepal

Epidemiological Context

• Viral: Rotavirus (leading cause of severe diarrhea in children), norovirus, adenovirus
• Bacterial: E. coli, Shigella spp., Salmonella spp., Campylobacter spp.
• Parasitic: Giardia, Cryptosporidium, Entamoeba spp.

I. Water, Sanitation and Hygiene (WASH) Measures

A. Safe Drinking Water

• Expansion of piped water supply to rural communities, especially hill and mountain districts where water-borne disease burden is highest
• Protection of traditional water sources (spouts, springs, wells) from fecal contamination
• Household water treatment and safe storage (HWTS): point-of-use chlorination, ceramic filters, solar disinfection (SODIS), and boiling promotion
• Nepal's WASH Sector Development Plan (2016-2030) targets universal access to safely managed water services
• Currently, 68-84% of water sources in Nepal are contaminated - treating water at source and at household level is essential
• Since 1990, access to improved water has risen from 73% to 93%, but quality gaps persist

B. Sanitation Improvement

• Open Defecation Free (ODF) declaration: Nepal declared itself ODF on 30 September 2019 - a landmark public health milestone. Open defecation fell from 65% to very low levels, driven by the Community Led Total Sanitation (CLTS) approach
• School-Led Total Sanitation (SLTS): A participatory, community-centered program first piloted in Nepal in 2006. It creates local ownership and sustained demand - recommended by research as the most feasible model for Nepal (Khanal et al., KUMJ 2013 [PMID: 24442178])
• Latrine construction and use in all households, schools, health facilities, and public spaces
• Sustaining ODF status: The Government of Nepal's Total Sanitation Campaign focuses on maintaining gains, safely managed sanitation (beyond just having a latrine), and targeting districts still lagging
• Fecal sludge management in peri-urban and urban areas to prevent sewage contamination of water bodies

C. Hand Hygiene

• Hand washing with soap at critical times: before eating, after defecation, before food preparation, and before and after handling infants
• Global Public-Private Partnership for Handwashing (PPPHW) model, based on behavior change marketing, has been shown effective; a combination of SLTS + PPPHW is considered the optimal strategy for Nepal
• School-based handwashing programs: Teachers trained as agents of change; children as messengers to households
• Free soap supply programs have shown effectiveness but limited sustainability - behavioral demand-creation approaches are more durable

II. Community Case Management of Diarrhea

A. ORS (Oral Rehydration Solution)

• The National Control of Diarrheal Diseases (CDD) Program began in 1982, making ORS promotion the primary intervention for reducing diarrhea mortality
• ORS was initially promoted through health facilities; FCHVs were later trained in home management of diarrhea
• Low-osmolarity ORS (WHO 2004 formulation: 75 mmol/L sodium, 75 mmol/L glucose, 245 mOsm/L) replaced the original high-osmolarity ORS and is associated with fewer unscheduled intravenous fluid requirements and fewer adverse outcomes
• ORS is estimated to reduce diarrhea mortality by approximately 70-93% in community settings
• FCHVs carry ORS packets and demonstrate preparation to mothers during home visits and mothers' group meetings

B. Zinc Supplementation

• WHO/UNICEF recommend zinc (20 mg/day for children >6 months; 10 mg/day for infants) for 10-14 days alongside ORS for all acute diarrheal episodes
• Zinc reduces the duration of diarrhea by ~25%, reduces severity, and provides a protective effect against recurrence for 2-3 months
• Nepal introduced zinc for diarrhea management through CB-IMCI, with FCHVs distributing zinc tablets alongside ORS
• The POUZN (Point of Use Water Disinfection and Zinc Treatment) project (USAID-funded) supported zinc scale-up in Nepal through both public health channels and social marketing
• Zinc/ORS co-packaging with the message "the most effective diarrhea treatment for children under 5" was promoted through radio, TV, and posters

C. Classification and Referral (CB-IMNCI)

• Persistent diarrhea (≥14 days) and dysentery (blood in stool) are referred to health facilities regardless of dehydration status

III. Vaccination

Rotavirus Vaccine

• Rotavirus is the leading cause of severe diarrheal disease in children under 5 in Nepal
• Nepal introduced the rotavirus vaccine (Rotarix or RotaTeq) into its National Immunization Program (EPI) with Gavi support - a major step in diarrhea prevention
• The vaccine is given orally at 6 weeks and 10 weeks alongside other routine vaccines
• Introduction is projected to significantly reduce rotavirus-related hospitalizations and deaths in children under 5

Other Vaccines

• Typhoid vaccine: Important in Nepal where enteric fever is endemic; conjugate typhoid vaccine now included in immunization
• Cholera vaccine: Oral cholera vaccine (OCV) campaigns conducted in outbreak-prone areas (particularly after floods and in endemic Terai districts)
• Hepatitis A vaccine: Recommended for travelers and at-risk populations

IV. Nutritional Measures

• Exclusive breastfeeding for the first 6 months: Breast milk provides passive immunity (secretory IgA) against enteric pathogens; reduces diarrhea risk by 50% or more. FCHVs promote breastfeeding through mothers' group counseling.
• Continued breastfeeding during diarrheal episodes (do not stop feeds)
• Complementary feeding: Timely introduction (from 6 months), nutritious and hygienic preparation of weaning foods
• Vitamin A supplementation: Biannual high-dose Vitamin A campaigns (6-59 months) through FCHVs reduce all-cause child mortality and severity of diarrheal episodes
• Growth monitoring: Use of growth charts to identify and address undernutrition early
• Supplementary feeding programs for severely malnourished children in high-prevalence districts

V. Health Education and Behavior Change Communication (BCC)

• Community-level BCC through FCHVs, mothers' groups, community health workers, and traditional healers (6,300+ traditional healers were oriented through CB-IMCI)
• School-based health education: Diarrhea transmission, handwashing, safe water storage taught in curriculum (classes 8-10)
• Mass media campaigns: Radio and TV spots on ORS preparation, zinc use, handwashing, safe water
• Social marketing: Zinc and ORS distributed through pharmacies and social marketing organizations (e.g., PSI Nepal in Kathmandu Valley)
• Interpersonal communication: FCHVs conduct household visits and mothers' group meetings to reinforce key messages

VI. Health System Strengthening

• Training of health workers: Upgraded skills in case management of diarrhea, rehydration therapy, and referral decision-making at all levels (sub-health posts, health posts, primary hospitals)
• Drug and ORS supply chain: Maintaining adequate stocks of ORS, zinc, and antibiotics (cotrimoxazole, azithromycin for cholera/shigellosis) at peripheral facilities and with FCHVs
• Surveillance and early warning: Strengthening disease surveillance through the Epidemiology and Disease Control Division (EDCD) for early detection of outbreaks (cholera, dysentery); rapid response teams deployed
• Cholera outbreak response: Rapid deployment of OCV in outbreak settings; emergency WASH interventions post-floods (a recurring problem in the Terai plains)
• Integration with CB-IMNCI: Diarrhea management integrated into the national CB-IMNCI framework so it is addressed alongside pneumonia, malnutrition, and newborn illness at the community level

VII. Environmental and Policy Measures

• Nepal's National Health Policy 2019 and the WASH Sector Development Plan (2016-2030) mandate universal safely managed WASH services
• Climate Change Health Adaptation Strategy (2023-2030): Addresses climate-sensitive diarrheal disease risk from floods and drought affecting water safety
• Food safety regulations: Nepal Food Safety and Quality Authority (DFTQC) regulates food hygiene at food processing, street food, and restaurant level
• Surveillance of water quality: Regular testing of public water sources, especially in urban areas and schools
• Disaster preparedness: Pre-positioned ORS and oral cholera vaccine stocks for flood and earthquake emergency response (critical in Nepal's high-disaster-risk context)

Summary of Key Priorities for Nepal