Всемирная организация здравоохранения (ВОЗ / WHO) · Meeting reports

Report of the regional meeting on cholera and diarrhoeal diseases, Alexandria, 1-5 June 1978

31 декабря 1978 г. Всемирная организация здравоохранения

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W O R L D H E A L T H ORGANIZATION Regional Office for tho Eastern Meditorranoan Bureau r4pion.l pour la M&dltarran&e orientate

November 1978

REGIONAL MEETING ON CHOLERA Ah3 DIARRHOEAL DISEASES

Alexandria, 1

- -----5 June 1978

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SUKVhlLLANCE FOR CHOLEKA PREVE;NTlUN AND DETECTION A. A c t i v i t i e s r e l a t e d to E p i d e m i o l o g i c a l S e r v i c e Surveillance

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PROORAMME FOR CONTROL OF EKTERIC I W C T I O N S IN THE EASTERN bEDITERRANEAN REGION (1978 - 1983)

WHO L M R O

OPENING OF THE MEETING The Regional Meeting on Cholera and Diarrhoea1 D i s e a s e s w a s opened under t h e

chairmanship of D r M.O. D r A.ti.

Shoib, D i r e c t o r , Programme Management,

0x1

behalt of

Taba, WHO D i r e c t o r , LPN.

The problem of c h o l e r a and d i a r r h o e a l d i s e a s e s i n g e n e r a l has been assuming g r e a t e r importance i n tile l a s t few y e a r s because of t h e p e r s i s t e n c e of t h e s e i n f e c t i o n s and t h e d i f i i c u l t i e s encountered i n t h e i r c o n t r o l . I n t n i s Region, t h e problem, p a r t i c u l a r l y i t s i n t e r n a t i o n a l a s p e c t s , was d i s c u s s e d l a s t beptember i n t h e Meeting of t h e D i r e c t o r s of P r e v e n t i v e Medicine of t h e Arab c o u n t r i e s . This was a g a i n d i s c u s s e d i n October 1977 d u r i n g t h e 27th S e s s i o n of t h e Regional Committee i n Kuwait and recommendations were made concerning t h e measures t o b e t a k e n t o p r e v e n t t h e s p r e a d of c h o l e r a through internationalboundaries, and che Regional O f f i c e was g i v e n a s p e c i f i c mandace co a s s i s t member S t a t e s of t h e Region i n t h e f o r m u l a t i o n of a u n i f i e d h e a l t h p o l i c y t o curb t h e p r e s e n t c h o l e r a o u t b r e a k s and t o p r e v e n t f u r t h e r e p i s o d e s . On t h e g l o b a l s c e n e , t h e T h i r t y - f i r s t World H e a l t h Assembly i n May 1978 passed a r e s o l u t i o n u r g i n g Member S t a t e s t o i d e n t i f y d i a r r h o e a l d i s e a s e s a s a major p r i c r i t y a r e a f o r a c t i o n and t o a p p l y known e f f e c t i v e measures f o r t h e management and c o n t r o l of d i a r r h o e a l d i s e a s e s i n t h e primary c a r e c o n t e x t . Director-General t o promote t e c h n i c a l co-operation The Assembly a l s o r e q u e s t e d t h e among Member S t a t e s i n t h e

f o r m u l a t i o n , implementation and e v a l u a t i o n of t h e programme and i n t h e t r a i n i n g o f workers a t d i f f e r e n t l e v e l s , and c a l l e d upon o t h e r i n t e r n a t i o n a l o r g a n i z a t i o n s s u c h a s U N U P , IrlRU and UNFPA, t o s u p p o r t t h e programme a s a l r e a d y done by UNICEF. The Governments of t h e United Kingdom and Kuwait have a l r e a d y c o n t r i b u t e d f i n a n c i a l l y t o t h e e f f o r t and i t i s e x p e c t e d t h a t o t h e r Governments w i l l f o l l o w s u i t and p r o v i d e f u r t h e r s u p p o r t t o a l l o w t h e programme t o expand. The problem of d i a r r h o e a l d i s e a s e s r e q u i r e s a m u l t i - d i s c i p l i n a r y a u t h o r i t i e s o t h e r t h a n h e a l t h a r e t o be i n v o l v e d . chose r e s p o n s i b l e f o r o v e r a l l socio-economic approach and

There i s t h e r e f o r e a need t o

d i s s e m i n a t e knowledge t o o t h e r r e l a t e d s e c t o r s o f t h e Governments and p a r t i c u l a r l y KO

p l a n n i n g and development s o t h a t due

p r i o r i t y is accorded t o t h e r e l a t e d a r e a s o f w a t e r s u p p l y and e n v i r o n m e n t a l s a n i t a t i o n .

L1 EM, D I A K I D L ~ ~ J hM/MTG.ChL.DHL.DlS. /12 Page 2 CPII LIlUL/

The c o u n t r i e s of t h e Region, aware o f t h e p r i o r i t y of t h e problem, a r e p l a c i n g on t h e e x p e r t s t h e i m p o r t a n t t a s k of

d e f i n i n g t h e p r o b l e m and of p l a n n i n g and

c o o r d i n a t i n g a u n i f i e d p o l i c y of c o n t r o l . I1

NOMIIiATION OF OFFICEKS D r A.M. E l Akkad, Under-Secretary

of S t a t e f o r the Preventive Sector, Ministry

of H e a l t h , C a i r o , Egypt; D r S . Ourshano, Department of M a l a r i a E r a d i c a t i o n and Communicable D i s e a s e s C o n t r o l , M i n i s t r y of H e a l t h and W e l f a r e , Teheran, I r a n ; D r S. A 1 S u b a i h i , D i r e c t o r of P r e v e n t i v e Medicine, M i n i s t r y o f H e a l t h , Amman, J o r d a n ;

D r S. B o k h a r i , P r o f e s s o r of B a c t e r i o l o g y , B a c t e r i o l o g i s t , Punjab Government, institute

of Hygiene and P r e v e n t i v e Medicine, Lahore, P a k i s t a n ; and Dr H.S. E l Dabbagh, D i r e c t o r G e n e r a l of P r e v e n t i v e Medicine, M i n i s t r y of P u b l i c i i e a l t h , Riyad, S a u d i A r a b i a , were nominated a s a l t e r n a t e d a i l y Chairmen f o r t h e f i v e days of t h e Meeting; Dr Bokhari was nominated R a p p o r t e u r t o b e a s s i s t e d by t h e S e c r e t a r i a t . 111 ADOPTION OF THL AGENDA The Agenda was unanimously adopted. IV

KEVIEW OF THE PROBLEM OF DIARRHOEAL DISEASES I N THE REGION

No doubt d i a r r h o e a l d i s e a s e s r e p r e s e n t a h i g h l y i m p o r t a n t problem i n t h e E a s t e r n M e d i t e r r a n e a n Kegion. and non-governmental This f a c t i s a l s o e v i d e n c e d by t h e i n t e r e s t shown by a l l o r g a n i z a t i o n s i n v o l v e d i n h e a l t h work. T h i s Meeting, which natiultdl 11edltl1d u ~ l r u r i ~ i e dud s i n ~ r r n a t i o n a lh e a l t h u r g a n i z a r i o n s a s w e l l a s b i l a t e r a l

f o l l o w e d t h e Meeting o f t h e I n t e r n a t i o n a l E p i d e m i o l o g i c a l A s s o c i a t i o n (IEA) h e l d a few days e a r l i e r i n A l e x a n d r i a , i s a c a s e i n p o i n t . h e l d d u r i n g t h e Twenty-Seventh The Meeting of t h e D i r e c t o r s of P r e v e n t i v e Medicine of t h e Arab c o u n t r i e s (September 1977) and t h e T e c h n i c a l S e s s i o n S e s s i o n o f t h e R e g i o n a l Committee f o r t h e E a s t e r n M e d i t e r r a n e a n i n Kuwait (October 1 9 7 7 ) , i n i t i a t e d c l o s e r e g i o n a l c o l l a b o r a t i o n i n t h i s i m p o r t a n t f i e l d which is now b e i n g f o l l o w e d up w i t h due emphasis on t h e o v e r a l l comprehensive problem o f d i a r r h o e a 1 d i s e a s e s .

ddO EMRO

I n t h e p a s t , c h o l e r a r e c e i v e d most o f t h e a t t e n t i o n amongst t h i s group of d i s e a s e s b u t o u r p r e s e n t knowledge i n d i c a t e s t h a t we have now e f f e c t i v e t o o l s t o c o n t r o l t h e s p r e a d o f c h o l e r a e p i d e m i c s and l i m i t i t s m o r t a l i t y t o l e s s t h a n

1 per cent. attention.

On t h e o t h e r hand, o t h e r d i a r r h o e a l d i s e a s e s , p a r t i c u l a r l y t h o s e of A s a n example, i n f a n t i l e g a s t r o e n t e r i t i s , s h i g e l l a and e n t e r i c f e v e r s

i n f a n c y and c h i l d h o o d c a u s e a h i g h e r m o r t a l i t y and m o r b i d i t y and d e s e r v e g r e a t e r come h i g h e r i n t h e l i s t t h a n c h o l e r a a s c a u s e s of m o r t a l i t y and m o r b i d i t y . Although

t h e s e d i s e a s e s c a n b e c o n t r o l l e d , v e r y few c o u n t r i e s h a v e d e v e l o p e d a n e f f e c t i v e and comprehensive c o n t r o l programme a g a i n s t d i a r r h o e a l d i s e a s e s . D i a r r h o e a 1 d i s e a s e s are p r e v a l e n t m o s t l y t h r o u g h o u t t h e y e a r , i n u r b a n a s w e l l a s i n r u r a l a r e a s o f o u r R e g i o n , w i t h some s e a s o n a l v a r i a t i o n s . They a f f e c t a l l a g e g r o u p s , males and f e m a l e s , a l t h o u g h t h e burden f a l l s p a r t i c u l a r l y o n i n f a n t s and c h i l d r e n , t h e s i c k and t h e aged. u u t o f e l e v e n m i l l i o n c h i l d r e n b o r n e a c h y e a r i n t h i s Region, o n e and a h a l f m i l l i o n d i e b e f o r e t h e a g e o f one y e a r and a f u r t h e r h a l f m i l l i o n between o n e and f i v e years. A rough a n a l y s i s o f a v a i l a b l e d a t a shows t h a t d i a r r h o e a l d i s e a s e s a r e t h e c a u s e

of 3u

600 000

- 45 p e r c e n t o f t h e t o t a l d e a t h s u n d e r f i v e y e a r s of a g e ; t h i s amounts t o - 900 000 d e a t h s e v e r y y e a r . D i a r r h o e a 1 d i s e a s e s a r e t h e number one c a u s e 20 p e r c e n t o f t h e d e a t h s i n a l l

o f d e a t h i n t h i s a g e g r o u p ; t h e y a l s o c a u s e 15 age groups.

Agents o f major i m p o r t a n c e a r e b a c t e r i a s u c h a s SuirnoneZZae i n c l u d i n g i. t-.,t . ; ,

slziye 1lae, Escherichia co i,i, V i h r i o ckro lerae, staphylococci and C l o s t r i d i m pcrIiw'ri..t r ~ s ; v i r u s e s such a s e n t e r o v i r u s e s o f t h e r o t a v i r u s and p a r v o v i r u s g r o u p s and p a r a s i t e s such a s amoebae and g i a r d i a . The c h a i n o f t r a n s m i s s i o n i n d i a r r h o e a l d i s e a s e s i s f a e c a l - o r a l fomites. diseases. contan~ination

i n v o l v i n g p r i m a r i l y e x c r e t a , w a t e r , f o o d s , h a n d s , and s e c o n d a r i l y , s o i l , i n s e c t s and T h i s c h a i n h a s t o be b r o k e n i n o r d e r t o c o n t r o l any o f t h e d i a r r h o e a l New c a s e s , c h r o n i c c a s e s and c a r r i e r s m a i n t a i n t h e c h a i n o f t r a n s m i s s i o n .

I t i s r a t h e r d i s a p p o i n t i n g t o n o t e from t h e World H e a l t h S t a t i s t i c s R e p o r t t h a t t h e r e h a s b e e n p a r t i c u l a r l y no i n c r e a s e i n t h e p e r c e n t a g e of u r b a n p o p u l a t i o n s s e r v e d by s a f e w a t e r s u p p l y between 1970 and 1975 i n t h e Kegion. Fifty-two p e r c e n t of t h e

u r b a n p o p u l a t i o n i n t h e Region (68 m i l l i o n ) had a c c e s s t o p i p e d w a t e r s u p p l y t h r o u g h

house c o n n e c t i o n s .

The p e r c e n t a g e i n c r e a s e s t o 80 p e r c e n t i f s e r v i c e s t h r o u g h In rural areas only 16 per cent had a c c e s s to s a f e

watcr stondposts arc included.

w a t e r i n 1975 (30 m i l l i o n ) . The same c a n be s a i d i n r e s p e c t o f e x c r e t a d i s p o s a l ; no i n c r e a s e i n p o p u l a t i o n s c o v e r e d from 1970 t o 1975. Only s i x t y - t h r e e p e r c e n t o f t h e u r b a n and 14 p e r c e n t o f t h e r u r a l p o p u l a t i o n s have s u c h f a c i l i t i e s . Food h y g i e n e and p e r s o n a l h y g i e n e a r e g e n e r a l l y poor i n most c o u n t r i e s o f t h e hegion. T h i s is d e t e r m i n e d by socio-economic s t a n d a r d s . H e r e , e d u c a t i o n and o r g a n i z e d

community e f f o r t s ore known t o y i e l d p o s i t i v e r e s u l t s .

A c o l l a b o r a t i v e e f f o r t among d i f f e r e n t Member S t a t e s o f tlie Region i n v o l v i n g

t h e f o l l o w i n g broad a r e a s s h o u l d be made:

f o r m u l a t i n g a r e g i o n a l p l a n t o p r e v e n t t h e s p r e a d o f c h o l e r a by b r e a k i n g t h e c h a i n of e n t e r i c d i s e a s e t r a n s m i s s i o n promoting t h e e s t a b l i s h m e n t o f e p i d e m i o l o g i c a l s u r v e i l l a n c e a t c o u n t r y and regional l e v e l s promoting t h e development of l a b o r a t o r y f a c i l i t i e s u s i n g s t a n d a r d i z e d t e c h n i q u e s promoting t h e u s e o f o r a l rehydration

t h e o r g a n i z a t i o n o f emergency s e r v i c e s i n c a s e of e p i d e m i c s . l h e i m p l e m e n t a t i o n o f s u c h a programme w i l l r e q u i r e a d d i t i o n a l f u n d s f o r o v e r a l l

general support.

T h i s i s n e c e s s a r y t o c o v e r t h e c o s t s of s h o r t - t e r m c o n s u l t a n t s ,

some e s s e n t i a l s u p p l i e s and equipment a s w e l l a s f e l l o w s h i p s , t r a i n i n g c o u r s e s , meetings, seminars a s well as r e s r a r c l r , ulrdrr t h e tlicar p r i n c i p a l p r o g r a r l w s shown

be low. A rougli e s t i m a t e and breakdown o f t h e a n n u a l c o s t s f o r t h e p e r i o d 1978

1981 i s :

Support t o S e r v i c e s Training Kesearch TOTAL $

350 000

=I========

EM/ DHOLI 21 EM/DIAR/DIS/S EMiMTG.CHL.DHL.DIS page 5

C o s t s a t c o u n t r y l e v e l cannot be e s t i m a t e d a t p r e s e n t a s t h e y depend o n t h e s i z e of the p r o b l e m and t h e s t a t u s o f d e v e l u p ~ n r n t of h e a l c h s e r v i c e s i n e a c h c o u n t r y ;

however t h e y would be much more s u b s t a n t i a l .

It is t h e r e f o r e e s s e n t i a l f o r t h e s u c c e s s of s u c h a n i m p o r t a n t programme t h a t e f f e c t i v e c o l l a b o r a t i o n b e a c h i e v e d between c o u n t r i e s of t h e Kegion i n c o v e r i n g i t s c o s t s through v o l u n t a r y c o n t r i b u t i o n s . Other p o t e n t i a l sources of support a r e t h e U n i t e d N a t i o n s C h i l d r e n ' s Fund (UbICEF), t h e U n i t e d f i a t i o n s Development Programme (UNDP), t h e I n t e r n a t i o n a l Bank f o r R e c o n s t r u c t i o n and Development (IURD), and t h e U n i t e d N a t i o n s Fund f o r P o p u l a t i o n A c t i v i t i e s (UNFPA).

t(bV1EiJ OF THE PROBLEM OF THE PRESENT SITUATION I N M E M B E R COUNTRIES

D i a r r h o e a 1 d i s e a s e s i n Egypt r e p r e s e n t a s e r i o u s p u b l i c h e a l t h problem. i n the following tables: P e r c e n t a g e d i s t r i b u t i o n of major c a u s e s of d e a t h i n i n f a n t s (1973) Gastroenteritis Comniunrcable d i s e a s e s , mainly r e s p i r a t o r y Prematurity Congenital malformations Other causes

They

form t h e most common c a u s e of d e a t h i n c h i l d r e n under t h r e e y e a r s o f a g e , a s shown

43% 30%

11%

37.

Even i n t h e t o t a l p o p u l a t i o n , d i s e a s e s of t h e d i g e s t i v e s y s t e m r e p r e s e n t a h i g h p e r c e n t a g e of major c a u s e s o f d e a t h i n Egypt: U i s e a s e s of d i g e s t i v e s y s t e m S e n i l i t y and i l l - d e f i n e d c a u s e s D i s e a s e s of r e s p i r a t o r y s y s t e m U i s e a s e s o f c i r c u l a t o r y s y s tem Other causes 18.67% 12.37%

WHO E M R O

M o r b i d i t y ana e n d e m i c i t y of a c u t e d i a r r h o e a l diseases-in

Egypt

E p i d e m i o l o g i c a l s t u d i e s prove t h a t , i n g e n e r a l , t h e r e a r e f o u r a t a c k s of a c u t e d i a r r h o e a p e r c h i l d p e r y e a r d u r i n g t h e p e r i o d from 6 t o 36 months of a g e . The f o l l o w i n g a r e t h e d i s p o s i n g f a c t o r s c l o s e l y a s s o c i a t e d w i t h t h e o c c u r r e n c e of a c u t e d i a r r h o e a 1 d i s e a s e s i n Egypt:

Poor s a n i t a t i o n Malnutrition Unhygienic h a b i t s and e a r l y b o t t l e - f e e d i n g Infectious diseases

P r e v e n t i o n and c o n t r o l The f o l l o w i n g measurps z r c b e i n g adopted: (a) Environmental s a n i t a t i o n

(b)

Nutrition

water supply food c o n t r o l l e g i s l a t i o n . s a n i t a r y sewage d i s p o s a l f nutritional surveillance n u t r i t i o n a l education

Compulsory v a c c i n a t i o n programme O r a l r e h y d r a t i o n programme Network of b a s i c h e a l t h u n i t s .

P r e v e n t i o n and c o n t r o l o t c h o l e r a The f 01lowing measures a r e a d o p t e d : (a) (b) (c) (d) (e) (f) Environmental s a n i t a t i o n T r a i n i n g of s t a f f f o r s u r v e i l l a n c e Laboratory f a c i l i t i e s V a c c i n a t i o n a g a i n s t c h o l e r a a p p l i e d a s mass v a c c i n a t i o n b e f o r e o u t b r e a k s Health education Mass chemotherapy f o r c o n t a c t s , c a r r i e r s and p e o p l e from endemic a r e a s Iran D i a r r h o e a 1 d i s e a s e s c o n s t i t u t e t h e second most p r e v a l e n t d i s e a s e s i n t h e c o u n t r y . I n 1973, a s i t u a t i o n a n a l y s i s showed t h a t t h e i n c i d e n c e o f d i a r r h o e a was 22.2 p e r c e n t in the O

5 y e a r s a g e g r o u p and 14 p e r c e n t i n a l l a g e groups.

WHO t M k O

EM/CHOLi21 EM, DIAR/DfS/5 LM/MTG.CHL.DHL.DIS.i 12 page 7

To p r e v e n t d i a r r h o e a l d i s e a s e s i n c l u d i n g c h o l e r a , t h e M i n i s t r y o f H e a l t h and Welt a r e iias two programmes : (a)

long-term prograinme and s h o r t - t e r m programne Long-term programme

(b)

(a)

(b)

t o supply s a f e water t o a l l r u r a l areas w a s t e d i s p o s a l system nealth education c o v e r i n g a l l t h e c o u n t r y by h e a l t h f a c i l i t i e s network

S n o r t - t e r m progrannne

e a r l y d i a g n o s i s of c h o l e r a by e s t a b l i s h m e n t of l a b o r a t o r i e s i n a l l p r o v i n c e s s u p p o r t e d by a r e f e r e n c e l a b o r a t o r y i n t h e c a p i t a l . i s o l a t i o n of c a s e s and t r e a t m e n t chemoprophylaxis o n l y f o r c l o s e c o n t a c t s .

Mass v a c c i n a t i o n i s n o t done anywhere, b u t v a c c i n a t i o n i s s t i l l g i v e n t o t h o s e who demand i t. Tne f i n a l s o l u t i o n t o c o n t r o l d i s e a s e s , e s p e c i a l l y d i a r r h o e a l d i s e a s e s i n r u r a l a r e a s , w i l l b e a c h i e v e d t h r o u g h c o v e r a g e of t h e c o u n t r y by t h e network o f h e a l t h n o u s e s and by u s i n g o r a l r e h y d r a t i o n s a l t s (ORS) a t r u r a l l e v e l by t h e a u x i l i a r y h e a l t h w o r k e r s , which w i l l r e d u c e t h e c a s e s of d i a r r h o e a r e q u i r i n g h o s p i t a l i z a t i o n . 3.

Jordan E n t e r i t i s , t y p h o i d f e v e r , d y s e n t e r y and i n f e c t i o u s h e p a t i t i s a r e p r e v a l e n t i n

Jordan. -

The M i n i s t r y o f ~ e a l t h ' s p o l i c y r e g a r d i n g c h o l e r a i s a s f o l l o w s :

N o mass v a c c i n a t i o n i s done. Cuenloprophylaxis i s r e s t r i c t e d t o c l o s e c o n t a c t s . N o i n t e r n a t i o n a l c e r t i f i c a t e o f v a c c i n a t i o n a g a i n s t c h o l e r a i s r e q u i r e d from a r r i v a l s from i n f e c t e d c o u n t r i e s . N o r e s t r i c t i o n is made o n food i m p o r t a t i o n from i n f e c t e d c o u n t r i e s e x c e p t o n u n p a s t e u r i z e d and uncanned m i l k , m i l k p r o d u c t s and f i s h .

P i l g r i m s a r r i v i n g f r o m i n f e c t e d c o u n t r i e s , on t h e i r way t o S a u d i A r a b i a , a r e n o t a l l o w e d t o e n t e r t h e c i t i e s o r camp n e a r w a t e r s u p p l i e s . b a r l y and c o r r e c t n o t i f i c a t i o n to W H O and a l l n e i g h b o u r i n g c o u n t r i e s . i n 1976 w i t h 152 c a s e s and

Two c n o l e r a e p i d e m i c s had o c c u r r e d r e c e n t l y , i . e .

i n 1977 w i t h 427 c a s e s and one d e a t h o n l y .

The r a t i o of c a r r i e r s t o c a s e s was 1 : 1.

The two e p i d e m i c s were due t o Vibrio cholerae b i o t y p e E l T o r , s e r o t y p e Ogawa. Saudi Arabia l11t c n t c r i c communicnblc d i s c a o e s c n c ~ u n t e r e di n Saudi Arabia a r c causcd by

c.cobi, s a l ~ ~ i o ~ ~ eslhlia g,e l l a , s t a p t ~ y l o c o c c i , e n t e r o v i r u s e s and c n t . h i s t o l y t i c a . Ouring t h e l a s t f i v e y e a r s , t h e r e w e r e t h r e e l o c a l i z e d o u t b r e a k s d u e t o c h o l e r a : (a) (b) December 1974

- February -

1975 i n t h e Western Region:

1 159 c a s e s w i t h 126 d e a t h s

1976 i n i l o f u f : 163 c a s e s w i t h one d e a t h 1977 In K a i b e r , Pledina: 86 c a s e s wath no d e a t h s .

(c)

S t r i c t c o n t r o l measures a r e t a k e n d u r i n g t h e Haj p i l g r i m a g e ouch 9s:

s a n i t a r y measures:

s a f e water supply food c o n t r o l

- e x c r e t a a'isposal - fly control n e a l t h e d u c a t i o n w i t h d e t a i l e d c o v e r a g e of t h e f o l l o w i n g a s p e c t s :

how t o p r e s e r v e food how t o p r e v e n t h y p e r p y r e x i a and h e a t e x h a u s t i o n h y g i e n e and c l e a n l i n e s s

quarantine

- personal continuous s u r v e i l l a n c e There i s c l o s e co-operation

a v a i l a b i l i t y of m e d i c a l s e r v i c e s s u c h a s r e h y d r a t i o n c e n t r e s

between v a r i o u s M i n i s t r i e s i n t h e f o r m of a Board

of E n v i r o n m e n t a l H e a l t h f o r t h e c o n t r o l and g u i d a n c e of a l l t h e tlaj r e q u i r e m e n t s .

Pakistan Causes of d i a r r h o e a l d i s e a s e s The i d e n t i f i e d c a u s e s of d i a r r h o e a 1 d i s e a s e s and g a s t r o e n t e r i t i s i n a d u l t s

(a)

a r e the following:

V a r i o u s s p e c i e s of s h i g e l l a .

These i n o r d e r of p r e v a l e n c e a r e :

Shiije lLa fl e x n e r i , Shi_oeP& s;tiyue, SiaigeZZu LoyJi and S r i i y o Zlu s u ~ ~ ri r .o

t n t e r o p a t h o g e n i c StapnyZococcus pyogenes. V a r i o u s s p e c i e s of s a l m o n e l l a . L u t e r o p a t h o g e n i c c'scnericizia c o l i . i n t h e form of o u t b r e a k s which o c c u r r e d i n t h e y e a r s 1958, 1960, 1365, 1967, 1968, 1969, 1970 and 1977.

- Viorio cnoleme (b)

The c a u s a t i v e organisms i n i n f a n t s and c h i l d r e n a r e t h e f o l l o w i n g : e n t e r o p a t h o g e n i c Escherichia c o l i ; v a r i o u s s p e c i e s of s h i g e l l a ; v a r i o u s s p e c i e s of s a l m o n e l l a ; e n t e r o p a t h o g e n i c Staphylococcus pyogenes;

(c)

Vibrio cholerae i n t h e form of epidemics mentioned above. I n c i d e n c e of e n t e r i c f e v e r s , d y s e n t e r y and c h o l e r a i n Pakis_stan No n a t i o n a l f i g u r e s a r e a v a i l a b l e . A s u r v e y based o n r e c a l l h i s t o r y i n

Ferozewella and G a j j a m a t t a v i l l a g e s r e v e a l e d t h a t d i a r r h o e a 1 d i s e a s e s c o n t r i b u t e d t o 8 0 p e r c e n t of m o r b i d i t y and m o r t a l i t y amongst a l l combined c a u s e s . 1974 In the years

1975 t h e f o l l o w i n g was t h e i n c i d e n c e of d i a r r h o e a l d i s e a s e s , g a s t r o e n t e r i t i s

and e n t e r i c f e v e r s :

Children 0

(d)

- 4 years

: 30.3%

C h i l d r e n above 4 y e a r s and a d u l t s : 10.22 Cholera outbreaks C l a s s i c c h o l e r a o u t b r e a k s o c c u r r e d i n 1947, 1948, 1949, 1960 and 1968. E l Tor

c h o l e r a , s e r o t y p e Ogawa, o u t b r e a k s s t a r t e d i n 1964 i n L a l y a r i a r e a i n Karachi and spread north along t h e r a i l r o a d . o u t b r e a k o c c u r r e d i n 1977. They o c c u r r e d p r a c t i c a l l y e v e r y y e a r . The l a s t A p o s s i b l e endemic a r e a i s t h e L a l y a r i a r e a of K a r a c h i .

However, Lahore, Multan, and S i a l k o t s h o u l d b e i n v e s t i g a t e d f o r e n d e m i c i t y . A s u r v e y of s t o o l s among h e a l t h y c o n t a c t s i n Kasur j a i l d u r i n g a n epidemic

o u t b r e a k i n 1977 i n d i c a t e d t h a t 3.8 p e r c e n t of t h e inmates of t h e b a r r a c k s were c a r r i e r s of Vibrio cholerae b i o t y p e E l Tor s e r o t y p e Ogawa. 1968

It was found d u r i n g t h e

epldemlc t h a t 25 p e r c e n t of t h e p a t i e n t s were h a r b o u r i n g o r g a n i s m s r e s i s t a n t

t o t e t r a c y c l i n e and t h a t 22 p e r c e n t s e n s i t i v e s t r a i n s became r e s i s t a n t t o t e t r a c y c l i n e during treatment.

LMI CtULlL1 EMIDIAKIDISI 5 ~IMZC;.C~L.DHL.LIS.~~~ page 1 0 of d i a r r h o e a 1 d i s e-ases F a c t o r s r e s p o n s i b l e f o r p e r s i s t e n c e ---

(el

These a r e determined by poor e n v i r o n m e n t a l c o n d i t i o n s ( w a t e r s u p p l y , sewerage and g a r b a g e d i s p o s a l ) . S u r v e i l l a n c e o p e r a t i o n s a r e l a c k i n g because of l a c k of public health laboratories i n t h e provinces. (f) Future plans A c h o l e r a and d i a r r h o e a 1 d i s e a s e s c o n t r o l programme c a n be i n s t i t u t e d under t h e

communicable d i s e a s e s c o n t r o l programme. v1

POTtNTIAL FOR THt CONTROL OF DIAKKtiOEAL DISEASES WITH VACCINES AND by CHEMOPKOPHYLAXlS

Cholera vaccines Vaccines t h a t a r e c u r r e n t l y a v a i l a b l e c a n n o t be r e l i e d on f o r t h e c o n t r o l of

cholera.

Although moderate l e v e l s of p r o t e c t i o n have been o b s e r v e d i n some f i e l d The d i s p a r i t y between r e s u l t s of some f i e l d t r i a l s and t h e i r

t r i a l s o f c h o l e r a v a c c i n e s , t h e i r e f f e c t i v e n e s s has n o t been s u b s t a n t i a t e d i n epidemic c o n t r o l . d i s a p p o i n t i n g a p p l i e d u s e i s due , t o s e v e r a l r e a s o n s : t h e r e i s a wide v a r i a t i o n i n potency of v a c c i n e s produced by d i f f e r e n t m a n u f a c t u r e r s and even l o t - t o - l o t manufacturer a t d i f f e r e n t times; measured l e v e l s o f v a c c i n e e f f i c a c y i n f i e l d t r i a l s a r e t h e r e s u l t of v a c c i n e induced i ~ m u n i t yr e i n f o r c e d by n a t u r a l l y o c c u r r i n g t r a n s m i s s i o n ; i n epidemic s e t t i n g s t h i s r e i n f o r c e m e n t is u s u a l l y minimal and l i m i t e d ; even v a c c i n e s of known h i g h potency p r o v i d e o n l y 50-60 p e r c e n t p r o t e c t i o n i n endemic a r e a s f o r a b o u t 2-4 months; they do not materially i n t e r r u p t transmission; t h e y do n o t a f f e c t t h e c a r r i e r s t a t e ; t h e y do n o t p r e v e n t t h e i n t r o d u c t i o n i n t o a r e g i o n o r c o u n t r y ; t h e y g i v e a f a l s e s e n s e of s e c u r i t y t o t h o s e who r e c e i v e them; t h e y give a false scnsc of accomplishment t o thwae w h u

v a r i a t i o n of v a c c i n e s produced by t h e same

d d m i n i s t e r them; t r e a t m e n t and s i m p l e

t h e r e a r e more e f f e c t i v e c o n t r o l measures s u c h a s o r a l - f l u i d s a n i t a t i o n which a r e l e s s e x p e n s i v e i n t h e l o n g r u n ;

. WHO EMRO

EM/CHOL/21 EM/DIAB/DIS/S EM/MTG.CHL.DHL .DIS i 12 page 11

(j) v e r y o f t e n v a c c i n a t i o n programmes a r e performed u s i n g t h e same needle o r s y r i n g e f o r s e v e r a l persons which a l l o w s t r a n s m i s s i o n of v i r a l h e p a t i t i s , a d i s e a s e much more s e r i o u s t h a n c h o l e r a . However, i f a vaccine of known high potency is a v a i l a b l e , s e l e c t i v e v a c c i n a t i o n of high-risk p o p u l a t i o n groups u s i n g a p p r o p r i a t e techniques may be a d v i s a b l e i n s p e c i a l circumstances. Some experimental v a c c i n e s appear t o o f f e r some hope i n o b v i a t i n g a few of t h e s e disadvantages. (a) 5 e s e experimental v a c c i n e s include: This vaccine

A r e c e n t l y t e s t e d albmiiliuh adjuvant b i v a l e n t whole-cell v a c c i n e .

has been found i n p r e l i m i n a r y t r i a l s t o p r o t e c t c h i l d r e n i n endemic a r e a s i n I n d i a and Indonesia t o a much g r e a t e r e x t e n t than g e n e r a l l y a v a i l a b l e v a c c i n e s and to

provide about SOX p r o t e c t i o n i n a d u l t s f o r approximately 11 months.

(b)

A p u r i f i e d toxoid o r

a combined t o x o i d - b a c t e r i a l vaccine.

Because of s h a r e d

a n t i g e n i c i t y between c h o l e r a e n t e r o t o x i n and t h e h e a t l a b i l e t o x i n of e n t e r o t o x i g e n i c B.coli, t h e r e i s a p r o s p e c t t h a t a c h o l e r a toxoid might p r o t e c t A p r e l i m i n a r y toxoid f i e l d t r i a l was d i s a p p o i n t i n g ,

a g a i n s t both d i s e a s e s . but another i s planned. (c)

N a t u r a l l y o c c u r r i n g and l a b o r a t o r y mutants of V. choleme.

Several s t r a i n s

have been t e s t e d b u t a t t h i s time none a p p e a r s t o be imminently promising.

Shigella vaccines Streptomycin- dependent s t r a i n s of Shigellu flexneri and S . sonnei have been

developed, e x t e n s i v e l y s t u d i e d and f i e l d t e s t e d .

High l e v e l s of t y p e - s p e c i f i c Laboratory r e v e r s i o n

e f f i c a c y have been demonstrated i n c h i l d r e n r e s i d i n g i n endemic a r e a s and i n members of t h e armed f o r c e s but p r o t e c t i o n l a s t e d f o r l e s s t h a n one y e a r . reporteu. of t h e s e s t r a i n s and i n one i n s t a n c e r e v e r s i o n i n man of a v a c c i n e s t r a i n have been

'i'nese f a c t s and t h e need f o r m u l t i p l e doses s e r i o u s l y l i m i t t h e p o s s i b i l i t y

of p u b l i c h e a l t h a p p l i c a t i o n of t h e s e v a c c i n e s . t i e a t - k i l l e d o r a l s h i g e l l a v a c c i n e s have been t e s t e d but have not been shown t o protect.

Kotavirus v a c c i n e s I n c r e a s i n g t i t r e s of a n t i b o d i e s a g a i n s t r o t a v i r u s w i t h i n c r e a s i n g age a s s o c i a t e d

I.MI CHOL/ 2 1

WHO EkIKO

LMID I M r DlS15 tH,MTG . C t f L . D d L .DIS. I 12 page 12 w i t h d e c r e a s e d s u s c e p t i b i l i t y t o t h e d i s e a s e s u g g e s t t h e p o s s i b l e u s e f u l n e s s of a r o t a v i r u s vaccine. Although r o t a v i r u s s t r a i n s a p p e a r t o be m o r p h o l o g i c a l l y ~ i m i l a r t h e r e may b e s u b t l e a n t i g e n i c d i f f e r e n c e s and t h i s q u e s t i o n i s b e i n g s t u d i e d a s a s t e p towards t h e development of a v a c c i n e . 4.

Chemoprophylaxis l e t r a c y c l i n e h a s been shown i n c l i n i c a l f i e l d t r i a l s i n Dacca, C a l c u t t a , and

. choterae among c l o s e c o n t a c t s of t h e P h i l i p p i n e s t o r e d u c e t h e t r a n s m i s s i o n of V c a s e s , a l t h o u g h i n one endemic a r e a t h e e f f e c t was r e p e a t e d l y shown t o l a s t o n l y a day o r two l o n g e r t h a n t h e p e r i o d of t r e a t m e n t . f o r 5 days was l e s s e f f e c t i v e . over 3 days. A l o n g - a c t i n g sulpha-drug s u l p h a d o x i n e (FenasiL) was a l s o found i n a f i e l d

T e t r a c y c l i n e was a d p i n i s t e r e d i n

some of t h e s e t r i a l s i n m u l t i p l e d o s e s f o r 3 t o 5 d a y s ; one l a r g e d a i l y dose g i v e n R e c e n t l y however, d o x y c y c l i n e i n o n l y one 300 m g d o s e was found t o be almost a s e f f e c t i v e a s m u l t i p l e d o s e s of t e t r a c y c l i n e g i v e n

t r i a l i n a newly-affected a r e a i n A f r i c a t o s h o r t e n t h e p e r i o d of v i b r i o e x c r e t i o n by c l o s e c o n t a c t s but t h e appearance of new c a r r i e r s among them, i . e . was n o t looked f o r . transmission, I n a n o t h e r t r i a l i n C a l c u t t a , s u l p i ~ a d o x i p ewas found a s e f f e c t i v e

a s t e t r a c y c l i n e i n r e d u c i n g transknission b u t was s l o w e r i n a c t i o n . b e i n g l e s s e f f e c t i v e d u r i n g t h e more i m p o r t a n t 4 8 h o u r s . These new r e s u l t s have l e d c o u n t r i e s t o u s e a n t i m i c r o b i a l s l i k e t e t r a c y c l i n e . chloramphenicol, s u l p h a d o x i n e and s t r e p t o m y c i n i n t h e c o n t r o l of c h o l e r a epidemics b u t t h e i r e f f e c t i v e n e s s has n e v e r been p r o p e r l y e v a l u a t e d . manner. A l l t h e s e d r u g s have

potentially scrious side effects, particularly w h ~ n administered i n an unsuparviscd

T e t r a c y c l i n e may c a u s e l i v e r damage and i s c o n t r a - i n d i c a t e d

i n pregnant

women, s m a l l c h i l d r e n and i n p e r s o n s w i t h r e n a l d i s e a s e ; s u l p h a d o x i n e may c a u s e blood d y s c r a s i a s and h y p e r s e n s i t i v i t y r e a c t i o n s i n c l u d i n g Stevens-Johnson syndrome; c n l o r a n ~ p h e n i c o lmay c a u s e a p l a s t i c anaemia. of m u l t i p l e d r u g r e s i s t a n c e . A l l t h e s e d r u g s can prqmote t h e d e v e l o p m e n t They may a l s o i n c r e a s e s u s c e p t i b i l i t y t o a v a r i e t y o f

e n t e r i c pathogens i n c l u d i n g V. cnolgrae by a l t e r i n g t h e i p t e s t i n a l f l o r a . A WHO working g r o u p d i s c u s s i n g t h i s p r o b l e n concluded t h a t t h e e v i d e n c e f o r t h e e f f e c t i v e n e s s and s a f e t y of d r u g s used f o r p r e v e n t i v e m e d i c a t i o n a g a i n s t c h o l e r a is n o t such t h a t t h e y c o u l d recommend any of them f o r mass a p p l i c a t i o n . It has a l s o

ljiiO

E M R O

EM/CHOL/Zl EM/DIAR/DIS/S EM/MTG.CHL.DHL.DIS./12 page 13

tern

pointed o u t c h a r , a s i n a community u s u a l l y not more t h a n 5 p e r c e n t w i l l b e

i n f e c t e d w i t h V. cholerae a t any one time and of them l e s s t h a n 5 p e r c e n t may g o on t o develop c h o l e r a , i t may b e n e c e s s a r y t o t r e a t about 400 persons t o prevent one c a s e . The r i s k / b e n e f i t r a t i o i s t h u s d i f f i c u l t t o j u s t i f y . Multiple systematic c a s e s o f c h o l e r a i n a f a m i l y a r e very r a r e . This k i n d o f t h e r a p y with t h e a p p r o p r i a t e drug may, however, be e f f e c t i v e i n c o n t r o l l i n g o u t b r e a k s i n s m a l l , r a t h e r i s o l a t e d and s t a b l e couununities, e.g. camps, on board s h i p s , e t c . dosage may be s u i t a b l e f o r t h a t purpose. refugee Doxycycline and o t h e r t e t r a c y c l i n e s g i v e n i n appropriate

It i s t h u s d i f f i c u l t t o f i n d t e c h n i c a l j u s t i f i c a t i o n f o r t h e u s e of t h e a v a i l a b l e b a c t e r i a l e n t e r i c v a c c i n e s o r chemoprophylaxis i n c o n t r o l of c h o l e r a and o t h e r d i a r r h o e a 1 d i s e a s e s , e x c e p t p o s s i b l y i n a few unusual c i r c u m s t a n c e s .

VIL

CONTROL OF EPIDEMICS An epidemic o u t b r e a k of c h o l e r a i s u s u a l l y a sudden e v e n t f o r which h e a l t h

a d m i n i s t r a t i o n may not be f u l l y prepared. ihnergr~iciesi n g e n e r a l r e q u i r e a s y s t e n ~ a t i capproach t o a v o i d d i s p e r s a l of

a v a i l a b l e r e s o u r c e s and d i s r u p t i o n of e s s e n t i a l s e r v i c e s .

I n g e n e r a l , i t may be s a i d

t h a t a well-organized emergency s e r v i c e should n o t d i s t u r b t h e o t h e r e s s e n t i a l h e a l t h s e r v i c e s b u t o p e r a t e w i t h e f f i c i e n c y p a r a l l e l t o and i n c o o r d i n a t i o n with them. The e s s e n t i a l e m e r g e n c y , s e r v i c e s i n c a s e of epidemics imply t h e f o l l o w i n g broad activities: (1) (2) p r e p a r a t i o n of a p l a n of a c t i o n w i t h assignment of r e s p o n s i b i l i t i e s a t c e n t r a l , p r o v i n c i a l and l o c a l l e v e l s ; p r o v i s i o n of medical c a r e f a c i l i t i e s ; p r o v i s i o n of t r a n s p o r t f a c i l i t i e s ; e p i d e m i o l o g i c a l s u r v e i l l a n c e i n c l u d i n g prompt i n v e s t i g a t i o n ; m o n i t o r i n g and e v a l u a t i o n . The methodology f o r t h e implenientation of t h e above-mentioned broad a c t i v i t i e s may v a r y with t h e type of emergency encountered and i s d e a l t w i t h i n t h i s p r e s e n t a t i o n i n r e l a t i o n t o t h e c h o l e r a problem.

(3) (4) (5)

LM/CHOL/Z~ EM/DIARIDISI 5 EM/MTG.CttL.DHL.DIS./lZ page 14

The first action to be taken on receipt of information that a cholera epidemic has started, or is likely to start, is the nomination of a responsible officer for coordination of all activities connected with the emergency. The responsible officer should be supported by a group of experts in the sectors of Health, Public Works (Water and Sewage), Information, Transport, Comunications, Local Administration, Finance and Planning, as may be required by the multidisciplinary nature of themeasures to be taken. 1. (a) The plan of action will include the following: Nomination of responsible officers; designation of reference 1aboratories;designation of reference hospitals; designation of environ:!tental health control officer. (b) Assignment of responsibilities at national and provincial levels. (c) ~efinitionof standard methodologies for: screening of cases, diagnostic criteria, collection of specimens, transport, laboratory examination, reporting and crosschecking, screening and treatment of contacts, treatment of cases including antibiotic schedules and rehydration techniques, transport of patients, disposal of infected material, epidemiological investiga~ionof cases and clusters, including environmental studies, examination of water, sewage, food, etc., techniques and reporting, follow-up of cases and contacts, measures at frontier posts, preventive measures including treatment of vater,and health education. (d) Collaboration and coordination with WHO in the following specific areas: Notification of cases and deaths; agreement on measures affecting international travel and trade; epidemiological study on the dynamics of the epidemic within the country as well as at international level; exchange and dissemination of information; coordination with neighbouring countries; provision of technical expertise and essential supplies and equipment not locally available.

Facilities, equipment and supplies Hospitals with an adequate number of beds for cholera patients Professional and sub-professional staff Sufficient quantities of antibiotics for the treatment of cases sufficient quantities ok intravenous rehydration fluids exclusively (Ringers' Lactate or 5.4.1)

of the recommended

type

Sufficient quantities of oral rehydration salts of the recommended type only.

E M ~ C H O L 21 I

EM/DIAR/DIS/5 EM/ MTG C H L DHL .DIS

. .

. 12 /

page 15

Laboratories conveniently distributed so as to cope with the needs of examination of stool specimens, duly equipped for cholera vibrio culture and isolation Sufficient quantities of TCBS, Krigler's and peptone media Sufficient quantities of specific diagnostic sera. Training of all responsible staff on: Appropriate clinical diagnostic techniques Appropriate treatment techniques Appropriate rehyaration techniques Appropriate laboratory techniques. Provision of transport facilities

Ambulance services to ensure the rapid transport of cases to the nearest treating nospl tal. For suppiles and equipment dls trlbutron and replenishment For epidemiological investigation teams For environmental sanitation teams For transport and disposal of iniected material.

(a)

ts tablishment of a centrdl epidemio1o;ical

intelligenre_2&i~

fs:

&eceipt of all notification of new cases of cholera Mapping of t t t r geogrdpliical spread of the disease Identitication of drCClE and population groups under risk s t u d y o i the returns of o&idemiological i n v e s t i g a t i o n and i d e n t i f i c a t i o n of'

sourc6:s and causes Lnitiation and implenientation ot further studies likciy to elucidate t i l e clyna~ics oi the epidemic Advice on measures to curb the epidemic tvaluation of the results of measures taken. hstablisnment of regional epidemiological units U n d e r t l l u d i r e c t i o n of the c e n t r a l epidemiological uni t

(b)

Active and passive search for cases and carriers Implement investigation of individual cases of cholera and oi each cluster

cul l e c t s p e ~ i o ~ e ui ~r st ~u o l s , w ~ t c r , sewage, t o o d ,

rtc.,

relevdnt t c

LIIL

lilves t i g d t i v n and o b t a l n t h c i r e x d m i n ~ t i o n

M a l n t a i n a map w i t 1 1 t h e d i s t r i b u t i o n of c a s e s and c l u s t e r s K e i ~ o r tt o t h e c e n t r a l epideutioloyical u n i t ~v,~lu,r ~etstu l t s o l c o n t r o l measures t a k e n . Md,x~itoritlgand E v a l u a t i o n The r e s p o n s i b l e o f f i c e r i n c h a r g e of t h e en~ergency o p e r a t i o n s i n c a s e of a

cnolcra c p ~ d e m i c , as w e 1 1 as tllr ~ e c l l ~ r i c d c~'l;fi~i l C C C C , S h o u l d , through1 t h e e p ~ d e ~ ~ ~ i c i l t , - -

g i c a l i n t e l l i g e n c e u n i t m o n i t o r t h e d i f f e r e n t a s p e c t s of t h e i m p l e m e n t a t i o n o f t l ~ c p l a n o t a c t i o n , e v a l u a t e t h e e f f i c a c y of t h e measures t a k e n , i s s u e t h e ~ n s t r n ' t i o n s t o tclose c o n c e r n e d f o r c o r r e c t i v e measures when n e c e s s a r y and have t h e power t o chan&e s t a f t o r modify i n s t r u c t i o n s a c c o r d i n g t o r e q u i r e m e n t s . ltle

plarlning o t tire n l o n l t o r i n g of c h o l e r a a s a p a r t o f f h e post-epidemic

s u r v e i l l d n c e s e r v i c e i n t h e c o u n t r y i s a l s o a p a r t o f t h e d u t i e s of t h e r e s p o n s i b l e ok t Lcer and of t h e s u p p o r t i n g t e c h n i c a l comnnlittee. Such a p l a n s n o u l d be p r e s e n t e d i n t h e form of recomnlcndations f o r a c r i v i t i e s t o be i n c l u d e d i n t o t h e r e g u l a r s u r v e i l l a n c e of communicable d i s e a s e s . In those c o u n t r i e s wirere such a conununicable d i s e a s e s s u r v e i l l a n c e s y s t e m d o e s n o t e x i s t , t h e s u c l e u s c r e a t e d f o r t h e p u r p o s e of a n emergency s h p u l d be r e t a i n e d and s e r v e a s a b a s i s f o r t h e e s t a b l i s h m e n t of such s e r v i c e s .

V L 11 SURVEILLANCE FUR CHOLERA PREVENTlON AND DLTECTION

ACTIVITIES RELATED T O EPIDLMIOLUGICAL SERVICE Surveillance Passive c l i n i c a l Active c l i n i c a l Active environmental

(i)

Screening Screening Screening

Clinical laboratory confirmation

dater Sewage

Public health laboratory con£ i r u i a t i o n

- Food

WHO EMKO

EM/CHOL/21 EM/UIAR/DXS/5 EM/MTG.CHL.DHL.DIS.112 page 17

(ii)

Epidemiological study

- Analysis of existing information:

mapping of the disease identification of population at risk

- Surveys and specific case studies: - identification of patlrogens - identification of causes or routes of transmission

- definition of receptivity (iii) Definition of control measures

For preventing the spread of infection within the country

(iv) tpidemiological Information System

through international boundaries

to the general public international notification to the medical profession

SUKVLILLANCE burverllance is a process of continuous monitoring of diseases among the

population witri tcttal coverage in time and space. 1.1onrtoring Implies the following essential requirements: (a)

(b)

the abrlity to diagnose; tile ability to communicate.

The tirst requirement, diagnosis, can be achieved with precision in the curative institutions, particularly where qualified medical personnel and equipped laboratories exist. Unfortunately, the curative institutions of this type are scarce or non-existent in most ok the rural areas. It is not necessary to emphasize the need for a minimum of service at the most peripheral level in a complete network of primary health care, but, can such a system ensure the "diagnosis" at primary level! The non-professional health worker needs some tools to satisfy the diagnostic requirement. These are:

( (L)

t h e c x i s t r n c e f o r eclcli d i s e a s e o f r e l i a b l e s c r e e n i n g c r i t e r i a ; tllv p o s ~ i b i l i t yof r a p i d v e r i f i c a t i o n tilrough s i m p l e L ~ b o r a t o r y t e s t s ltle s i m p l e "primary" s c r e e n i n g perforined by ttie primary healt11 worker would

lead t o by h i m ,

morr p r e c i s e J i a ) : n o s i s by l a b o r a t o r y t e s t i n g o f t h e speci!orn c o l l e c t e c i

u s i n g s i m p l e and s a f e t e c h n i q u e s .

llle p r i ~ ~ a r sy c r e e n i n g would be f o l l o w e d by a morr p r e c i s e d i a g n r ) s i s throu,:tr simpliticd laboratory techniques. I n tile c a s e of c h o l e r a i t i s o b v i o u s t h a t a t pritpary s c r e e n i n g l e v e l , i t would

n o t be 1 , o s s i b l e t o d i a g n o s e t h e i n i t i a l c a s e s of c h o l e r a o c c u r r i n g w i t h o u t laborcltury support. I n p r a c t i c e , t h e primary s c r e e n i n g f o r c h o l e r a siiould be hased on r e g u l a r

c o l l e c t i o n of s t o o l s p e c i r i ~ e n sf ronr any c a s e of d i a r r t l o e g o c c u r r i n l ; aniont; a d u l t s . l l l e r~ietliodologyo t i n v e s t r g d t r o n ~ n c i u d e s ; (4)

l d e n t i f i c a ~ i o nof t h e e r l t e r o p a t t i o g e n i c a g e n t ; l d e l l t i f i c a t i o n of t n e nlost p r o b a b l e r o u t e of i n f e c t i o n ; D e t e r m i n a t i o n o i tile intensity c > i ttie f a e c a l - o r a l c y c l e of i n t e c t i o n ; l d e i l t i f i c a t i o n of t h e c o r r l g i b l r o r b r e a k a b t e bonds of t h e c h a i n of ~rdrra~l~iuaiurl; Uef i n i t i o n of t h c methodology o i c o n t r o l .

(o)

(e)

Ttie second e s s c r i t i d l r e q u i r e m e n t i o r any s u r v e i l l a n c e systeni i s tire " a b i l i t y t o communicate". l l l e communication p r o c e s s i s a two-way exchange of i n f o r m a t i o n

w h i c n i n v o l v e s tile I i e a l t h w o r k e r s on one s i d e and t h e p o p u l a t i c ~ non t h e o t h e r .

!<tien i n ~ p l e m e n t i n g s r l r v e i l l a n c e a s a p a r t of a s y s t e m o f h e a l t h c o r e d e l i v e r y we have t n r r e f o r e t o c o n s i d e r two main a s p e c t s : (a) (b)

'the e x i s t e n c e of a demand f o r t h e s e r v i c e s ; t h e p r a c t i c a l p o s s i b i l i t y of d e l i v e r i n g t h e s e r v i c e s .

fio d i s e a s e n o t i f i c a t i o n s y s t e m w i l l e v e r be e s t a b l i s h e d i f a commu~l;ty h a s no demand f o r i t , o r i f s u c h demand d o e s n o t r e s u l t i n t h e d e l i v e r y o f a s e r v i c e . To b e a c c e p t e d by t h e conlmunity, s u r v e i l l a n c e s h o u l d p r o v i d e t a n g i b l e b e n e f i t s . The o f f e r of a d e q u a t e t h e r a p y and e n v i r o n m e n t a l s a n i t a t i o n s e r v i c e s w i t t i no e l e m e n t of compulsion a r e a l l f a c t o r s which i n c r e a s e t h e a b i l i t y t o communicate.

WHO EMKL,

EM/CHOL/21 EM/DIAR/DIS/S EMIMTG.CHL.DHL.DIS./ 12 page 19

ENVIRONMENTAL SANITATION ASPECTS I N TlIE CONTROL OF DIARRHOLAL D I S E A S E S

The benefits of environmental sanitation in the control of diarrhoeal diseases have been demonstrated by statistics.

In point of fact, experience from past efforts

to control these diseases has led to the generally accepted conclusion that the only effective and long-lasting solution to the problem is the country-wide provision of safe water supplies and sanitary facilities for excreta disposal, coupled with food

sanitation, health education and personal hygiene. 1. Water S u p * For urban communities, the accepted goal is to provide water through piped systems to the households. Water may be derived from underground or surface sources, appropriately treated as required to meet established quality standards. Properly designed and ogerated systems of this type should deliver s a f e water

in adequate

quantities to the premises of use at all times, and should involve no possibility of spreading diarrhoea1 diseases. However, many piped systems are, in reality, poorly operated, inadequately maintained and overloaded due to delayed expansion to meet the ever-increasing water demands. In such instances, though the water produced at

the treatment plants may still be safe, the chances for post-contamination are high. especially in systems where t i l e supply is intermittent and where household storage (roof tanks etc.) are used due to inadequate supply and inadequate system pressure. Despite these possible sl~ortcomings,epidemiological findings oi recent cholera outbreaks in the Kegion generally ruled out the involvement of piped water supply systems in the transmission of the disease. up-grauea as soon as possible. dasCd on iinancial considerations, it is obviously unrealistic to expect that Kevertheless, inadequate sys tens should be

each and every r u r ' i l cowunity will b e provided with piped water supplies and house connections in the foreseeable future. Technically speaking, unless regional systems are used, to provide each village with an individual system involving treatment and/or pumping would create insurmountable operational and maintenance problems. type of supply as well as the level of service generally considered practical and acceptable tor rural communities is still a protected dug well with a handpump or a rope-and-bucket water-drawing arrangement, a tubewell~handpump installation, or a standpost on a piped water supply system. The main emphasis in this approach is to The

tMlLtlULl21 '

WHO

Lb&U

EM/UlAAlUlS/5 LMIMTG.CHL.DHL.DIS./~~ page 20 e n s u r e t h e s a f e q u a l i t y of t h e w a t e r a t t h e s o u r c e . However, t h e chances f o r

c o n t a n i n a t i o n d u r i n g t r a n s p o r t a t i o n from s o u r c e t o household and d u r i n g home s t o r a g e a r e g r e a t , and t h e r e seems t o be no e f f e c t i v e means of c o n t r o l o t h e r t h a n h e a l t h education. F u r t h e r , time and e f f o r t a r e s t i l l needed t o c a r r y w a t e r home f o r u s e , and t h e p o p u l a t i o n involved must be encouraged t o c a r r y and u s e more w a t e r t o e n s u r e personal c l e a n l i n e s s . Should t h e w a t e r f o r any household be u n f o r t u n a t e l y c o n t a m i n a t e d , t h e s p r e a d of d i a r r h o e a 1 d i s e a s e s would p r o b a b l y be l i m i t e d t o t h e f a m i l y concerned, a s long a s t h e water i s s a f e a t the source. Thus, t h i s s i m p l e type of s u p p l y does make a u s e f u l c o n t r i b u t i o n towards t h e c o n t r o l of d i a r r h o e a 1 d i s e a s e s . Unprotected w a t e r s o u r c e s such a s open dug w e l l s , s t e p p e d w e l l s , v i l l a g e ponds, r i v e r s , i r r i g a t i o n canals, etc., of t r a n s m i s s i o n . a r e normally contaminated and c o u l d s e r v e a s v e h i c l e s T h e i r u s e f o r d r i n k i n g and d o m e s t i c purposes s h o u l d b e d i s c o n t i n u e d

and tiley s h o u l d b e r e p l a c e d w i t h improved s a n i t a r y s u p p l i e s .

Sewerage systems

wit11

t r e a t m e n t f a c i l i t i e s , i f p r o p e r l y d e s i g n e d and i n s t a l l e d ,

s h o u l d p r o v i d e s a n i t a r y and s a f e e v a c u a t i o n and d i s p o s a l oE human w a s t e s , and a r e s u i ~ d b l eI u r use in urban agglome=arions where wacer is a v a i l a b l e a s Waste c a r r i a g e . Where such s y s t e m s e x i s t , i t i s i m p o r t a n t t o e n s u r e t h a t t h e v a r i o u s c o l l e c t i o n , pumping and t r e a t m e n t f a c i l i t i e s a r e s a t i s f a c t o r i l y o p e r a t e d and m a i n t a i n e d s o t h a t t h e y w i l l p r o v i d e t h e s a f e e v a c u a t i o n of l i q u i d w a s t e s f o r which t h e y a r e i n t e n d e d . There a r e c a s e s where sewers a l o n e a r e c o n s t r u c t e d and t h e sewage c o l l e c t e d i s discharged into a water course or o lakc or the sea without treatment of any sort.

T h i s w i l l c r e a t e p o t e n t i a l r i s k zones i n t h e r e c e i v i n g w a t e r s which c o u l d s p r e a d water-borne d i s e a s e s , e s p e c i a l l y when t h e r e a r e o u t b r e a k s of s u c h i n f e c t i o n s . long-term s o l u t i o n t o t h i s s i t u a t i o n i s of c o u r s e t o p r o v i d e s u i t a b l e t r e a t m e n t b e f o r e t h e l i q u i d w a s t e i s d i s c h a r g e d a n d / o r t o improve t h e d e s i g n and c o n s t r u c t i o n of o u t f a l l s i f t h e e f f l u e n t i s d i s c h a r g e d i n t o t h e s e a o r a l a r g e l a k e . I n o r d e r t o c o n s e r v e w a t e r r e s o u r c e s , i t i s l o g i c a l t o c o n s i d e r t h e r e - u s e of t r e a t e d sewage e f f l u e n t s f o r a g r i c u l t u r a l p u r p o s e s , e s p e c i a l l y i n a r i d a r e a s where only scant water is a v a i l a b l e . However, t h i s b e a r s a p o t e n t i a l h e a l t h h a z a r d and The u s e of u n t r e a t e d sewage f o r t h e i r r i g a t i o n must be p r a c t i s e d w i t h extreme c a r e . The

EM/ CHOL/ 2 1 EMIDIARI DIS i 5 EM/MTG.CHL.DHL.DIS.t page 21 of v e g e t a b l e s e a t e n raw h a s u n f o r t u n a t e l y been p r a c t i s e d i n some p a r t s of t h e Region and h a s been proven t o be one of t h e v e h i c l e s f o r t h e t r a n s m i s s i o n of c h o l e r a . p r a c t i c e s h o u l d be d i s c o n t i n u e d . I n r u r a l a r e a s , human e x c r e t a c a n be d i s p o s e d of i n a r e a s o n a b l y s a f e manner t h r o u g h t h e u s e of s a n i t a r y l a t r i n e s s o d e s i g n e d a s n o t t o c o n t a m i n a t e s o i l and

his

ground o r s u r f a c e w a t e r and n o t t o p e r m i t a c c e s s of f l i e s and a n i m a l s t o t h e e x c r e t a .

l h e p i t p r i v y , t n e a q u a p r i v y and t h e w a t e r - s e a l

l a t r i n e a r e among t h o s e commonly

i n u s e i n d i f f e r e n t p a r t s of t h e w o r l d , and it s h o u l d n o t b c d i f f i c u l t , f r o n i a

t e c h n i c a l v i e w p o i n t , f o r t h e n a t i o n a l h e a l t h a u t h o r i t i e s t o work o u t a d e s i g n s u i t a b l e for local conditions. The i m p o r t a n t s t e p i s , however, t o promote t h e a c c e p t a n c e and

t h e u s e of l a t r i n e s by t h e r u r a l p o p u l a t i o n and t o m o t i v a t e t h e i r p a r t i c i p a t i o n i n t h e r u r a l s a n i t a t i o n programme.

I n u r b a n s i t u a t i o n s , f o o d s a r e p r e p a r e d by f o o d p r o c e s s o r s , t r a n s p o r t e d t o t h e community, and d i s t r i b u t e d by middlemen. Food p r e s e r v a t i o n and long-term s t o r a g e Although t h e urban food a r e a l s o f e a t u r e s of t h e u r b a n , i n d u s t r i a l i z e d food c h a i n .

c h a i n i n d e v e l o p i n g c o u n t r i e s may be s i m p l e r and more d i r e c t , y e t t h e f o o d c o n t r o l problems t h e r e a r e c e r t a i n t o i n c r e a s e w i t h t i m e and w i t h g r a d u a l i n d u s t r i a l i z a t i o n . Complete f o o d c o n t r o l e n t a i l s c a r e f u l s u r v e i l l a n c e of t h e whole c h a i n of f o o d p r o d u c t i o n , p r o c e s s i n g , s t o r a g e , d i s t r i b u t i o n and p r e p a r a t i o n . Nevertheless, c e r t a i n

food s a n i t a t i o n measures such a s s u r v e i l l a n c e of permanent food e s t a b l i s h m e n t s and of food h a n d l e r s , c o n t r o l l i n g t h e q u a l i t y of w a t e r and i c e used t o p r e p a r e f o o d and d r i n k s , p r o t e c t i n g food from c o n t a c t s w i t h f l i e s , e t c . , i f p r o p e r l y planned and o r g a n i z e d t a k i n g i n t o c o n s i d e r a t i o n t h e n a t u r e of t h e problem under l o c a l c o n d i t i o n s , shouLd prove u s e f u l i n t h e c o n t r o l of food-borne numbers. enteric diseases. However, t h e r e a l

problem i n sonle d e v e l o p i n g c o u n t r i e s is . t h e e x i s t e n c e of s m a l l food v e n d o r s i n l a r g e They may be i t i n e r a n t o r may s e l l food i n t h e m a r k e t o r i n some o t h e r p l a c e s There

d u r i n g f e s t i v a l s o r f a i r s , and i t i s d i f f i c u l t t o a p p l y f o o d c o n t r o l s t o them.

i s a l s o t h e problem of food c o n t a m i n a t i o n r e s u l t i n g from t h e p r a c t i c e of washing g r e e n v e g e t a b l e s w h i l e i n t r a n s i t with w a t e r whir11 hazard. m a y b e polluted.

The

of soft

w a t e r a t s u p e r v i s e d p o i n t s a l o n g t h e r o u t e of t r a n s p o r t a t i o n may h e l p a l l e v i a t e t h e

EM/ChOL/Zl

LMIDLAKIuIS/~ kM,MTG.CHL.DHL.DIS./lZ page L Z I n r u r a l a g r i c u l t u r a l s o c i e t i e s , home p r e p a r a t i o n and consumption of l o c a l l y produced f o o d s is s t i l l t h e g e n e r a l p a t t e r n of l i f e . The promotion of improved p e r s o n a l h y g i e n i c h a b i t s is p r o b a b l y t h e o n l y measure t h a t i s r e q u i r e d t o e n s u r e food s a f e t y i n such s i t u a t i o n s . It p e o p l e c o u l d be t a u g h t t o form a h a b i t of washing t h e i r h a n d s t h o r o u g h l y

b e f o r e t o u c h i n g o r e a t i n g any f o o d , much would h a v e been a c c o m p l i s h e d i n c h e c k i n g t h e Spread of d i a r r h o e a l d i s e a s e s t h r o u g h food a s a v e h i c l e . E d u c a t i o n oi t h e p e o p l e

tu r n c r e a s e t h e l r u n d e r s t a n d l n g o i t h e mode of t r a n s m l s s l o n of t h e s e d i s e a s e s and t o

improve t h e i r p e r s o n a l h y g i e n e i s t h e r e f o r e a v e r y i m p o r t a n t u n d e r t a k i n g .

Vector C o n t r o l The house f l y is p r o b a b l y t h e most i n v o l v e d i n s e c t v e c t o r i n t h e s p r e a d of

diarrnoeal diseases.

Whereas c h e m i c a l c o n t r o l p r o v i d e s q u i c k r e s u l t s , p r o p e r d i s p o s a l

of s o l i d w a s t e s ( g a r b a g e , e t c . )

i s s t i l l t h e permanent s o l u t i o n t o f l y c o n t r o l .

S u i t a b l e s o l i d w a s t e management programmes s h o u l d t h e r e f o r e b e o r g a n i z e d by r e s p o n s i b l e government a g e n c i e s a s p a r t of t h e i r s a n i t a t i o n programmes d i r e c t e d a t t h e c o n t r o l of diarrhoea1 diseases. S o l i d w a s t e s management programmes w i l l a l s o have t h e b e n e f i t o i r e d u c i n g t h e r o d e n t and c o c k r o a c h p o p u l a t i o n s , which m i g h t have m a r g i n a l involvement

i n t h e t r a n s m i s s i o n of d i a r r h o e a 1 i n f e c t i o n s . Cnvironmental s a n i t a t i o n is t h e key t o c o n t r o l l i n g t h e d i a r r h o e a 1 d i s e a s e s , including cholera. I t i s a c c e p t e d t h a t a p r o p e r l y implemented e n v i r o n m e n t a l s a n i t a t i o n prograrnnle i s e x p e n s i v e ; n e v e r t h e l e s s , i t s b e n e f i t s a r e l o n g - l a s t i n g . I n r e c o g n i t i o n of r h e need f o r accelerated development of w a t e r s u p p l y and s a n i t a t i o n , t h e U n i t e d N a t i o n s Water C o n f e r e n c e h e l d i n A r g e n t i n a i n March 1977 reconmende~l t h e a d o p t i o n of t h e t a r g e t of s a f e w a t e r s u p p l y and s a n i t a t i o n f o r a l l by 1YYU and tile d e s i g n a t i o n of 1981-1990 a s t h e ' I n t e r n a t i o n a 1 D r i n k i n g Water Supplv and

S a n i t a t i o n Uecade. Assembly i n 1977.

b o t h recommendations were a d o p t e d by t h e U n i t e d N a t i o n s G e n e r a l

. WHO

E M K O

EM/CHOL/2 1 tM/DIAR/DIS/S EM/MTG.CHL.DHL.I)IS.i12 page 23

tiCALTH LDUCATIOK ASPOCTS I N THE CONTROL OF DIAHKHOCAL UISWSES The h e a l t h e d u c a t i o n progrannne and a c t i v i t i e s have t o be a component of t h e

d i a r r h o e a 1 d i s e a s e c o n t r o l programme w i t h i d e n t i f i e d main o b j e c t i v e s u n d e r which s p e c i f i c o b l i g a t i o n s c a n be worked o u t i n r e l a t i o n t o i d e n t i f i e d s p e c i f i c p r o b l e m s , e.g. r e l a t e d t o o r a l rehydration, breast-feeding, cholera n o t i f i c a t i o n , e t c . A

s y s t e m of c o n t i n u o u s a s w e l l a s p e r i o d i c e v a l u a t i o n of h e a l t h e d u c a t i o n a c t i v i t i e s sllould b e planned f r o m t h e s t a r t and c a r r i e d o u t t o e n a b l e a p r o p e r u n d e r s t a n d i n g of r e s u l t s and m o d i f i c a t i o n o f t h e s e a c t i v i t i e s , i f n e c e s s a r y . P r i n c i p l e s , a p p r o a c h e s and methods of h e a l t h e d u c a t i o n : (a) Principles

(b)

i d e n t i f y s p e c i f i c h e a l t h problems n e e d i n g h e a l t h e d u c a t i o n s u p p o r t and s o c i o cultural constraints ; proposed a c t i v i t i e s s h o u l d be i n c o n f o r m i t y w i t h s o c i o - c u l t u r a l b e l i e f s and v a l u e s of communities; c r e a t i o n of community a w a r e n e s s and n a t i o n a l w i l l t o u n d e r t a k e t h e programme.

Approaches

- ensuring a c t i v e p a r t i c i p a t i o n - e n l i s t i n g general educational education) ;

of communities and i n d i v i d u a l s ; s y s t e m s whenever n e c e s s a r y ( i . e . s c h o o l h e a l t h

s p e c i f i c o b j e c t i v e s need t o b e s o f o r m u l a t e d s o a s t o meet e s s e n t i a l c r i t e r i a of b e i n g t e c h n i c a l l y r e a l i s t i c , m c o s u r a b l c ,

economically f c a s i b l c ; t a r g c t

g r o u p s n e e d i n g b e h a v i o u r a l c h a n g e , n a t u r e of b e h a v i o u r a l c h a n g e , when and where. (c) Methods have t h e i r a d v a n t a g e s and l i m i t a t i o n s and need t o b e u s e d i n s u i t a b l e combinations - mass media o f r a d i o , t e l e v i s i o n , f i l m s , n e w s p a p e r s , p a m p h l e t s , p o s t e r s , e t c .

l a r g e and s m a l l groups ; person-to-person contacts. i l l b e rather s m a l l i n

O r g a n i z a t i o n a l r c q u i r c r n c n t s o f p c r s o n n c l and f a c i l i t i ~ s w

c o u n t r i e s where h e a l t h e d u c a t i o n u n i t s a t c e n t r a l and p r o v i n c i a l l e v e l s a l r e a d y e x i s t . I n o t h e r c o u n t r i e s t h i s programme s h o u l d h e l p s t i m u l a t e t h e e s t a b l i s h m e n t of h e a l t h education u n i t s .

EM/CHOL/2 1 EMjDIAKi DIS/5 rM/MTG.CHL.DHL.DIS.flZ page 24 A main problem i s t h e d e c l i n e i n breast-feeding

WHO E M R O

i n relation t o diarrhoeal

d i s e a s e s among i n f a n t s and c h i l d r e n . Another important f a c t o r i s t h e c o o r d i n a t i o n of demonstration of v a r i o u s a c t i v i t i e s , i .e. s u c c e s s of o r a l r e h y d r a t i o n , breast-feeding h a b i t s and improvements with t r a i n i n g a c t i v i t i e s and s e r v i c e s i n f i e l d t r a i n i n g a r e a s (of s i z e a b l e r u r a l and urban p o p u l a t i o n s ) e x i s t i n g o r t o be e s t a b l i s h e d i n r e l a t i o n t o i n s t i t u t i o n s f o r h e a l t h personnel t r a i n i n g , e.g. demonstrated a c t i v i t i e s . Health e d u c a t i o n , t o have any c r e d i b i l i t y , should be i n r e l a t i o n t o a c t u a l programme a c t i v i t i e s and not i n a vacuum. F i e l d t r a i n i n g a r e a s should be used t o t h e e x t e n t p o s s i b l e . Exchange of e v a l u a t e d h e a l t h e d u c a t i o n m a t e r i a l s among c o u n t r i e s should be encouraged. XI

medical and n u r s i n g s c h o o l s .

Temporary demonstration away with

a r e a s a r e notorious f o r being u n r s a l i s ~ i c , Lading away and t a k i n g

them t h e

TREATMENT AND ORAL REHYDRATION ASPECTS I N T H E CONTROL OF DIAKRHOEAL DISEASES There a r e f o u r p a r t s t o t h i s s u b j e c t :

Drug treatment Intravenous r e h y d r a t i o n D i e t a r y management Oral r e h y d r a t i o n Drug treatment A n t i b i o t i c s may o r may not be u s e f u l i n i n d i v i d u a l c a s e s , according t o t h e

3. 4. 1.

n a t u r e of t h e i n f e c t i n g organism and whether o r not i t i s r e s i s t a n t t o t h e p a r t i c u l a r antibiotic. I t i s i n s h i g e l l a t h a t t h e r e may be most use

but even h e r e , t h e Specific But f o r t h e g r e a t m a j o r i t y

emergence of m u l t i p l e drug r e s i s t a n c e may be a problem i n epidemics. t r e a t m e n t i s a l s o a v a i l a b l e f o r amoebiasis and g i a r d i a s i s .

of c a s e s of a c u t e d i a r r h o e a 1 d i s e a s e i n i n f a n t s and young c h i l d r e n , which is by f a r t h e g r e a t e s t problem, drug treatment h a s l i t t l e p l a c e , s i n c e t h e i n f e c t i o n w i l l o f t e n be s e l f - l i m i t i n g , t h e r e a r e no a n t i v i r a l a g e n t s , and t h e r e i s no chance i n t h e v i l l a g e circumstances even t o i d e n t i f y t h e organism o r t e s t i t s s e n s i t i v i t y i f i t i s b a c t e r i a l .

WHO EMKI)

EM/CHOL/21 EM/DIARIDIS/S EM/MTG.CHL.DHL.DIS./12 page 25

Intravenous rehydration

This s h o u l d b e r e s e r v e d f o r t h e c h i l d o r a d u l t ( i n c h o l e r a ) i n s t a t e of shock and u n a b l e t o swallow, o r f o r r a r e c a s e s of i n t r a c t a b l e vomiting.

D i e t a r y management Its p r i n c i p l e s a r e s i m p l e and c a n b e s t a t e d t h u s :

(i)

No c e s s a t i o n of b r e a s t - f e e d i n g .

(ii) N o starvation. accept.

f h i s normal food w h a t e v e r h e w i l l L e t t h e c h i l d d r i n k and e a t o i n s t e a d of cows' m i l k , e s p e c i a l l y d r i e d skim m i l k ,

Ln some c a s e s , b e c a u s e of s e c o n d a r y l a c t o s e i n t o l e r a n c e , i t may be n e c e s s a r y

t o s u b s t i t u t e o t h e r protein-foods

i f i t becomes a p p a r e n t t h a t each t i m e t h i s is t a k e n t h e c h i l d h a s i n c r e a s e d d i a r r h o e a . d u t t h i s i s advice f o r such cases only, not a u n i v e r s a l p r e s c r i p t i o n . ( i i i ) A s soon a s p o s s i b l e normal f e e d i n g s h o u l d b e resumed, and more t h a n t h i s , t h e c h i l d s h o u l d r e c e i v e compensatory f e e d i n g a f t e r t h e d i a r r h o e a is o v e r . illness", 4.

Some a d v i c e

s h o u l d be g i v e n s u c h a s " t r y t o g i v e him a s e x t r a a l l t h e f o o d h e m i s s e d i n h i s o r "an e x t r a meal a day f o r a s many days a s h e was ill".

O r a l rehydra-

i s t h e one measure which g i v e s u s n a t ~ h e o p p o r t u n i t y t o make in

a marked r e d u c t i o n i n t h e a p p a l l i n g d e a t h - t o l l from a c u t e d i a r r h o e a 1 d i s e a s e s c h i l d r e n under t h r e e y e a r s of age.

XII

PATHOPHYSIOLOGY OF DIAKRHOU

There a r e two main c a u s e s of d i a r r h o e a , namely m i c r o b i a l i n v a s i o n of t h e g u t and m a l a b s o r p t i o n of s u g a r s . t h e problem e n masse. The t o x i n e n t e r s t h e e p i t h e l i a l c e l l s of t h e s m a l l i n t e s t i n e , and s t i m u l a t e s t h e p r o d u c t i o n of a d e n y l c y c l a s e , which r e g u l a t e s c y c l i c AMP. AMP under normal

The former i s almost c e r t a i n l y n u m e r i c a l l y t h e most

i m p o r t a n t , but t h e l a t t e r d e s e r v e s c o n s i d e r a t i o n a l s o , even when we a r e d e a l i n g w i t h

p t ~ y s i o l o g i c a lc o n d i t i o n s is r e s p o n s i b l e f o r s e c r e t i o n of c h l o r i d e from t h e e p i t h e l i a l c e l l s through t h e a c t i o n of v a r i o u s hormones. of c h l o r i d e i n t o t h e lumen of t h e g u t . When e n t e r o t o x i n s s t i m u l a t e a d e n y l cyclase c h e l e v e l of c y c l l c AMP I n t h e c e l l r i s e s , which t h e n l e a d s t o e x c e s s s e c r e t i o n

This s e c r e t i o n , r e s u i t s i n t h e d i f f u s i o n of

o t h e r e l e c t r o l y t e s and w a t e r from t h e e p i t h e l i a l c e l l s i n t o t h e g u t lumen t o m a i n t a i n

EM/CHOL/ 21 LM/DIAK/DIS/5 EM/MTG.CHL.DHL.DIS . / I 2 page 26 ~ fluid. o s m o t i c b a l a n c e between t h e c y t o p l a s m o f the re11 and t h gut

WHO E M R O

The d i f f u s i o n

of w a t e r and e l e c t r o l y t e s from t h e e p i t h e l i a l c e l l t o t h e g u t l e a d s a l s o t o d i f f u s i o n of s i m i l a r components from o t h e r p a r t s of t h e body i n t o t h e e p i t h e l i a l c e l l s and t h e n a g a i n o u t i n t o t h e g u t lumen. Thus t h e r e i s a c o n t i n u o u s l o s s o f f l u i d and e l e c t r o -

l y t e s f r o m t h e p a t i e n t ' s body i n t o t h e g u t lumen, and a l a r g e amount of w a t e r y s t o o l s . There is a l s o e x c e s s i v e s e c r e t i o n of mucus f r o m t h e g o b l e t c e l l s . The e f f e c t of t h e e n t e r o t o x i n o n t h e e p i t h e l i a l c e l l i s i r r e v e r s i b l e and p e r s i s t s u n t i l t h e c e l l through n a t u r a l growth and movement upwards f a l l s o f f t h e t i p of t h e v i l l u s i n t o t h e l u n ~ e a , a p r u c r s s ~ d k i l l gLhree d a y s i n t h e h e a l t h y p e r s o n .

T h i s is why a n ~ i b i o t i c s

treatment cannot s t o p d i a r r h o e a q u i c k l y even i f t h e pathogen is e r a d i c a t e d w i t h i n a few h o u r s . T r ~ ecommonest form of s a c c h a r i d e m a l a b s o r p t i o n i s l a c t o s e m a l a b s o r p t i o n , b u t s u c r o s e m a l a b s o r p t i o n is a l s o s e e n i n d i a r r h o e a . When t h e mechanism f o r a b s o r p t i o n of s a c c h a r i d e i s n o t f u n c t i o n i n g n o r m a l l y , t h e n t h e s a c c h a r i d e r e a c h e s t h e c o l o n where i t i s decomposed by t h e b a c t e r i a which a r e a b u n d a n t t h e r e i n t o , o r g a n i c a c i d s . T h i s r e s u l t s i n h i g h e r o s n ~ o l a r i t yof t h e lumen which i n t u r n l e a d s t o t h e movement of w a t e r and e l e c t r o l y t e s from t h e i n t e s t i n a l e p i t h e l i u m , and f r o m t h e r e s t of t h e body, i n t o t h e lumen. Characteristic of t h i s form of d i a r r h o e a i s a s t o o l pH of l a s s clian 6 and a h i g h s a c c h a r i d e c o n c e n c . These s a c c h a r i d e m a l a b s o r p t i o n s a r e o f t e n d e v e l o p e d by p a t i e n t s i n t h e c o u r s e of a d i a r r h o e a 1 a t t a c k , b e i n g t h u s s e c o n d a r y t o i n f e c t i v e d i a r r h o e a and t e m p o r a r y ,

The p r e v e n t i o n and t r e a t m e n t of d e h y d r a t i o n a r e o f c o u r s e t h e key t o s a v i n g t h e l i v e s of t h e s e c h i l d r e n . Mild and e v e n m o d e r a t e d e h y d r a t i o n , e v e n up t o j u s t s h o r t

of t h e p o i n t where t h e c h i l d s t a r t s t o become c o m a t o s e , c a n b e o r a l l y r e h y d r a t e d . Moreover, a t t h e v i l l a g e l e v e l w i t h no p o s s i b i l i t y of e l e c t r o l y t e c o n t r o l , and e v e n a t h o s p i t a l l e v e l i n some ways o r a l r e h y d r a t i o n i s much s a f e r . For t h e l a s t t h r e e y e a r s , UNICEF h a s b e e n s u p p l y i n g t h e i n g r e d i e n t s of t h e g l u c o s e e l e c t r o l y t e m i x t u r e i n a n aluminium f o i l p a c k a g e . The c o s t i s a b o u t 12 cents

each.

A number o f c o u n t r i e s a l s o package t h e i n g r e d i e n t s l o c a l l y .

EM/CHOL/21 EM/DIAR/DLS/S EM/MTG.CHL.DHL.DIS.I12 page 27 To u n d e r s t a n d why o r a l r e h y d r a t i o n h a s b e e n found SucceSSful both i n c h o l e r a

and i n i n f a n t i l e d i a r r h o e a we c o n s i d e r t h e p a t h o p h y s i o l o g y and t h e e f f e c t of a g l u c o s e e l e c t r o l y t e m i x t u r e i n t h e lumen of t h e g u t i n d i a r r h o e a . e l e c t r o l y t e s and w a t e r . E n t e r o t o x i n s a f f e c t t!le i n t e s t i n a l e p i t h e l i u m and produce a n o u t f l o w of c h l o r i d e f o l l o w e d by t h e o t h e r However, a r e m a r k a b l e p o i n t i s t h a t t h e a b s o r p t i o n capa_c-i9 of t h e i n t e s t i n a l e p i t h e l i u m i s n o t i m p a i r e d i n d i a r r h o e a . That means t h a t i f by some means t h e movement of s a l t s from t h e i n t e s t i n a l f l u i d i n t o t h e e p i t h e l i u m could i n c r e a s e , t h e a b s o r p t i o n of w a t e r and o t h e r e l e c t r o l y t e s would be i n c r e a s e d and one c o u l d a c h i e v e r e h y d r a t i o n through t h e e p i t h e l i u m . Many e f f o r t s were made o v e r many y e a r s t o d o t h i s , sometimes w i t h d i s c o u r a g i n g results. T h i s l e d t o t h e g e n e r a l b e l i e f t h a t o r a l r e h y d r a t i o n was n o t s a t i s f a c t o r y Then i n tire e a r l y 1960s s t u d i e s on t h e p h y s i o l o g i c a l uptake of Glucose is t h e i m p o r t a n t f a c t o r , f o r i t i n c r e a s e s markedly o r even i m p o s s i b l e .

sodium by various cells showed that sodium absorption is greater when glucooe is added

t o t h e sodium s o l u t i o n . and water f o l l o w .

t h e a b s o r p t i o n of sodium back i n t o t h e c e l l w i t h t h e r e s u l t t h a t t h e o t h e r e l e c t r o l y t e s So e f f i c i e n t i s t h i s a c t i v e t r a n s p o r t of g l u c o s e and sodium t h a t i t r e v e r s e s , i n t h e d i r e c t i o n of r e h y d r a t i o n , t h e b a l a n c e between o u t f l o w and a b s o r p t i o n of water and e l e c t r o l y t e s t o and from t h e lumen. C y c l i n e would d o j u s t t h e same, b u t i s much t o o e x p e n s i v e t o i n c l u d e i n a formula f o r t h i s kind of mass u s e . Even g l u c o s e i s r a t h e r e x p e n s i v e and one would l i k e t o u s e s u c r o s e i n s t e a d , s i n c e i t w i l l b e s p l i t i n t o g l u c o s e and f r u c t o s e , b u t t h e q u e s t i o n

i s s t i l l under s t u d y whether s u c r o s e m a l a b s o r p t i o n would outweigh t h e a d v a n t a g e of g r e a t e r cheapness. of c a s e s Even with glucooc, m a l a b s o r p t i o n occurs in about five p e r crxlr

. w h i l e on t h e o t h e r hand i t may o v e r t a x

The c o n c e n t r a t i o n of g l u c o s e r e c o r d e d h e r e i s e s t a b l i s h e d by many s t u d i e s which have l e d t o t h e c o n c l u s i o n t h a t i n c r e a s i n g t h e c o n c e n t r a t i o n beyond 20 grams p e r l i t r e does n o t a p p r e c i a b l y i n c r e a s e r e - a b s o r p t i o n , t h e c a p a c i t y of t h e g u t t o a b s o r b i t w i t h r e s u l t i n g m a l a b s o r p t i o n d i a r r h o e a .

EM/CHOL/21 LM/DIAR/DIS/5 EM/MTG.CHL.DHL.DIS./12 page 28 XIV RLSULTS OF ORAL REHYDRATION TRIALS

WHO EMHO

To a s c e r t a i n whether a suggested t r e a t m e n t i s b e t t e r , and i n what way and t o what d e g r e e b e t t e r , t h a n t h e t r e a t m e n t a s g i v e n a t p r e s e n t , i t i s n e c e s s a r y t o have a t r i a l w i t h a s t u d y group r e c e i v i n g t h e proposed new t r e a t m e n t and a c o n t r o l group r e c e i v i n g t h e p r e s e n t t r e a t m e n t ( a s t h e p r e s e n t t r e a t m e n t is supposed t o be g i v e n ) . I n t h e i n s t a n c e s we a r e concerned w i t h , i.e. a s p o s s i b l e t o each o t h e r . e a r l y treatment a t the v i l l a g e

l e v e l , we must t h e r e f o r e have e x p e r i m e n t a l and c o n t r o l groups of v i l l a g e s a s s i m i l a r I n one group, t h e c o n t r o l , t h e u s u a l t r e a t m e n t i s g i v e n , The s t u d y group g e t s t h e same i . e . medicines and s p e c i f i e d i n s t r u c t i o n about making t h e c h i l d d r i n k p l e n t y , n o t s t o p p i n g b r e a s t - f e e d i n g and n o t s t a r v i n g t h e c h i l d . medicine and i n s t r u c t i o n s , and a l s o o r a l r e h y d r a t i o n i . e . t h e mother i s shown how

t o mix t a e powder, she g i v e s some of i t under s u p e r v i s i o n t o t h e c h i l d i n t h e c l i n i c i t s e l f , and t h e n i s given two p a c k e t s t o t a k e home w i t h t h e c h i l d t o l a s t t h e n e x t

24 hours.

Both o r a l r e h y d r a t i o n and c o n t r o l p a t i e n t s must r e t u r n d a i l y u n t i l t h e They a r e weighed on e v e r y o c c a s i o n , and a r e a l s o weighed r e g u l a r l y

end of t h e e p i s o d e .

u n t i l a t l e a s t s i x months a f t e r t h e episode. The o r a l r e h y d r a t i o n i s e v a l u a t e d i n r e s p e c t of amount consumed and a c c e p t a b i l i t y , and i n comparison with t h e c o n t r o l i n r e s p e c t o f : 1. 2.

weight g a i n o r l o s s d u r i n g t h e e p i s o d e ; d u r a t i o n of t h e e p i s o d e ; necessity f o r r e f e r r a l t o hospital; average monthly weight gain over the s i x t o eighteen months a f t e r the episode.

3. 4.

T r i a l s such a s t h o s e d e s c r i b e d a r e b e i n g conducted, w i t h WHO c o l l a b o r a t i o n , i n some twenty c o u n t r i e s i n t h e world,among them I r a n and Egypt i n o u r Region. and a l s o i n p a r t from t h a t b e i n g conducted i n Laos. The consumption of o r a l f l u i d p e r c h i l d p e r day p e r kg bodyweight, a s could b e expected, was h i g h e r i n t h e c h i l d r e n aged 1 2 The r e s u l t s a r e a v a i l a b l e f o r t h e t r i a l s conducted i n Turkey and i n t h e P h i l i p p i n e s ,

- 24 months who a r e

l i k e l y t o be severely

a f f e c t e d but are not r e c e i v i n g much i f any b r e a s t milk, and are l i k e l y t o be more

s e v e r e l y dehydrated t h a n t h e t h r e e - o r four-year o l d .

WHO hMKO

EM/CHOL/21 EM/ DIAR/DISI 5 EM/MTG.CHL.DHL.DIS./12 page 29

I t i s n o t e w o r t h y t h a t i n t h e P h i l i p p i n e s t h o s e c h i l d r e n who had two o r more e p i s o d e s of d i a r r h o e a d u r i n g t h e s t u d y p e r i o d (85 o u t of 341) a c t u a l l y t o o k a n i n c r e a s i n g amount p e r kg p e r d a y , d e m o n s t r a t i n g t h a t t h e t r e a t m e n t a c t u a l l y i n c r e a s e d i n acceptability. I n t h e P h i l i p p i n e s , t h e o r a l r e h y d r a t i o n group g a i n e d a mean of 129 grams v e r s u s 74 grams i n t h e c o n t r o l , i n Laos a g a i n o f 187 grams v e r s u s a l o s s of 170 grams i n t h e c o n t r o l . I n Turkey, i n t h e c o n t r o l v i l l a g e s a s i g n i f i c a n t l y h i g h e r p r o p o r t i o n of c h i l d r e n l o s t u e i g t ~ tdrrring t h e e p i s n d p than i n t h e o r a l r e h y d r a t i o n v i l l a g e s . There

was a l s o a d i f f e r e n c e i n t h e d u r a t i o n of t h e i l l n e s s which was s i g n i f i c a n t l y s h o r t e r i n t h e o r a l r e h y d r a t i o n group than i n t h e c o n t r o l . However, i n b o t h P h i l i p p i n e s and Turkey t h e r e was a s i g n i f i c a n t l y g r e a t e r a v e r a g e monthly w e i g h t g a i n a t a l l a g e s f o r months a f t e r t h e e p i s o d e i n t h e o r a l r e h y d r a t i o n tliair i n tht:

c o ~ l t r o lg r u u p s .

I t is d i f f i c u l t t o e x p l a i n why t l r r w a y i r i wtiich a c h i l d

i s managed d u r i n g a n e p i s o d e o f d i a r r h o e a s h o u l d a f f e c t h i s n u t r i t i o n a l s t a t u s n o t f o r merely weeks b u t f o r months a f t e r w a r d s ( s e v e n months i n t h e c a s e of t h e P h i l i p p i n e s t u d y and s i x t e e n i n t h e c a s e of t h e T u r k i s h o n e ) . I t p e r h a p s i n d i c a t e s t h a t d i a r r h o e a is f a r more i m p o r t a n t i n t h e a e t i o l o g y of e n e r g y p r o t e l n m a l n u t r i t i o n t h a n had b e e n p r e v i o u s l y r e c o g n i z e d . I f one pursues t h i s This l i n e o t t h o u g h t p e r h a p s s e v e r e m a l n u t r i t i o n is much more t h e r e s u l t of d i a r r h o e a 1 d i s e a s e and o t h e r i n f e c t i o n t h a n i t i s t h e r e s u l t of i n a d e q u a t e d i e t a r y i n t a k e .

would e x p l a i n why marasmus and k w a s h i o r k o r c a n e x i s t e v e n i n t h e p r e s e n c e of abundant cheap and n u t r i t i o u s ( b u t n o t always c l e a n ) f o o d . I t would e x p l a i n a l s o why t h o s e p r o j e c c s and programmes which ~ 0 n c e n K r i i ~ ea dl m o s r e x c l u s i v e l y o n i n c r e a s i n g q u a n r i r y and q u a l i t y of food i n t a k e , s u c h a s n u t r i t i o n e d u c a t i o n p r o j e c t s , h i g h - p r o t e i n weaning f o o d s , A p p l i e d N u t r i t i o n Programmes, and Supplementary F e e d i n g p r o j e c t s , seemed t o h a v e i n t h e main r a t h e r d i s a p p o i n t i n g r e s u l t s . O r a l r e l l y d r a t i o r i is i n f a c t a v e r y s i m p l e t r e a t m e n t i n i t s e l f , and c a n b e c a r r i e d o u t b y a v i l l a g e l e v e l h e a l t h worker o r by a s s i s t a n t n u r s e i m i d w i f e ; o r i n s t e a d , and h e r e l i e s o u r b e s t itope, by tlie m o t h e r h e r s e l f . The creacmenr. of u e t i y d r a c i o n ar: a n e a r l y s t a g e i n t h e v i l l a g e and i n t h e home

i s t h e n , i n e f f e c t , p r e v e n t i v e of s e v e r e d e h y d r a t i o n n e c e s s i t a t i n g i n t r a v e n o u s t h e r a p y o r causing death. I t is a c c e p t a b l e , and i t r e s u l t s i n l e s s w e i g h t l o s s d u r i n g t h e I t may s h o r t e n t h e i l l n e s s , and i t c e r t a i n l y e p i s o d e , o r even i n g a i n i n s t e a d o f l o s s .

MI CHOL, 21 tM/UIAK/L)lS/5 EM/MTG.CHL.DHL.DIS page 30 results

WHO EkNU .I

1 1 . 1markedly

b e t t e r n u t r l t l o n a l s t a t u s afterwards f o r reasons not a t a l l

u n u e r s t u o a , b u t c o n s t i t u t i n g i n f a c t a n improvement s i m i l a r i n magnitude t o t h a t d c n i e v e d by s e v e r a l months' a t t e n d a n c e a t a n u t r i t i o n r e h a b i l i t a t i o n c e n t r e . If i t were w i d e l y a v a i l a b l e and p r o p e r l y implemented a t v i l l a g e l e v e l ,

ttlrougrlout our Region, i t would p r o b a b l y r e s u l t i n t h e s a v i n g of a q u a r t e r of a n l i l l i o n l i v e s a y e a r , o r e v e n more. And it would seem t o o f f e r u s a l s o t h e o p p o r t u n i t y t o make a r e a l impact o n t h e p r e v a l e n c e of s e v e r e m a l n u t r i t i o n i n e a r l y chi1d;rood.

The p a r t i c i p a n t s t o t h e Fleeting, h a v i n g c o n s i d e r e d t h e v a r i o u s a s p e c t s of d i a r r h o e a l d i s e a s e s i n t h e R e g i o n , h a v i n g t a k e n n o t e of t h e r e c e n t a d v a n c e s i n t h e knowledge of t h e epidemiology of e n t e r i c i n f e c t i o n s and c h o l e r a , h a v i n g r e c o g n i z e d t h e i m p o r t a n c e of o r a l r e h y d r a t i o n a s a b a s i c t o o l f o r t h e r e d u c t i o n of m o r t a l i t y among c h i l d r e n due t o d e h y d r a t i o n , b e i n g aware o f t h e need f o r t h e d i s s e m i n a t i o n of t h e r e c e n t advances i n t h e d i a g n o s i s and t r e a t m e n t of c h o l e r a and d i a r r h o e a l d i s e a s e s , have p r e s e n t e d t h e f o l l o w i n g reco~mnendations : 1.

Member c o u n t r i e s s h o u l d d e v o l b p , w i t h WHO t e c h n i c a l c o - o p o r a t i o n ,

national

programmes f o r t h e c o n t r o l of d i a r r h o e a l d i s e a s e s , s u i t e d t o t h e i r i n d i v i d u a l needs,

Tne Kegional programme d i s c u s s e d and a g r e e d upon d u r i n g t h e m e e t i n g f o r a coo r d i n a t e d c o n t r o l o f e n t e r i c i n f e c t i o n s s h o u l d be implemented.

For t h e i m p l e n ~ e n t a t i o nof t h e R e g i o n a l programme of e n t e r i c i n f e c t i o n s c o n t r o l , a d e q u a t e f i n a n c i n g s h o u l d be p r o v i d e d t h r o u g h v o l u n t a r y c o n t r i b u t i o n s by t h e Member c o u n t r i e s and c o l l a b o r a t i n g A g e n c i e s .

The c o u n t r i e s of t h e Region s h o u l d , i n c o n s u l t a t i o n w i t h WHO, s t u d y t h e i n d i v i d u a l r e q u i r e m e n t s and e s t i m a t e t h e amount of e x t e r n a l a s s i s t a n c e r e q u i r e d a s s o o n a s possible. The c o s t of t h e R e g i o n a l programme, e x c l u d i n g t h e c o u n t r y programmes,

is e s t i m a t e d t o be o f t h e o r d e r o f US $ 350 000 p e r annum i n t h e i n i t i a l p h a s e o f t h e programne. 5. Fur

t h e a p p r o p r i a t e d i s s e m i n a t i o n of ~ e c h n i c a li n f o r m a c i o n c o n c e r n i n g c h o l e r a and t e c h n i c a l g u i d e l i n e s and n o t e s o n r e c e n t advances

d i a r r h o e a l d i s e a s e s , up-to-date

i n t h e e p i d e m i o l o g y , d i a g n o s i s , t r e a t l i l e n t and p r e v e n t i o n of e n t e r i c i n f e c t i o n s i n c l u d i n g d i a r r h o e a l d i s e a s e s and c h o l e r a s h o u l d b e i s s u e d by WHO. a u t h o r i t i e s s h o u l d a l s o i s s u e g u i d e l i n e s on t h e b a s i s o f up-to-date National knowledge.

WHO EMKU

EMiCHOLj21 EMIDIARiDISI5 EM/MTG.CHL.UHL.DIS .I12 page 3 1

W h O should s u p p o r t and encourage t h e c o u n t r i e s of t h e Region i n t h e e s t a b l i s h m e n t of v i r o l o g i c a l l a b o r a t o r i e s and where a l r e a d y e x i s t i n g , e n l a r g e t h e i r s c o p e and c a p a b i l i t y t o c l a r i f y t h e r o l e of v i r o l o g i c a l pathogens a s c a u s a t i v e a g e n t s of enteric infections. not y e t r e a d y . Regional r e f e r e n c e and c o l l a b o r a t i n g v i r o l o g i c a l l a b o r a t o r i e s should a l s o be e s t a b l i s h e d t o a s s i s t t h o s e c o u n t r i e s where such f a c i l i t i e s a r e

7. 8.

C l o s e l i a i s o n s h o u l d b e e s t a b l i s h e d between p e r i p h e r a l and c e n t r a l l a b o r a t o r i e s , and e p i d e m i o l o g i c a l s e r v i c e s . O r a l r e h y d r a t i o n s t ~ o u l db e i n t r o d u c e d a t a d o m i c i l i a r y l e v e l a s t h e most i m p o r t a n t component f o r t h e t r e a t m e n t and p r e v e n t i o n of c o m p l i c a t i o n s i n t h e c a s e of g a s t r o e n t e r i t i s among c h i l d r e n . For t h i s purpose o r a l r e h y d r a t i o n s a l t s s h o u l d I n t h e c a s e of c h o l e r a e p i d e m i c s , be lnaue a v a i l a b l e a t primary h e a l t h c a r e l e v e l . administered along with appropriate medical c a r e .

a c t i v e c a s e s e a r c h s l ~ o u l db e i n t e n s i f i e d s o t h a t t i m e l y o r a l r e h y d r a t i o n c a n b e 9.

Most r e c e n t advances i n t h e p a e d i a t r i c f i e l d which a r e r e l a t e d t o t h e t r e a t m e n t and management of i n f a n t i l e g a s t r o e n t e r i t i s , b r e a s t - f e e d i n g e t c . s h o u l d b e communicated t o t h e p a e d i a t r i c p r o f e s s i o n and d i s s e m i n a t e d among d o c t o r s and n u r s e s , a s w e l l a s m e d i c a l and n u r s i n g s t u d e n t s . WHO s h o u l d s u p p o r t r e g i o n a l and s u b - r e g i o n a l m e e t i n g s f o r t h e d i s s e m i n a t i o n of s c i e n t i f i c knowledge among

r e s p o n s i b l e p a e d i a t r i c i a n s and a l s o d i s s e m i n a t e t r a i n i n g m a t e r i a l s and s c i e n t i f i c notes a s appropriate.

WHO tMKO

EMiCtlOLi 21

E M /DIAR/DIS/ 5 tM/MTG.CHL.DHL.DlS Annex I

KhGIONAL MEETlNC OL< CHOLERA AlLU I ) M K t t O t A L DISEASES &\lexanaria, 1

-5

J u n e 1978

Opening S e s s i o n non~i n a t i o n of O f f i c e r s (Chairman, Vice-Chairmen, Kapporteur) Adoption of tile Agenda keview of t h e problem of d i a r r h o e a 1 d i s e a s e s i n t h e Region Review 01 tile p r e s e n t s i t u a t i o n i n each c o u n t r y : Cvuntry r e p o r t s ~ p i d e r n i o l o g yof d i a r r h o e a l d i s e a s e s i n tile Region C o n t r o l o r t.piaemics b u r v e i l l a n c e f o r C h o l e r a P r e v e n t i o n and D e t e c t i o n Mrasures t o c o r ~ t r o ld i a r r h o e a l d i s e a s e s : (a)

e ~ l v l r o n m e n t a ls a r i i t a t i o n h e a l t l ~e d u c a t i o n t r e a t m e n t and o r a l r e h y d r a t i o n

(o) (c)

i'rogramme f o r t h e C o n t r o l of t n t e r i c I n f e c t i o n s i n t h e t a s t e r 1 1 M e d i t e r r a n e a n drgiun l i . a p e c l a 1 problems 12. 1 ) r a t t i n g of r e g i o n a l p l a n on t h e b a s i s o t recommentlat~ons

13. C l o s i n g s e s s i o n

EM/ CHOL/ 2 1 LMIDLARIDISI~ EM/MTG.CHL.DHL .DIS .I 12 Annex I1 page ( i )

KEGIONAL MEETING UN CHULEKA A N D DIAKKLiUEAL DISEASES Alexandria, ----------

5 J u n e 1978

LIST OF -.-PARTICIPANTS EGYPT Dr A.M. E l Akkad U n d e r - S e c r e t a r y of H e a l t h f o r the Preventive Sector M i n i s t r y of P u b l i c H e a l t h Cairo

D r S. Uurshano Uepartment o f M a l a r i a E r a d i c a t i o n and Cornmunicab l e Dispases Control M i n i s t r y of H e a l t h and W e l f a r e international H e a l t h R e l a t i o n s Department Teheran

D r Saadoun K h a l i f a A1 T i k r i t i Director-General of P r e v e n t i v e Medicine M i n i s t r y of Health Baghdad

D r Suliernan A1 S u b a i h i D i r e c t o r of P r e v e n t i v e Medicine M i n i s t r y of Health

Llr G a a f a r M. E z z a t ~ ~ i r e c t o r - G e n e r ao lf P r e v e n t i v e Medicine M i n i s t r y of P u b l i c H e a l t h Kuwait

LEBANON

D r Mohamed Mohanna Director-Genera1 of P r e v e n t i v e Medicine Ministry of Public Health Beirut D r (Mrs) Shamim B o u k h a r i I n s t i t u t e of Hygiene Lahore

* Did n o t a t t e n d

LM/ CIIOLI 21 EM, DIAR/ DTSI 5 LMIEITG.CHL.DHL.DIS. /12 Annex I I page ( i i )

SAUDI AKABLA

D r M. Hashem E l Dabbagh D i r e c t o r - G e n e r a l of P r e v e n t i v e Medicine M i n i s t r y of P u b l i c H e a l t h Ri yad

D r Nouri Ramzi Vice-1.iinis t e r o f H e a l t h M i n i s t r y of H e a l t h Damascus

D r Adnan B u d e i r Director, Communicable D i s e a s e s Department M i n i s t r y of H e a l t h Damscus

Dr Adnan T i k r e e t i Profcooor o f Bacteriology

F a c u l t y of Medicine U n i v e r s i t y of Damascus Damascus --WHO SECKETARIAT

Ur A . h .

Taba

Kegiona 1 ~i rector

Kegional U f f i c e t o r t h e b a s t e r n Mediterranean, Alexandria Regional O f f i c e f o r t h e Eastern Mediterranean, Alexandria R e g i o n a l Off i c e f o r t h e E a s t e r n Mediterranean, Alexandria Regional O f f i c e f o r t h e E a s t e r n Mediterranean, Alexandria B a c t e r i a l Diseases Division, Center f o r Disease Control, A t l a n t a , USA Formerly Center f o r Disease C o n t r o l , A t l a n t a , USA and H a r v a r d U n i v e r s i t y , USA Vice-Dean, High I n s t i t u t e of Public Health, Alexandria

D r M.O.

Shoib

D i r e c t o r of H e a l t h Services Public Health Administrator (Communicable D i s e a s e s ) R e g i o n a l A d v i s e r on Epidemiology, and S e c r e t a r y t o t h e Meeting W H O Temporary A d v i s e r

D r Y. Partow

Ur V. P a r i s i

Ur E. Gangarosa

U r A . Langmuir

WHO Temporary A d v i s e r

D r M.H.

Wahdan

W H O Temporary A d v i s e r

Did n o t a t t e n d

EMlCHOL12 1 EM/DIAR/DIS/ s EM/MTG.CHL.DHL.DIS./12 Annex IT page ( i i i )

WHO SECHE'L'AKUT ( c ~ n'dl t

D r Y . Watanabe

WHO Temporary Adviser

Adviser f o r L a b o r a t o r i e s , Ministry of Health, Kuwait

Regional Adviser, Cornunity Water Supply Regional Adviser on

Regional O f f i c e f o r the Castern Mediterranean, Alexandria Keyianal U f f i c e t o r t h e Eqstern Mediterranean, Alexandria Region41 Office f o r t h e E a s t e r n Mediterrapean, Alexandria Regional O f f i c e f o r t h e Eastern Mediterranean, Alexandria Regional Qffice f o r the E a s t e r n Medif e r r a n e a n , Alexandria Regional Off i c e f o r the L a s t e r n Mediterranean, Alexandria

tiealth Laboratory S e r v i c e s

I)r R , Cook

Kegional Adviser. klaternal and Child Health/ Nutritiop Regional Adviser on Family nealttl Con£erence O f f i c e r

Dr S.A. Z a i i r Mrs C. CartoudisIJE~nllbtrio Mrs 1. Parid

Secretary

Did not a t t e n d

PROGRAMME FnR CO?JTROL9 F E : ! T E R I C INFECTIO?I? T?' TIE EbSTCRP \[ED1 f~:'r;RA?'Et?" REGION (1976 - 1983) as r~cnnanendedby tho Regional Efccting on Cholere 3fid Diarlhcredl Diseases, Alexandria, 1 3 June 1978

- ~ I N l R C D F C T I O N The Sixth General Programme of IJork defines, amnng others, the folloving broad objectives for the implementation of disease prevention and rc>ntrol In I I?, general : ,t (1) strengthen national and international epidemiological surveillarice of

communicable diseases of public health itnportance, and collaborate w i t h ccruntries in evolving programmes fpr their control ; (2) I

provide prompt and effective a s . : : ;tance in emergencies ; promote research on measures to prevent and control communicable diseases, develop and apply means for.the control of vectors, .interniediate'hosts and

(3) (4) '

reservoirs of pathogenic agents.

, .

The Sixth General Programme of Work slated that "the impetd given to cholera control should be extended throbgh prophylactic, therap&tic and'environmental

health measures to the entlre range of acute infections of the intestinal tract" which also represent a major cause of morbidity and mortality, severely affect young children and ;equire a multidigciplinary approach. 7

Tt further stated among

- -

the detailed objpctives

"to prompt and coordinate the developmehk ok research on

effective and economical measures for the prevention and control of comunicable diseases'.' To achieve the objectives set above, this programme envisages the participation of WHO/EhlR@ in the countries of the Region in (a) establishing the profile of the epidemiological situatio~rand determining the health and docio-economic parameters that justify priority of action; (b) determining the possibility of

preventing or controlling the communicable diseases using the most effective and cconomically most suited n l e t l ~ u d s .

The above broad objectives are fully applicable to the prevention and control of enteric infections as a part of a larger programme of comniunicable disease control for which a comprehensive medium-term programe shall.be prepared in due course. 1

SITUATION ANALYSIS The occurrence of enteric infections is ubiquitous in all countries o f t h e Region. Parasitic and bacterial pathogenic agents are recognized through the

existing laboratory facilities but identification of viral pathogens is feasible only in very few countries where facilities for virological work exist. The common determinant of mortality among children with gastroenteritis is deh;,dration,therefore rehydration if instituted in time, may save the life of the child. Until recently, rehydration treatment was given to patients intravenously.

With the de-relopment of oral rehydrotion techniquen tilxely core can hc trought to

the house of the patient in most reriiote areas by health workers with simple training The countries of the Eastern Mediterranean Region are not thought to harbour, according to available evidence, endemic cholera, but are subject every year to the importation of the disease from the endemic foci. The disease first appears around

April/May in the most eastern countries of the Region and progressively proceeds towards west to reach its maximum around August/September and disappear towards November/Decenber. A cause for particular concern is the annual gathering of more

than a million pilgrims from all parts of the lnoslem world at a time, which, in the next

Live years, will cuirrcide w i L 1 1 the cllulera epide~uic seasun.

There is growing evidence of the relationship of enteric infections including cholera in the Middle East linked with the practice of using sewage mixed with irrigation waters in vegetable gardens. This practice is difficult to correct through educational or legislative measures.

On the other hand the implementation

of sewage treatment plants is extremely expensive. A cost benefit analysis would be necessary. The presence of cholera even in sporadic form, has so far brought psychological and socio-economic problems to the affected countries and determined outsized reactions among neighbouring countries. banned with consequent economic losses. Importation of perishable goods has been The health resources of the countries

have been drained to cope with the public demand for vaccination despite the knowledge of the poor protection afforded by it. The knowledge of the epidemiology of enteric infections in general and infant gastroenteritis in particular is incomplete and a system of epidemiological surveillance is necessary.

The developmcnt of such system would bring timely

remedial measures to the most remote areas as soon as outbreaks appear and would help with disseminating practice and knowledge about oral rehydration.

~ l r i n e xi l L

page ( i i i )

TARGETS AM) ACTIVITIES The e x t e n t o f WHO i n v o l v e m e n t w i l l depend on t h e p r i o r i t i e s f l x e d a t

t h e n a t i o n a l and r e g i o n a l l e v e l s and on t h e a v a i l a b i l i t y o f f u n d s .

The

g e n e r a l objectives and t a r g e t s may be a c h i e v e d i n a p h a s e d programme o f p r o g r e s s i v e expansion. The p l a n t h e r e f o r e e n v i s a g e s t a r g e t s which may h a v e t o b e r e v i s e d i n

t h e c o u r s e o f t h e p r e s e n t programming p e r i o d (1978

1983).

For an a p p r o p r i a t e p l a n n i n g and programming, t h r e e m a i n p r e - r e q u i s r t c ~ have t o be s a t i s f i e d : e n t e r i c irlfectrons; (a) (b) d e t a r l e d knowledge o f t h e e p i d e m i o l o g y o f t h e e x p a n s i o n o f t h e s u r v e i l l a n c e mechanism t o r e a c h (c)

t h e most remote a r e a s ,

improvement o f t h e diagnostic c a ; a b i l i t y

of the

public h e a l t h l a h n r a t n r i e s .

The p r e s e n t programme i n t h e a r e a c o n c e r n e d w i t h t h e c o n t r o l o f e n t e r i c infections c o m p r i s e s t h e f o l l o w i n g :

(a)

e p i d e m i o l o g i c a l s t u d y o f e n t e r i c i n f e c t i o n s I n c l u d i n g c h o l e r a a t c o u n t r y and

r c g i o n a l level fur. t l ~ r q u a n ~ i f l c a r l o nof n e e d s and t h e f o r m u l a t i o n o f c o u n t r y

and r e g i o n a l p l a n s ;

(b)

broad

programming

f o r t h e e s t a b l i s h m e n t o f epidemio-

l o g i c a l i n f o r m a t i o n c o l l e c t i o n and r e t r i e v a l ; ( c ) b r o a d programming a t c o u n t r y l e v e l s e t t i n g o b j e c t i v e s and a p p r o a c h e s , t a r g e t s , m e t h o d s , manpower r e q u i r e m e n t s , p h y s i c a l f a c i l i t i e s , a c t i v i t i e s , and o u t p u t i n d i c a t o r s f o r e v a l u a t i o n . The t a r g e t s d e f i n e d i n t h i s medium-term programme a s w e l l a s t h e o b j e c t i v e s b e l o n g t o two o r d e r s , t h e f i r s t g e n e r a l t a r g e t s a p p l i c a b l e t o a c t i v i t i e s o f the W H O R e g i o n a l O f f i c e , t h e second s p e c i f i c c o u n t r y t a r g e t s t o b e i n t e g r a t e d i n t h e h e a l t h p l a n s of t h e c o u n t r i e s concerned.

Annex I I I ;,age

(iv)

Following recommendations of t h e Regional Committee, t h e Government of Kuwait has already i n i t i a t e d t h e f i n a n c i n g ~f t h e programme w i t h an o f f e r of Kuwaiti Dinars 5 000 and more c o n t r i b u t i o n s a r e expected from o t h e r c o u n t r i e s a s well a s from o t h e r i n t e r n a t i o n a l a g e n c i e s such a s UNDP and UNICEF.

OBJECTIVES AND TARGETS A T REGIONAL LEVEL

Objectives C o l l a b o r a t e w i t h Governments i n t h e implementation o f : 8.1 a system of n o t i f i c a t i o n and r e p o r t i n g of e n t e r i c i n f e c t i o n s i n c l u d i n g c h o l e r a i n a l l c o u n t r i e s of t h e Region 1 ( Session a.2

RC27A

- Technical a t n a t i o n a l and

f i r s t and t h i r d paragraphs)

a system of information s t o r a g e , r e t r i e v a l and a n a y s i s r e g i o n a l l e v e l s (Res.4

RC27A

Technical Session)

a.3

convening a Regional Group of Experts f o r t h e study of e n t e r i c i n f e c t i o n s i n t h e Region and formulate a u n i f i e d r e g i o n a l plan t o prevent t h e spread of c h o l e r a i n t h e Eastern Mediterranean Region (Res.5 Session)

RC27A

Technical

a.4

a system of l a b o r a t o r y s t a n d a r d examinations f o r d i a g n o s i s of e n t e r i c infections

a.5

a standard methodology d i a r r h o e a 1 d i s e a s e s treatment

( 1 . 6 o r g a n i z a t i o n of emergency s e r v i c e s i n c a s e of epidemics a.7 a t r r ~ ~ g t l r e ~ t ie ux gi s t i ~ ~ l~ g r ath l e d u c a t i o n u n i t s and a c t i v i t i e s or

e s t a b l i s h i n g new ones i n t h e c o u n t r i e s i f necessary a.8 co-ordination of r e l a t e d progrannnes a t r e g i o n a l and country l e v e l (Environmental s a n i t a t i o n , MCH, e t c . ) a.9 e n t e r i c infections control.

Annex 111 page ( v )

TARGETS TARGET A. 1 Compilation

ACXIVITIES

of b a s e l i n e information t o a s s i s t country planning

Related A c t i v i t i e s A.l.l Study of t h e d i s t r i b u t i o n of e n t e r i c d i s e a s e s countrywise and r e g i o n w i s e . A.1 . 2

Determination of population groups a t r i s k . D e t e r m i n a t i o n o f r e l a t e d socio-economic and e n v i r o n m e n t a l f a c t o r s I n v e n t o r y o f p r e s e n t and p o t e n t i a l r e s o u r c e s : m a t e r i a l and f i n a n c i a l . human, i n s t i t u t i o n a l ,

A.'.3 A.'.4

A.1.5

D e f i n i t i o n o f most s u i t a b l e and economic t e c h n o l o g i e s f o r :

A.1.6 A.1.7 Estimate of c o s t s

surveillance d i a g n o s i s , c l i n i c a l and l a b o r a t o r y treatment prevention control

E s t i m a t e o f a d m i n i s t r a t i v e and o p e r a t i o n a l n e e d s

TAKGhT A.2

Assistance t o countries i n planning of e n t c r i c i n f e c t i o n s control integrated

i n t o b a s i c h e a l t h s e r v i c e s i n g e n e r a l and p r i m a r y h e a l t h c a r e i n p a r t i c u l a r bergency assistance

Related .'\ctivities

A.7.1

V i s i t n f Rpginnal

Advisers

A. 2.2

P r o v i s i o n of short-term c o n s u l t a n t s and/or long- term a d v i s e r s P r o v i s i o n o f t e c h n i c a l l i t e r a t u r e and l i b r a r y r e f e r e n c e s r e l a t e d

A.2.3

to t h e s u b j e c t

A.2.4 A.2.5

Organization of technical meetings, seminars and training courses, Provision of exchange of technical staff through fellowship programmes (travel, fellowships)

TARGET A.3

Establishmgnt of Regional technical groups made of experts of the Region with national technical assistance. Related Activities A.3.1 A.3.2 Call for nomination from most affected countries Convening of the meetings of the technical groups, establishment of terms of reference and plan of work A.3.3 A.3.4 Drafting of the plan of work of the technical group Approval of the plan by Regional Cormittee.

TARGET A. 4 Definition of most suitable laboratory technologies

Drafting and dissemination of related practical manual of laboratory techniques. Related Activities A.4.1 A.4.2 A.4.3

Consultations with appropriate technical bodies Study of practicability at field level Translation of manuals into Arabic Workshops on laboratory techniques related to enteric infections

A.4.4

@,.L,-'

':esi,--latior. ?f a~:;ab3ratir:g l a : > a r ~ t o r i e ra: t re,isl,al 2atior.a; l e v e l s . A .,>

B:.c;

111,cr-

'rA i ; A > :

3efi:.i i i )., g f tec:mo~ogies.

l,:os t

s u i - a u l e uia;r,sz t i c , trcatmer. s 0x1 't~i;!.

bn;

prevet.ti,r)

-iral'ting: rnd .Jissenir!kition of rrai,ual

uiarri~oe;i: a i s e a s e s

uiagnosis, treatrv!ent ar.a c r r v e n t i o n an6 i n f a n t i l e i i a r r r r ~ a a . P,rl~tell

W r t i ~ u l a r e f e m n p e ts choler*

AActlvlLles Consultation with a p x r o p r j a t e i e c i % ~ i c a bodies i 2 t u d i e s o! p r a c t l c a b i l i t y a t f i y l d leve! T r a b s l a ~ i o no f e s s e n t i a l educatior. mai,erial i n t c Alaoic Seminars on d i a g n o s i s , treatn;er.t and preventiorl of d i a r r h o e a 1 d i s e a s e s artu s u r v e i l l a n c e rneckartiqrn :2eLlows!.ip cro;ratme f o r prcfes$ional and sub-professional s t a f f witn r e s p o n s i b i l i t y i r l d i a r r h o e a 1 d i s e a s e s Orgarlization of rlational t r a i n i n g courses and seminars

A. A,:.:

5.1

A.5.3 A,

5.4

5 .j

A.5.6

drganiza t i o n of emergency s e r v l o e s i n c a s e of epidemics Related A c t i v i t i e s

A.6.1 A.6.5

Formulation of plan of a c t i o n Asgignment of r e s p o p s i b i l i t i e s Provisaon 01 emergency s e r v i c e s such a6 medlcal c a r e f a c i l i t i e s , t r a n s m r t , equipment and s u p p l i e s 3piden.iologicai e p i d e a i c ~ e r v i c e s Implementation of inter-epidemic seryices.

A.6.3 h .6.4

A .6.5

Annex 11 1

page ( v i i i j

Strengthening e x i s t i n g h e a l t h education u n i t s and a c t i v i t i e s o r e s t a b l i s h i n g new ones i n t h e c o u n t r i e s i f necessary. Related A c t i v i t i e s A.

7.1

I d e n t i f i c a t i o n of r e l a t e d s p e c i f i c problems both i n - t h e areas of h e a l t h aqd s o c i o - c u l t u r a l aspects. Formulation of the sub-programme f o r h e a l t h education r e l a t e d t o d i a r r h o e a l diseases. Co-ordination a t c e n t r a l , p r o v i n c i a l and peripheral l e v e l s i n each country and assignment of r e s p o n s i b i l i t i e s . Preparation and f i e l d t e s t i n g of s u i t a b l e materials and t h e i r d i s t r i b u t i o n qnd u t i l i z a t i o n . Carrying o u t r e l a ted t r a i n i n g programmes. Evaluation t o be planned from t h e start and implemented on a continuous as w e l l a s periodic b a s i s .

A .7.2

A. 7 . 3 A.7.4 A .7.5

A .7.6

TARGET A . 8 I d e n t i f i c a t i o n of r e l a t e d programmes a t Regiopal and c ~ w t r y levels. Related A c t i v i t i e s

A.8.1 A.8.2

Co-ordinate r o l e of MCH i n the prevention a f d i a r r h o e a l d i s e a s e s among c h i l d r e n Sub-programme 3.2.1

CQ-ordinate r o l e of SHE i n t h e c o r r e c t i o n of environment f a c t o r s fqvouring $ransmissian of d i a r r h o e a l d i s e a s e s Sub-programme 5.1.:

~ . 8 . 3. Promote p a r t i c i p a t i o n of r e l a t e d i n t e r n a t J o q a 1 agencies i . e . T D P , I!P;FPA and b i l a t e r a l agencies UNICEF, FAO, IBRD, L TARGET A.9 Collaborate with c o u n t r i e s i n t h e implementation of e n t e r i o I n f e c t i o n s Evaluate efficiency and e f f i c a c y of m e a a r e s applied, Related A c t i v i t i e s A.g.1 Provide advisory s e r v i c e s through Headquarters and Regional Office s t a f f , and shart-term consu$tant;s, a s w e l l a s m a t e r i a l gssistance. Provide a s s i s t a n c e f o r a n a l y s i s of s t a t i s t i c a l r e t u r n s on morbidity and m o r t a l i t y f o r d i a r r h o e a l d i s e a s e s . "' Implement comparative study of c o n t r o l measures applied. benefit analysis. Cost-

cpntrol;

A.9.2

A.9.3

11.

OBTECI'IVES AND TARGETS A T C O W R Y IEVEL (GUIDELINES) Objectives I d e n t i f i c a t i o n of t h e e n t e r i c i n f e c t i o n s problem. I d e n t i f i c a t i o n of human resources and t h e i r adequacy i n terms of number and performance 3 I d e n t i f i c a t i o n of s u i t a b l e and economic methods of e n t e r i c inf e c t i o n s c o n t r o l , implementation of t r a i n i n g . B.4. I d e n t i f i c a t i o n of m a t e r i a l and i n s t i t u t i o n a l resources and t h e i r adequacy i n terms of q u a n t i t y and ~ u a l i t y . B.5. Drafting of plan f o r e n t e r i c i n f e c t i o n s control, including a properly planned h e a l t h education component. ~ . 6 . Implement plan f o r diarrhoea1 d i s e a s e c o n t r o l . B.l. B.2.

TAFtGETSI ACTIVITIES Each country ohall attempt to define the time-table of t h e following targets;

TARGET B.l Define p r i o r i t i e s and d r a f t b a s e l i n e information f o r e n t e r i c i n f e c t i o n s c o n t r o l . Related A c t i v i t i e s B.1.1.

B.1.2. B.l.3.

B.1.4.

Comparative study of h e a l t h p r i o r i t i e s and s i t u a t i o n a n a l y s i s i n t h e enteric infections area. Implement appropriate epidemiological a d hoc s t u d i e s . he-investment a n a l y s i s , comprising study of economic l o s s e s due t o m o r t a l i t y and morbidity caused by diarrhoea1 d i s e a s e s and economic damage on tourism, t r a d e and p r o d u c t i v i t y due t o t h e presence of e n t e r i c infections. Study on behaviour and a t t i t u d e s towards e n t e r i c i n f e c t i o n s and rel a t e d problems.

TARGET B,2 Development of h e a l t h manpower required f o r e n t e r i c i n f e c t i o n s c o n t r o l and r e l a t e d research. Related A c t i v i t i e s B.2.1 2 . 2

E s t a b l i s h h e a l t h manpower requirements. Implcmcnt training couraee, seminars and technical meetings at national

B.2.3.

l e v e l and p a r t i c i p a t e i n inter-country meetings. Promote dissemination of r e l a t e d t e c h n i c a l knowledge.

TARGET B.3

Standardize methodologies of e n t e r i c i n f e c t i o n s c o n t r o l a p p l i c a b l e t o l o c a l conditions. Related A c t i v i t i e s B.3.l

Introduce and e v a l u a t e appropriate t h e r a p e u t l c technologies with t h e appropriate responsible s t a f f . This includes p a r t i c u l a r emphasis on t h e use of rehydration techniques. Introduce and evaluate a p p r o p r i a t e l a b o r a t o r y techniques f o r t h e s e l e c t i v e d e t e c t i o n and recognition of causes of e n t e r i c i n f e c t i o n s i n p a r t i c u l a r flowcharts methods of s t o o l examination.

B.3.2

Introduction and evaluation of methods of environmental monitoring ( i . e . r o u t i n e t e s t i n g and b a c t e r i o l o g i c a l examination of water, sewage and f o o d ) .

TARGET ~ . 4

Define needs i n terms o f medical c a r e f a c i l i t i e s r l a b o r a t o r i e s and org a n i z a t i o n a l i n s t i t u t i o n s required f o r implementing e n t e r i c i n f e c t i o n s control. Related Activities B.4.1

Inventory of i n s t i t u t i o n a l resources a t country and r e g i o n a l l e v e l s , i n c l u d l r ~ gMCH services, p l b l i c h e a l t h l a b o r a t o r i e e nnd h o o p l t a l carc f a c i l i t i e s f o r r o u t i n e needs and f o r emergencies. Inventory of t r a n s p o r t and communications a v a i l a b l e and e s t i m a t e needs f o r s u r v e i l l a n c e s e r v i c e s r epidemiological i n v e s t i g a t i o n s , ambulance s e r v i c e s and c o n t r o l operations.

B.4.2

TARGET B.5 Prepare and finalize for implementation a plan for enteric infections control within the limits of available humqn, material and financial resources, according to local needs and priorities. Related Activities 5.5.1

Plan and organize a surveillance system including a rjystem of rapid notification and referral of cases.

8.5.2

Plan and organize a network of laboratories at peripheral level capable of rapid diagnosis for early identification of cholera.

B.5.3

Plan and organize a system of rapid assistance for dehydrated cases at their own domicile through village workers and village collaborators. This plan will include rapid referral to specialized institutions in case of severity of clinical symptoms.

B.5.4

Plan and organize a system of environmental control linked to the system of environmental monitoring.

B.5.5

Plan and organize health education activities with specific reference to enteric infections.

B.5.6

Secure financing of all activities from internal and/or external sources.

TAW,>ETB.6 Implement control plan in all its multidisciplinary aspects. Related Activities B.6.1 The activities for control from the selected methodologies and policies adopted. These will include: - a system of surveillance a rapid notification system at national and international level - epidemiological study of outbreaks - expanded utilization of oral rehydration - standarddiagnostic methods routinely applied also in cholera interepidemic periods. - standard formulation of intravenous and antibiotic treatment - environmental control measures ? - health education of the public

TA'ARGET 1

30 ooc

3c oco

39 ooc

3s ooc!

TAXGET 3

20 C 0 C

20 000

25 OOG

25 000

33GE'; 4

4 1 OGC

1 6 OCC

4 1 000

1 6 000

TARGET 7

TARGET

10 000

1 C 000

10 000

Grand t o t a l f o r 4 y e a r s :

$ 1 428 00:

A rrsre d e t a i l e d breakdown o f c o s t f o r a c t i v i t . i e s i s a l s o a v a i l a b l e

The c o s t o f some a c t i v i t i e s are n e t by other programmes.

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Meeting reports

Дата принятия 31 декабря 1978 г.

Источник Всемирная организация здравоохранения