Diarrheal Disease Control Program Research Articles

The cholera endemic in the Democratique republic of Congo: The last decades

Background: Between 2010 and 2017, the DRC reported 25% of all cholera cases in Africa. Despite the multisectoral plan for cholera implemented since 2008, the country faced a major epidemic in 2017, being the second most extended one after the Goma-epidemic following Rwandan genocide. This study aim describe spatio-temporally the epidemics from the last 20 years and redefine the National Program for Cholera Elimination and Prevention of other Diarrheal Diseases. Methods and materials: This is a descriptive study of cholera epidemics in the DRC from week 1, 2000 to week 41, 2019 based on cholera surveillance databases of the Ministry of Health coordinating data from the different cholera treatment facilities. Using time-series and mapping the spatio-temporal dynamics of the epidemics were studied. Various strategies, their limits and implementations, put in place by the Ministry of Health, were comparatively analyzed while social-community interactions were promoted Results: From week 1, 2000 to week 41, 2019 a total of 481012 cases and 11897 deaths were reported (Case fatality rate 2.5%). The 2017epidemy recorded, 54779 cases and 1157 deaths (case fatality rate 2%). In 2017, only 772 stool samples were taken of which 19% returned positive for Vibrio cholerae O1 Ogawa. During this epidemic 24 of the 26 provinces of the DRC were affected by cholera. Given the impactful situation in 2017, it was decided to bring the Diarrheal Diseases Control Program under the National Program for the Elimination of Cholera and the Control of Other Diarrheal Diseases (PNECHOL- MD), for a better coordination of activities. The emergency Water-Sanitation-Hygiene (WASH)-strategy developed by the PNECHOL-MD included massive community involvement combined with good case management in the treatment centers which with immunization helped to control this epidemic. The laboratory and microbiology aspects however should be improved. Conclusion: Specifically the extended-2017 outbreak showed the necessity of integrating the different analytical levels and actors in order to effectively master the epidemiology and infectiology. The input of social and human behavioural aspects seems essential while new and/or emerging microbiological approaches like phages- and vaccine- research are warranted especially in the light of increasing antibiotic resistances

The Knowledge and Attitude About Diarrhea of Mothers of Students Attending an Elementary School in a Suburban Area in Istanbul

Objective: Diarrhea is one of the main cause of morbidity and mortality among children age under 5 years in Turkey though diarrheal disease control program has been performing and death ratio due to diarrheal disease under 5 years has been decreasing year by year in Turkey. This study is undertaken to evaluate knowledge, attitude and practice of mothers about childhood diarrheal diseases in a suburban area.Methods: This descriptive study was carried out in a primary school in a suburban area of İstanbul. One hundred and forty four mothers of children included accepted in the study with response rate of 85%. A questionnaire form was applied for data collection. Epi-Info programme was used for statistical analysis. In addition to the descriptive statistical methods, for the comparison of qualitative data a chi-square test was used .Results: In our study, the percentage of mothers who could define diarrhea correctly was 40%. Abdominal pain and watery defecation were the main signs which the mothers understand their children have diarrhea. Most of the mothers indicated that microbes as the cause of diarrhea. One of every two mothers stated that they would take their children to the doctor as they notice their child has diarrhea. Among the homemade treatments we asked, Potatoes cooked in boiling water and banana were the most frequent answers. Only one of mothers mentioned about using drugs at home for diarrhea and percentage of hearing about ORS was 21.5%. Eleven percent of mothers mentioned they believed to decrease liquid intake would be an effective practice in the treatment of diarrhea. Education level was very influential about knowledge and attitude about diarrheal disease. Conclusion: This study reveals the importance of continuous health education of mothers as well as the need for raising their status especially schooling in communities. Circulating of correct information is also important as well as educating population.

A review of rotavirus diarrhea in Pakistan: how much do we know?

Rotavirus diarrhea has a worldwide distribution, infecting almost all children by the age of 3-5 years. A comparable etiological 2-year survey carried out by the W.H.O Diarrheal Disease control (CDD) Program in 1991, in a multicenter study in 5 developing countries including Pakistan revealed that Rotavirus was found to be the most frequently detected pathogen in diarrheal episodes, during the first year of life, with the highest incidence (20%) occurring among 6-11 months old. Two other studies done in Pakistan, in under five children done in Lahore (between 1985 and 1991) and Rawalpindi (between May 1983 and April 1984) showed that Rotavirus was the second most common Diarrhea causing enteric pathogen following E.Coli Rotaviruses are shed in high concentrations 2 days before and as many as 10 days after onset of symptoms in immunocompetent hosts, thus being an important source of viral transmission. A multicenter study in 5 developing countries including Pakistan conducted by WHO CDD program revealed that only 1.8 % of cases presented with severe dehydration and these were mostly due to Rotavirus, V. Cholerae and ETEC13. A study conducted in local hospitals in Pakistan during the period of October 1985-April 1986 compared the different diagnostic modalities for the detection of rotavirus in the faeces of children with acute diarrhea. The study all methods detected Rotavirus to varying degrees but ELISA was found to be the most sensitive method with 72.4% stools being positive. PREVENTIVE STRATEGIES: A study was conducted in Lahore (Pakistan) among 72 infants 6 weeks old in 1991 to assess safety and efficacy of RRV vaccine. It was found that of all infants given RRV with OPV, 50% had a two to four-fold rise in neutralization titers against rotavirus. RRV was found to be safe and not associated with adverse reactions in the 6 weeks old infants. With regards to Pakistan, there is a great need for defining rotavirus associated disease burden and strain prevalence. We also need to conduct Rotavirus vaccine trials to assess its efficacy and safety in our setting.

Surveillance of norovirus among children with diarrhea in four major hospitals in Bhutan: Replacement of GII.21 by GII.3 as a dominant genotype.

BackgroundDiarrhea is a major cause of morbidity and mortality among Bhutanese children. The etiology of diarrhea is not well known due to the challenges of conducting routine surveillance with Bhutan’s modest research facilities. Establishing an etiology is crucial toward generating evidence that will contribute to policy discussions on a diarrheal disease control program. Our previous study, during 2010–2012, revealed that norovirus (NoV) is an important cause of diarrhea among Bhutanese children, and that GII.21 was the major genotype circulating at that time. In other countries, GII.4 is the major genotype responsible for NoV infections. In this update report, we provide new prevalence data to describe the progression of the transformation and distribution of the NoV genotype among Bhutanese children.MethodsFrom June 2013 through May 2014, diarrheal stool samples were collected at one national referral hospital in Thimphu, two regional referral hospitals in the eastern and central regions, and one general hospital in the western region of Bhutan. NoV was detected by reverse transcription–polymerase chain reaction (RT–PCR), by amplifying the capsid gene. The RT–PCR results were confirmed by nucleotide sequencing of the amplicons.ResultsThe proportion of NoV-positive stool samples was 23.6% (147/623), of which 76.9% were NoV GII and the remainders were NoV GI. The median age of infected children was 15.5 months, with a fairly balanced female: male ratio. NoV GII was most prevalent in the colder months (late November–mid April) and NoV GI had the highest prevalence in the summer (mid April–late September). Nucleotide sequencing was successful in 99 samples of GII strains. The most common genotypes were GII.3 (42.6%), GII.4 Sydney 2012 (15.8%), and GII.4 unassigned (11.9%). No GII.21 was found in any child in the present study. Phylogenetic analysis showed that GII.3 strains in the present study belonged to an independent cluster in lineage B. These strains shared an ancestor with those from different countries and Bhutanese strains circulating during 2010.ConclusionNoV remains an important cause of diarrhea among Bhutanese children. Genotype GII.3 from a single ancestor strain has spread, replacing the previously circulating GII.21. Current NoV genotypes are similar to the strains circulating worldwide but are primarily related to those in neighboring countries. NoV GII is prevalent during the cold season, while GI is prevalent during the summer. To develop a NoV infection control policy, further studies are needed.

Integrated approach to child health in developing countries

This article focuses on the integrated approach to child health in developing countries. The Integrated Management of Childhood Illness (IMCI) is a strategy developed by ten programs of WHO working with UN International Childrens Emergency Fund and many other agencies institutions and individuals. IMCI focuses on the disease of childhood that causes the greatest global burden while allowing for the content to be adapted to an individual countrys needs. An integrated approach is justified by good clinical practice and most importantly treating the child as a whole and not simply his or her most obvious disease. The strategy involves not only curative care but also interventions to promote healthy growth and development and prevent diseases. In health facilities the IMCI strategy promotes the accurate identification of childhood illnesses in outpatient settings ensures appropriate combined treatment of all major illnesses strengthens the counseling of caretakers and the provision of preventive services and speed up the referral of severely ill children. The strategy also aims to improve the quality of care of sick children at the referral level. In the home setting it promotes appropriate early home care and care seeking improved nutrition and prevention and the correct implementation of prescribed care. Through improving the coordination and quality of services provided by existing child health and other programs the IMCI strategy will help increase the effectiveness of care and in time reduce recurrent costs.

Lessons learnt from Diarrheal Diseases Control Program and implications for the future.

The national Diarrheal Disease Control Program was launched with the aim of improving the knowledge and practice of appropriate case management among caretakers of young children as well as health care providers. The National Family Health Survey (1992-3) revealed that 42.7% of mothers knew about ORS packets and 25.9% had ever used them. ORS use rates in children who suffered from diarrhea during the previous two weeks varied from 8.3% in Rajasthan to 50.1% in West Bengal. These findings represent substantial accomplishment, and also are a reminder that we still have to reach more than half of the households. Further analysis of the NFHS data showed that exposure to electronic mass media had a significant impact on mothers' awareness about ORS packets (56% in exposed, 32% in unexposed) and ORT use rates (38% in exposed, 25% in unexposed). In this review, future strategies for increasing the impact of the program are discussed. These include involvement of licensed and unlicensed medical practitioners, greater use of the electronic mass media, ORS standardization, greater focus on poorly performing states and resolving residual issues in the case management of diarrhea in malnourished children and infants under 6 months of age.

Possibilities for zinc in the treatment of acute diarrhea

Zinc therapy shows promise in the treatment of acute diarrhea. Several questions must be answered before it can be incorporated into diarrheal disease control programs, namely, whether it should be targeted at the groups of children in whom it has been shown to work and what the optimal dosing regimen should be, the amount of therapeutic zinc, optimal duration of therapy, and the interaction of zinc and copper absorption. The evidence supporting inclusion of zinc in treatment programs is strong and may become more so when these questions are answered. Am J Clin Nutr 1998;68(suppl):480S–3S.

Health research in the developing world: a gastroenterological view from Bangladesh.

Ill health is a serious impediment to progress in most poor countries, yet health is not a high priority on foreign aid agendas. Health research, which provides the essential base for sustainable progressive health programs, is barely visible in developing countries. For example, in Bangladesh, one finds unacceptably high morbidity and mortality rates among infants and children, health programs that are struggling and a rudimentary health research establishment; for the huge foreign donor community in that country, health programs and research do not appear to warrant major investments. Diarrheal diseases are at the top of the list of killers in many poor nations including Bangladesh. Recent advances in our understanding of diarrhea suggest that when prevention may not be possible soon, improved active treatment can evolve from an aggressive research effort centered in a developing country and linked to appropriate international partners. Global agencies such as the World Health Organization have demonstrated a declining interest in health research, as reflected in the policies of their Diarrhoeal Disease Control Programme. Major donors to the developing world, the Canadian International Development Agency for example, have had a relatively minor involvement in health and little commitment to health research. University links with the west, private enterprises and specially targeted programs are involved in developing world health research but they have not been able to foster and leave behind sustainable, high quality research programs. The problem should be attacked directly by supporting focused, relevant health research centres in regions of the world where the burden of disease continues to impede progress and where the environment is conducive to high quality research that is well integrated with care delivery programs. An instructive model of this approach is the International Centre for Diarrhoeal Disease Research in Dhaka, Bangladesh.

Diarrhoeal disease morbidity and home treatment practices in Egypt

Diarrhoeal disease is a major cause of death in children in the developing world. In developing countries a quarter of infant and childhood mortality is related to diarrhoea. The World Health Organization started the Diarrhoeal Disease Control Programme (CDD) in 1980 with the objective to decrease diarrhoeal mortality and morbidity among young children in developing countries. The aim of this study was to measure the prevalence and incidence of diarrhoeal diseases among young children and to assess the quality of home case management of diarrhoeal cases. Particular emphasis was put on the assessment of drug use during diarrhoea. The survey included also the assessment of breast feeding practices. Geographically the survey was limited to two governorates, Dakahlia and Gharbia, in lower Egypt, which have the largest population (7.12 million) and were thought to be representative of lower Egypt. The total sample size was 11032. Seasonally adjusted diarrhoea incidence was 3.6 episodes per child under five years of age per year. This means a minimum estimate of 30 million cases annually in Egypt. Although the majority of the caretakers knew of Oral Rehydration Salts (ORS), only 22% of cases with diarrhoea in the last 24 h received ORS. 54% of cases had received drugs, and many of the children with diarrhoea received more than one drug. The source of drug prescription was most often a private doctor and the use of drugs was common also among government doctors and health workers. The high proportion of cases treated with drugs, other than ORS, is the major problem in diarrhoeal home case management in Egypt. The message of ORS has penetrated into the general population well, but the practices of health professionals have not changed. To improve the situation further, training of health workers in correct case management is needed. Paediatric forms of symptomatic antidiarrhoeal drugs should also be withdrawn from the market.

Occurrence of diarrhoeal diseases in relation to infant feeding practices in a rural community in West Bengal, India.

In a rural community-based prospective study, diarrhoea in relation to the feeding patterns of a cohort of infants was studied. A total of 148 infants between the ages of 0 and 2 months were enrolled and followed until the completion of 1 year of age. Survival analysis showed that by the fourth month of age exclusive breastfeeding dropped by 75%. The proportion of complementary breastfeeding increased from 18.6 to 52.9% during the same period and to 83.7% by the eighth month. This study clearly highlights the tendency for early switch over from exclusive breastfeeding to complementary breastfeeding. Early weaning was associated with an incidence rate ratio (IRR) of 3.02 (95% CI 1.043-8.802). The IRR of 3.02 and its confidence limits (1.043-8.02) suggest a significant protective effect of exclusive breastfeeding against diarrhoea in infants. The results of this study indicate that promotion of exclusive breastfeeding has a potential role to reduce the incidence of diarrhoea amongst infants. The findings of this study will be useful for Diarrhoeal Disease Control Programme in reducing diarrhoeal morbidity.

The utility of case-control methods for health policy and planning analysis: An illustration from Kinshasa, Zaire

Recent evaluation literature has highlighted the utility of the case-control study design for program evaluation research. To date, the emphasis has been on application of the methodology for impact evaluation purposes. However, thepower, relative simplicity and cost-effectiveness of the method make it an equally useful research tool for policy development and program planning analyses. This article illustrates the use of the case-control methodology as an applied policy/planning research tool in assessing the potential effectiveness of behavioral interventions in connection with diarrheal disease control programs in Kinshasa, Zaire.

Does ORT reduce diarrhoeal mortality?

Researchers analyzed 1976-88 data from rural Matlab in Bangladesh to examine changes in diarrhea and in acute watery diarrhea mortality among infants and children before and after the implementation of an oral rehydration therapy (ORT) program. Overall diarrhea mortality among infants increased consistently (3-13) in both the area with maternal and child health-family planning (MCH-FP) services and the comparison area (p<.001). Mortality from acute watery diarrhea among infants also rose in both areas (1-7; p<.001). Trends in diarrhea mortality among children were not as straightforward however. It peaked in 1983-84 due to a dysentery epidemic. 92% of mothers in both areas knew about the benefits of glucose and oral rehydration salts (G-ORS) packets or homemade ORT solutions but most mothers (78% in MCH-FP area and 85% in comparison area) incorrectly believed ORT would stop diarrhea. Only 58% of G-ORS local distributors had G-ORS packets on the day the community health worker visited. Infants with severe acute watery diarrhea ingested a mean of 400 ml of ORS during the 1st 2 days of illness which is inadequate to treat infants with severe dehydration or high purging rates. ORT promotion and home distribution of G-ORS did not decrease infant and child deaths from acute watery diarrhea. Possible reasons for this phenomenon are suggested: complications other than dehydration the small amounts of ORS used and reduced reliance on hospitals and increased delays before taking severely ill children to the hospital. The question of whether the relative increase in diarrhea deaths among infants was due to the decline in infant mortality from other diseases thus making diarrhea a predominant replacing disease in the Matlab was considered. The results indicated that health educators should work toward formulating clear messages which promote correct use of ORT. Health workers should consider ORT as 1 component among others in diarrheal disease control programs.

Usage of oral rehydration solutions (ORS): a critical assessment of utilization rates

Policymakers and program managers rely on the oral rehydration solution (ORS) use rate as an indicator of program performance. The ORS use rate has several limitations e.g. it disregards other program objectives. Other diarrheal disease control program objectives may include reducing the source of infection promotion of effective home-based treatment and training of health workers in appropriate diarrhea case management. WHO and the Demographic and Health Surveys (DHS) try to standardize the methodology for estimating ORS use rates but they have not looked at them as cross-country indicators. Error sources lie in the terms used for diarrhea the reference period and the sequence of questions referring to treatment. In Bangladesh the people recognize different types of diarrhea and treat each type differently. In 1 instance health workers informed mothers to prepare and give a homemade sugar salt solution. Later they learned that mothers did not use ORS very much because they only used ORS for the type of diarrhea the health workers described. There has been considerable variation of ORS use rates in Bangladesh perhaps because of the differences in meanings of the words used for diarrhea. The DHS uses a 2-week reference period yet a Bangladesh survey finds underreporting of diarrheal episodes which occur early in the week of the survey. Other surveys do not use a specific reference period and mothers tend to remember only serious diarrheal episodes. A direct question about ORS use in surveys is too leading as indicated by higher ORS use rates when interviewers prompt respondents. ORS use rates do not give a true picture of a program and can even be counterproductive. No consensus exists as to what is high ORS use rate and what is low ORS use rate. Managers should not use ORS use rates as the only program indicator.

Cereal-based oral rehydration therapy. II. Strategic issues for its implementation in national diarrheal disease control programs

Field studies in Bangladesh demonstrated that after proper training, village mothers were able to prepare and use rice-based, salt-enriched oral rehydration solutions containing safe concentrations of sodium, and were capable of achieving significantly fewer treatment failures and a reduction in the duration of diarrhea than with glucose-based oral rehydration solutions (ORS). An additional longitudinal study showed that improved growth and weight gain occurred with the consistent use of ORS; the effect was greater when rice-based ORS were used. In addition, the following possible limitations and benefits of cereal-based oral rehydration therapy, which are relevant to the strategies for its implementation in national diarrheal disease control programs, are discussed: safety, osmolarity, hypernatremia, spoiling, effectiveness, rehydration ability, reduction in diarrhea volume and duration, nutritional effects, effect on food intake, acceptance and usage by care givers, training of health workers, self-reliance of families, effect on other child survival activities, costs, potential problems in changing to cereal-based ORS, and the role of industrial production in packaged cereal-based ORS.

Why promote breastfeeding in diarrhoeal disease control programmes?

WHOs Diarrhoeal Disease Control (CDD) Programme encourages national CDD programs to center activities around improving case management practices to reduce mortality from diarrhea since proper case management practices can deliver 90% of children with diarrhea from death. Its 2nd priority is to reduce diarrheal incidence and associated harmful effects especially malnutrition. In fact WHO provides in service training on breast feeding promotion for health workers to support national CDD programs. Eventually it will support research on implementation of breast feeding programs. Research indicates that breast feeding could reduce diarrhea morbidity 8-32%. Further it shows that breast feeding not only significantly reduces the risk of diarrhea for infants especially 1-6 month infants but also can prevent adverse nutritional effects of diarrhea. In addition a child with diarrhea often does not want to eat solid foods but eagerly wants to breast feed. Further the frequency and duration of breast feeding changes little during a diarrheal episode thus the much needed energy intake during sickness remains relatively high. Moreover continued breast feeding during a diarrheal episode reduces the mortality risk greatly. For example the median relative risk of death from diarrhea among 1-6 month old infants who do not breast feed at all is 25 when compared to exclusively breast fed infants. This risk falls to 8.6 among the same age infants who partially breast feed when compared to those that are exclusively breast fed. The benefits of breast milk include its important role in preventing and managing diarrhea related dehydration and in reducing exposure to contaminated foods and fluids. Cost effectiveness studies demonstrate that the cost/diarrhea episode and cost/diarrhea death averted could be greatly reduced if CDD programs promote breast feeding.

Sociodemographic and clinical factors affecting recognition of childhood diarrhea by mothers in Kwara State, Nigeria

Early diagnosis of infant and child diarrhea by family members is the key to timely treatment. Factors that influence the caregiver's recognition of diarrhea have not been systematically studied, but may include characteristics of the caregiver, the child, or the illness itself. This paper examines the relationships between the caregivers' diagnoses of diarrhea during the previous 24 hr and the reported frequency and consistency of their children's bowel movements during the same period of time, using information from a representative sample of 2655 children less than 3 years of age in Kwara State, Nigeria. Diarrheal point prevalence based on maternal diagnosis (10.0%) was about half that based on the clinical criteria of three or more liquid or semi-liquid stools (18.8%). Only 36% of the mothers recognized a recent episode of diarrhea defined by the clinical criteria. Mothers were more likely to recognize diarrhea when a greater number of stools of watery consistency were excreted or when the stools contained blood or mucus. Mothers were least likely to recognize diarrhea when the child was a girl or less than 2 months of age. These results suggest that cross-cultural comparisons of diarrheal rates should use consistent, objective evidence of illness to compare rates rather than maternal diagnosis alone. Also, diarrheal disease control programs should explore those factors affecting recognition of illness in local contexts to assure that treatment recommendations can be applied in a timely fashion.

Acute Diarrheal Disease in Children under Five Years of Age in the Eastern Province of Saudi Arabia

A follow-up study was conducted in 859 children younger than 5 years who were treated for acute diarrhea at the Diarrhoea Control Center, Dammam, during 1408H (1987-1988). The purpose of the study ...

Using surveys in Mozambique for evaluation of diarrhoeal disease control

Mozambique had used surveys extensively to evaluate its Diarrheal Diseases Control program. Topics have included diarrhea morbidity and mortality health center management and home followup diarrhea prevalence and dehydration and household knowledge. The surveys found high diarrhea-associated morbidity and mortality rates. Although knowledge rates about oral rehydration salts were between 88% and 93% problems in the program included poor distribution of ORS packets varying availability of sugar and salt inadequate case management and poor effective use in the home. Policy and strategy have been revised accordingly to improve healthworker training and to increase us of alternative home solutions. The authors make recommendations for future surveys based on the revised program; a change from large surveys measuring mortality to small local surveys of health center management with home followup to measure effective use with indicators on knowledge included in routine Expended Program on Immunization (EPI) coverage surveys. (authors)

Economic adjustment and current trends in child survival: the case of Zimbabwe

The relationship between health and welfare policies and economic performance and the efficacy of economic adjustment measures in Zimbabwe since independence are examined along with the accompanying changes in infant and young child health. As a result of the successful struggle for independence certain economic measures and social reforms have been instituted and these have had a positive influence on health. The most important include the setting of minimum wages for all categories of labor food subsidies the land resettlement program expanded education water development and drought relief programs. The management and delivery of health care; in line with the new primary health care (PHC) approach has been transformed slowly. The curative and preventive services have been integrated in provincial and district health team structures accountable both to higher levels of the health structure and to the local government structures at the level of service. Active steps have been taken to reform medical education to make the training of physicians more relevant to the needs of Zimbabwe. Some of the changes introduced since independence include: free health care; hospital and rural health center building program; the Zimbabwe expanded program on immunization (ZEPI); diarrheal disease control program (DDCP); a national nutrition program; a program of child spacing; and a national village health worker program. All these and other programs call for expansion of government expenditures. A table shows how the vote allocations and the actual expenditure of the Ministry of Health changed over the period. Due to the scarcity of data it is difficult to be anything but speculative regarding the impact of the health sector interventions on infant and child mortality and morbidity. Yet it is likely that certain programs -- particularly ZEPI and DDCP - have had and continue to have a rapid positive impact on child survival. Any significant impact on deaths resulting from respiratory infections low birth weight and other neonatal causes as well as deaths resulting either directly or indirectly from malnutrition would require improvements in nutritional status of both children and mothers as well as reductions in levels of crowding and further improvement in access to health care. The primary effect on the health sector of the recession period has been to restrict the Ministry of Healths ability to finance services.

The implementation of a diarrheal disease control program in Honduras: Is it ‘selective primary health care’ or ‘integrated primary health care’?

International public health scientists have debated the distinction of selective and integrated primary health care since the development of new selective primary health care interventions such as the Expanded Programme on Immunizations and the Diarrhoeal Disease Control Programme of the World Health Organization were developed. This paper argues that the codification offered by the identification of two incompatible paradigms is not a productive one for describing the implementation of national-level primary health care programs. This paper will explore these concerns by reviewing case materials of the implementation of a diarrheal diseases control program in Honduras.