World Health: the magazine of the World Health Organization: April 1986 [full issue]: diarrhoeal diseases

Tackling diarrhoea on a world scale All the indications are that WHO's global programme to control diarrhoea! dis- eases is well on the way to achieving the goals that have been set for 1989 by Michael H. Merson ii he control of diarrhoea! disease is nowadays a subject of en-thusiastic discussion at national and international gatherings con- cerned with child health. This is prob- ably because much progress has been made in a relatively short time in initiating national programmes to control these diseases and because the future holds even greater promise for children living in the developing world. The proper case management of diarrhoea! illness, especially the use of oral rehydration therapy (ORT), has been given the greatest emphasis in the WHO Diarrhoea! Diseases Control (CDD) Programme from its inception in 1978. Since then ORT has become well-known throughout the develop- ing world. More and more countries are investigating fluids that could be 2 used at home in the early stages of diarrhoea to prevent dehydration, while exploring ways of making Oral Rehydration Salts (ORS) widely available from treatment facilities and village health workers to treat dehydration. Continued feeding dur- ing and after illness, whether from the breast or using appropriate weaning foods, is an integral part of this case management strategy. Today, more than 100 countries (comprising about 95 per cent of the under-five population of the develop- ing world) have launched national CDD programmes as part of their primary health care strategy. Al- though many of these programmes have yet to reach a level of perform- ance adequate to realise the full poten- tial of ORT, a large number of children are already benefiting from them. In these programmes, priority is being given to training health personnel, promoting the use of home solutions early in diarrhoea (using communica- tion approaches to increasing the fami- ly's understanding of oral therapy), procurement and/or production of ORS packets, and supervision, moni- toring and evaluation of activities to ensure effective ORT use and to mea- sure its impact. Training for health workers at all levels in technical aspects of diar- rhoea! disease control, particularly the management of cases, has so far been undertaken in 79 countries, much of it in national training units established in existing institutions. In view of the need to develop managerial skills for proper planning, operation, and eva- luation of technically sound pro- grammes, WHO's CDD Programme has W oRLD HEALTH, April 1986 Egyptian mothers giving oral rehydration to their babies, under trained supervision. Photo WHO/H. Tammam developed special courses which have trained over 1,300 senior health staff from 131 countries in programme management and about 4,000 mid- level personnel from 88 countries in supervisory skills. Improving the teaching of disease control in training institutions for physicians, nurses, and paramedical staff is another area that is receiving priority attention. To support these training activities and disseminate new technical infor- mation, numerous manuals, guidelines and audio-visual aids have been de- veloped and widely distributed. Since 1980, the Programme has been pro- viding support to the global newsletter "Dialogue on Diarrhoea" (published in four languages by AHRTAG, London, with a circulation of about 175,000), and distributing general and special bibliographies. In 1985, about 270 million ORS packets were available from ~ll sources-five times the number avail- able in 1982 and more than twice the number in 1983. While UNICEF continues to be the major external source of supply, it is noteworthy that, by the end of 1985, more than 40 developing countries had undertaken local production and were themselves the main source of ORS packets. Re- vised, comprehensive guidelines for ORS production have recently been issued by WHO to aid national efforts. The replacement of 2.5 g of sodium bicarbonate in the ORS formula by 2.9 g of trisodium citrate, dihydrate, will prolong the shelf-life of the pack- ets and may also help to reduce the severity of the disease. At the same time, efforts are in progress to assess various fluids avail- able in the home for effectiveness in preventing dehydration, and ~o dete:- mine the best means of assurmg their accurate preparation. Attempts by some national CDD programmes to increase the understanding of and de- mand for ORT by using the mass media and other communication techniques-that is, through the "social marketing" approach- have proved remarkably successful. The global CDD Programme is now de- veloping guidelines for the use of "communication" approaches in na- tional CDD programmes. It is difficult at present to determine accurately the proportion of children W oRLD HEALTH, April 1986 under five in developing countries with access to ORT, or the proportion actually using it. Much of this infor~a­ tion is being obtained through morbid- ity, mortality and treatment surv~ys and/or programme reviews which have each now been undertaken by some 40 countries. Many of the latter have also shown how overall primary health care systems can be streng- thened. From the available informa- tion, it appears that whereas in 1~82 only six per cent of children under five had access to ORS, in 1984 this figure had increased to 33 per cent globally (reaching about 40 per cent in the Eastern Mediterranean and Western Pacific Regions, and 66 per cent in South-East Asia). The minimum pro- portion of diarrhoea episodes actually treated with adequate ORT was 12 per cent in 1984 (of which eight per cent received ORS) . Health facilities in many parts of the world have recorded significant reduc- tions in diarrhoea case-fatality rates and in admissions of cases. For exam- ple, in the Massey Street Clinic in Lagos, Nigeria, case-fatality was found to decline from 17 per cent to three per cent within seven months of the establishment of the ORT clinic. Over- all diarrhoea mortality has been found to decrease by 40 to 50 per cent in Egypt, Honduras, the Philippines, and Thailand. The key attributes of these successful programmes have been high level commitment and focus, sound programme planning, careful attention to programme management, task- oriented training, well-researched communication activities, due em- phasis on supervision, and monitoring and practical evaluation. These data indicate that the global Programme is well on the way to achieving the goals it has set for 1989: - one-half of all childhood diarrhoea cases will have access to ORT; - 35 per cent of all childhood diarrhoea cases will be receiving adequate ORT ; - at least one to one-and-a-half mil- lion childhood deaths due to diar- rhoea will be prevented annually. While continuing to promote ORT as a short-term strategy for saving lives, in coming years the CDD Pro- gramme will also be giving increasing emphasis to other strategies aimed at reducing the incidence of diarrhoea. Interventions involving community participation and believed to be hig~ly cost effective, such as' the promotion of breast-feeding, appropriate wean- Cover : Diagram of the digestive tract by Peter Davies IX ISSN 0043c8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor : Christiane Viedma Art Editor: Peter Davies News Page Editor : Peter Ozorio World Health appears ten times a year in English, French. German. Portuguese, Russian and Spanish. and fourtimes a year in Arabic and Farsi. Art icles and photographs not copyrighted may be repro; duced provided credit is given to t he World Health Organization. Signed articles do not necessanly reflect WHO's views. World Health. WHO, Av. Appia, 1211 Geneva 27. Sw itzerland. Contents Tackling diarrhoea on a world scale Michael H. Merson. . . . . . . . . . . . . 2 How harmful is diarrhoea? by Leonardo Mata . . . . . . . . . . . . . . . . 5 Diarrhoea management by Mathuram Santosham .. and Raymond Reid .. . .... . . . . .. , . . 8 Where drugs don't help lbrahim I. Elarabi .. . ... . .. . . . . . UNICEF: 1 years in the field by Roger M. Goodall . .. . . ... .. . • . , . 12 Bacillary dysentery by Sudhir Chandra Pal . . . . . . . . . . . . . 14 The battle against diarrhoea. , . . 16-17 Prevention better than cure by Richard G. Feachem ..... . . .. . '·. 18 Cholera control by D. Barakamfitiye, D. Barua and D. Buri.ot . . . . . . . . . . . 20 Prospects for vaccines by Myron M . Levine . . . ... . Haiti's national programme by Lambert Jasmin . ....... . .... • " 26 UNDP plays its part by Timothy Rothermel. . . . . . ... . . . 27 • Departments Health communication : Egypt by Hosny A. Tammam . . . . . . . . . . . 7 ' Primary Health Care: Thailand by Sawat Ramaboot. . . . . . . . . . . . . . . 23 Health Education : Ethiopia by Channyalew Belachew . . . . . •. . . . . 29 News Page . . .. . .. . .. . . ... . , . 30-31 Access to safe drinking water-a vital step in preventing diarrhoea] diseases. Photo W HO/Zafar ing practices, use of safe water and latrines, and good personal and domestic hygiene, will receive particu- lar attention and more specifically defined targets. In addition to collaborating with countries in their national CDD pro- grammes, the WHO Programme also has a large research component. This is responding to the needs of countries by supporting health services research to determine the best ways of applying available strategies, and at the same time promoting more fundamental re- search to find new tools for control, such as vaccines. Some 350 projects in 78 countries have so far been awarded support, 61 per cent of them in developing countries. Perhaps the most exciting develop- ment to date is the prospect of de- veloping an improved ORS formula- tion that can reduce the volume of diarrhoea by as much as 50 per cent. Another important area is determining the best foods to be given during illness. At the same time, in the area of prevention, new vaccines against rotavirus diarrhoea, typhoid fever 4 and cholera have been developed to the stage of field-testing. Among the many scientists and institutions col- laborating with WHO in this research, the participation of the International Centre for Diarrhoea! Disease Re- search, Bangladesh (ICDDR, B) has been especially valuable. The effective and rapid curative action of ORT gives mothers and other family members confidence in their ability to care for themselves. Because diarrhoea is so common and ORT is re- cognised by mothers as being effective, national CDD programmes are an invaluable entry point for other pri- mary health care activities. According- ly, many of the activities of the WHO Programme are undertaken jointly with other programmes such as those for Immunization, Nutrition, and En- vironmental Health. The impressive progress of national efforts to reduce the ill-effects of this disease would not have been possible without the close and invaluable collaboration and sup- port of other international agencies, especially UNDP and UNICEF, and of numerous bilateral agencies and non- governmental organizations. The con- tinuation of these joint efforts holds great promise for control of the diar- rhoea! diseases in the next decade. • ICORT 11 ii he second International Conference on Oral Rehyd-ration Therapy (ICORT 11) was held in Washington, DC, USA on December 1 0-13 1985. Spon- sored by the US Agency for Inter- national Development in coopera- tion with WHO, UNICEF, UNDP, the World Bank, and the International Centre for Diarrhoea! Disease Research, Bangladesh, the Con- ference was 'attended by some 1 ,200 participants from over 90 developed and developing countries. ICORT 11 built on the successes of the first meeting, held in June 1983, which stimulated the expan- sion of ORT efforts in many coun- tries. The 1985 conference fo- cused on implementation issues and ways to overcome barriers to the greater use of ORT. Some of the topics covered were: new understanding of the diarrhoea! disease pr'ocess and new thera- pies ; integration of ORT with other health activities; communi- cations and social marketing; dis- tribution and logistics; training of health personnel; supervision and monitoring; evaluation and cost; and other interventions to prevent and control diarrhoea! diseases. Photo W HO/A. S. Kochar A highlight of the conference was a vivid poster presentation of some fifty country COD pro- grammes, illustrating their ac- tivities and achievements to date. The Proceedings of ICORT 11 will be available by mid-1986 from : Dr. R. M. Clay, ICORT 11 Coor- 'dinator, Office of Health, Bureau of Science and Technology, Room 702, SA-18, Agency for Interna- tional Develof3ment, Washington, DC 20523, USA. • W oRLD HEALTH , April 1986 How harmful is diarrhoea? Apart from the physical suffering and deaths that they cause at the individual and family level, diarrhoea! dis- eases also play a negative role in national development ii oday, diarrhoea! diseases are considered the commonest and most important single health problem in the developing countries of the world, as well as one of the major contributors to malnutrition, poor health and inadequate performance of children. Many do not survive its devastating effects. Diarrhoea affects host nutrition and health through reduction in food con- sumption, alterations in digestion and absorption, impaired utilisation of nut- rients and disturbances in metabolism. When it occurs repeatedly in children -a common phenomenon in most less developed countries-their nutrition, growth and development are im- paired. Due to the debilitating and incapacitating nature of the disease, children become detached from the family nucleus, while adults may be affected in their work attendance and performance. Impaired food intake is one of the obvious manifestations of diarrhoea, particularly among infants and small children. Those who have experienced severe attacks would recognise its awful clinical manifestations : lack of appetite (anorexia), vomiting, fever, profuse loss of fluids through the intes- tine, prostration and weakness. The anorexia may be worsened by cultural traditions, beliefs or taboos resulting in food being withheld for days or weeks since this is thought to relieve the child. Anorexia and vomit- ing may result in a reduction of 20 to 70 per cent in food intake. Anorexia may persist for days or weeks regard- less of the kind or amount of stimula- W o RLD HEALTH, April 1986 by Leonardo Mata tion provided. As much as 20 per cent of the expected food intake in tradi- tional populations may be lost due to diarrhoea alone. Impaired digestion and absorption in infectious diarrhoea result in a small part from the accelerated transit of food through the intestine, but A case of severe malnutrition resulting from acute diarrhoea. Photo WHO/M . Levine mostly from the direct action of agents or their products on mucosal function. Various agents of the disease (viruses, bacteria, protozoa, worms and fungi) affect directly or indirectly the integ- rity and performance of the intestinal mucosa and sometimes its underlying layers. Some agents multiply or live in the intestinal lumen without causing overt lesions, but they liberate toxins, enzymes or products that impair di- gestion, or diminish absorption or in- crease secretion into the lumen. Other micro-organisms actually attach to the mucosal surface and in this manner cause harm. One protozoan adheres to the surface of epithelial cells without invading them (Cryptosporidium). Others (rotaviruses) invade epithelial cells, multiply, and destroy them, thus affecting digestive and absorptive functions. Certain invading bacteria (Shigellae) have the capacity to multiply in epithelial cells and in deeper layers, resulting in inflammation, ulceration, loss of blood, nutrients and cells, and profound alterations in intestinal func- tion. Still other bacteria (Salmonellae) may traverse the intestinal barrier to fall into the lymph and blood, and in this manner can creat~ havoc, for instance causing septicaemia and ab- scesses in organs such as the brain. A person with diarrhoea may lose as much as 10 per cent of the body weight in a matter of hours, with great danger to his or her life. Weight loss, if not corrected by proper rehydration and feeding, persists for weeks or even months. The nutritional consequences may persist for as long or longer when the disease becomes chronic. As regards altered metabolic func- tions, it is believed that enteric infec- tions, like other infections, induce the release of mediators (hormones) by macrophages, which trigger a variety . of responses in many different organs. The most obvious are anorexia and fever, which so commonly appear in persons with infectious diarrhoea. Another alteration m the host metabolism consists in the destruc- 5 tion of muscle protein required to meet energy needs, with resulting muscle wastage. Metabolic responses translate into losses of nitrogen, vit- amins and minerals . Other effects are the release of insulin and other hor- mones, depression of plasma levels of iron, zinc and other trace elements, and stimulation of the immune system. Metabolic alterations are required by the host to cope with infection and its aftermath; unfortunately, they have a considerable nutrient cost, par- ticularly for children who are weak or malnourished as a result of repeated bouts of diarrhoea or other infectious diseases . These children exhibit persis- tent weight faltering, stunting (short stature) and sometimes anaemia. Loss of fluids and electrolytes (essential salts) and other metabolic alterations in very small babies may result in transient or permanent brain damage. What are the psychosocial effects of diarrhoea? It is impossible to know what infants and small children feel when they fall ill, but it must be 6 Proper protection from diarrhoea helps to ensure normal healthy growth in babies. Photo WHO/J. Mohr similar to, and possibly more serious than, the experience of adults. During a severe attack of acute watery diar- rhoea or dysentery, we feel great anxi- ety and fear; we are restless and exhausted. The cramps and tenesmus (straining) are very uncomfortable; if dehydration occurs, there is pain in the legs and other parts of the body; fever and headache, and cold sweating during defecation, are among the most unpleasant and fearsome signs and symptoms that we may experience. Somehow we know that the disease we are suffering is serious, one that debilitates us and threatens our exist- ence. The anxiety and fear are easily recognised in the eyes of sick children, and may be similar to those seen in cases of child abuse. Children with diarrhoea are not very pleasant to be with, especially if they live in deprived environments. They are crying, feeble, irritable, smelly and unloving children, and they may be rejected by their own families, particularly when they suffer from repeated or chronic diarrhoea! episodes. In the process, they may be subjected to various forms of neglect, abuse and deprivation. Because the overall time of possible interaction with the mother or family is reduced, diarrhoeic children have diminished opportunities to learn and develop within the home and to ex- plore the environment. If they attend school, absenteeism due to the disease or its complications may interfere with learning, progress and completion of training. Malnutrition It is clear that children who suffer from several attacks of diarrhoea eventually become malnourished. Restriction in food intake, losses of fluid, nitrogen and other nutrients, and altered digestion, absorption and metabolism induce progressive wast- ing and stunting. The effect of diar- rhoea on nutritional status is accentu- ated when the child has experienced malnutrition in utero. Children who have suffered from intrauterine growth retardation, and who have an impaired immune function, are more prone to severe clinical manifestations of infection and malnutrition. Malnourished children in turn are more likely to develop severe protein- energy malnutrition when stricken by an acute infection-whether diarrhoea itself, measles, whooping-cough or an- other common communicable disease. Thus, in regions where lack of food is not the primary factor (that is, in most of the developing world), diarrhoea may be regarded as the main inducer of progressive wasting and stunting of the child population. It is also a cause of diminished productivity and well- being, and of absenteeism from work by the adult population. One additional reason why it is more threatening than other infectious diseases is its higher frequency and greater complexity, particularly in small children. The incidence may be as high as six to 12 episodes per child per year in most developing countries, W oRLD HEALTH , April 1986 and these episodes are generally as- sociated with other infectious diseases, making treatment and prevention more difficult. The total diarrhoea morbidity for a given child may be as high as one-third of its first two years of life. Overall, children are ill with diarrhoea for 10 to 20 per cent of their first three years of life. Obviously, children debilitated by the vicious interaction between diar- rhoea and malnutrition are at high risk of dying prematurely. Mortality statis- tics for most developing countries rate diarrhoea as a main killer of infants and young children, occupying the first or second place in most countries. In the tropical belt, it may account for 15 to 40 per cent of all deaths in the under-fives, that is, several million per year. Any child can die from diarrhoea regardless of its nutritional status. Well-nourished children with diar- rhoea plus dehydration or toxicosis may die within a few hours if the infectious dose ingested was large, and if prompt assistance was not provided. There is still some mortality due to diarrhoea in industrialised countries. But the effect is more serious in chil- dren who already exhibit some mal- nutrition. They do not have enough bodily stores and therefore become rapidly dehydrated; also, their im- mune response may be altered, for instance in those with fetal growth retardation. It is quite obvious that controlling and preventing diarrhoea is a sine qua non for improving nutrition and health and increasing survival of the child population. The sizeable reduction in diarrhoea mortality in Chile, China, Costa Rica, Cuba, Mauritius, Trinidad and Tobago and other countries is a good omen; it shows that this disease can be controlled in less developed countries, without their necessarily undergoing industrialisation and de- veloping a large capital income. The important thing is that, in countries where significant control has been at- tained, there has been clear recogni- tion of the negative role of diarrhoea in national development, and a politi- cal decision has been taken, with economic backing, to invest in holistic interventions aimed at its control and prevention. • W oRLD HEALTH, April 1986 Health Communication Egypt: social marketing approach by Hosny A. Tammam n the recommendation of WHO, the Ministry of Health of Egypt started to advocate the use of oral rehydration therapy for diarrhoea! diseases in 1961 . Five years later, when the Ministry published a booklet offering guidelines on maternal and child health, a formula for ora l rehydra- tion salts was included. Distribution to health centres of ORS packets supplied by UN ICE F was insti- tuted in the following decade, and since 1982 the packets have been manufactured in Egypt by the Chemi- ca l Industries Development Company. Meantime, a study conducted in a project on "Strengthening of Rural Health Delivery Services" provided ample evidence that diarrhoea mortali- ty in chi ldren cou ld be reduced by ORT. The government signed a grant agreement with the United States The ORS emblem has become familiar throughout Egypt. Photo WHO/H. Tammam Agency for International Development (uSAID). and in January 1983 the Nation- al Control of Diarrhoea! Diseases Pro- ject (NCDDP) started operations. it was designed to reinforce, expand and acce lerate diarrhoea! diseases control activities. A major innovation of the project has been to blend modern health services with a social marketing approach, using the mass media - including tele- vision, radio, printed materials, posters and billboards- to reach a maximum number of people with uniform mes- sages . Public events with the added attraction of we ll-known entertain- ment personalities have also played their part. More than 70 per cent of Egypt's population have regular access to tele- vision, and more than 90 per cent listen to the radio . Consequently edu- cationa l messages reach a majority of the population within a very short time. There have now been three annual television campaigns to drive home the message about oral rehydration . That in 1985, for instance, used 11 "spots" of either one minute or 30 seconds, each rotated on a two-week cycle. The messages included how to recognise dehydration in children, the proper use of ORS, the importance of breastfeeding and continued nutrition during illness, and preventing diar- rhoea through personal hygiene. These messages also find their way into materials used for training health workers . In less than three years, the death rates from diarrhoea in chi ldren aged under two years have been reduced throughout Egypt from 130,000 deaths annually to about 40,000. In terms of infant mortality, the reduction has been from about 91 per thousand to 44 per thousand. Use of ORS has increased from one per cent of diarrhoea episodes to 70 per cent. Some 3,000 rehydration . centres have opened in primary health care facilities ranging from hospitals to rural units, and in 1984 nearly one million ch ildren attended these centres . Over 12,000 health workers have learned rehydration techniques, and the annual production of ORS is now around 15 million litres. So the NCDDP has succeeded, in just under three years, in mobilising the public and private sectors in a coordi- nated campaign to lower infant and young child mortality from diarrhoea! diseases. • 7 Diarrhoea management Today we can confidently state that ORT can be safely and successfully used in treating acute diarrhoea due to all etiologies, in all age groups, in all countries by Mathuram Santosham and Raymond Reid [!] ntil the middle of the nine-teenth century, very little in-formation was available in re- corded literature about the scientific management of the diarrhoea! dis- eases, even though they have been known to man throughout history. The use of intravenous fluid therapy was first described only a little over 150 years ago, and the word "dehy- dration " did not appear in scientific literature until the first part of this century. But more recently there has been a tremendous increase in our knowledge of both the physiological disturbances that occur during illness and its man- agement. Perhaps the most important advances in this century have been our understanding of the mechanisms of water and electrolyte (essential salts) absorption from the gut, and the development of oral rehydration therapy. In 1831, British physicians first de- scribed the use of intravenous fluid therapy and the use of bicarbonate to correct acidosis, which often accom- panies diarrhoea. This therapy was not used extensively, however, until the beginning of the twentieth century when workers in India and in the Philippines demonstrated that it could bring about dramatic reductions in cholera mortality. In the 1930s and 1940s, the use of intravenous therapy was further refined by workers in the United States, who conducted careful studies of infants with diarrhoea and described the importance of replacing lost potassium. During the first half of this century, it was widely believed that oral fluids 8 Continued feeding-an integral part of diarrhoea management Starving a child who has diarrhoea can cause undernutrition, or make any existing undernutrition worse. Even during acute diarrhoea, at least 60 per cent and usually more of the normal absorption of nutrients oc- curs. Greater weight gain has been documented in infants given a libe- ral dietary intake during diarrhoea compared with others on a restric- ted intake. The early resumption of breast- feeding and half-strength milk feeds in infants is essential for meeting normal daily fluid requirements and also for maintaining adequate nutri- tion. Breastfeeding during diarrhoea may lower stool volume and shorten the duration of illness. In non- breast-fed babies, full-strength milk formula can be started again when the diarrhoea has stopped. In addi- tion, as soon . as rehydration has been completed and appetite re- turns, but without waiting for diar- rhoea to stop, all children older than 4-6 months, and all adults, should eat foods that are energy-rich (such as milk products, vegetables, eggs, fish and well-cooked meat, or sta- ples enriched with fats and oils) and foods containing potassium (e. g. fruit juices, bananas, coconut water) to replace potassium lost during diarrhoea. Foods that are difficult to digest (with a high fibre content) should be avoided. The child should be allowed to eat as much as it wants. Food should be offered often (5-7 times a day) dur- ing diarrhoea, because the child is not likely to eat much each time. lt should have at least one extra feed a day for a week after diarrhoea has stopped. • should not be given to sufferers. Con- trary to this belief, in 1946 Dr Harold Harrison of the U.S. used an oral electrolyte solution as maintenance therapy for treating acute diarrhoea. To prevent protein breakdown and its possible consequences, his oral rehy- dration solution contained about three per cent glucose, although nobody at that time recognised the role of glu- cose in enhancing the absorption of sodium and water. It also contained potassium to replace that lost in diar- rhoea! stools. During the 1950s, oral rehydration therapy began to be used extensively in the U.S. The solution was dispensed in powder form and parents were instructed to mix the powder in an appropriate volume of water. Unfor- tunately, they often mixed the wrong proportions of sugar, salt and water, so that many infants received solu- tions containing very high concentra- tions of sugar or sodium; this led to hypernatraemia (excess of sodium in the blood) and some deaths. Con- sequently, oral rehydration became less accepted as a standard form of therapy. In the 1960s, scientists in the U.S. described an important finding which provided a scientific basis for further development of oral rehydration solu- tions. They demonstrated that the ab- sorption of sodium through the intesti- nal membrane was enhanced by the coupling of glucose with sodium, and that this mechanism remained intact throughout the diarrhoea! episode. Since water is absorbed along with sodium, the absorption of water is also enhanced. W oRLD HEALTH, April 1986 Based on this finding, together with the knowledge that electrolyte losses occur in diarrhoea! stools, an oral rehydration solution was developed in which one litre contained 3.5 grams of sodium chloride, 2.5 grams of sodium bicarbonate, 1.5 grams of potassium chloride and 20 grams of glucose. This solution underwent a number of safety and efficacy studies in India and Ban- gladesh in adult patients suffering from cholera, and it was found that this therapy could be used for all but the most severe cases of cholera in adults. A number of questions, however, remained to be answered. Could in- fants with cholera drink the large volumes of fluid required for rehydra- tion and maintenance therapy? Could this solution be used safely to treat other types of diarrhoea besides chol- era? To answer some of these ques- tions, several studies were conducted during the 1970s in different parts of the world, primarily in developing countries. They showed that the solu- tion was safe and efficacious for treat- ing diarrhoea in all age groups includ- ing new-born infants, regardless of the cause of illness. But paediatricians from developed countries were still concerned about the possibility of hypernatraemia caused by these solutions, and they were reluctant to use this therapy. Findings during the past five years in the U.S. as well as a recent study in Costa Rica have now convincingly shown that oral rehydration therapy, when appropriately administered, can be used safely in well-nourished chil- dren and even in patients with hyper- natraemic dehydration. This treatment is now becoming more accepted in developed countries. WHO recently recommended that trisodium citrate be used in the solu- tion instead of sodium bicarbonate. Solutions containing citrate proved as efficacious as solutions containing bicarbonat~ in correcting acidosis in individuals suffering from diarrhoea. This change will enable _health work- ers to store oral rehydration salts for longer periods of time, since citrate is a more stable base than bicarbonate. Vomiting is often associated with diarrhoea and because of this physi- cians were in the past reluctant to use oral rehydration therapy to treat in- W oRLD HEALTH, April 1986 ORS for a small child in Thailand. Oral rehydration therapy is the mainstay of treat- ment for diarrhoea. Photo WHO/UNICEF/Nikonrat fants with diarrhoea. Many centres around the world have now realised that most infants with vomiting can be safely rehydrated provided that the solution is given in small, frequent feedings until the vomiting stops. An alternative approach to using in- travenous therapy for patients with persistent vomiting is to use a naso- gastric drip. A naso-gastric drip can be administered by less trained person- nel and is less expensive than intra- venous fluids . An exciting recent development in the treatment of diarrhoea has been the potential to develop improved forms of oral rehydration solutions which contain substrates such as amino acids, di-peptides and tri-pep- tides. These substrates, which are di- gestive end-products of commonly eaten foods, enhance the absorption of water and sodium from the gut. It follows that commonly available foods with appropriately added amounts of salt could potentially be used. Recent research in Bangladesh showed that rice powder could safely be added to a standard oral rehydration solution. Another study in India compared three oral rehydration solutions; one contained glycine, a second contained rice powder, and the third was the standard oral rehydration solution. The solutions containing the glycine and rice powder reduced stool output by approximately 50 per cent and reduced the duration of diarrhoea by 30 per cent. A number of solutions containing similar products are now being tested in different parts of the world. If the findings from India are confirmed, we may be able to use oral rehydration solutions, not only for rehydration and maintenance therapy, but also as a "medicine" to reduce both stool output and duration of illness. We can look forward to still other developments in the future to add to our current treatment methods. Oral rehydration therapy is the mainstay of treatment for diarrhoea, including those few illnesses for which antibiotics are indicated, such as chol- era and shigella. We can confidently state that oral rehydration therapy can be safely and successfully used in treat- ing acute diarrhoea due to all etiologies, in all age groups, in all countries. In summary, we have learned a great deal about the management of diarrhoea since intravenous fluid therapy was first used 150 years ago. The goal of eliminating deaths due to these diseases is still far off, but health professionals can proudly claim that in the last few years they have taken the first steps towards achiev- ing this goal. • 9 Where dmgs don't help A great many infants suffering from diarrhoea do not die from the disease but from mismanagement -and the principal cause of death is dehydration ecause diarrhoea in infants and children has so often resulted in death in the past, parents always tend to panic. Grandma herself may take the lead: "Don't give him anything by mouth ... and particularly not milk. " "Water?" "No ... it makes him vomit." Anxiety and inexperi- ence make mothers do as they are by lbrahim I. Elarabi told; they impose fasting to "rest the gut" when their child has watery stools and when the diarrhoea is ac- companied by vomiting. Only a few diarrhoea! episodes are needed for such children to become overtly mal- nourished. Besides imposing fasting, mothers tend to turn to their second weapon: drugs. Particularly in developing countries, people somehow believe that a successful treatment must in- clude drugs "and the more the bet- ter". Parents frequently buy them without even consulting a physician. "Why shouldn't we? Doctors ulti- mately prescribe them anyway." The most popular of the so-called anti- diarrhoea! medicines are antibiotics, constipating mixtures, anti-motility drugs and anti-emetics. A great many children with diarrhoea in developing countries receive such drugs in dif- ferent combinations, if their parents have access to them. Are they really necessary? Although it may sound logical to say that antibiotics are necessary in cases of diarrhoea, the truth of the matter is that they usually are not. The causa- tive agents of diarrhoea are mostly viruses and therefore are not affected by antibiotics . In addition, research and practice have proved that many bacterial cases can do without antibio- tics, and that their use may even be hazardous. Only a minority of specific diarrhoea! cases really require antibio- tic treatment, and these are usually identifiable by physicians. Constipating mixtures include a var- iety of substances known to lessen the fluidity of stools, such as pectin, kaolin and chalk. They are sold either alone or in combination with various anti- biotics, and are so popular that one can find them in every home as a rapid treatment for diarrhoea. It is true that they may lessen the fluidity of motions, but this is be- cause of their presence in the stools and not because they represent a cure. They have been found to affect neither the infectious process nor the changes that lead to intestinal fluid loss. On the contrary, they may even facilitate microbial attachment to the intestinal wall, and may cause intes- tinal obstruction when given to the newborn. The most "fashionable" drugs among parents and physicians in treat- ing diarrhoea these days are the so- called anti-motility medicines. These lower the motility of the gut, but by doing so they retain diarrhoea] fluid within the intestine. Thus, though they are claimed to have a "magical effect" in diarrhoea, they are in fact conceal- ing it and not treating it. In fact toxic symptoms that can prove fatal have been reported. Cholera victim recovering at a rural treat- ment centre. Many others die as a result of mismanagement. Photo WHO/M. Levine W oRLD HEALTH . April 1986 More often than not, vomiting is over-estimated by mothers who be- come very anxious and scared about their babies. This vomiting frequently abates if oral fluids are given in small quantities. Mothers (and doctors too) often rush to use anti-emetics, which may have adverse effects, not the least of which is the impairment of con- sciousness and interference with tak- ing of fluid orally. The outcome of this kind of treat- ment of diarrhoea, as urged on the mother by Grandma, can be haz- ardous: dehydration, a dash to hos- pital and perhaps even death. A "Dehydration kills " says this Brazilian government poster, urging the use of rehy- dration solution and continued feeding. great many infants with diarrhoea do not die from the disease but from mismanagement, and the principal cause of death is dehydration. In essence the prevention and treatment of dehydration is the key to saving the lives of children with diarrhoea. In short, the most recommended treatment for acute diarrhoea is for mothers to give their children oral rehydration salts (ORS)-preferably without stopping feeding them. • 11 UNICEF: 11 years in the field UNICEF bought its first supply of oral rehydration salts nearly 11 years ago. Today ORS are being consumed all around the world at a rate of eight packets every second ast year saw a continued dramatic increase in the global .__ .. supply and use of oral rehy- dration salts (ORS). More than 270 million packets were produced and, of these, more than one-half were made in developing countries them- selves. Together with WHO, UNICEF has assisted about 40 countries to under- take local production of ORS-provid- ing technical expert assistance, plant and machinery, raw materials and packaging. In addition, UNICEF is now providing over 70 million packets a year directly to CDD (Diarrhoea! Dis- ease Control) programmes around the world. It was nearly 11 years ago, in July 1975, that UNICEF purchased its first supply of ORS on what then no 12 by Roger M. Goodall doubt seemed an ambitious scale- 1,088,000 packets from Australia . These lasted 18 months, as the de- mand for this new and fairly unknown product was slow. Today UNICEF's warehouse in Copenhagen ships ORS at the rate of one million packets every three and a half days-a major logistical feat. These salts are so well known that they are being consumed at the rate of about eight packets every second around the world. A turning point in UNICEF's activities came in January 1983 when a meeting was held in New York between the UNICEF and WHO secretariats and with a number of invited specialists in the field of diarrhoea! disease control. A course was charted for taking a much greater initiative to promote ORT; it had been included as the "0" in "GOBI ", the now famous acronym for UNICEF's focus on: Growth Monitoring Oral Rehydration Therapy Breastfeeding Immunization From that meeting was born the UNICEF/WHO Joint Statement, "The Management of Diarrhoea and Use of Oral Rehydration Therapy," which was published in June 1983 and has since been reprinted in a second edition in 1985. At UNICEF's 110 field offices and in HQ New York, CDD programmes and the promotion of ORT have been a priority in our efforts in support of the Child Survival and Development Re- volution, and have been used as an entry point in getting Primary Health Care into an operational reality. UNICEF is now using the improved formula of ORS in which trisodium citrate, dihydrate, replaces the sodium bicarbonate of the original formula. The advantage of the citrate ORS is that it is far more stable when stored under tropical conditions, and can be packaged in polyethylene or lighter gauge aluminium foil. In addition, it may reduce the amount of stool out- put in severe acute diarrhoea (e.g. in cholera), and has the ancillary benefit of being better-tasting. Mothers who in the past sometimes reacted ad- Traditional birth attendants in the Philip- pines learn about ORS. Photo WHO/J. Abcede WoRLD HEALTH, April 1986 versely to the "bicarbonate" taste of the old ORS now have less hesitation in giving it to their children. At pre- sent UNICEF and WHO do not advocate flavouring ORS, since this may poss- ibly cause problems of over-use after a child has been restored to a normal degree of hydration. We are also running tests to judge the usefulness of providing with every five packets of ORS a plastic bag which when filled with water will measure one litre. The litre of water can then be put into a mixing bowl to make up the solution. The bag will be printed with instructions in pictograms and with text in several languages, which of course cannot be fitted into the space available on a single packet. Thus the bag will overcome two long- standing problems-how to measure a litre of water accurately and how to print the instructions for use in pic- tures and in appropriate languages. UNICEF is sponsoring a number of KAP (Knowledge-Attitude-Practice) surveys to determine how best to popularise oral rehydration in a way that is acceptable to the people. It is also vigorously developing social mobilisation programmes with numer- ous governments to ensure wide- spread knowledge of the benefits of ORT: this includes both the use of home-prepared solutions made from ingredients normally available in the household, such as starchy soups or sugar and salt in the correct propor- tions, to prevent dehydration occur- ring as a result of an acute attack of diarrhoea, and the use of prepackaged ORS, usually available from a local health centre, dispensary or worker, primarily as an effective treatment of dehydration if that should have set in. Various approaches have been tried with success, including teaching im- parted through the church or the mosque, through traditional mid- wives, schoolteachers, party officials and women's organisations, and through television, radio and news- papers. A good example of this kind of initiative is in Bangladesh, where a public information campaign started in 1984. This resulted in 87.5 per cent of primary schoolchildren being involved in some form of follow-up activity; over 52 per cent knew how to make W oRLD HEALTH, April 1986 Fathers too have no difficulty in giving oral rehydration to their children, as here in Pakistan. Photo W HO/UNICEF/B. Thomas ORS solution, and in 73 .5 per cent of homes, household-prepared solutions were used to treat diarrhoea episodes. Valuable lessons have been learned from this first campaign to involve primary schoolchildren, and future programmes of this kind are planned. UNICEF supports and assists the development of comprehensive CDD programmes in more than 7 5 coun- tries. These aim not only to ensure the universal availability of ORT or pre- vent dehydration, but also to concen- trate on basic preventive measures including: - promotion of breastfeeding ; - immunisation against measles, which is often closely associated with deaths from diarrhoea! diseases; - provision of clean drinking water and good hygiene and sanitation mea- sures. UNICEF provides assistance total- ling some US$ 70 million a year to over 94 countries for water supply and sanitation projects, bringing fresh water supplies for the first time to over 15 million people each year ; - clean preparation and storage of food; - health education of parents, par- ticularly in respect of sound nutri- tional practices ; - providing high-potency retinol cap- sules for infants and children in the community, since vitamin A deficien- cy is linked not only to blindness but also to diarrhoea! disease. • 13 Bacillary dysentery by Sudhir Chandra Pal uring the first half of 1984, a severe epidemic of bacillary dysentery swept through the districts of West Bengal and a few other eastern Indian States, affecting over 350,000 people and leaving about 3,500, mostly children, dead. It was like a nightmare as the disease stubbornly refused to respond to con- ventional treatment, and its galloping spread could not be contained by all available public health measures. People became confused and panicky, not knowing what to do. Bacillary dysentery, characterised by frequent passage of blood and mucus in the stools accompanied by excruciating abdominal pain, fever and intense weakness, has been afflict- ing mankind since recorded history began. It has been responsible for millions of deaths and disabilities dur- ing wars, floods, famines and other human catastrophes. Infection is caused by bacteria be- longing to the genus Shigella, and hence the disease is known as shigel- losis. The genus Shigella comprises four subgroups-S. dysenteriae, S. flexneri, S. boydii, S. sonnei-and 34 serotypes. Of the various types of shigellosis, infections caused by S. dysenteriae type 1 are the most severe and often occur in epidemic form. This type is also known as Shiga bacillus after the Japanese scientist Dr Kiyoshi Shiga who discovered the organism in 1890. Bacillary dysentery has a global dis- tribution but the highest prevalence is in countries where hygiene and sanita- tion are poor. There, endemic shigel- losis still remains a significant cause of morbidity and mortality, especially among pre-school children. In the de- veloped countries, bacillary dysentery is a mild disease mostly caused by the less virulent S. sonnei. Man is both the reservoir and natur- al host of shigella. Infection is by the faecal-oral route and the most com- mon mode of spread is by person-to- person transmission owing to the low 14 infectious dose. It requires only 10 to 100 shigella bacteria to produce dys- entery, whereas one million to ten million germs may need to be swal- lowed to cause cholera. By 1920, dysentery due to the most virulent variety, the Shiga bacillus, had almost disappeared from Europe and North America. However, it con- tinued to be reported from the de- veloping countries in the form of local- ised outbreaks. During the late sixties, Shiga's bacillus reappeared with a big bang as the main culprit of a series of devastating epidemics of dysentery in a number of countries in Latin America, Asia and Africa. In 1967 it was first detected on the border between Mexico and Guatema- la and then spread into most parts of Guatemala, Belize, El Salvador, Hon- duras, Nicaragua and Costa Rica. An estimated half million cases with 20,000 deaths (including 13,000 chil- dren) were reported during 1967 to 1971 from these countries. The case- fatality rate was as high as 15 per cent in some villages. Delayed diagnosis and improper treatment might have been the cause of the high death rate, particularly among children. An addi- tional disturbing feature was that the causative agent was resistant to the commonly used antibacterial drugs such as sulfonamides, tetracycline, chloramphenicol and streptomycin. During 1970 to 1972, the disease spread to the United States but could not get a firm foothold and was limited to only 140 cases. The next devastating epidemic oc- curred in Bangladesh in 1972 and continued with undiminished ferocity up to 1978. The cases were uniformly severe and the case-fatality rate in a well-equipped Dhaka hospital was as high as 10 per cent by contrast with only 0.5 per cent in cholera. The death rate was highest among infants (41 per cent) and elderly persons (22 per cent). In addition, several uncommon serious complications such as toxic megacolon, haemolytic uraemic syn- drome and leukaemoid reactions were also reported. Similar epidemics due to the multiple-drug-resistant S. shigae have also occurred in Somalia (1976), three villages in South India (1976), Sri Lanka (1978-80), Central Africa (1980-82), Eastern India, Nepal, Bhu- tan and the Maldives (1984) and Bur- ma (1984-85). The pattern was more or less the same everywhere. The disease spread with terrific speed in spite of all available public health measures, attacking over 10 per cent of the population and killing between two and 10 per cent even of the hospitalised cases, but mostly infants and children. In Central Africa it spread 800 kilometres in the first year and attacked several countries. The State of West Bengal (as well as the rest of India) has been endemic for bacillary dysentery, but the propor- tion of cases always remained less than five per cent of the total acute diarrhoea cases referred to hospital. But clinical dysentery cases with fre- quent passage of blood and mucus in the stool, abdominal cramps and fever started occurring in large numbers in northern districts of West Bengal from early 1984. The disease spread rapidly to the southern part of the State, and a team from the National Institute of Cholera and Enteric Diseases inves- tigated an outbreak in a village 70 kilometres from Calcutta in March that year. The village of Dhamasin had 91 acute dysentery cases with two deaths among its 937 population during a one-month period, giving an attack rate of 9.7 per cent and a case-fatality rate of 2.2 per cent. The attack rate was highest (22.7 per cent) in the below-one-year age group. Seven pa- tients were admitted to the local health centre, of whom a boy and a girl aged two years died. Shigella shigae was isolated from six out of 22 stool samples examined. All these bac- teria were resistant to the commonly used drugs and similar to those re- W oRLD HEALTH, April 1986 parted from neighbouring Bangladesh and elsewhere. The matter was promptly brought to the notice of the State as well as of the central government for early initiation of control measures. Information on the epidemic was flashed by newspapers, radio and television to raise public awareness, and health functionaries at the district level were alerted. As a result, the State Health Directorate started receiving reports of dysentery cases from one district after another. The numbers started increasing shar- ply, with the addition of 2,000 to 3,000 new cases and 100 to 150 deaths per day. The public started to panic, and the clinicians felt frustrated because the conventional treatment regimen proved ineffective. The epidemic also spread to Calcut- ta, and the number of clinical dysen- tery cases started increasing at the local Infectious Diseases Hospital from the middle of April. A total of 3 ,493 W oRLD HEALTH, April 1986 Simple prevention-washing hands with soap and water before eating and after going to the toilet. Photo W HO/S. C. Pal cases were admitted to the hospital by the end of May, and there were 70 deaths (two per cent). Samples of stool from 382 patients revealed different species of shigella germs in 52 per cent and Shigella shigae in 35 per cent of cases. These germs were sensitive to nalidixic acid (96.7 per cent), gen- tamycin (83 per cent) and furazo- lidone (77.7 per cent) , and moderately sensitive to ampicillin (42.2 per cent), kanamycin (37.4 per cent), neomycin (21.8 per cent) and co-trimoxazole (23.2 per cent), but were resistant to other commonly available antibiotics and drugs. For most of the clinicians, this was the first encounter with an epidemic of severe bacillary dysentery and there was terrible confusion over the choice of antibacterial drugs and other treat- ment. Nalidixic acid was found to be the drug of choice, but its high cost precluded its common use. Oral rehy- dration, the magic therapy for watery diarrhoea, was effective in only 10 per cent of these cases since 90 per cent had no dehydration. The sudden appearance of the large- scale epidemic took the public health authorities by surprise. But soon pre- ventive measures were undertaken at all levels of health care. The mass media undertook a vigorous prop- aganda campaign for public aware- ness, advocating boiling or chlorinat- ing drinking water, covering faeces with soil, protecting food from flies, avoiding eating exposed raw veget- ables and cut fruits, and washing hands with soap and water before eating and after going to the toilet. However, the efficacy and feasibili- ty of such methods of prevention are questionable. For example, the total production of halogen tablets-used for purifying drinking water-was only enough to meet the requirements for one or two days in the State of West Bengal alone. Similarly the scarcity of fuel restricted its use for boiling water for drinking. There is convincing evi- dence that washing hands with soap and water reduces transmission of the pathogen, but people cannot be edu- cated overnight to practise this simple procedure. As a result the epidemic took its own course and subsided only gradually, traumatising both the pub- lic and physicians in the process. Epidemics of bacillary dysentery which had been thought a thing of the past have emerged once again as a major threat to the poverty-stricken people of developing countries. The disease has already spread to as many as seven out of 11 countries in the South-East Asian region. The cause of this resurgence is not yet understood. Further alarming features are that the causative agent, Shiga's bacillus, has become resistant to most of the anti- bacterial drugs and the case-fatality rate is unbelievably high. Scientific knowledge about the dis- ease and the · germ is still inadequate. More needs to be known about the exact mode of transmission of the pathogen, about the mechanisms of pathogenicity, or even about the actu- al cause of death due to the disease. This would help in formulating more effective and practicable control measures, including development of an effective vaccine. • 15 Above left : breastfeeding Above : measles immunization Oral rehydration therapy Interventions In its efforts to save children's lives from diarrhoea. WHO gives top priority to oral rehydration therapy (ORT). which in- cludes continued feeding during and after illness. ORT ensures that fewer children need to go to hospitals or health centres and reduces the costs of treatment. Other vital interventions to prevent diar- rhoea and the malnutrition that goes with it are breast-feeding for the first two years of life and proper weaning . Measles immunization is another cost- effective means of preventing diarrhoea and reducing the dreadful toll of deaths it causes. The use of safe water and well- maintained latrines. and good personal and domestic hygiene, especially hand- washing, are simple environmental measures that can prevent disease transmission. Above: clean water Left : well-kept latrines Below : hand- washing - three factors that can help to beat killer diseases CO CO (J) I '::J <! L.U I 0 _J a: 0 s How diseases are transmitted Above : appropriate feeding Research Operational research is a key activity for national programmes to control diar- rhoea! diseases. First of all it is helping them to find the most effective means of applying available control strategies . But in addition more fundamental research , in both developed and developing countries, is seeking new ways to prevent sickness and death from diarrhoea. Avenues of research include: • devising appropriate ways of preparing ORT solutions in the home and assess- ing their impact ; • developing improved ORS that will also reduce the volume and duration of diarrhoea; • developing simple tests to identify enteric pathogens; • studying how infection is transmitted and how to interrupt its spread; • studying the association between Vita- min A deficiency- and diarrhoea sick- ness and death, and the effectiveness of Vitamin A supplements ; • developing oral vaccines against the major pathogens. Research to develop and test new control tools Prevention better than cure by Richard G. Feachem ii reating diarrhoea effectively, and reducing the fatality rate among children who get diar- rhoea, are the number one priority fo.r most poorer countries. Effective treat- ment is, however, only a short-term priority. In the longer term, diarrhoea prevention is of greater significance to the well-being of children. Diarrhoea prevention encompasses two types of activities . First are mea- sures designed to reduce the transmis- sion of the pathogens which cause diarrhoea and so to reduce the inci- dence rate and mortality rate. Since all major diarrhoea pathogens are trans- mitted by the faecal-oral route (that is from the faeces of an infected person or animal to the mouth of a susceptible child), measures to reduce transmis- sion emphasise the traditional triad of improved water supply, improved ex- creta disposal and improved domestic and food hygiene. Second are mea- sures which strengthen the ability of a child to cope with an infection and to reduce the risk of severe disease and death. In other words, these measures are designed to turn severe and fatal diarrhoeas into mild diarrhoeas or symptomless infections. These mea- sures include breastfeeding, good weaning practices and certain vacci- nations. Until now, the list of possible inter- ventions to prevent diarrhoea has been long, and it has been difficult for governments to select a few affordable and effective interventions to spear- head their activities in diarrhoea pre- vention. Careful analysis of the costs and effectiveness of a range of possi- ble interventions to prevent diarrhoea has changed this situation and it is now possible to advocate a short list of interventions of known effectiveness. Most people in the developing coun- tries, in both urban and rural areas, do not have an adequate supply of clean water close to their homes. Without 18 this basic facility, personal and domes- tic hygiene is made extremely difficult and family members may ingest pathogens contained in the faecally contaminated water. All countries are making great efforts to improve water supplies in both urban and rural areas and these efforts have been stimulated in some countries by the International Drinking Water Supply and Sanitation Decade (1981-1990). What about you? For your own culture, ask yourself the following questions. 1. In your own language are the word(s) used to describe the faeces of infants different from the words used for adult faeces ? If so, are the words for infant faeces " baby words " implying that the material is less offensive than adult faeces ? 2. In your culture, do parents when cleaning their own infants appre- ciate the highly pathogenic nature of the infant stool or do they regard the infant stool as relatively harmless compared with the adult stool? The epidemiological truth is that the faeces of children under five years of age are more likely to contain diarrhoea pathogens than the faeces of older people. The faeces of the young child are a potent source of infection within the family and germs are easily transmitted to brothers and sisters and to the child minder (often the mother). • Many problems remain, however, perhaps the greatest of which is the failure both of government agencies and of communities to adopt viable arrangements for long-term mainte- nance and the financing of mainte- nance. Because the pathogens that cause diarrhoea are shed in the faeces of an infected person, the hygienic disposal of excreta tackles the problem of transmission " at source". Every fami- ly needs good, preferably exclusive, access to a hygienic toilet or latrine. The toilet must be kept clean and must be used by all members of the family old enough to do so. Most families in developing countries lack such a facili- ty and progress on this front is slow. In many countries the number of families without adequate sanitation is grow- ing as population increases outstrip the modest sanitation programmes. Considerable progress with appro- priate technology has been made. The VIP latrine (ventilated improved pit latrine) is now well known in Africa, especially in Zimbabwe-its birth- place. In Asia, especially in the Indian subcontinent, the double-vault pour- flush latrine is being widely installed in urban areas. Access to a water supply and a toilet will not improve the health of a family unless the facilities are correctly used and other related areas of hygienic behaviour are satisfactory. Studies in Bangladesh, Guatemala and the United States have shown that the promotion of hand-washing alone can have a marked impact on diarrhoea incidence. Epidemiological studies are required in many settings to define precisely the aspects of domestic and personal hygiene that are significant risk factors for diarrhoea. In addition to hand-washing, such matters as the hygienic disposal of the stools of young children, improved food hy- giene, and the improved storage of water in the home may be important in many settings. Having defined the most important risk factors, pilot edu- cational programmes can be mounted, followed up by vigorous local or national promotion of selected edu- cational messages. Current evidence tells us that im- provements in water supplies, sani- tation and hygiene may reduce the W oRLD HEALTH, April 1986 incidence rate and mortality rate of diarrhoea by 20 to 40 per cent. These are very substantial results. But mothers can also protect their children from diarrhoea by adopting appropriate child-feeding practices. Most importantly, mothers can breast- feed their children-exclusively for the first four to six months of life and partially thereafter up to 12 months or beyond.' It is important that mothers realise that the breastfed child is at very much less risk of severe diar- rhoea and diarrhoea death than the bottle-fed child. Recent data from Brazil and Iraq show that the differ- ence in risk may be 20-fold or more. Breastfeeding in the developing countries has declined rapidly in the past two decades, especially in the more wealthy countries and in urban areas. The situation is particularly seri- ous for children being raised in urban slums, where diarrhoea remains a major cause of death and yet breast- feeding has become less popular. Vig- orous programmes of breastfeeding promotion, education and facilitation are required. Promotion and educa- tion must be directed not only at mothers, but equally importantly at fathers, at young women, and at medi- cal staff in maternity hospitals and elsewhere. Some time after four months of age, breastfeeding alone will not satisfy the child's nutritional requirements and weaning must start. Poor weaning practices are a major risk factor for diarrhoea and are partly responsible for the peak in age-specific diarrhoea incidence in the 6 to 18 months age group. Good weaning is a combination of 'the when', 'the what', and 'the how'. Weaning foods should be intro- duced neither too soon nor too late (the when) ; they should be nourish- ing (the what); and they should be hygienically prepared and given (the how). Weaning practices vary greatly from culture to culture and general- ised statements of problems and solu- tions are not possible. So local or national programmes of weaning edu- cation need to be designed and put into effect. Social scientists have a key role to play in ensuring that weaning education programmes are not in con- flict with deeply held convictions. W oRLD HEALTH . April 1986 Parents can also protect their chil- dren from diarrhoea by making sure that they are vaccinated against measles. Reports from various coun- tries show that diarrhoea accompanies between 20 and 60 per cent of measles episodes, and that 10 to 20 per cent of children will have a diarrhoea episode in the six months following a measles attack which they otherwise would not have had. This illness is exception- ally severe and is associated with a case fatality rate of between two and nine per cent. Because of this, a child immunized against measles is at reduced risk of death from diarrhoea. No effective vaccine against any major enteric infection is currently available for widespread use, though much research is underway and prospects are good. Breastfeeding, along with good weaning and certain vaccinations, sharply reduce the risk of severe disease and death. Photo WHO/ICDDR Bangladesh/ A. Ansari Tools to prevent diarrhoea are available today. While continuing to strengthen their oral rehydration ac- tivities, countries will be carefully ex- amining the available preventive mea- sures in order to select those which are locally appropriate. Some of these preventive measures are already being vigorously pursued in most countries (for instance, water supply improvement). For these the challenge is to improve their effective- ness and accelerate the growth in coverage. Others (for instance, hy- giene and weaning education) are be- ing seriously carried out in only a small minority of countries, and much epidemiological and operational re- search is required. But public health professionals and social scientists are working with communities to intro- duce effective and affordable inter- ventions, and it is safe to forecast that significant progress in diarrhoea pre- vention can be achieved in the next five years. • Cholera control by D. Barakamfitiye, D. Barua and D. Buriot Cholera vaccination campaigns give the public a false sense of protection. But with the correct use of the available resources, backed by health education messages, a great deal can be achieved even in the most desperate situations EJ lthough cholera evokes more fear that almost any other infectious disease (except pos- sibly AIDS) in the minds of the public and health administrators alike, it is amazing how little is done about it once the epidemic scare has passed. This is unfortunate since cholera is best controlled by activities in be- tween epidemics. For these to be suc- cessful, it is important to consider why cholera occurs in certain communities and populations (and not in others); and why, despite all the recent ad- vances in medical science, people still die from it. Cholera occurs primarily in areas where other acute diarrhoeas abound -that is, where conditions favour the spread of the causative germs from one person's faeces to another per- son's mouth. Germs are generally car- ried by contaminated water or food in places where there is a lack of safe water and proper excreta disposal facilities, and where personal and food hygiene practices are deficient. These factors, again, are closely connected with socio-economic status, over- crowding and cultural and traditional practices, particularly those that relate to the care of sick people, funerals, and food consumption. Recently, cholera germs (or vibrios) have been found to multiply in many cooked foods left at an ambient tem- perature; thus the habit of eating left- over food may play a more important role than was thought previously. Many instances have been reported of cholera being caught through eating seafoods. Ceremonies such as the washing of dead bodies and feasting during funerals are known to have helped the disease to spread. The cholera vibrio responsible for the current pandemic, which has af- fected more than 90 countries since 1961, is the Ogawa or Inaba serotype Cholera- the name still strikes fear through- out the world. Photo W HO/A. S. Kochar W oRLD HEALTH, Apri l 1986 of the El Tor biotype of Vibrio cholerae 01. This biotype is somewhat more hardy and therefore survives longer outside the human host than the classical biotype. The two biotypes currently co-exist only in Bangladesh. Cholera infection, in its endemic form, may persist in a community as subclin- ical or mild cases that go unrecognised as cholera for a time. The El Tor biotype has now been shown to sur- vive also in aquatic reservoirs (shell- fish, plankton) until circumstances become favourable for the vibrios to multiply and infect man. Depending on these factors, cholera outbreaks may occur seasonally or periodically at intervals of several years . The recent epidemics in drought-stricken countries of Africa, associated with migration, water and food scarcity and lowered resistance of the victims, are examples of such epidemiological events. It is well known that individuals are not equally susceptible to cholera; resistance has been found to be associ- ated particularly with high gastric acidity and immunity acquired by re- peated infections. The latter may ex- plain why, in an endemic area, cholera is particularly common in children and young adults. Cholera is rare in infants (breast milk appears to be protective) and is particularly serious in pregnant women who abort unless they are quickly rehydrated. Modern methods of treatment, which can limit the number of deaths among patients to about one per cent, are now widely known; yet death rates of up to 30 or 40 per cent continue to be seen, particularly dur- ing the first few weeks of cholera epidemics. The only reason for this high case-fatality is the lack of treat- ment facilities with trained health workers and of supplies at or near the sites of epidemics. Unfortunately, scarce resources are often spent on inappropriate fluids, useless antimi- crobials and other drugs. Unnecessary laboratory investigations using scarce material and manpower are also corn- mon. After laboratory confirmation of the first few cases of an epidemic, all cases of watery diarrhoea should be treated as cholera. The improvement of sanitary facil- ities, installation of a safe water supply, and food safety measures, ac- companied by health education, are the most important activities for the immediate and long-term control of cholera. Although the current socio- economic situation in many develop- ing countries does not permit rapid progress in these fields, some simple measures are available that may pro- vide considerable relief. For example, a recent study in India has shown that proper storage of water at home in narrow-mouthed earthen or other containers can significantly reduce wa- ter contamination. Domestic chlorina- tion of water with chlorine (bleach), consumption of only cooked food when it is still hot, and washing of hands with soap and water after using the toilet and before preparing food or eating are all feasible and effective means of cholera control. If available manpower, supplies and other re- sources can be directed to these ac- tivities and backed up with intensive health education conveying realistic and practical messages, a great deal can be achieved even in the most desperate situations. The limitations of vaccination, chemoprophylaxis, and quarantine measures in cholera control are now widely recognised. Vaccination cam- paigns give a false sense of protection to the public and a false sense of achievement to health administrators. Most of the currently available vac- cines are not tested for potency, which is the only reliable proof that the vaccine can provide even the partial protection seen in field trials. In the early 1970s, WHO used to receive requests for the supply of 20 to 22 million doses of cholera vaccine each year; such requests amount now to only about half a million doses a year. The El Tor biotype causes many asymptomatic infections (as many as 21 An East African girl draws water from a polluted well-potential source of epidemic disease. Photo WHO/J . Bland 100 carriers for every clinical case in overcrowded communities with poor hygiene); and because cholera vaccine does not prevent the carrier state, the spread of the disease by carriers can- not be prevented by vaccination. It was in recognition of this and other limitations of the current cholera vaccine that the Twenty-Sixth World Health Assembly in 1973 abolished the requirement of a certificate of vaccination against cholera in the International Health Regulations. While the treatment of contacts of patients with antimicrobials appears theoretically an attractive strategy to prevent cholera, experience with this approach has been disappointing. This is mainly because any drug needs time to work and its effect is short lasting. In a newly affected area, infection is usually much more widespread than appears from the number of clinical cases, which means that not all carriers are treated, nor are all carriers treated simultaneously. In addition to being ineffective, mass treatment with anti- 22 microbial drugs causes the emergence of resistant V. cholerae 01 strains. · There have been many examples of a "cordon sanitaire" failing to prevent the spread of cholera both within a country and between countries. This is not at all surprising because it is al- most impossible to arrest or even effi- ciently monitor movements of popula- tions. Restrictions on travel and trade have not prevented the introduction of cholera to any area, but have caused unnecessary harassment and led to attempts to suppress informa- tion about the presence of the disease. Most cholera cases can be ad- equately treated with oral rehydration therapy, which is simple and inexpen- sive. This therapy can be provided by a trained health worker without for- mal professional education if proper supplies of ORS packets are available. Only a small proportion of patients (usually two to five per cent) develop a severe disease requiring intravenous fluid, which needs to be available in all treatment centres. Antibiotics are not essential but can help to reduce the duration and volume of diarrhoea. They should be available to be given orally when vomiting stops; injectable antibiotics are costly and unnecessary. There is no need for any other drugs . Recent experience in Bangladesh has again demonstrated that the cholera death rate can be reduced to around one per cent by strengthening community-based treatment centres through supplies and training. If treat- ment is made available at or near the site of an outbreak, cases rarely die and there is no panic; moreover, cases and their contacts do not travel for treatment and there is less spread. The improvement of water supplies, sanitation, and food safety to make countries "non-receptive" to cholera clearly cannot be achieved overnight. Nor can vaccination and mass chemo- prophylaxis help to prevent the intro- duction of cholera or its spread. Rec- ognising these constraints and, more importantly, the implications of recent advances in knowledge about cholera and acute diarrhoea! diseases, health administrators have come to realise that cholera can best be controlled through a comprehensive diarrhoea! disease control programme. The be- nefits of such a programme are enorm- ous since other diarrhoeas are 80 to 90 times more frequent than cholera. The strategies of this programme include proper treatment of cases to reduce mortality from all diarrhoeas, and the promotion of appropriate maternal and child health and sanitation prac- tices to reduce morbidity. One important element of a control programme is the training of all health workers in treatment, with emphasis on oral rehydration therapy, and mak- ing this simple, inexpensive method available through all treatment facil- ities and community health workers. At the same time, a simple surveil- lance system needs to be set up for early detection of epidemics, to ensure prompt control measures and also rapid notification and international collaboration in the case of cholera. Thorough searching for cases and prompt treatment near their homes constitutes the most effective strategy for cholera control, alongside efforts to prevent the disease through sani- tary measures supported by health education. A global commitment to the control of all diarrhoea! diseases in the context of primary health care is without a doubt the key to success in cholera control. • W oRLD HEALTH , April 1986 Primary Health Care Thailand: attainable targets D n Thailand diarrhoea! diseases are the leading cause of sick-ness and death. The problem is especially severe in children aged under five, who account for about 40 per cent of all cases and about 50 per cent of all deaths due to diarrhoea. Thailand's national control of diar- rhoea! disease programme began in October 1980. lt had as its targets a substantial reduction in mortality from acute diarrhoea! diseases through ORT by way of the primary health care approach, and reduced morbidity by promoting better nutritional and ma- ternal and child health practices and safer water supply and sanitation. The government's Pharmaceutical Organization produces 750-millilitre packets of ORS to W HO formula specifications. These are purchased by the Department of Communic- able Diseases and distributed to all W oRLD HEALTH, April 1986 by Sawat Ramaboot health facilities and to village health volunteers through the provincial health offices . Some villages have their own drug cooperatives run by village committees or by volunteers. where people can also buy ORS and other essential drugs. Two years ago, the health authorities began promoting early treatment with locally available fluids mixed at home. W HO and UNI CEF are helping to supply training materials in the Thai language for health staff at all levels, to familiarise them with clinical and programme management. The vol- unteers themselves receive training as providers of ORS and as dis- seminators of health information. Village drug cooperatives in Thailand stock and sell ORS packets. Photos WHO/S. Ramaboot Since 1983, more and more mes- sages reach the public through the mass media, especially television and radio. Most hospitals are able to screen slide sets and video cas- settes about ORT and diarrhoea prevention while the mothers sit in the waiting rooms . Between 1981 and 1984, the proportion of the population under five years of age with access to ORT has risen from 12 per cent to about 60 per cent . In areas where the programme is fully developed, the use rate of ORS in the same group has gone up from 12 per cent to 30 per cent. Throughout Thailand as a whole, the use rate in children under five suffering from diarrhoea is about 18 per cent. According to the Division of Epidemiology in Bangkok, the mor- tality rate from diarrhoea in these young children between 1981 and 1983 fell from 4.97 per 100,000 to 2.35 - a reduction of 53 per cent. Surprisingly, in 1984 the mortality rate increased from the previous year while the morbidity rate de- creased. One reason may be that most non-severe cases can be self- managed by ORT, while more sev- ere cases are detected and referred by the village health volunteers and other health workers, and this re- sults in a higher number of deaths being reported at the health facilities. Some problems still exist. particu- larly as regards health education of the public and professional resist- ance to the new concepts of diar- rhoea management. But given the continuing good cooperation with concerned institutions. the targets of reduced mortality and morbidity are expected to be achieved within the next five years . • 23 Prospects for vaccines lt is 101 years since a cholera vaccine was first tested in Spain, yet the ideal cholera vaccine still eludes us. Today, encouraging advances are being made m the search for vaccines against most of the agents that cause diarrhoea efore the mid 1970s, the specific agents that cause diar- rhoea! infections in young chil- dren were largely unknown; in only about 25 per cent of cases could a known pathogen be identified. Thus, at that time, the concept of vaccines against diarrhoea! infections had no scientific basis and could not be consi- dered as a potential control measure. Since then there has been a veritable explosion of knowledge on this sub- ject, with the identification of many important new agents, including bac- teria, viruses and protozoa, that cause diarrhoea. It is now possible with appropriate microbiological tests to identify a dis- ease-causing agent in 60 to 85 per cent of cases of paediatric diarrhoea reach- ing health facilities in less-developed areas. As the agents became known, their epidemiology was studied to de- termine their relative importance, the ages and geographical areas affected, and the seasons when they occur. This was accompanied by research on pathogenesis-which is basic to vac- cine development. The result is that during the past few years we have witnessed extraordinary progress in the development of new vaccines against many of the most important agents that cause diarrhoea! disease, dysentery and enteric fevers. In trying to set priorities for vaccine development and the implementation of vaccine programmes, the relative importance of the various pathogens A schoolboy in Chile receives oral typhoid vaccine in a WHO-supported field trial. Photo WHO/M . Levine 24 by Myron M. Le vi ne that cause diarrhoea in young children can be considered from several per- spectives. Two bacterial enteric infec- tions, cholera and Shiga (Shigella dy- senteriae 1) dysentery, are of special epidemiological and historical impor- tance, because of their severe clinical manifestations and their propensity to spread in extended epidemics. Also of bacterial origin are the enteric fevers (typhoid and paratyphoid), which affect primarily school-age children. While parenteral vaccines have been available for many years against cholera and typhoid fever, these pro- vide only partial protection and are not well accepted because of their side-effects. In several studies of the etiology of infant diarrhoea in less-developed countries, which involved weekly vis- its to households (thereby detecting mild forms of diarrhoea that are often not seen at health centres), enterotox- igenic Escherichia coli was found to be the most important single etiological agent. This pathogen causes approxi- mately five episodes per child per year in the first two years of life. By contrast, when the etiology of diarrhoea has been examined at treat- ment centres, where more severe forms of diarrhoea are seen accom- panied by overt dehydration, rotavi- rus has been the single most common pathogen identified, often followed by enterotoxigenic E. coli. These two agents together, in some studies, ac- count for between 60 and 70 per cent of the dehydrating diarrhoeas in chil- dren in the first two years of life. Another perspective involves the relationship to malnutrition. Both en- terotoxigenic E. coli and Shigella in- fections, even if clinically mild, have been significantly correlated with the development of malnutrition-a corre- lation not found for rotavirus. It follows that, if safe, highly effec- tive, inexpensive and practical vac- cines were available against a few of the most important enteric pathogens, an important alternative intervention would join the battle to control enteric infections world-wide. So what is the present status of development of some of these new vaccines against enteric infections? Rotavirus Investigators across the world have taken diverse approaches to develop vaccines against rotavirus diarrhoea in human infants. However, the ap- proach that has rapidly yielded prom- ising results involves the use of animal rotaviruses as vaccines in humans. This is based on the fact that, because rotaviruses are very species-specific, animal viruses do not cause full-blown clinical infections. The vaccine (vac- cinia, derived from cowpox virus) which led to the eradication of small- pox was based on the same principle. Two animal rotavirus vaccines can- didates are being extensively evalu- ated in human trials under the aus- pices of WHO. Strain RIT4237, a virus of calf origin, has caused no notable adverse reactions in hundreds of young children vaccinated in the Gam- bia, Finland, Peru, Rwanda, and the United States. In a placebo-controlled field trial in Finland, this live oral vaccine proved highly protective. But preliminary results from studies in the developing countries suggest that high levels of protection may not be achievable with this vaccme m those areas. Scientists in the United States adapted a Rhesus monkey rotavirus, strain MMU18006, as a live oral vac- cine. This vaccine strain caused fevers in some infants between five and twelve months of age in industrialised countries but is well-tolerated by younger infants below four months of age, in both developed and developing countries. This tolerance is apparently due to the effect of the maternally- acquired antibody which is present in young infants but not in those older than four months. Field trials of effica- cy of this vaccine are under way in Finland, Peru, Sweden, the USA and Venezuela. WoRLD HEALTH, April 1986 Enterotoxigenic E. coli Observations from epidemiological and volunteer studies show that an initial enterotoxigenic E. coli infection gives rise to a high level of immunity to the same strain, but that about five separate clinical infections with dis- tinct variants of enterotoxigenic E. coli are necessary to stimulate broad spec- trum protection. There are two main approaches to developing vaccines against en- terotoxigenic E. coli. The first involves stimulating intestinal (secretory) anti- body against the colonisation factors that permit the organism to colonise the upper small intestine, the anatomi- , cal site at which these bacteria actually Clusters of rota virus seen under the electron microscope. The chances are good for find- ing a vaccine against this common cause of infant diarrhoea. Photo WHO/M . Levine cause diarrhoea. Colonisation factors are hair-like protein appendages cal- led fimbriae found on the surface of the bacteria. The second approach is the use of oral vaccines consisting of toxoids made from the heat-labile and heat- stable enterotoxins of enterotox- igenic E. coli. Shigellae Several new prototype Shigella vac- cines have recently been reported. One is a Shigella sonnei/Salmonella typhi bivalent vaccine prepared by introducing the genes that encode the production of the S. sonnei 0 antigen into an attenuated S. typhi vaccine strain, Ty2la. The resultant bivalent strain, 5076- 1C, has proved to be safe, im- munogenic and protective as a live oral vaccine in volunteer studies ; field trials are scheduled to begin in Chile, Israel, and Thailand in 1986. If this prototype proves sufficiently protec- tive against S. sonnei, then variants will be prepared against other sub- groups such as S. flexneri 1, 2, 3, and 6 and S. dysenteriae 1. Another Shigella live oral vaccine candidate consists of an E. coli strain genetically modified to invade epithe- lial cells and to express on its surface the 0 antigen of S. flexneri 2a. This vaccine is safe and protective in mon- keys, and human trials are beginning. Cholera It is 101 years since the first cholera vaccine candidate was administered to humans in Spain by Ferran, yet an ideal cholera vaccine still eludes us. However, recent progress has yielded several promising candidates and it is here that some of the most exciting and innovative applications of genetic engineering have occurred. Investigators in Goteborg, Sweden, have prepared an oral vaccine consist- ing of a combination of killed cholera bacteria plus the B (binding) sub-unit of cholera toxin, separated from the active A (toxic) sub-unit. In volunteer studies, this vaccine gave a moderate degree of protection but three spaced doses were required. A field trial is at present under way in Bangladesh com- paring three doses of the combination vaccine versus placebo or versus killed cholera bacteria alone. Scientists in Maryland and Boston, USA, have applied techniques of genetic engineering to selectively re- move the genes that encode the A sub- unit of cholera toxin from the cholera bacteria, leaving the strains no longer able to cause severe diarrhoea. The genetically-engineered vaccines avidly colonise the small intestine, stimulate high levels of antibody and are protec- tive after a single oral dose. However, most of the vaccine candidates cause diarrhoea (usually mild) in about one- third of the subjects, the cause of which is being investigated. It is argu- able that mild diarrhoea from an inex- pensive, highly effective, single dose vaccine may be a fair price to pay if it 25 provides solid, long-term protection against potentially lethal cholera. Typhoid fever Two attenuated strains of Salmon- ella typhi, Ty2la developed by Swiss, and 541 Ty by US scientists, are being evaluated as live oral vaccines. Exten- sive trials in Chile and Egypt have demonstrated the safety of Ty2la in more than 500,000 schoolchildren. The efficacy of Ty2la has also been shown but the levels of efficacy have been variable, in great part depending on the formulation and the number of doses administered. In Egypt, three doses of a liquid formulation gave 96 per cent protection for at least three years. In WHO-sponsored field trials in Santiago,Chile, three doses of vaccine in enteric-coated capsules gave about 65 per cent protection, while two doses gave some 55 per cent protec- tion. Further field trials to directly compare the efficacy of a liquid versus an enteric-coated capsule formulation of Ty2la are planned this year in Indonesia and Chile. Clinical trials with attenuated S. typhi strain 541 Ty have only recently begun, but in these initial studies the vaccine has been safe and highly immunogenic. Summary The agents that cause infant diar- rhoea have been largely identified, and vaccine candidates against most of the important pathogens (rotavirus, enterotoxigenic E. coli and Shigella) are being prepared, using the modern tools of biotechnology. Most of these vaccine candidates are administered orally as the preferred route to stimu- late local intestinal immunity. If these vaccines are to play a role in the control of endemic and epidemic diar- rhoea and enteric fever, they must be well-tolerated, highly effective, inex- pensive, practical, and ideally deliver- able through expanded programmes on immunization. Specific vaccines to diminish much of the sickness and death caused by infant diarrhoea are now feasible, or even imminent. They will comprise an important new weapon m the battle against enteric infections. • 26 Haiti's national programme by Lambert Jasmin ii he number one public health problem for Haiti is diarrhoe-a! dehydration, which is esti- mated to cause the deaths every year of more than 25,000 babies. This is why the government of this Caribbean republic, in July 1983, launched a national programme for diarrhoea! disease control arid promotion of breastfeeding (PRONACODIAM). This multisectoral programme op- erates at different levels right down to the village community. lt has four main objectives: to encourage most Haitian mothers to breastfeed their babies exclusively during the first three months of their lives and as long as possible after that; to make oral rehydration salts available to babies from the first signs of diar- rhoea, and for as long as the illness lasts; to ensure that children with diarrhoea receive digestible foods (but especially breastmilk) during their illness; and to promote indi- vidual and communal hygiene prac- tices with a view to reducing the frequency and persistence of diar- rhoea in the environment. Among the activities under the programme are the training of nurses and paediatricians in the management of seriously dehy- drated cases, the training of health auxili13ries to staff 300 oral rehydra- tion centres and to instruct mothers and health workers in the use of the salts, and the setting up of 12,000 community sales posts where the salts can be bought. Some 10,000 volunteers are also undergoing train- ing, and educational materials in support of the national programme are being disseminated through the press, radio and television. Besides this media campaign, the boy scout and girl guide movements are enthusiastically spreading the messages about oral rehydration through songs and little plays per- formed around the camp fire . All health personnel are busily convey- ing the same story in talks to indi- viduals and communal groups, through booklets and training kits. PRONACODIAM already has 200 re- hydration centres in action and · more than 3,000 sales posts display the packets. Over one milli.on pack- ets have been manufactured, ~nd 10,709 technicians in different disci- plines have received training in sup- port of the programme. A nation- wide survey taken among 1 ,050 mothers chosen at random in 30 villages found that 60 per cent of them immediately identified the packets of ORS they were shown, bven tete byen V t pit it mwcn tete pi ]on tan Allaitemenl Mat erne/: Oon Alimentaire. Don Altectif. lVJ .:.. Haitian poster encouraging breast- feeding. and 75 per cent said they knew how to prepare the salts at home and administer them correctly. This year, the PRONACODIAM pro- gramme should start making drama- tic inroads into the infant mortality figures for Haiti . • W oRLD HEALTH, April 1986 UNDP plays its part by Timothy Rothermel uring the spring of 1971, over six million people from East Pakistan, now Bangladesh, fled civil war and sought refuge in neighbouring India. An outbreak of cholera in the monsoon months of June and July attacked refugees already devitalised by exhaustion, malnutrition and exposure. Logistical difficulties and a lack of trained personnel made treatment of the sick with intravenous fluids virtu- ally impossible. The death toll grew heavy in overcrowded camps where three out of every ten people afflicted with cholera and cholera-like diseases were dying. In the library-room of the Johns Hopkins Centre for Medical Research and Training in Calcutta, a team of relief workers set-up a make-shift assembly line, measuring portions of glucose and salt into polythene bags, inserting simple instructions, and seal- ing the bags with a hot iron. A round- the-clock convoy trucked the packets some 50 miles to an emergency treatment centre at Bongaon, near the India-Bangladesh border, where more than 350,000 refugees were encamped. Over a two-month period, more than 3,700 people stricken with chol- era were treated with an oral solution prepared from the packaged powder and fresh drinking water. Administra- tion of the "oral glucose-electrolyte" solution brought dramatic results: only 135 deaths occurred-a case fatality rate of just 3.6 per cent. Cholera- related deaths had been cut nearly four-fold below the norm. The experimental treatment which saved the lives of Bangladesh refugees was the direct product of many years of intensive research work carried out by such institutes as the Cholera Re- search Laboratory in Dhaka-a long- time pioneer in testing and develop- WoRLD HEALTH , April 1986 ment of cholera treatments . Soon after the successful field trials in the refugee camps, the now famous "Dhaka cock- tail" was being tested by CRL scien- tists on a larger scale in several Bang- ladesh villages afflicted with severe dysentery. After a two-year study, researchers reported that diarrhoea- related deaths had been reduced more than four-fold in communities which used oral rehydration salts (ORS) pac- kets prepared by local UNICEF officers. UNDP has helped millions of people, mostly in the rural Third World, to gain access to safe drinking water. Photo WHO/Zafar Development and popularisation of cost-effective therapies like ORS are more often the results of long-term, cost-intensive, basic research, broad- scale organization and concerted social marketing. Diarrhoeal diseases treatment and prevention have proved no exception. Complementing the activities of other UN bodies, the UN Development Programme (UNDP) has focused atten- tion and resources on furthering the basic research essential to effective treatment of diarrhoeal diseases, and ensuring that the latest research findings are promptly disseminated through a global network of concern- ed institutions. UNDP's direct involve- ment began in 1978 when US $5 million of Interregional Programme resources were committed to a global Diarrhoeal Diseases Control programme in collaboration with WHO, UNICEF, the World Bank and other donors. Total UNDP commitments now exceed $9 million. Important catalyst Some $1.5 million of that initial UNDP grant have gone to support the groundbreaking work of the Cholera Research Laboratory, now known as the International Centre for Diar- rhoea! Disease Research. The Centre is an important catalyst in promoting ORT practices, synthesising research findings, disseminating health-care in- formation, and training health-care workers for the entire world. The UNDP and UNDP-associated funds are also assisting in boosting produc- tion of pre-packaged ORS formulas both in developed and developing countries, most recently in Somalia and Mozambique. About 270 million ORS packets were produced worldwide in 1985, 135 million of them in more than 40 Asian, African and Latin American countries. The UNDP, the World Bank, and other UN bodies have stepped up their support for the water and sanitation sector since the launch of the Interna- tional Drinking Water Supply and Sanitation Decade (mwssD) in 1980. An estimated 345 million people- mostly in poor rural regions of the developing world- gained access to safe drinking water during the first three years of the UN "Water De- 27 Biogas plant in an Indian village. UNDP and other agencies are helping developing coun- tries to benefit from new waste disposal facilities. Photo W HO/C. Stauffer cade." In addition, about 140 million people in developing countries bene- fited from new waste disposal facilities . But while progress during the Decade has been impressive, some 1,200 million people in developing countries remain without access to safe water, and some 1,900 million without adequate sanitation. Hardship in Africa Fifteen years ago world concern focused on addressing the deprivation and human suffering in the emerging nation of Bangladesh. Out of such desperate conditions came not only the promise of ORT but also the realis- ation that the fight against diarrhoea! diseases was really just one part of a 28 larger battle to overcome chronic pov- erty and malnutrition. The economic hardship and despair ravaging the Af- rican continent today is again remind- ing the international community that comprehensive relief and develop- ment aid responses are essential. It was malnutrition which took the lives of nearly five million African children during 1984; malaria, chol- era, sleeping sickness, yellow fever or other endemic diseases were simply additional scourges. Inadequate food, contaminated drinking water, over- crowded dwellings, poor sanitation and poor maternal education underlay the vast majority of serious illnesses. The African crisis is clearly systemic and corresponding responses must be holistic. UNDP is responding to Africa's ur- gent needs at two levels. At the pro- gramme and project level, the tradi- tional emphasis on integrated ap- proaches with a strong rural bias has been redoubled. In the health sector, the preference is for integrated rural health care over metropolitan medi- cal and training facilities-and a bal- ance is sought between prevention, control and treatment of disease. Dur- ing the first five years of the IDWSSD, UNDP and its associated funds have invested some $85 million in African projects featuring low-cost sanitation methods, rural handpumps and inte- grated resource recovery. UNDP is responding at the policy level by offering support in some 18 African countries for major aid review meetings with their principal external partners in a process of "round table" consultations. These are now based on thorough sector analyses and provide a coordinated means by which govern- ments can evaluate the substantive implications of the development strategies they wish to pursue, review them with their major aid partners and jointly forge programmes of sustained development cooperation. Through this more comprehensive approach to development planning, UNDP is con- tributing to build durable bridges to assist Africa's recovery and alleviate poverty in the long term. • W oRLD HEALTH, April 1986 Health Education Ethiopia: Life Saver by Channyalew Belachew D n Jimma. the capital of Ethiopia's Kaffa administrative region. oral rehydration ther- apy (ORT) is widely used to treat diarrhoea! diseases. The experience of health workers at the hospital and clinics is that most families bring in their diarrhoea- affected and dehydrated children for treatment only after they have first tried to treat them with home- prepared salt and sugar solutions. They have learned to prepare the sugar-salt solution from health per- sonnel in the hospital. at health centres and clinics and at different mass organization meetings. The community's appreciation of the effectiveness of the ORS is also vividly illustrated by the ORS pack- ages that have been spontaneously posted on front doors and walls of homes to demonstrate that members of these households have been saved by these precious solutions . When Ethiopia's National Control of Diarrhoea! Diseases Programme (which was started by the Ministry of Health in 1980) reviewed its activities in October 1984- January 1985. it found that an average of 22.5 per cent of children under five in the eight areas surveyed had been treated with ORS during their last episode of diar- rhoea . ORS use varied from 15 to 40 per cent among the regions surveyed . In Kaffa the ORS coverage was 40 per cent. which was achieved through the susta ined efforts of health workers and the mass organizations . These organizations provide not only a vehicle for health education messages but also for promoting the four strategies of the COD pro- gramme: improvement of maternal Ethiopia: where oral rehydration salts are literally life-savers. Photo W HO/J. Bland W oRLD HEALTH, April 1986 and child health care. promotion of environmental health and sanitation. epidemic control efforts. and case management. An example of the way in which better environmental health and sani- tation is bringing nearer the long-term goal of improving nutrition and reduc- ing diarrhoea! diseases is found in another region of Ethiopia. in Arssi. The women of Dodota in Arssi region are running a water project which will provide piped drinking water for the rural inhabitants of the community, whose population is expected to top 65,000 in 1995. The women maintain the pipelines. administer the project and collect water fees. The importance of involving all members of the society, and not just mothers. has been underlined in all training activities . During the period of drought and famine. the COD programme pro- vided guidelines to health personnel working in relief shelters and settle- ment areas . The emphasis was on oral rehydration. and very few intra- venous fluids are seen in these areas compared with earlier famine periods in Ethiopia . "Nefs Aden". the Amharic for "Life Saver". is one of the many local names for ORS in Ethiopia, and the name reflects the degree to which the community accepts and welcomes these salts. The availability of ORS has increased more than tenfold from 1984 to 1985. and the salts are distri- buted not only through the health facilities but in some areas also through the kebe/es- sessions of the Urban Dwellers Associations and Peasants Associations which em- brace the whole country. The challenge of the COD pro- gramme is to ensure that the right messages about ORT are being con- veyed to the public. and to accelerate the programme activities. through an intensification of health education . By making use of all available channels. the life-saving oral rehydration salts can be made available and familiar to a great majority of the population of Ethiopia. • 29 The Risk to Health Of Tobacco on the I Non-Smoking Smoker~ lt is ca lled side-stream smok- ing, or passive smoking, or en- forced smoking, or involuntary smoking. By whatever name, it is a description of a non-smoker forced to breathe smoky air- at home, in the office, in restau r- ants, for instance- and w ho thus becomes, paradoxically, a non- smoking smoker. A number of studies cited in a new report on WHO's programme on tobacco and health have underscored the hazard to health from smoking that is inflicted upon the non-smoker. One study, published in the British Medical Journal in 1981, found the risk of lung cancer higher among w ives of smokers than non-smokers. Recent find- ings by the International Agency for Research on Cancer in Lyon, France, states "that 'passive smoking' gives rise to some risk of cancer." In particular "the elderly, chi l- dren, and ca rd iac or asthmatic and hypersensitive subjects can be adversely affected by smoke produced in their vic inity," the WHO report says, w hile adding : Photo WHO/Norwegian Council. Smoking & Health A call for the right to breathe smokeless air. "Health hazards apa rt, smoke in the environment is a nuisance; exposure to it brings discomfort to many non-smokers." After studying the report. WHO's 31-member Executive Board drafted a resolution last January for consideration by the World Health Assembly w hich meets in Geneva this May, saying, in part. t hat "passive, enforced, or in- vo luntary smoking violates the 30 right to health of the non-smoker, who must be protected against this noxious form of environmen- tal pollution." The report flatly blames the spread of tobacco-related disease to "unscrupulou s commercia l enterprise and governmental inactivity." About a million "premature deaths occur yearly because of tobacco use," the report estimates . About 95 per cent of all cases of lung cancer, 75 per cent of chron ic bronchitis and emphyse- ma, and 25 per cent of ischaemic hea rt disease are caused by smoking. Some $2,000 million per year is spent by the tobacco industry world-wide on "mass ive adver- tising and sponsorship of sports and cu ltural events." according to f igures from the U.N. Conference on Trade and Development. Maternal Mortality: Almost Exclusively In the Third World Over a half of all mothers giving birth in developing countries do so without the assistance of trained personnel. A total of 57 million such births were unat- tended, est imates at around 1980 show, with mothers delive ring without the help even of TBAs - traditional birth attendants . The lack of ca re accounts for maternal mortality that is from 100 to 200 times higher in the Third World than in industrialised countries, according to experts at a recent WHO meeting in Geneva. Of all mate rnal deaths world- wide, 99 per cent occur in developing countries among women, predominantly in rural areas-where maternal care ser- •••••• ••••••• ••• ••• ••• •••••• •••••• ••••• • ••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• ••••••• • •••••••••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• • •••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• Smokers, in turn, spend be- tween $85 and $100 thousand million yearly, buying four million cigarettes to support their habit - or about 1 ,000 cigarettes for each human being on earth. In many developed countries, smoking is on the decline, and becoming socially less accept- able. But in developing countries, w hich generally lack programmes of information and education, "it is on the increase, fue led mainly by intensive and ru th less promo- tional campa igns on the pa rt of trans-national tobacco com- panies" that suggest "smoking symbolises modernism and afflu- ence". There is "common govern- ment reluctance to act on tobacco" because its production, manufacture and trade provide jobs and tax revenues, the report admits. But economic gains are out- stripped by losses - f rom increas- ing medical bills and from fires caused by ca reless smokers, for instance. In the United States alone, losses exceed earnings by some $8,000 million yearly, and in Canada by $3,000 million. Noting that "only the tobacco industry denies the role of tobac- co in causi ng disease," the report says that "the onus of proving that tobacco use is not a cause of disease should thus be on the tobacco industry itself." • vices are vi rtual ly non-existent - among those malnourished, poor, and illiterate . Thus. maternal mortal ity is an almost exclusive ly a Third World problem. "More women die in Ind ia in one month than die in all of North America, Europe, Japan and Aus- tralia in one year," the experts point out, stat ing that "the differ- entia l in maternal mortality be- tween rich and poor countries is among the highest in public health." Births too closely spaced, pre- gnancies too young, or in women with large families are among the reasons cited for the numbers of deaths. Added to those is the Third World's lack of medical faci lities and supplies - for in- stance, of blood for transfusions - as we ll as skill s, for instance, to perform Caesareans. But most of al l, it is the lack of trained pe rson- nel, and particularly TBAs, that is blamed for death rates described as "unacceptably high" by par- t icipants at the conference in Nai robi last year that marked the end of the U .N. Decade of Women. In a major recommendation to bring down mortality, the WHO experts called for stepped-up pro- grammes to train TBAs, who are trusted and respected by vi llage women. TBAs deliver an est i- mated 200,000 babies daily in the Third World . Although their ski lls are acqui red through trial and Photo WHO/A. S. Kochar A call for the training of tradition- nal birth attendants. error from relatives or friends, they have been shown to provide better ca re with training. There are still not enough of them. Women who live in "unaccess- ible areas should be accommo- dated, prior to delivery, in special 'waiting houses' near to materni- ty care facilities," the experts say in another recommendation. They also ca ll for family planning pro- grammes "targeted in particular at those at high risk of maternal mortality, at the very young, and at women who already have a large number of children" . • Trial of Birth Control Vaccine In Australia Thirty women, all vo lunteers, are taking part in the first phase of a trial to test a birth control vac- ci ne, now being carried out at Flinders M edical Centre, a WHO col laborating cent re in Adelaide, Australia. This phase, which wi ll ru n to the end of this yea r, aims at determining the safety and side- effects of the vaccine in women who are already steri li sed. A second phase, to last about two years, wou ld test the vaccine in fertile women as a method of fami ly planning, and determine as well the duration of its effective- ness, expected to be between one and two years. The development of the vac- cine is the result of work by Ohio State University in the United States, supported by Sandoz, a Swiss pharmaceutica l company, and WHO's research programme on human reproduction. The vac- cine has already been shown to be safe in several animal species. If all phases of the trial prove satisfactory, WHO officia ls say, the vaccine cou ld be available com- mercially by the mid-1990s. • W oRLD HEALTH, April 1986 News briefs e Age of Fruition. Traditionally in Japan, the age 55 and up is referred to as ronen, "old age, "or the "tired age, "and those in that age group as rojin. "old people." Now with longevity rates among the world's highest- 74.8 years for men, and 80.7 years for women - it was inevitable that senior citizens, many of whom are already resentful over forced retirement, would also object to themselves being so characterised. That led health and welfare minister, Hiroyuki Masuoka, himself 62, to launch a campaign last November to change that unflattering image. Within a month over 300,000 people had suggested 25,000 new names. A 74-member selection committee settled on jitsunen, from jitsu, "npeness." "harvest," or "fruit", and from nen, "age " - or simply the Age of Fruition. it is an indication that Japan is a country that takes seriously what the 7 982 UN. World Assembly on Aging advocated- add- ing life to years. Last year at a UN. press conference, an expert on aging pointed out that "virtually nothing has been done since that time." • Cavities in Poland. An analysis of oral health in Poland, carried out by WHO's regional office in Copenhagen, shows an average "decayed, missing and filled" tooth ratio of seven in 7 2-year-o/ds, a "very high" rating. According to targets set in 1979, the goal is a OMF average of three for all countries by the year 2000. Also, the analysis shows, 50 per cent of those aged 7 3 and 7 4 suffer from gingivitis, an early stage of gum disease that is generally a major problem - at least in developed countries - for adults. These facts, adding up to "poor oral hygiene," have led to a recommendation for a stepped-up programme for the training of "the key persons in implementing oral disease prevention programmes, particularly in schools and working places"- the dental hygienists. In the next issue How are the world's nations going to pay for the strategies needed to reach WHO's goal of Health for all by the year 2000? The May issue of World Health will suggest some of the ways in which countries are trying to solve this problem. e Mental Health. In New York, the Nathan S. Kline Institute for Psychiatric Research. which is administered by the state's office of mental health, has been designated a WHO collaborating centre in mental health. There are now e1ght collaborating centres in the USA. - In Australia, a newly-established mental health committee of the Victoria division of the UN. Association of Australia, wants to contact "similar groups internationally for information on mental health, "accord- ing to Judi Leggetts, the association's convener. (For details. write to· U.N. Association of Australia, 341 Collins Street. Melbourne. Victoria) • People. Re-appointed last January as director, WHO's regional office for South-East Asia in New Delhi, Or U Ko Ko (Burma), who. began his first five-year term of office in 1981. - Appointed as officer-in-charge of WHO 's programme on AIDS, the dreaded acquired immune deficiency syndrome, Or Jonathan Mann (US.}, formerly director of the Zairian-Be!gian-US. research programme on AIDS, Kinshasa, Zaire, who assumes his new responsibilities at mid-year. e Snuffing Out the Havana. To deg!amourise smoking, and to support an anti-tobacco campaign launched in 1981, President Fidel Castro said then: "My contribution will be not to smoke in public. " Prior to that he was seldom seen without a cigar. Now he has put out his Havana altogether. According to an interview on Brazilian television he described his decision to quit as a "sacrifice I must make for public health. " The President began smoking in his early teens, long before the link between tobacco and ill health had been established. ' Authors of the Month Dr Michael H. MERSON i~. Director of WHO's Diarrhoea! ·· Diseases Control programme (CDD) in Geneva: Professor Leonar'do MATA is Visiting Professor at . the Harvard Ul1iversity School of l'llblic Health, Boston; USA. Dr l-4athur~m SANTOSHAM and Dr Ray- mond REID are with the Johns Hopkins University, lnfectious Disease , Re- search. Center, Arizona, USA. Professor Ibrahim I. ELARABI is Ptofes" sor of Paediatrics <~t King Abdulaziz .... University, Jeddah, Saudi Arabia. . ···· Mr Roger M. GooDALL is Senior Ad- viser on Essential,Drugs, UNICEF, New York. · Dr Sudhir Chandra PAL heads the Na- n •· tional Institute of Cholera and Enteric Diseases in Calcutta, India. WORLD HEALTH The battle against diarrhoea · Dr Richard G. FEACHBM is Head of the Department ofTropical Hygiene at tl)e London School of Hygiene and Tropi- cal Medicine; Or. D. BARAKAMFITIYE is Programme Director and Dr D. BuRIOT is .Regional Adviser responsible for cm> at WHO's African Regional Office, Brazzaville, Congo; Dr D. BARUA is a consultant with CDD in Geneva. For readers everywhere 1986 Subscription Rates One year Two years Three years US$ Sw. fr. 12.50 25.- 22.50 45.- 30 .- 60.- ORDER FORM Please enter my subscription to "World Health" as follows: One year D Two years D Three years D W oRLD HEALTH, April 1986 Page 16: Top left (breastfeeding)- poster of Ministry of Health, Peru Top right (immunization)- photo WHO/J. Littlewood Main illustration (oral rehydration) - photo WHO Small inset (proper weaning)- photo UNICEF Upper right (clean water)- photo UNICEF Centre right (latrine)- from UNICEF poster. Jordan Bottom right (hand-washing) - photo Mujibur Rahaman Page 17: Top left (transmission)- graphic by Ross Institute Centre left (feeding) - photo Ministry of Health, Ecuador Bottom left (improved ORT solutions)- photo UNICEF Top right (vitamin A)- graphic by WHO Lower right (improved ORS) - photo UNICEF Main illustration (research) - photo WHOIT. Farkas Bottom right (oral vaccines) - photo ICDDR- B, Bangladesh Professor Myron M . LEVINE is Direutor ()f. the Center {or yaccine Development at the UJ1iversity of Maryland School of Medicine, USA. Dr Lambert JASMIN heads the Maternal and Child Health Service in ·the Depart- ment of Public Health and Population, Port-au-Pri~ce ," Haiti. . ,, Mr Timothy RoTHERMEL is Director of the Division for Global and Interreg- ional Projects, United Nations Devel, opment Programme, New York. : Dr Hosny,. A. TAMMAM is Director . of the Maternal and Child Health Centre, Ministry of Health, Cairo, Egypt. Dr Sawat RAMABOOT is AssistantCDD ProgrammeM;mager a(the Ministry of Public Health in Bangkok, Thailand. Mr .. Channyalew BELACHpW is CDD Manager at the Ethiopian Ministry of Health , Addis Ababa. . 0