Tackling diarrhoea on a world scale / by Michael H. Merson

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