Technical Literature Update library I AND L. documentation UNIT on DIARRHEA
Item
- Title
-
Technical Literature Update
library I AND
L. documentation
UNIT
on DIARRHEA - extracted text
-
SDA-RF-CH-3.3
CH 3.IS-
(T/ieme: Integration
library
I
L.
AND
documentation
Technical Literature Updat
UNIT
on DIARRHEA
Technical Editor: Robert Northrup, M.D.
Managing Editor: Karen White, M.L.S.
1993
Vol. VIII, N°3
Integration
The movement in child survival efforts is toward integration. BASICS, the Agency for
International Development's new child survival project, which will manage the activities
of the current diarrhea, immunization, and health communications projects (PRITECH,
REACH, and HealthCom), is integrated. In addition, the WHO/CDR program has been
developing its "sick child initiative," which stresses the desirability of an integrated
approach to sick children. The program will seek to integrate diarrhea and acute respiratory
infection (ARD case management with a broader assessment and management of the child,
including nutrition. Many African health ministries have sought to add diarrheal disease
control (CDD) programs organizationally to their primary care units, and have combined
CDD operationally with other maternal and child health activities in the implementation
of supervision, training, information systems, and other field and central functions.
Diarrheal disease control efforts have long given priority to the close interaction between
diarrhea and nutrition.
This issue of the Technical Literature Update is the last under PRITECH direction, and
fittingly seeks to explore some of the issues facing the integration of diarrheal disease
control and oral rehydration therapy with other elements of child survival and primary
health care. The articles raise the question of a variable mix of interventions depending on
local epidemiology, discuss the tension between selective primary health care and
comprehensive primary health care and whether they are different in practice, and analyze
the potential and actual impact of integrated programs.
PRITECH^—
Management Sciences for Meaitfi
Address Correspondence to: Information Center, PRITECH, 1925 North Lynn Street, Suite 400, Arlington, VA 22200-1707, USA
Phone:703-516-2555 Fax:703-525-5070
AJ.D.-supported Contract# DPE-5969-Z-00-7064-00, Project * 936-5969
ISSN 1063-7486
because the health system is generally underdeveloped
in situations having this level of IMR. This combination of
interventions will both reduce IMR and initiate community
based primary health care with community health workers.
Hirschhom, N.; Grabowsky, M.; Houston, R.; and
Steinglass, R. “ARE WE IGNORING DIFFERENT
LEVELS OF MORTALITY IN THE PRIMARY HEALTH
CARE DEBATE?” Health Policy and Planning, vol. 4,
1989,343-53.
Order *3298
In areas with medium levels of IMR (119 to 60), ORT
and nutrition programs, immunization, and programs to
reduce low birth weight would be the priorities. In low IMR
areas, antenatal care, health education and hygiene,
water programs, and ORT would take priority as primary
care interventions. As IMR decreases, integration of
services within the primary level, and integration of the
primary level with effective referral services at the
secondary or tertiary level (e.g. support for underweight
newborns) would also be needed to reduce infant
mortality further, because of the more complex nature of
its causes at this residual level of IMR. At the same time a
lowered IMR from selective targeted programs may
stimulate the increased political commitment to health
needed to implement a true comprehensive primary
health care system.
Summary
Critics compare selective primary health care to
comprehensive primary health care, and say that the
former is top-down and fixed in nature, not responding
flexibly to variations in local conditions. Selective primary
health care is often militaristic, with minimum attention to
community empowerment. It creates dependence and
does little to build sustainable health care at the commu
nity level. Its narrow focus on infectious diseases
ignores the social, economic, and nutritional antece
dents of infections. Children saved from today's illness
by selective primary health care may die tomorrow of
something else (replacement mortality).
Editorial Comment
The authors describe a more flexible and responsive
selective primary health care. They analyzed published
infant mortality rates (IMRs) and specific mortality causes
in a number of countries at various stages of
development in health. The analysis showed that, as
IMR falls, deaths from diarrhea first increase proportional
ly, then decrease, while neonatal tetanus deaths fall,
then essentially disappear at low IMR levels. Measles is
prominent at high IMRs, along with other parasitic and
infectious illnesses including malaria, but decreases in
proportional importance at lower IMRs. Nutrition-related
deaths similarly decrease in importance. Perinatal and
respiratory deaths remain proportionally constant. Thus,
at low IMRs (59 to 24), the total number of defined caus
es contributing substantially to death declines, with
perinatal deaths and diarrhea being the most prominent
of the defined causes.
This article provides justification for the increasing
importance of integration as health status improves. An
unintegrated collection of interventions can make a sub
stantial impact on mortality in high IMR areas, where there
are many cases of a small group of simple problems man
ageable by comparatively simple interventions. As health
levels improve, the simple responses to the simple prob
lems will already be taking place. More complex service re
sponses to both sick and well children, needing more
complex support and management and integration in
order to achieve greater biologic effectiveness and oper
ational efficiency, will be needed if mortality is to be fur
ther lowered without overwhelming available resources.
Technical Literature Update
The TLU is produced by the PRITECH Project under
Contract #DPE-5969-Z-00-7064-00, Project #936-5969
with the Office of Health, Bureau for Research and
Development, of the United States Agency for
International Development (A.I.D.). The summaries and
editorial comments represent the opinions of the TLU
editorial staff and are not meant to represent A.I.D.
policies or opinions. Inclusion of an article in the TLU
does not denote endorsement or validation of the article
cited, but rather indicates that it is worthy of attention and
further critical appraisal.
The authors draw the conclusion from these findings
that selective primary health care programs should not
consist of a fixed set of interventions, but should vary in
programmatic content, according to the level of IMR and
therefore the causes of mortality.
Thus, at high levels of IMR (240 to 120), the recom
mended components of selective primary health care
should probably include vaccination against measles
and neonatal tetanus; availability of antimicrobials for
pneumonia, malaria, and dysentery; ORT for acute wat
ery diarrhea; and vitamin A for measles treatment. All
should be available at community and household level,
Technical Literature Update
Copies of articles featured in the TLU are available
through the PRITECH Information Center, 1925 N. Lynn
St., Suite 400, Arlington, VA, 22209. Please use the
order number listed at the end of each title when ordering
articles. Your comments are welcome.
2
Vol. VIII, Na3
as well as the PRITECH Project's even more focused
emphasis on ORT, can be considered examples.
Neither selective primary health care nor GOBI’ has
given priority to community participation and empower
ment, even control, of health care. The interventions
are chosen by external experts, not the people. They
target individuals, in particular “ignorant” mothers. They
lead to dependence on a health care system. In their
effort to minimize costs and maximize impact they have
utilized mass media social marketing and “massive ad
hoc delivery systems.” These approaches in particular
undermine the formation of local grassroots organiza
tions which join parents and primary health care workers
in truly autonomous collaboration. The interventions
also distract people from demanding that they be given
what they themselves define as their needs. In addition,
they distract people from efforts to overcome the obsta
cles imposed by factions of the privileged seeking to
protect the status quo and keep the people in poverty.
Integration of interventions could enhance
effectiveness and efficiency in high IMR areas as well.
Integration of such services would be primarily
horizontal, that is, across diseases and programs but
essentially all at the primary care level. In a low IMR area,
in contrast, further reductions in mortality would need
planning for integration at different levels of health care
services in addition to horizontal integration. For
example, in perinatal care, establishing effective referral
mechanisms such as screening for early identification of
problems, communications, and transport would allow
care at the primary level to be effectively integrated with
services at secondary or tertiary levels for those mothers
or infants requiring them. Decisions at all IMR levels of
about whether to integrate certain interventions must
primarily be determined on the basis of biologic and
operational synergism: whether one intervention will
biologically enhance the effectiveness of another (will
hygiene enhance ORT, for instance, by reducing the
number of diarrhea cases), and whether one
intervention will fit operationally into or alongside
another (such as vitamin A capsule distribution readily
being joined with immunization).
Editorial Comment
Wisner’s unstated goal, upon which most of his
arguments are based, is the primary health care process,
a movement which in a larger political context would be
seen as akin to communism. In this movement, the
people or community should be helped to assume the
power to solve their own problems. The hierarchy
inherent in a system in which a few people "control” the
knowledge and skills needed to bring about good health
is inherently bad, according to this approach, and must
be reduced or if possible eliminated. If it were not for the
evil controlling doctors, who are keeping the inherently
simple knowledge and skills needed for their own use
and profit, the people could deal with their health
problems themselves. People have a right to health, he
implies (not to health care but to health), presumably
measured by the usual indicators of mortality and
morbidity. He seems to contend that improving health
via the politically appropriate pathway is more important
than the health itself.
The authors argue that, carried out in this flexible and
responsive fashion, selective primary health care is not
the monolithic, anti-community approach of which its
critics complain. In fact, they say, even the more
justifiably separate interventions appropriate to
situations of high IMRs would be benefitted by greater
emphasis on community involvement or training village
health workers.
The study, based on data from many countries,
draws attention to general patterns. These patterns
should be valuable to international donor agencies
developing approaches for many countries. Such
patterns should not be overused in planning programs
for an individual country, however. Special local social
conditions, such as educational levels, climate or
geography, economics, and existing health facilities, as
well as local mortality and morbidity data, must be
analyzed and incorporated in developing local plans.
The goals of selective primary health care and GOBI,
are, in contrast, clearly stated—better health, specifically
the reduction of mortality of children. These approaches
seek to achieve that by the most direct and rapid meth
ods available. As the author notes, the selective primary
health care movement arose in response to disappoint
ments with the primary health care movement and with
earlier efforts to improve developing country health sys
tems as a whole. Despite substantial investment, these
efforts, when carried out on a large scale, had not result
ed in much impact on mortality. Children were still dying
at about the same rates.
Wisner, B. “GOBI VERSUS PHC: SOME DANGERS OF
SELECTIVE PRIMARY HEALTH CARE.” Social
Science and Medicine, vol. 26, 1988,963-69.
Order *3287
Summary
This article targets for criticism the selective primary
health care approach, for which UNICEF's GOBI strategy,
1 GOBI consists of growth monitoring, oral rehydration therapy for diarrhea,
breastfeeding, and immunization.
Vol. VIII, Na3
3
Technical Literature Update
In my own experience, communities may not put
health first, or may drift away into other endeavors,
despite sincere efforts to facilitate their development of
primary health care. Much effort can be made by
governments without a corresponding response by the
people, and therefore with minimal impact on mortality.
Philosophically the comprehensive primary health care
approach is attractive, just as communism and a
managed economy were attractive to the founders of
the Soviet Union. But put into practice in a variety of
situations, the comprehensive primary health care
approach is inconsistent at best in bringing about the
hoped-for improvements in health, as measured in
children's deaths. Because of this, the selective primary
health care/GOBI approach chose a few effective and
efficient interventions that could be implemented in a
way which would circumvent the immense investment
that comprehensive primary health care seemed to
require, and still achieve major reductions in mortality.
Kendall, C. “THE IMPLEMENTATION OF A
DIARRHEAL DISEASE CONTROL PROGRAM IN
HONDURAS: IS IT SELECTIVE PRIMARY HEALTH
CARE' OR INTEGRATED PRIMARY HEALTH CARE?'”
Social Science and Medicine, vol. 27, 1988, 17-23.
Order #2175
This article addresses the debate between
integrated or comprehensive primary health care and
selective primary health care. Kendall notes many of the
same differences between the two as Wisner (above):
concerned or not with the structure and organization of
services and of communities, functioning exclusively
within the health sector or involving other sectors in
broad development, driven by epidemiologic and cost
considerations versus considerations of social equity,
emphasizing community participation or not, and
narrowly focused on single interventions or aimed at
broader institutional and health system development.
I continue to believe that this logic is valid. We
cannot willingly allow children to die in the name of
comprehensive primary health care or any other
philosophy, no matter how internally moral that
philosophy may be. In some settings, human beings are
able to manage the complex relationships and divisions
of labor and education that are needed for sustainable
PHC to take place, and to bring about better health. But
in many communities this does not seem to be possible.
A more dependency-producing, more controlled and
controlling, less consensus-dependent system seems
to be necessary to keep children from dying within
available budgets in such circumstances.
He finds, however, that in the effective
implementation of selective primary health care as in the
Honduran natinoal CDD program, the distinctions
between the two approaches become much less clear.
The initially more focused selective primary health care
implementors were forced to respond to issues related
to community involvement, strengthening of basic
health system functions such as health education,
management, supervision, and supply logistics, and
problems in the underlying basic primary health care
system (such as village health worker and community
fatigue). The CDD program went beyond case
management of diarrhea patients with ORT to engage
actively in water and sanitation and hygiene activities,
which of necessity involve the community if they are to
be successful. The program worked through multi
purpose workers at the community level and
professionals at all levels of the health care system, not
through a dedicated vertical system of specialized
workers.
Wisner makes a number of stimulating suggestions,
in particular where he cites mechanisms by which we
could enhance community and group involvement and
use selective primary health care as the "leading edge"
of primary health care. The following paper by Kendall
on Honduras shows how this can happen. In the last
few years, we have seen in a number of countries how
governments and politicians have been stimulated to
invest more in health and primary health care by the
success of immunization days and aggressive
breastfeeding programs, for example. Our future efforts
must continue to seek ways to engage the community in
health-generating activities while not jeopardizing those
activities that keep children from dying today.
Technical Literature Update
Honduras had an integrated primary health care
system in place, which had as many problems as
successes. The CDD program had to work with those
problems, and the problems of the primary health care
system became the program's problems. In some cases
it could bypass such problems. For example, it used
radio to reach community members directly, thereby
creating demand which in turn provided incentive for
both the nurses and auxiliary health workers of the
primary health care system. It used municipal mayors to
distribute ORS, which subsequently led to a rekindling
of interest by volunteer health workers in their work.
4
Vol. VIII, Nfi3
Kendall concludes that issues of design and
utilization of services at local levels, obstacles to service
delivery, household level integration, political and
economic implications of health services, and other
questions and problems are issues that cut across
primary health care and selective primary health care.
When these issues are addressed from the more
practical perspective of implementation than from a
purely theoretical perspective, they are more fruitful in
organizing what we already know about primary health
care and what we should address in our research than
the theoretical debate that inappropriately codifies and
polarizes them.
host governments must recognize and provide support
for activities aimed at integrated problem solving in
addition to the pure selective primary health care
program activities which are their main focus.
Collaboration with the basic primary health care systems
of the health ministry and the private sector and its
primary health care services, will both assist the targeted
selected primary health care program in meeting its
objectives, and help to solve the problems and achieve
the philosophical goals of the underlying integrated
primary health care system.
Block, R.E. “WOULD CONTROL OF CHILDHOOD
INFECTIOUS DISEASE REDUCE MALNUTRITION?” Acta
Paediatrica Scandavica, supplement, vol. 374,
1991,133-40.
Order #5191
Editorial Comment
This article speaks for many of us with experience in
the field. We find the theoretical debate between
integrated or comprehensive primary health care and
selective primary health care as expressed particularly in
CDD programs frequently irrelevant as we struggle via
our “vertical" program efforts to deal with problems of
village level participation and communication, parental
education, home versus health facility treatment, home
solutions versus ORS packets, and the like. Yes, the
integrated primary health care approach seems to
emphasize a participatory, community-driven process of
health care rather than impact on mortality, certainly
more than most CDD programs do. Yet CDD programs
must ultimately face the problems of sustainability, of
poor health services coverage at least by government
health workers, and of the need to get ORS or drugs for
dysentery out to the community and delivered
appropriately. All of these concerns lead the programs
to become involved with communities and village health
workers, as happened in Honduras.
Pediatric infections have long been recognized as
important influences on the physical growth of children
and the nutritional status and rates of malnutrition in
populations. Particular infectious diseases, such as diar
rhea, measles, respiratory diseases, and malaria, have
been identified as probable determinants of growth in
seminal studies in various settings. The studies exam
ined in this review article were mostly studies of the
frequent childhood infectious diseases of developing
countries, especially diarrhea and respiratory diseases.
In some studies, measles, malaria, skin infections and
other illness categories were also included.
Examples: (1) Seven hundred sixteen Guatemalan
children under seven years of age were followed for 23
months. Illness histories were collected every two
weeks and related to 6 monthly and yearly increments in
weight and height. The percentage of days ill with
diarrhea was found to be significantly associated with
reduced gains in weight and height. Respiratory
illnesses, which were present 30-35% of the time in the
first four years of life, were not associated with reduced
growth outcomes.
Perhaps the most important characteristic of the
Honduran situation was that the CDD project was
implemented with a project to strengthen basic and
primary health care services. Both will apparently
continue to be funded by USAID. By working together
and being integrated, the projects could address
fundamental and joint problems.
(2) In The Gambia, 152 children 3-36 months of age
were studied for one year. Diarrhea was demonstrated
to be significantly related to reduced increments in
weight and height. Malaria prevalence adversely
affected weight gain, but not linear growth. Other
categories of infections, including upper and lower
respiratory tract infections, were not found to affect
growth significantly in this population of children.
In contrast, CDD or other child survival programs
working in situations where governments and donors
are not addressing basic health service problems may
be too minimally funded to address even the most
critical basic primary health care system problems
adequately. This is true particularly if they are tightly
constrained by their funding sources to address only
the problems and activities of the particular disease
control program. To be successful, both donors and
Vol. VIII, Na3
(3) A longitudinal study in Uganda involving 45
children less than 3 years of age showed the
5
Technical Literature Update
occurrence of diarrhea to be significantly associated with
reduced weight gain. Diagnosed malaria and fever of
unknown origin were also associated with reduced
weight gain. Other disease categories, such as upper
and lower respiratory illness and skin infections, were
not associated with adverse growth outcomes.
supplementation programs to the critical period of high
diarrheal prevalence among infants and young children
in order to increase the effectiveness of such programs
in preventing growth retardation.
When infectious diseases and routine dietary intake
have been evaluated simultaneously, inadequate
dietary intake rather than the infectious disease per se
was found to have the predominant role in growth
faltering. In many cases another bout of
disease—frequently diarrheal disease—overtakes the
child before the initial "catch-up" period has been
completed, preventing by poor appetite the increased
food intake needed. The magnitude of effect of
diarrheal diseases on growth is difficult to estimate since
effects ranging from 10-80% of the growth retardation in
the first few years of life have been reported.
The Lutter study is powerful evidence of the
importance of integrated programs in controlling one of
the most important negative effects of diarrhea, its effect
on nutrition and growth, bearing out the conclusions of
Black in the previous summary. A subsequent study
from Peru, detailed in an abstract by Kenneth Brown
and colleagues (FASEB Journal, vol. 5, A1079, 1991)
examined a very similar question, whether having an
adequate basic diet as compared to a deficient diet
would influence the negative effects of diarrhea on
growth. One would presume that diets of the children
receiving supplements in the Lutter et al study would be
considered "adequate” according to Brown's criteria.
They used weight gain rather than length as their
indicator.
Editorial Comment
This variability in the observed effects may be
explained in part by the presence of other factors that
modify the potential effect of diarrhea, and possibly
other infectious diseases. Control of infectious disease
through prevention or proper case management can be
justified for itself, but is not as cost effective in improving
nutritional status and reducing malnutrition as more
direct nutritional interventions such as breastfeeding
support, dietary supplementation, or convalescent
feeding approaches.
Brown reported that those children whose regular
dietary energy intake was greater than 75% of their
recommended intake showed no relationship between
diarrhea prevalence and weight gain, while children with
energy intakes less than 75% of recommended levels
did show poorer weight gain with greater diarrhea
prevalence.
This study confirms that having an
adequate diet can offset the negative results of diarrheal
disease on growth, both with regard to weight and
length.
Lutter, C.K.; Mora, J.O.; Habicht, J-P. ef al.
“NUTRITIONAL SUPPLEMENTATION: EFFECTS ON
CHILD STUNTING BECAUSE OF DIARRHEA,”
American Journal of Clinical Nutrition, vol. 50,
1989,1-8.
Order#3296
In both situations the critical action—adequate
feeding or food supplementation—had to occur
between diarrhea episodes, and would not ordinarily be
part of the usual CDD program concentrating on case
management.
One presumes that in most
circumstances children receiving a supplement would
be chosen through a process of growth monitoring. In
such a fashion, growth monitoring followed by
supplementation or effective maternal education on diet
to the most needy children would act synergistically with
ORT and adequate diarrhea case management to
prevent nutritional damage from diarrhea. Integration of
interventions in this manner, that is, strategically
planned integration, can take advantage of these
biological synergisms and indeed improve both the
effectiveness and the efficiency of the well-chosen
interventions.
Research has demonstrated that the positive effect
of nutritional supplementation on child growth in
malnourished children is small relative to the large
negative effect of diarrheal disease. Length and
diarrheal morbidity were compared at 36 months of age
for two cohorts of Colombian children, testing the
hypothesis that routine dietary supplementation can
modify the negative effect of diarrhea on height. Among
unsupplemented children, diarrhea was negatively
associated with length, that is, children with more
diarrhea were more frequently stunted.
Among
supplemented children, in contrast, diarrhea had no
effect on length: the supplementation appeared to
offset the stunting effect of diarrheal disease
completely. The authors recommend targeting food
Technical Literature Update
Such strategically planned, integrated interventions
are very likely the appropriate response to the problems
6
Vol. VIII, N93
described by Black in the preceding summary. A pure
ORT program, even one that tried to improve feeding
during and immediately after the diarrhea episode,
would probably not have the same effect.
effective in mortality reduction because those cases of
diarrhea that do occur despite better hygiene can be
provided with a lifesaving intervention. Targeting
interventions to high-risk groups will further increase the
efficiency of the interventions. Operations research to
improve existing interventions, developmental research
to generate new appropriate technologies, and more
consistent investment in evaluation research to
document the demographic impact of interventions, are
needed to further strengthen existing efforts.
Mosley, W.H.; Becker, S. “DEMOGRAPHIC MODELS
FOR CHILD SURVIVAL AND IMPLICATIONS FOR
HEALTH INTERVENTION PROGRAMMES.” Health
Policy and Planning, vol. 6,1991,218-33.
Order*5151
Editorial Comment
Summary
This article stresses the continuing need for child
survival services, even in the Asia-Near East region
where so much progress has already taken place. Its
data and projections show clearly that continuing
support from governments and donors will be needed
just to maintain existing health gains. It is not time to
shift health dollars into care for adults. Further
reductions in mortality will demand either an increased
level of support, or an increase in the efficiency and
effectiveness of the current level of interventions.
The authors review available data on child mortality
from the Asia-Near East region. Major declines in child
mortality have occurred over the last two decades.
Some of this improvement occurred prior to the more
intensive child survival and primary health care efforts of
the last decade. Evidence from Demographic and
Health Surveys and other sources, however, shows
substantial correlation between mortality decline and
increasing utilization (coverage) of primary health care
services, particularly immunization. Further declines in
mortality can be expected in the near future, also related
to the effects of preventive interventions of the sort
UNICEF and USAID have supported through their child
survival strategies.
In this scenario, integration of interventions that
takes advantage of the synergy between diseases
(such as vitamin A deficiency and measles), or in some
cases the operational synergy between interventions
(such as vitamin A distribution carried out at the same
time as immunization), is unavoidable if further progress
is to be made within the limitations of available resourc
es. Like Taylor and Parker (see below), these authors
recommend starting with a small package of activities or
even a single intervention, and later expanding and
integrating others as the initial intervention solves its
problems and becomes institutionalized. The challenge
to those working with the child survival interventions is
to differentiate between those situations where more
problem solving within a single intervention is still the
priority, and those situations where the priority should
shift to adding and integrating new interventions which
can be synergistic with the ongoing intervention.
But much work remains to be done. A substantial
decline in mortality has not occurred in all of the
countries of the region; some will probably not achieve
the WHO/UNICEF mortality target of 70 per thousand
(expressed as probability of dying by age 5) by the year
2000, for example, Bangladesh. For the region overall,
the total numbers of deaths of children under 5 will
remain substantial—between 4 and 5 million per year,
only 20 to 40 percent less than current numbers. And
the relatively constant numbers of annual births
projected along with declining deaths will lead to a
gradually increasing number of children needing
services. Thus maintaining current levels of support for
child survival will be needed just to consolidate and
maintain the health gains already achieved, while further
reductions in child mortality will require increases in the
current levels of service.
Taylor, C.E.; Parker, R.L “INTEGRATING PHC
SERVICES: EVIDENCE FROM NARANGWAL, INDIA.”
Health Policy and Planning, vol. 2,1987,150-61.
Order*3580
Critical to success, say the authors, will be strategies
to improve program efficiency and effectiveness, most
fundamentally those that combine interventions. For
example, combining ORS/ORT with interventions to
improve personal hygiene will have a multiplier effect.
ORS will become more efficient because hygiene has
reduced the number of cases, and hygiene will be more
Vol. VIII, N93
Summary
This paper reviews the findings from Narangwal in
North India, where different combinations or packages
of nutrition, infection control, family planning, women's
7
Technical Literature Update
health, and children’s health services were introduced
into different sets of villages. The investigators collected
data to measure inputs and costs, changes in
health-related practices, and impact on morbidity,
mortality, growth, psychomotor development, and
fertility. Significant reductions occurred in morbidity and
mortality in children and their growth improved in
experimental villages receiving nutrition and/or infection
control services compared to control villages. Family
planning use increased in all villages receiving family
planning inputs. The combined cost of services was
about SUS 2.00 per capita (1971 prices).
villages where the services were integrated (such as
nutrition with health care) as they did in single-service
villages. That may mean that all children got less of a
particular service, or that the average was less, which
could mean that some problem children got lots of
service while others got almost none. In this overview
article the data to clarify this point are not available. Given
that the services had already been trimmed down to the
most critical, it seems likely that the latter was true, and
that the increase in efficiency was obtained by shifting
time spent by health workers from one particular task to
another.
Integrated or combined services generally
performed at least as well as more selective approaches,
and because of their integrated nature were often more
efficient. The major advantage of integrated services
was that they provided multiple benefits, an important
consideration in areas with many competing causes of
morbidity and mortality. It was concluded that Narangwal
demonstrated the potential of an incremental approach
to integration, based on a process of learning by
experience and supported by the continuous feedback
of information from both formal and informal
assessments.
The authors comment that they delegated the tasks
that could be readily standardized to the periphery, and
kept the total package of interventions to a feasible
level—5 or 6 interventions seemed to be manageable.
These were then supported by a surveillance system to
monitor the population and a supervisory/management/
evaluation system with readily available consultation to
monitor and support the workers.
The report confirms the importance of a well
functioning management system to success, a factor
shown to be crucial in the narrowest of selective primary
health care programs as well as the broadest of primary
health care efforts. Add to this a judicious limitation of
services and activities selected for feasibility, delegation
of the most standardized services to the periphery and
to lower level workers, targeting of intensive services to
those with the greatest need for them, and inclusion of
an information system that identifies problems and
supports their correction, and you have a program that
can respond to the most important health problems of
the community in a cost-effective manner.
Editorial Comment
This general review can only touch on the rich store
of information that can be learned from the Narangwal
experience, and reminds us again of how often we
seem to have to keep re-learning what has been
demonstrated clearly in the past but forgotten. The
Narangwal project used a classic primary health care
structure involving village volunteers and family health
workers who lived in the village, supported by
supervisory doctors and nurses who received referrals
for problems unable to be handled by the village-level
manpower.
Is such a program feasible on a national level? The
authors urge an incremental approach, starting with a
smaller package of activities and subsequently
expanding. This is just where many countries are today,
having functioning CDD and immunization programs
running, usually through but sometimes in parallel with a
basic health care system. Using Narangwal’s example,
we could incrementally expand those programs, adding
in turn acute respiratory infections, vitamin A
distribution, prenatal care, or targeting via growth
monitoring, while not forgetting to strengthen the
necessary supportive referral services. This approach
would be preferable, in my view, to implementing a
whole package of services at once but of necessity at a
superficial level, and would be much more feasible for
most countries. The key is not to forget the need for
solid management to identify and solve the problems
which will inevitably arise.
While the services were integrated in terms of their
delivery, they were not uniformly provided to the whole
population.
Instead, surveillance and screening
identified children with high-risk, early problems which
could become severe, or greater need, and intensive
services were directed at these targeted cases. By
integrating such surveillance and screening as well as
the subsequent services, the program could identify
and respond to multiple kinds of problems, not just one.
The result was a significant impact on health problems at
a feasible cost.
I was struck by the statement that family health
workers spent only half the time on certain services in
Technical Literature Update
8
Vol. VIII, N83
CH 3.11^
□VULATIDN METHOD
(BILLINGS
CERVICAL
FAMILY WELFARE SERVICE DEPT.
ST. JOHN'S MEDICAL COLLEGE HOSPITAL,
BANGALORE 560 034
Phone:
565435
MUCUS
CHART
METHOD)
Centre ...........................................................................................
Name ........................................................................................
2
!
■
......
4
5
6
7
. —__—------- --------- -
5.
DATE
DATE
3
3
8
9
10
11
12
13
_----- _------------------
..
5
t
7
g
14 H1.5
-
I ♦
w
ij
z
"c T
DATE
DATE
I
1
r
6
17
\L,
18
S9
20
21
22
23
24
25
26
27
28
It
if
(g
y?
20
2J
22- U
2H(
29
30' 31
32
33
34
35
CHARTING
INSTRUCTIONS
The Ovulation -Method (O.M.) of Family Planning (F.P )
.... The O.M. is a natural method of F.P. (N.F.P.). It is based on the scientific fact
That a wC'men can only become pregnant when she is in her fertile period.
She can identify this fertile period easily by certain signs caused by the rise
of female oestrogen (sex hormone) in her blood at this time. She does not need to
be educated or have regular periods to use this method effectively.
These signs are :—1. Mucus secretion from the cervical glands in the uterus (womb). This is felt as
a wet sensation in the genital area.
2. The mucus may be also seen as a raw egg-white discharge at this time.
3. There is pain in the lower abdomen on one side felt as a sharp pain> or backache
often going down the thigh.
4. The breast feels heavy, and there may be a dull pain.
5. There may be a little bleeding or brownish discharge called midmenstrual spotting
6. There maybe mood changes. The strongest sign is the mucus.
Charting to detect your fertile period.
Mark your chart daily at night. Colour red in the square on the days you
menstruate.
Menstruation is usually followed by days of dryness. When the cervical glands
begin to get stimulated by oestrogen they discharge a thick white secretion which
marks the beginning of the fertile period and the woman begins to feel wet. Then it
becomes thin and transluscent. (egg-white).
The wetness is a warning sign to the woman who wants to use the O.M. for
F.P. She stops all genital contact with her husband. She abstains for all these wet
days or whenever she sees the secretion. The last wet day is called the Peak Day
and it is followed by Ovulation, i. e. Dayl.
The ovum may live upto 18 hours so she abstains on Day 2 and Day 3 for
safety. By this time she becomes infertile and can resume intercourse. (The sperm or
male egg can live upto 2 days in mucus.)
Start chartirig immediately in the square corresponding to the day of your cycle.
For e g. the first day of your menstrual period is square 1. When you start a new cycle
mark in this square (1) and write the date. Show your chart to a N.F.P. Teacher.
Mark Blue for dry days when nothing is felt. Mark 0 circle with a dot (sign
of ovum) for wet days. Mark a X on Peak Day which you will only know on Day 1.
Mark in 2 and 3 on the following 2 days.
This Natural Family Planning (NFP) method is safe, effective and acceptable to
all couples.
30 P.
<CH 3-lfe
BOARD OF DIRECTORS
PRESIDENT
NEWSLETTER
September 1979
ROBERT W. HARKINS. Ph.D.
AMERICAN INSTITUTE
OF NUTRITION
ORAL REHYDRATION FOR ACUTE DIARRHEAL disease
KENNETH MORGAREIDGE. Ph
AMERICAN CHEMICAL
SOCIETY
SECJ^ARY-TREASURER
H7TOOLD V. WALTON. Ph.D.
Lyn Howard, Ph.D.
Department of Medicine
Albany Medical College; Union University
Albany, New York 12208 USA
AGRICULTURAL ENGINEERS
GARY F. BENNETT. PH.D.
AMERICAN INSTITUTE
C. O. CHICHESTER. PH.D.
INSTITUTE OF FOOD
TECHNOLOGISTS
In many developing countries 25-^0% of children die before
the age of five.
Almost half of these deaths are due to
diarrhea and dehydration, accompanied by malnutrition. Stud
ies in Guatemala-4, India^, and Indonesia3 have shown that
nearly every child has one or two attacks of diarrhea a year
and 1-U% of these sick children die unless treated.4
JOHN H. NELSON. Ph.D.
AMERICAN ASSOCIATION
OF CEREAL CHEMISTS
HENRY NORMAN
VOLUNTEERS IN
TECHNICAL ASSISTANCE
HUGH L. POPENOE. PH.D.
AMERICAN SOCIETY
OF AGRONOMY
S. JACK R1NI
AMERICAN OIL
CHEMISTS' SOCIETY
L. I.F.E. NEWSLETTER
CAROL I. WASLIEN. PH.D.
ASSOCIATE EDITOR
ANN L. DYER
FOR
FURTHER INFORMATION
DR. CAROL I. WASLIEN
EXECUTIVE DIRECTOR
LEAGUE FOR INTERNATIONAL
FOOD EDUCATION
1126 SIXTEENTH STREET. NW
WASHINGTON. DC 20036 USA
TELEPHONE (202) 331-1658
THE OPINIONS EXPRESSED IN
THIS PUBLICATION ARE THOSE
OF THE CONTRIBUTORS. THEY
ARE NOT NECESSARILY THE
VIEWS OF THE CONSORTIUM
SOCIETIES. L.I.F.E., OR AID.
THE L.I.F.E. NEWSLETTER IS
FUNDED
BY
A
CONTRACT
THE U.S. AGENCY FOR
INTERNATIONAL
DEVELOP.
FROM
MENT
Studies of severe diarrhea in cholera epidemics in Bangla
desh show that mortality can be reduced by 90$ if family
members are instructed in simple oral rehydration measures.
In oral rehydration, sugar and various salts are mixed with
water and fed by mouth.
The salts and water are intended
to compensate for that lost with the diarrhea and the sugar
is added to improve the absorption of the salts by the in
testine .
The rehydration fluid, which must be made up fresh each day,
can be as simple as a teaspoonful of salt and four of sugar
dissolved in a quart of boiled water, or the same ingredients
measured out by a special plastic spoon promoted by the In
stitute of Child Health^ in London.
More complex mixtures
recommended by "WHO are also available. (See Table 1). They
are available in separate aluminum foil packages for long
shelf life (Oralyte $0.12/L) or more cheaply in a tin given
to the village health worker for individual distribution
using a measuring scoop.
Studies comparing the cost and
therapeutic effectiveness of these different solutions have
not yet been published.
In the January 1979 L.I.F.E. Newsletter a rehydration recipe was given using
lactose (milk-sugar) and gelatin. On theoretical grounds this formula would
not receive wide acceptance since the enzyme splitting lactose into glucose
and galactose is often severely diminished in diarrheal diseases. Further
more, neither ingredient is readily available in devel oping countries.
Simple, early rehydration measures are the crux of good therapy and need to
be taught by village health workers and school teachers to all mothers and
others who may be caring for small children.
They must be advised that
while oral rehydration may appear to increase the stool losses or even cause
vomiting, yet it is important to persist, getting the child to drink one cup
(200-500 ml) of the fluid for each stool passed, while the adult should
double that quantity.
While oral rehydration at home is the most effective therapy for 90-95% of
children and adults with acute diarrheal diseases,
there are some circum
stances which health workers and mothers must learn to recognize where hos
pitalization is necessary.
(See Table 2).
TABLE 1
'Oralyte1, a glucose electrolyte,
by WHO
oral rehydration solution,
recommended
Na 01 (salt)
3-5 gms
Na+
90 meq/L
NaHCO^ (baking soda)
2.5 gms
H CO3-
30 meq/L
K Cl
1-5 gms
K+
20 meq/L
Glucose
20
gms
Cl-
80 meq/L
Water
1
L
Glucose
110 mmol/L
TABLE 2 7
1.
Patients with severe dehydration,
with hypotension, shock, stupor, or
coma. These patients need very rapid water and salt replacement.
2.
Patients who cannot drink because of fatigue, stupor, or sustained vomit
ing.
3-
Patients with sustained oliguria (<700 ml of urine/day in an adult and
<20 ml/kg/day in a child). These patients need very precise fluid re
placement .
U.
Infants less than one month of age; such infants dehydrate very rapidly.
/
V
-2-
.References
1.
Gordon, J.E., Ascoli, W., Mata, L.J. & Guzman, M.A. Nutrition and in
fection field study in Guatemala villages, 1959-1964.
Arch. Environ.
Health 16: 424, 1968.
2.
Gordon, J.E., Chitkara, I.D. & Wyon, J.B.
Med. Sci. 245: 345, 1963.
3.
Brotowasisto. Epidemiology of diarrhea, in: Diarrhea, Dept, of Health,
Indonesia, 1975•
4.
Rodhe, J.E. & Northrup, R.S Therapy begins at home-management of acute
diarrhea in the developing world. XV Int. Congress Pediatr.,
Delhi ,
1977.
5-
Mahalanabis, D., et.al.
Oral fluid therapy of cholera among Bangladesh /
refugees. Johns Hopkins Med. J. 1^2: 197, 1973.
6.
Inst, of Child Health,
Morley).
7.
Pierce, N.F. & Hirschhorn, N. Oral fluid - a simple weapon against de
hydration in diarrhoea. WHO Chronicle, JI: 87, 1977.
Guildford St.,
Weanling diarrhea.
London WCIN IEH
(attn:
Am. J.
David
COCONUT CHERRY CUBES
In Sri Lanka a tasty jelly-like dessert is being made from coconut water
which was previously thrown away as a waste product. Based on a traditional
Philippine dish, Nata de Coco, this product is obtained by growing the bac
terium, Acetobacter xylinum, in sugared coconut water. In addition to coco
nut water, various other fruits of Sri Lanka, such as mango, guava, pine
apple, papaw, and wood apple, can also be used. A production, demonstration,
and training unit has already been established to popularize this product
and to promote this industry.
Further information is available from:
In
dustrial Development Board;
PC Box 9; Moratuwa, Sri Lanka
(Excerpted from the June 1979 issue of Technonet Asia
of Technonet Asia Newsletter.)
Digest - Supplement
INTERESTED IN RURAL WATER SUPPLY?
The National Water Well Association (NWWA) is looking for people who would
be interested in receiving training materials pertaining to rural water
supply and sanitation systems appropriate for developing countries. These
materials will be developed as part of the National Demonstration Water
Project, funded by the U.S. Agency for International Development.
To be ,i
available early in 1981, the materials should be useful to people responsi- I
ble for water supplies. If you are interested, or know of someone who might 1/
benefit from this information, please contact: Anne E. Simmons, Information I
Coordinator; National Water Well Association; 500 West Wilson Bridge Road;.
Worthington, Ohio 43085 USA
|
-3-
GHANA'S NATIONAL RABBIT PROJECT
Rabbit breeding appears to be an attractive proposition for meat production
in a developing country.
It has been estimated that the backyard breeder
who invests $8 each for a buck and a doe can furnish his family with a sup
ply of meat, over the course of a year, equivalent to the weight of an en
tire cow. Another advantage is the rabbit's omnivorous eating habits. The
diet may include table scraps, sugarcane waste, various grasses, groundnut
and sweet potato vines, dried cassava, and brewer's mash.
After more than six years of patient groundwork, Ghana's National Rabbit
Project seems finally to have gathered momentum to the point where scarcity
of breeding rabbits is more of a problem than lack of either official or
popular support. The rabbit's potential role in Ghana's drive toward food
self-sufficiency has become the beneficiary of a massive media campaign,
complete with radio jingles ("get the bunny money"), television spots, and
posters designed by local artists.
Ghana currently produces all of its own rice and nearly all of the maize
required for its 9-5 million population, but animal protein is another mat
ter. What meat does reach the market is usually priced far beyond most fam
ily budgets.
In 1972 Newlove Mamattah, using a grant from Ghana's National Redemption
Council and technical help from the US organization Technoserve, set up a
32-ha farm -withan initial breeding stock of 80 animals. By the end of 1977
a survey of registered breeders put the basic rabbit population at 13,9^8.
Now rabbit breeding is on school curricula and rabbit on school menus.
Would-be rabbit raisers must take an intensive three-day course in rabbit
husbandry to qualify for the purchase of breeding stock. Andthe demand for
breeding stock is so strong that supply is unable to keep pace.
(Excerpted by 'cerescope' in Ceres, May-June 1979-)
ANNUAL REPORT ON RICE UTILIZATION NOW AVAILABLE
Rice Report 1977Annual Report of World Research and Development on the
Post-Harvest Utilization of Rice (Working Party on Rice Utilization, Inter
national Union of Food Science and Technology, 1978, 287 pp, paperback).
This is a report of the scientific and technical activities of centers and
organizations around the world relative to new techniques in post-harvest
rice utilization derived from research and industrial development. It in
cludes information on storage, processing, and nutritive value of milled
rice as well as on rice by-products, such as rice bran and rice husks. Pro
cessing technology ranges from that appropriate to home level to industrial
scale.
Available from:
Institute de Agroquimica y Tecnologia de Alimentos; Jaime
Roig 11; Valencia-10, Spain.
for the
prevention and
treatment of
Diarrhoea
CMAIoAHRTAG "UNICEF
Dialogue on^g
Diarrhoea
PRACTICAL ADVICE
FOR THE
PREVENTION AND
TREATMENT
OF
DIARRHOEA
CMAI
AHRTAG
UNICEF
FOREWORD
AHRTAG, UNICEF and CMAI together, are bringing out this edition
which presents some of the best of the back issues of “Dialogue on Diarrhoea”for
people in health work. I want to take the opportunity of thanking the editorial
team at AHRTAG for giving CMAI this privilege and UNICEF for making
funds available for the same.
This publication will be available to those interested and hopefully will
contribute to improved child survival and health care. We would value your
comments and feedback on this publication.
Dr. Daleep S. Mukarji
General Secretary
CMAI
CHRISTIAN MEDICAL ASSOCIATION OF INDIA
P.BOX NO. 24
NAGPUR. M.S. 440 001
Dialogue on Diarrhoea is a quarterly international newsletter which
focuses on all aspects of the prevention and treatment of diarrhoeal
diseases, and has been published in London by the Appropriate Health
Resources and Technologies Action Group (AHRTAG) since 1980. The
newsletter now has a worldwide readership of over 250,000 and is available
in translation in French, Spanish, Portuguese, Arabic and Tamil editions.
Future editions are planned in Bengali and Urdu. Readers who would like
to know more about Dialogue on Diarrhoea should write to AHRTAG,
1 London Bridge Street. SEI 9SG, U.K.
Practical Advice for the Prevention and Treatment of Diarrhoea is a
special compilation based on the best‘Practical Advice’ pages from eight
years publication of Dialogue on Diarrhoea. These pages cover a wide
range of topics, from feeding the anorexic child, making soap and purifying
water, to storing oral rehydration salts, developing health education
materials and evaluating training. Produced in collaboration with and
published by the Christian Medical Association of India and AHRTAG
with support from UNICEF.
Page
Contents
□
□
□
□
□
□
□
Causes and Control
How to recognise dehydration,
Simple laboratory investigations into diarrhoea, T. Moody.
Control strategies, Dr. D. Barua
Successful ORT, Dr. N. Hirschhorn and Dr. Ahmed Yousef
Storing and maintaining supplies of ORS, CDD/ World Health Organisation
Medicines with care. Professor P. D’Arcy and Dr. D.W.E. Harron
Using a nasogastric tube, C. Candy, SRN
I
2
3
4
5
6
7
□
□
□
□
Water and Sanitation
Choosing a handpump, J. Cuthbert
Appropriate latrines, G. Read
How to make soap,
Water purification,
8
9
10
'1
□
□
□
Feeding and Diarrhoea
Breast to family diet. Dr. M. Gurney
Feeding the anorexic child, Dr. S. Ghosh
Vitamin A : preventing blinding malnutrition,
□
□
□
□
Education and Training
Carrying out a survey on attitudes to diarrhoea,
Dr. J. Allman and Dr. M. B. Pierre-Louis
Getting the message across,
Simple but not easy, M. Zimmerman and J. Haffey
Evaluation of training. Dr. B. Forsberg
’
12
15
*4
15
10
IK
19
Causes and control
How to recognize
dehydration
Diarrhoea kills because it causes
dehydration. The stools of a healthy
child contain relatively little water but a
child with diarrhoea passes very watery
stools which also contain vital salts
(sodium, sodium chloride, potassium
and bicarbonate). If the losses are
great, both the water and the salts must
be replaced or the child will die. To
recognize the signs of dehydration it is
necessary to ask, look, feel and, if
possible, weigh the child.
Important signs and symptoms
• Stools Ask about the number and
size of the diarrhoea stools. Has there
also been vomiting? These answers
may also give clues to the severity of
dehydration.
• Thirst This may be the earliest
sign of dehydration. Until a child has
lost more than five per cent of his body
weight, dehydration causes few signs.
When severely dehydrated, a child may
not be fully conscious and may be
unable to drink.
• Urine A healthy child usually
passes urine about every three hours.
The body of a dehydrated child tries to
save water and only produces a small
amount of dark coloured urine. Mothers
usually know how much urine their
children have passed, so ask them if
there has been less that usual.
• Condition If there is no dehvdration. a child will appear alert and well.
At a later stage, he will be weak,
irritable and may look unwell or sleepy
A severely dehydrated child may
appear very sleepy or be unconscious.
He may also have fits or convulsions.
® Sunken eyes A child's eyes lie in
soft, wet, fatty tissue. If he becomes
dehydrated, this tissue shrinks and
becomes drier and his eyes sink back
into his skull. His eyes also lose their
shining appearance and stay half open
when he is asleep.
© Dry mouth A dehydrated child
cannot make enough saliva and so his
mouth and tongue become dry. This is
an important sign.
• Breathing Sometimes, a severely
dehydrated child breathes fast and
deeply. This kind of breathing occurs
when a child has been dehydrated for
some days or has been rehydrated with
the wrong fluids. Do not mistake this
deep, fast breathing for the shallow,
rapid breathing of pneumonia.
© Loss of skin elasticity The skin of a
healthy child is elastic. If you pinch the
skin of the abdomen and then let go,
the skin quickly flattens again. De
hydration makes a child's skin dry and
less elastic so when pinched it sticks up
for some seconds before going flat
again. If a child is very thin or very fat,
loss of skin elasticity is not easy to
detect and therefore not a helpful sign
in diagnosing dehydration.
O Pulse Dehydration makes a child's
pulse faster and weaker. When he
becomes severely dehydrated, it may
not be possible to feel the pulse at the
wrist, you may have to feel at the groin
or listen to the heart. (With very severe
dehydration, the pulse is sometimes
A seriously dehydrated child.
Photograph courtesy of TALC
• Sunken fontanelle The fontanelle
is the soft place between the bones at
the top of a baby's skull. It is large when
he is born but closesover by the time he
is about 18 months old. When a baby
becomes dehydrated, his brain and
tissues in the skull lose water and
shrink. The fontanelle sinks down
between the bones of the skull.
• Loss of weight This may cWar
quickly during a few hours or over
several days. A severely dehydrated
child may have lost a tenth or more of
his normal body weight. If he weighed
ten kilograms before the onset of
diarrhoea, he may have lost at least a
kilo of water and may now weigh only
nine kilograms. Loss of weight due to
malnutrition occurs more slowly over
several weeks or months.
Conclusion
Dehydrated children need urgent re
hydration and should be encouraged to
drink even if vomiting occurs. Those
with severe dehydration and complica
tions such as convulsions should be
given oral rehydration fluid and taken
to a centre where they can receive
special care.
Diarrhoea Dialogue, issue 2, August 1980.
1
Causes and control
Simple laboratory
investigations into
diarrhoea
Tony Moody looks at the range of laboratory work that can be
carried out at health centre level.
The complete investigation of diar
rhoea requires complex and sophisti
cated laboratory techniques to isolate
and characterize the causative agent.
This does not exclude the laboratory
worker with only simple, basic equip
ment from being able to provide useful
information for the management of
fcarrhoea.
“ Essential laboratory equipment con
sists of:• a microscope
• microscope slides and coverslips
o saline solution
• pipettes
• some basic stains and litmus paper
Total cost — less than $500 US dollars.
Macroscopic appearance
Useful information can be gained by
careful inspection of the faeces with the
naked eye1. The history of the patient’s
diarrhoea should be kept in mind whilst
looking at the faeces. The Clinician's
Guide to Aetiology published in Diar
rhoea Dialogue 7 and the new wall
charts now available from the Ross
Institute of Tropical Hygiene* may be
useful aids in this preliminary screening.
h Profuse watery stools, sometimes
flecked with mucus, occur in toxi
genic E. coli diarrhoea and in cholera
(rice water stool).
• Smaller, soft and frequent stools
containing blood and mucus occur in
amoebic dysentery and in bacillary
dysentery due to shigella or Cam
pylobacter infections.
• Pale, frothy stools occur in giar
diasis, tropical malabsorption and in
lactase deficiency in infants.
Acid or alkaline reaction (pH) A simple
litmus paper check on the stool pH can
be helpful. Acid stools occur in
amoebic dysentery and in lactase defi
ciency. In bacillary dysentery the stool
is alkaline.
Microscopic examination
The stool should be as fresh and warm
as possible when examined.
Saline preparation Place a drop of
saline (0.9% sodium chloride) at room
temperature onto a warm slide and,
selecting an appropriate section of the
faeces, i.c. from an area of bloody
mucus or from the liquid part of the
sample, use a stick to transfer a small
amount to the slide. Emulsify this in the
saline and place a coverslip over the
preparation (discard the stick safely
into disinfectant or burn). Examine the
sample under the microscope using a
lOx eyepiece and, initially, a lOx
objective. Close the condenser iris dia
phragm sufficiently to give good con
trast. Careful searching of the whole
coverslip area at this magnification
could reveal active larvae of Strongyloides, ova of Schistosoma or other
helminths, or clumps of pus cells and
erythrocytes which indicate an inflam
matory response to bacteria or
amoebae.
Now turn the 40x objective into the
viewing position and again search the
whole coverslip area.
Dysentery At this level of investigation,
the most important distinction that can
be made is between amoebic and bacil
lary dysentery. Both stools may contain
pus cells and macrophages and these
show up well if a drop of 1% methylene
blue stain is run under the coverslip.
There may also be erythrocytes (red
blood cells) in the stools.
In amoebic dysentery, if the specimen
is fresh (still warm), very active tro
phozoites of Entamoeba histolytica
(20-40 microns in size, i.e. about twice
the size of polymorph leucocytes (pus
cells)) ought to be easily observed
moving rapidly across the slide, push
ing out clear pseudopodia and contain
ing ingested red blood cells. There
should be no confusion between
amoebae and macrophages which may
also contain red blood cells. The
amoebae move about and constantly
change shape. The macrophages be
come immobile within a few seconds.
In bacillary dysentery, caused by infec
Diarrhoea Dialogue, issue 11, November 1982.
tions such as Shigella, Campylobacter
and possibly invasive E. coli, there will
be many pus cells, erythrocytes and
macrophages, but no active amoebae
or cysts. (Occasionally patients may
have both amoebic and bacillary dysen
tery at the same time).
Flagellates Few or no cells in a fatty or
unformed sample may indicate the cys
tic or trophozoite stages of Giardia
lamblia in the saline preparation. The
refractive axostyle and flagellar compo
nents of the cysts can be shown more
clearly by using an iodine stain (1 in 5
dilution of Lugol's iodine in 10% acetic
acid). A thin saline suspension of
faeces smeared on a slide, air dried and
fixed in methyl alcohol can be stained
with a 1 in 20 dilution of Giemsa stain in
pH 6.8 buffer for 15 minutes and will
demonstrate the morphology of tf
trophozoites of Giardia. Fat is seen a.,
yellow globules or fine needles and can
be stained red with 1% alcoholic Sudan
111 stain.
Other flagellates may be present but
are not pathogenic.
Vibrio cholerae Dark ground illumina
tion and a hanging d'op preparation
are needed to iden rfy the darting
motility associated with cholera vib
rios. A dark field condenser costs about
£90 to modify a normal microscope. A
temporary version can be contrived
using plasticine or putty to use with the
40x objective (see page 61 in volume 1
of Monica Cheesbrough’s Medical
Laboratory Manual for Tropical Coun
tries — reviewed on page seven).
Hanging drop preparation Take
slide and make a ring of about ierr^
using vaseline. Place a coverslip fiat Or,.
a table, add one drop of the liquid stool
in the centre and place the vaseline ring
on the slide over this drop. Quickly in
vert the slide and inspect under the 40x
objective for the typical darting move
ment by rod-shaped organisms.
Tony Moody, Senior Chief MLSO, Hos
pital for Tropical Diseases, St Pancras
Way, London NW1, U.K.
'Banu et al 1982 Epidemiologic and
clinical features of patients infected with
shigella who attended a diarrhoeal dis
eases hospital in Bangladesh. The Jour
nal of Infectious Diseases, Vol. 146 no
2:177-183.
* Inquiries to Dr Isabelle de Zoysa, Ross
Institute of Tropical Hygiene, London
School of Hygiene and Tropical
Medicine, Keppel St, London WC1, U. K.
2
Causes and control
Proper disposal of excreta is vital to
protect water sources and the en
vironment. In the absence of any
facilities, burial of all excreta,
specially those of cholera cases, is
Although many questions remain about the epidemiology of
essential. Refuse disposal by burn
cholera, there is little doubt about the most effective control
ing, burial, or other methods
measures. Dhiman Barua reviews the key strategies.
should be ensured to prevent fly
breeding.
9. Chemoprophylaxis i.e. the ad
ministration of antimicrobials to
Cholera control can best be achieved
Emphasis on personal hygiene
healthy persons who are suspected
through a national CDD programme (especially hand-washing with soap and
of carrying V. cholerae and are
that ensures adequate training, proper water) and on food and water safety is
likely to become sick or spread the
treatment, community involvement, essential. The necessity for eating only
infection is theoretically a sound
uninterrupted supplies of ORS, labora cooked food while still hot and drinking
measure. Yet many countries have
tory and other back-up facilities, regu only safe water (boiled, treated, or
experienced that mass chemo
lar surveillance, and measures to im collected from a safe source and stored
prophylaxis does not produce tte
prove water supply, excreta disposal, properly) should be explained. The
desired results mainly because 0.,
personal hygiene and food safety. The need to protect all water sources from
infection spreads faster than the
important strategies for cholera control contamination must be emphasized; in
time it takes to reach and treat
are described below:—
fection is acquired not only by drinking
members of the community. More
1, Early detection of epidemics water, but also by bathing or washing
over. by inducing drug resistance,
through continuous surveillance.
articles at contaminated sources. The
it deprives the actual cases of an
2. Active case-finding with the help population should also be informed
effective drug for their treatment.
of community elders, religious about the dangers of:
Therefore, chemoprophylaxis only
leaders and teachers, and through • community feasts and gatherings of
home visits by local health workers
any kind, particularly funerals, of close contacts in the home of a case
reinforced by mobile teams, if
where safe food and water and was recommended. Recent experience
necessary.
proper excreta and waste disposal has shown, however, that in many
areas the custom of intimate mixing of
3. Provision of early and proper treat
cannot be assured;
ment of cases. This includes the • visiting sick relatives and eating/ members of the community and of visit
ing and sharing foods with extended
establishment of temporary treat
drinking in the homes of cases;
ment centres if the permanent • contaminated foods e.g. fish and families makes it difficult to identify
facilities are not within easy reach,
especially shellfish collected from close contacts; the recommendation
so infected people travel as little as
suspect waters, vegetables irrigated thus becomes unpractical. Chemo
possible.
or freshened with sewage-contami prophylaxis may still be effective in
situations where everybody in the
4. Extremely thorough disinfection of
nated water.
the clothing, utensils, excreta, 6. Epidemiological investigations to affected community can be treated
vomit, and environs of cholera
determine how transmission is quickly and simultaneously e.g.^'
cases (by boiling, or with disinfec
occurring should be undertaken by refugee camp.
tants like lysol, cresol or lime, as
health workers. In most instances, 10. Vaccination is no longer seen as an
effective weapon for cholera co,.
appropriate). The dead bodies of
several factors are involved because
trol because of its low efficiency in
cholera victims should be disposed
of the complex socio-cultural
preventing disease and almost total
of with the minimum of transporta
customs of intimate mixing and free
ineffectiveness in preventing the
tion and rites, which can spread the
exchange of foods/drinks etc, but
carrier state. Vaccination is still
disease.
there are instances when a common
undertaken in some situations,
5. Health education, properly carried
source/vehicle (like a well, shellfish,
mainly because it is demanded by
out,- can achieve a great deal, even
vegetables) has been detected by
an uninitiated public. This should
in the most desperate situations.
epidemiological investigations, in
be countered by proper health edu
All health workers should provide
which case the outbreak can be
cation explaining the limitations of
health education while providing
quickly controlled by specific inter
the vaccine and the risks of mass
services. All appropriate media
ventions.
vaccination (e.g. hepatitis).
should be used and special atten 7. Provision of safe water is very
tion’ given to densely populated
important, as the boiling of water is
areas. Simple explanations of
not practical in many situations. Dr Dhiman Barua, Programme for the
factors helping the local spread of
Numerous simple and innovative Control of Diarrhoeal Disease (CDD),
disease and the ways in which the
methods are available for the WHO, Geneva, Switzerland.
population can help interrupt
supply and treatment of water.
transmission will secure com
Special attention should be paid to
For further reading on this subject
munity involvement and minimise
the proper protection, storage and
contact CDD/WHO at the above
panic.
use of water in the home.
address.
Control strategies
Diarrhoea Dialogue, issue 12 February 1983.
8.
3
Causes and control
Successful ORT
Bert Hirschhorn and Ahmed Youssef lists some
important points for doctors, nurses and other health
practitioners to remember when giving oral rehydration
therapy.
a A health worker must show the
the rate of one teaspoonful (5cc) a
mother how to mix and give the oral
minute. This may seem slow but
rehydration solution. This is equally
provides 300 cc per hour and will
important in the clinic and at home,
nearly always prevent further vomi
to ensure understanding and correct
ting.
use.
• The amount vomited is usually
o ORT does not stop diarrhoea; it
smaller than the quantity of ORS
stops and reverses the dangerous
taken. If the child vomits less than
dehydration caused by diarrhoea. In
four times an hour, enough ORS is
50 per cent of children under the age
probably being retained. If vomiting
of three, treated with ORT, diar
persists (more than four times per
rhoea will continue for three to four
hour), use a nasogastric tube to give
^hdays or sometimes even longer. This
the ORS.
must be explained to mothers. Once
The thirsty child
children have been properly rehy
drated, they should be given about • A thirsty child is a dehydrated child.
Once rehydration is complete, chil
400-500cc of ORS each day, as well
dren usually refuse more ORS, un
as being fed, to maintain rehydration
less hungry and not being offered
until the diarrhoea stops.
food.
The child with watery diarrhoea
• A child with hypernatraemia (high
o A child who has passed just three
blood serum sodium content) may
watery stools will have lost 15O-3OOcc
drink a large amount very quickly
of fluid (water containing essential
but seldom vomits in spite of this
body salts). This dehydration rep
rapid intake. The child’s thirst is a
resents a loss of 1.5 - 3 per cent of
good guide to successful ORT.
body weight in a child weighing 10
kg. Once 2 per cent of weight is lost,
The child who refuses ORS
the body reacts to conserve water and This may be because:
electrolytes (body salts). The rec • the child is no longer dehydrated and
ommended WHO/UNICEF for
wants food or sleep.
mula for ORS contains 90 mmol/ • the child is still dehydrated but tired
litre of sodium and is the correct
and needs to be patiently persuaded
treatment for dehydration. If pack
to drink (see below).
ets of ORS are not available, an • the child is irritable because of some
^hequivalent home-made sugar and
other cause such as another infec
^salt solution should be used. Plain
tion. A nasogastric tube may be the
water, or other drinks which contain
answer but first try to give ORS with
little salt, are not recommended for
a plastic dropper by slipping this
dehydrated children, except where
between the child’s clenched teeth
salt and sugar are unobtainable. In
and cheek. The child will usually
such extreme circumstances, any
swallow as a reflex rather than spit
out the ORS.
drink available should be used to
treat a dehydrated child.
The weak or drowsy child
• The child will often pass a large
watery stool just after ORT has been • The child who is conscious but too
weak to drink may need to be rehy
started. Mothers, and even some
drated by nasogastric tube or by
health workers, may believe the ORT
intravenous infusion if in shock. It is
has increased the diarrhoea. This is
worth first trying the plastic dropper
not true. What is happening is called
technique (or a 5cc plastic syringe
the ‘gastro-colic’ reflex in which
without the needle) to squirt the ORS
anything entering the stomach
into the child’s mouth.
causes the bowel to expel its contents.
ORT does not increase diarrhoea
The sleeping child
except when too much sugar is used.
• Seriously dehydrated children some
times sleep with their eyes partly
The vomiting child
open so that only the whites show.
• I f a child vomits, stop giving ORS for
Sleep during rehydration means one
five to ten minutes. Then give ORS at
Dialogue on Diarrhoea, issue 22, September 1985.
of two things. Either the child is not
recovering quickly enough and is
becoming unconscious and needs to
be woken up and given more ORS; or
rehydration is complete and the child
is ready for normal sleep.
Abdominal distension
A distended abdomen in children with
diarrhoea is caused by:
• giving salt solution without potassi
um, either orally or intravenously
• giving anti-motility drugs
• giving cow’s milk feeds to a child
with lactose intolerance
• surgical problem — this is rare.
Newborns
• Most newborns can take spoon feed
ings. If not, a plastic dropper or
plastic syringe without the needle can
be used to give ORS. Newborns are
often seen to suck at the tip of the
dropper.
The child on a nasogastric tube'
Use this:
• at night in hospital when both
mother and child need sleep.
• in persistent vomiting when the child
is not in shock.
• in emergency — for example while
setting up an IV in a shocked child or
transporting the child to hospital.
When using a nasogastric drip, mark the
starting level of the fluid with a piece of
adhesive tape. Write the time on this and
mark in the same way the correct level
for each following hour. This is to check
the drip is working at the correct rate.
The child in shock
See above — the weak or drowsy child.
• Give ORS in addition to the IV if the
child is conscious, and stop the IV as
soon as the child is drinking well.
Feeding the child with diarrhoea
• Breastfeeding should be continued
throughout ORT.
• The child with diarrhoea needs extra
feeding as soon as rehydration is
complete. If bottle fed, give smaller
amounts of the normal feed more
frequently. There is no advantage to
the old method of ‘slow reintroduc
tion’ of milk and the mother may
dilute the feeds for far too long a
time. Older children should be given
their normal foods but fed more
frequently for a few weeks. Yoghurt,
orange juice, bananas and coconut
water are recommended to bring up
the potassium level. (Do not give
coconut water during rehydration as
its potassium content.is too high).
Dr N. Hirschhorn, JS1, 210 Lincoln
Street, Boston, Ms. 02111, USA.
4
Causes and control
Storing and maintaining
supplies of oral
rehydration salts (ORS)
Whether a country is producing ORS locally or using UNICEF
sachets, the product must be properly stored so that it remains
effective from the time it is delivered to the central store to the
moment it is used. Sodium bicarbonate causes decomposition
of glucose in oral rehydration salt mixtures. High temperatures
and humidity may accelerate this process and manufacturers
must consider these factors when preparing and packing ORS.
_____________ Storage_____________
• Temperatures in buildings where
ORS is stored should not exceed 30°C.
Above this temperature the ORS may
melt or turn brown. If this happens, it
may be very difficult to dissolve and
should not be used. If, however, it has
only turned yellow, as long as it can be
properly dissolved, it is still safe to use
and effective.
• Supplies of ORS should not be
stored in buildings with galvanized
roofs directly exposed to the sun
without adequate ventilation. These
rooms get very hot.
• Humidity in stores should not exceed
80 per cent. In higher humidity the
ORS is likely to cake or turn solid.
Increase ventilation and avoid standing
water in or near storage rooms.
• As far as possible, storage areas
should be cleared of insects and
rodents.
• Packets should be packed so they are
protected from puncturing by sharp
objects.
• UNICEF recommend storing their
ORS sachets in stacks of cartons
approximately 1 to V/2 metres high.
• A rotating system should be
introduced so that the oldest ORS
Photograph by Asem Ansari
Preparing sachets of ORS in Bangladesh.
- Diarrhoea Dialogue, issue 8, February 1982.
(identified by date and batch number)
is used first. When in a hurry, avoid
distributing the packets which are at the
front or the top unless you are sure they
are the oldest in the store.
• Regional storage areas should be
located in places that will be convenient
for subsequent distribution.
Regular inspection of packets
• Laminated foil ORS packets have an
estimated shelf life of at least three
years. Note the production date on the
label. Packets of ORS must be checked
regularly (every three months) to see if
the quality is still acceptable. Open at
least one packet in each batch to see if
the ORS is usable. Locally produced
packets of ORS are often packaged in
plastic and will probably have a shorty
shelf life. It is especially important t"
check them regularly.
* Check ORS packets in any boxes
that appear to be damaged. Open at
least one packet from the top, middle
and bottom of the box to see if the ORS
is still usable.
Keeping records at each point
where ORS is received and
delivered.
• Records should show:
- the quantity, batch number or letter,
and date received.
- the quantity and date issued (i.e. sent
from one point in the distribution
system to another).
- the amount currently in stock.
- stock level at which a new supplv
should be requested.
£
• Records should also indicate any
problems (such as spoilage due to a
leaking warehouse).
• Supplies should be counted every
three months and results compared
with quantities shown in the records.
• The evaluation of stock is an
important factor in determining future
quantities of ORS required.
If you are interested in further
information on local production of
ORS and quality control, the following
publications are available from the
Programme Manager, CDD Pro
gramme, World Health Organization,
1211 Geneva 27, Switzerland.
• Guidelines for the production of oral
rehydration salts.
• Good practices for the manufacture
and quality control of drugs.
Causes and control
Special precautions with medicines for
diarrhoea
Medicines with care
Drugs must be purchased, stored and distributed with
professional skill. Patients should use them carefully; this
often depends on clear instructions. In this article Professor
D’Arcy and Dr Harron outline some practical guidelines.
Purchase
Containers and labelling
• All medicines must be purchased • All bulk medicines must be stored in
from reliable and well proven
suitable closed containers which are
sources; if purchased in bulk by
labelled to indicate the nature of the
Third World health authorities, then
medicine, its source, quantity,
advantage should be taken of the
dosage and, where applicable, its
WHO certification scheme, through
expiry date.
which the quality of medicines is • Smaller quantities of medicines
assured.
prepared for individual patient use
• If medicines are purchased by the
must be dispensed in a suitable clean
P individual patient, then, where
and closed container which is
possible, professional advice should
labelled with the name of the
be sought, preferably from a
medicine, the name of the patient,
pharmacist. It can be dangerous to
the date of supply, and the
buy medical supplies from non
instructions for use in a form that can
official or non-professional sources.
be readily understood by the patient
(if necessary pictograms should be
Storage
used to illustrate the required
• Medicines must be stored with care.
dosage schedule):
The basic requirements are the same
both for home storage and bulk
dispensary storage.
—
• Medicines:
- must be kept in a cool and dry
place;
- bulk containers should be stored
off the ground so that they cannot be
spoiled by rain puddles;
- should never be allowed to stand in
Medicines must not be supplied to
the sun;
- should be protected in sealed patients in a screw of paper or in an
A containers, from attack by insects open and unwashed container provided
and rats and containers should be by the patient. Every distribution
system of medicines should consider
properly labelled;
- must not be used after their expiry the provision of cheap, closable,
date - often this is marked on the multipurpose containers as a priority.
label - if not, assume two years from
purchase for all solid dosage forms Distribution to the patient
and one year for liquid preparations • Distribution of medicines should
always be in the care of a trained
and creams and ointments. Discard
health care worker (preferably
any medicines that show discolor
supervised by a pharmacist and
ation, fungal growth or any other
signs of physical deterioration.
according to the prescription of a
doctor) who dispenses them in a
• Some medicines need storage in a
suitable container.
refrigerator at a temperature below
5°C; this requirement is usually • Labelling of medicines should be
reinforced by verbal instructions to
shown on the container. Do not
the patient or relative. Check to
place any medicines in the freezing
make sure that the instructions have
compartment of the refrigerator
been
understood before
the
(except for some vaccines which
medicine is handed over.
should be stored frozen.)
COSTLY MEDICINES WILL BE
COSTLY
MEDICINES
WILL
DETERIORATE IF THEY ARE
WASTED IF THEY ARE NOT
USED CORRECTLY.
NOT STORED CORRECTLY.
%
Dialogue on Diarrhoea, issue 25, June 1986.
%
Oral rehydration salts (ORS) are available
through the United Nations Children’s
Fund (UNICEF) in water-proof foil
packets. Both WHO and UNICEF are
assisting countries to produce WHOrecommended formulations of ORS; for
local production WHO recommends
packaging of ORS in polythene where
possible. The ORS formulation containing
trisodium citrate dihydrate (ORS-citrate) is
more stable than the sodium bicarbonate
formulation (ORS-bicarbonate) especially
in tropical countries where it has to be
stored in conditions of high humidity and
temperature. Avoid the use of non-WHO
recommended formulations of ORS which
may be less effective, less stable and more
expensive.
Although the use of germ-free water is
preferable for mixing the rehydration
solution, ORS solution for oral rehydration
can be prepared even when pure water is
not available. The cleanest safest local
water should be used. However, where
possible, boil and cool the water before use.
To minimise contamination, ORS solution
should be made fresh every day, covered
and stored in a cool place. Ensure that the
volume of water in which the ORS is
dissolved is correct. This is vital both in the
pharmacy and the home. Check that the
patient’s relatives understand about the
correct volume, and possess a suitable
container.
Solutions for intravenous infusion have a
role in the treatment of severe dehydration
in diarrhoeal diseases. Care is needed as
some solutions do not contain appropriate
or adequate amounts of electrolytes requir
ed to correct the losses from dehydration
associated with acute diarrhoea. The
needles, tubing, containers (bottles or
plastic bags), and fluids used for in
travenous therapy must be sterile.
Correct storage of these components is
therefore crucial and storage conditions
must maintain sterility. It is not necessary to
store infusion fluids in a refrigerator. The
containers should be inspected at regular
intervals for damage caused during trans
port or storage (e.g. leaks, cracks, or splits
in containers); all damaged containers
should be discarded.
When in use, it is helpful to mark
intravenous fluid bottles at various levels
with the times at which the fluid should have
fallen to those levels. This allows easy and
rapid monitoring of the rate of administra
tion of the fluid.
Professor P F D’Arcy, Department of
Pharmacy, and Dr D W G Harron,
Department of Therapeutics and Phar
macology, The Queen’s University of
Belfast, Lisburn Road, Belfast BT9
7BL, Northern Ireland.
6
Causes and control
Using a nasogastric tube
Christine Candy describes the practical issues involved.
Where possible, oral rehydration sol
ution and food should be given by
mouth. A nasogastric tube is useful
when children are unable to drink
safely and in sufficient amounts for any
of the following reasons: severe dehy
dration; if IV therapy is unavailable;
low birth weight infants; or the child is
drowsy or vomiting. Severely mal
nourished children may be fed initially
in this way if they are too weak or
anorexic to eat or drink normally. It is
therefore important that health work
ers know how to use nasogastric tubes.
(retches or chokes) and see if the tube
is coiled in the mouth. If it is. gently
pull out the tube and try again.
• If the child is conscious, give a drink of
water. This helps to pass the tube down
towards the stomach and reduces
discomfort.
• If the child coughs, the tube may be
going into the trachea (windpipe) —
pull it out gently and try again.
NB. A child who is partly or com
pletely unconscious, may not have a
cough reflex and the tube could go
down the trachea without causing
coughing. Always watch for cyanosis
(blue lips and tongue) and distressed
Equipment
breathing. These may be the only
The health worker will need the following:
signs in an unconscious patient that
• Nasogastric tube. A 6 french gauge tube
the tube is entering the lungs.
with an internal diameter of Hmm. or
an 8 french gauge tube with an internal • Continue to pass the tube down until
the position marked reaches the nos
diameter of l-8mm, is usually suitable.
Check that fluid will flow easily down the
tril. The end of the tube should then
tube, before passing it down. (If proper
be in the stomach. Check once again
nasogastric tubes are not available,
for choking, restlessness or cyanosis.
polythene/nylon tubes of the right size
Fix the rest of the tube with adhesive
can be used, provided they are clean.
tape below the nose and to the cheek
rinsed and have no rough edges.)
or side of the forehead.
• Lubricating fluid such as: ‘KY Jelly’ or
vaseline if available; water; or mothers’ • To check that the tube is in the
stomach, use the syringe to suck up
saliva, if working in field conditions.
some fluid and test with blue litmus
• Syringe (20 ml or 50 ml). This can be
used afterwards as a funnel for giving
paper. If the colour changes from
feeds.
blue to red the tube is in the stomach.
• Blue litmus paper, if available.
If blue litmus paper is not available,
• Adhesive tape.
but the fluid sucked up is clear, con
• Stethoscope if available.
taining mucus or partially digested
• Fluid to be given.
food, this also shows that the tube is
in the stomach.
• Another test is to inject 20 to 50 ml
Method
of air down the tube while listening
• Explain to the child’s parents and the
to the upper abdomen, either with a
child, if old enough to understand,
stethoscope or directly with the ear.
what you are going to do.
A distinct gurgle will be heard as air
• Lie infants flat. Lie unconscious
enters the stomach. (This will not be
patients on their sides to avoid aspi
heard if the tube is in the lung).
ration (the regurgitation and inhala • If satisfied the tube is in the correct
tion of fluid into the lungs). Older
position, inject 5 to 10 ml of fluid
children may prefer to sit up.
(saline or OR solution, not milk for
• Measure the approximate length
mula) by syringe, and again look for
from the child’s nostril to the ear lobe
choking or cyanosis.
and then to the top of the abdomen
Rehydration and feeding
(just below the ribs) with the tube,
and mark the position. This will be a Where possible, give a continuous drip
guide to how far to insert the tube.
of fluid. If this is not possible, give fre
• Clean the nostrils to remove mucus. quent small amounts using the syringe
Lubricate the tip of the tube and as a funnel. Hold the syringe upright,
gently insert into the nostril. Pass the about 30 ems above the child’s head, for
tube down through the nose slowly a slow and gentle flow. After each feed,
and smoothly. Stop if the child gags close the tube with a stopper or clamp
Dialogue on Diarrhoea, issue 26, September 1986.
and note amount given. Before each
feed (or every four hours in continuous
feeding), look into the mouth to make
sure the tube has not come out of the
stomach into the throat. Suck up a little
fluid and check as before.
Children who are able to drink will
normally refuse ORS once rehydration
is complete and they are no longer
thirsty. However, in nasogastric feed
ing, the normal thirst mechanism is
bypassed and it is possible to give too
much fluid. It is therefore important to
stop giving ORS by nasogastric tube as
soon as the child is able to drink norm
ally or is fully rehydrated. Overhydra
tion can be dangerous.
Prolonged nasogastric feeding
If feeding continues for more than
hours, do the following:
° Clean the nostrils with warm water
every day, especially around the
tube. Change the tube to the other
nostril every few days. Keep the
mouth very clean with a dilute solu
tion of 8 per cent sodium bicarbon
ate, if available, or citrus fruit juice.
This helps to keep the saliva flowing
and prevents infections.
• Wet adhesive tape quickly makes
skin sore. Take off damp tape with
plaster remover or ether. Clean skin
with water and dry thoroughly.
Change the position of the tape from
time to time.
Stopping nasogastric feeding
If feeding has been continuous, start
by changing to hourly then two houA'
feeds. Then give every other feed Dy
mouth during the day, continuing tube
feeds at night. Tube feeds can then be
gradually stopped as the amount taken
by mouth increases. To remove the
tube:
• Remove the adhesive tape.
• Take the tube out gently and
smoothly. (Older children may prefer
to remove it themselves).
• Offer the child a drink and gently
cleanse the nostrils.
After prolonged nasogastric feeding a
child may have feeding problems or loss
of appetite. Patience and encourage
ment are needed to establish feeding
by mouth again.
Christine Candy, Paediatric Nurse
Ttitor, Queen Elizabeth School of Nurs
ing, Edgbaston, Birmingham, U.K-
Water and sanitation
Choosing a
hand pump
John Cuthbert reports on recent testing of hand pumps
The choice of pump must take into
account the depth of the well and local
conditions, particularly with regard to
maintenance. Many pumps are installed
in areas where they cannot receive the
necessary maintenance and therefore
stop working after a short time. A suit
able pump should be:
O simple to maintain locally
|O easy to repair without using expen
sive, imported spare parts
O constructed so that it is difficult to
steal parts of the machinery.
Other important points:
O there should be as few external fit
tings as possible, as these can easily be
knocked out of place
© if the water is corrosive, the
materials from which the pump is made
should be chosen to minimise the
effects
O if the well dries out from time to
time, a conventional pump cylinder
with leather cups should be avoided
O otherwise conventional brass cylin
ders with leather piston cups are quite
satisfactory
O the pump must be simple to work. A
long handle with a relatively small arc
of movement and a counter-balance
weight is easiest to use.
Best buys
The India Mk. II
In tests of 12 pumps carried out in the
United Kingdom, the India Mk. II
pump was found to be reliable, re
quired little maintenance, was very
easy to use and cheap (£65)*. Its dis
advantages are that careful positioning
Alternatives
is required in installation and that it can
Verguot
Hydropumpe
4C2
only be used in wells of 20 metres or
more since it relies on the weight of the Other pumps worth considering in
water column to carry the piston down clude the Verguot Hydropumpe 4C2
from France at about £35O-£4OO*. This
wards.
is a foot operated pump which was
The Constallen
relatively easy to use, although women
The Constallan pump from England is wearing saris or long dresses might
also good value at £170* and uses stain have some problems. It seems to be
less steel and plastics in its cylinder for reasonably reliable and corrosion resis
corrosion resistance. It was found to be tant. However, it is a complex, novel
reliable, although some wear results design. Availability of spares could be a
from pumping waters containing sand. problem and repairs in the field may be
It is not as easy to use as the India Mk. difficult. A well organized system
II, having a much shorter handle. Instal would be necessary for maintenance
lation of the thin and easily damaged although this should rarely be needed.
cylinder requires care, and maintenance
or repairs to the cylinder could be dif The Mono ES 30
The Mono ES 30, an English rotarv
ficult in the field.
pump at £370*, is very strong and rel
able and requires hardly any mainten
ance. There could be problems in
sealing it against contamination of the
well, unless a robust well head is avail
able. It is also easy to push rubbish into
the spout and down the pump. The
samples tested gave a poor perform
ance but the manufacturer claims that
the design has now been considerably
improved.
It is clear that no one pump is suitable
for all countries and all situations.
Further evaluation is needed and the
World Bank, with United Nations
Development Programme (UNDP)
funds, is now implementing further
extensive tests of such pumps around
the world.
’ All prices and information correct at time
of going to press in 1981.
John Cuthbert is Director of the Water
Research Centre, Stevenage, Herts.
Diarrhoea Dialogue, issue 4, February 1981.
8
Water and sanitation
Appropriate latrines
Geoffrey Read describes two types of excreta disposal
systems which are both affordable and appropriate for most
developing countries.
There are some 2,000 million people in
the world today who have no excreta
disposal facilities. These will all have
low incomes and are unable to afford
piped sewerage. It may also be techni
cally inappropriate for them. Alter
native, well-proven technologies can
be used and, if properly designed, they
will safely dispose of excreta on site,
while being both socially acceptable
and affordable to the house-holder.
The on-site excreta disposal technolo
gies appropriate for most developing
countries are the Ventilated Improved
Pit Latrine (VIP) and the Pour Flush
Waterseal Latrine (P/F).
exit by a non-corrodable insect-proof
screen. The pipe removes odours and
gases and is effective in controlling
insects which breed in the pit. Remov
able concrete covers enable the pit to
be emptied when full (pits fill at the rate
of between 40 and 60 litres per person
per year).
The preferred VIP design has twin
pits which are used alternately. When
one pit is full, it is rested, and the
excreted pathogens die away over time
leaving a rich humus. During this time,
the adjacent second pit is used till full.
Two years should be allowed to ensure
that the contents of the first pit are
pathogen-free. The first pit is then
The Ventilated Improved Pit
emptied and re-used and the second pit
is rested. In this way the latrine remains
Latrine (VIP)
This latrine comprises a seat or squatt in one position.
The householder can construct a
ing plate (depending on cultural pre
ference) which forms part of a concrete building over the pit in any available slab over a large pit. The pit is venti but preferably permanent - material.
lated by a pipe which is covered at the The pit cover slabs should not be con
structed using wood, bamboo or other
materials which will rot. In cases where
the water table is high or the ground
unstable it will be necessary to line the
pit with brickwork or blockwork,
ensuring that the lined pit remains
porous.
The Pour Flush Waterseal
Latrine (P/F)
Illustrations by Richard Inglis
Diarrhoea Dialogue, issue 5, May 1981.
This model comprises a squatting plate
and pan over a water seal, connected by
small diameter pipework to an under
ground leach (filter) pit. The preferred
design has twin leach pits, which are
used alternately as with the VIP latrine.
Deposited excreta and urine is flushed
away by manually pouring between two
and three litres of water into the pan.
The waterseal is thereby maintained
keeping out odours, gases and insects.
The leach pits are generally lined with
honeycomb brickwork through which
liquids filter away into the ground. The
pits fill at about 30 litres per person per
year, and are emptied alternately. In
heavy clay soil or impermeable rock,
the effluent will need to be piped away.
The P/Fis most appropriate in Hindu
and Islamic societies where water is
used for anal cleansing. The VIP will
give excellent service in situations
where water is in very short supply.
When planning sanitation programmes,
existing socio-cultural practices must
be carefully considered and the programme tailored accordingly. Provision
should also be made for disposing of
dirty wash water, either into a separate
soakaway or into a piped or covered
stormwater drain.
Latrines should be located as far
away as possible from water supplies; if
in doubt get professional advice. Health
education, technical support and in
formation programmes are essential
components of sanitation development
work. In particular, use by all the family
must be ensured if the sanitation pro
gramme is to be successful.
The provision and effective use of
affordable and appropriate excreta dis
posal systems will bring significant
long-term health benefits to the millions
of people presently living in unhygienic
conditions and continually suffering
from gastro-intestinal infections, high
infant mortality and low life expectancy.
Geoffrey Read, World Bank/UNDP
Technology Advisory Group (I AG).
9
1
Water and sanitation
How to make soap
This article shows how soap can be made cheaply and easily
on a small scale, in the home or village, using locally available
ingredients.
Soap is a very great help to people in
being able to keep themselves and their
surroundings clean, and is therefore
important in preventing the spread of
disease. In some countries soap is unav
ailable or very expensive. The table
below shows the ingredients necessary
to make soap.
Basic ingredients
For one bar of soap you will need:
• 230 ml (1 cup) of oil or clean, hard fat.
115 ml (’/• cup) of water.
23.5 gms (5 teaspoons) of caustic soda (sodium
hydroxide) crystals or lye.
• Borax and a few drops of perfume are
optional.
For 4 kg of soap you will need:
• 3 litres/2.75 kg (13 cups) of oil or clean, hard
fat.
® 1.2 litres (5 cups) of water.
• 370 gms of caustic soda (sodium hydroxide)
crystals or lye.
• Animal fats such as tallow, mutton
fat, lard, chicken fat or vegetable
oils such as olive, coconut, palm and
palm kernel, cottonseed, castor,
maize, soybean, safflowers and
groundnut can be used. The best
soap is made from a mixture of oil
and fat. Even polluted fat can be
used as long as it is first melted then
a strained through a finely woven
cloth. Coconut oil makes a softer
soap than the other oils (because it is
low in stearic acid) and can be
greasy. It is however the only soap
that will produce a lather in seawater
— so in some cases using some
coconut oil is good.
• The best water to use for soapmak
ing is soft water. Rainwater is there
fore good. Hard water contains min
eral salts which hinder the cleansing
action and lathering of the soap. To
soften water, add 15 ml or 1 tables
poon of lye to 3.8 litres/1 gallon of
hard water and leave to stand for
several days after stirring. The water
poured off from the top, leaving a
sediment behind, is soft water.
• Only caustic soda can make hard
soap. The alternative, if caustic soda
is not available, is potash or lye,
leached from ashes. Caustic soda
should be stored in sealed containers
to prevent absorption of moisture
from the atmosphere.
• Borax, although not necessary, can
be used to improve the appearance
of the soap and increase the amount
of suds produced.
• Perfumes can act as a preservative,
but, if used should be resistant to al
kali. For 4 kg of soap one of the fol
lowing should be used: 4 teaspoons
of oil of sassafras; 2 teaspoons of oil
of Wintergreen, citronella or laven
der; or 1 teaspoon of oil of cloves or
lemon.
• Different proportions of ingredients
produce different types of soap: for
hard scrubbing soap use tallow for
the fat quota; for laundry soap use
lard/cooking fat with Vi tallow; for
toilet soap use V6 tallow with Vi veg
etable oil.
Equipment
To make soap you will need:
• Two large bowls or buckets made from iron,
clay, enamel or plastic. Never use aluminium
— it is destroyed by lyc/caustic soda.
• Measuring cups made from any of the same
materials as above, again except for
aluminium.
• Wooden or enamel spoons, or smooth sticks
for stirring.
• Watertight wooden, plastic, cardboard or
waxed containers for a mould; gourds,
coconut shells or split bamboo halves can also
be used.
• Cloth or waxed paper can be used to line the
moulds so that the soap can be easily
removed.
Method
• Dissolve caustic soda in water to
produce lye water.
• Pour oil into separate container (add
borax at this point if desired).
• Pour the lye water slowly onto the
oil, stirring continuously in one di
rection. If an oil-fat combination is
being used add the melted and
cooled fat to the oil/lye solution.
• Add perfume/colouring now if desired/available.
• When the mixture has a thick constistency, put into lined moulds/
Diarrhoea Dialogue, issue 18, August 1984.
cooling frames and leave to set for
two days.
• If fat only is being used, it should
first be clarified by boiling it up with
water and allowing the mixture to
cool down and set. The clean fat can
then be easily separated and melted
again for soapmaking. Always allow
the fat to cool down before adding to
the lye water, slowly stirring in one
direction.
Once the soap is made
• Do not move the moulds.
• When ready, cut the bars into slabs/
smaller bars.
• Stack on trays and leave to dry
thoroughly for 4-6 weeks.
• When dry, cover to prevent further
loss of moisture.
• If the soap is not set after two days,
or there is grease visible on top of the
soap, leave it to set a little longer.
How to recognise good soap
Good soap should be hard, white,
clean-smelling, tasteless and should
shave from the bar in a curl. It should
not be greasy or taste unpleasant. The
main point to remember is that the soap
you make does not have to be perfect.
As long as it is usable it is better than no
soap.
If, however, problems occur, there
may be several reasons. Spoiled soap
orly happens when:
• the wrong materials are used.
• the oil or fat is too rancid or salty.
• the lye water used is too hot or cole
• the mixture is stirred either too fast
or not long enough.
To reclaim soap:
• cut into small pieces and add to five
pints of water.
• melt over a low heat.
• boil the mixture until it becomes
syrupy.
• pour into a mould and leave for two
days before cutting up as before.
WARNING --- caustic soda is very
dangerous and can bum skin and eyes. Protective
gloves should be worn if possible when making
soap. If bums occur they should be washed
immediately with cold water and then treated
with vinegar or citrus juice. Never add water to
caustic soda — always add the soda to the water.
For further reading, please write to
AHRTAG, 1 London Bridge Street
London SE 19SG
10
Water and sanitation
iii 1111
Water purification
Most surface water — from rivers.
streams and ponds — needs to be
purified before it is fit to drink, as it
may be contaminated with soil,
decayed vegetable matter, and human
or animal faeces. Drinking contami
nated water is a major cause of diar
rhoea. This article briefly describes
various ways in which water can be
purified. The four most common
methods of water purification are:
• storage;
• filtration;
• chemical disinfection;
• boiling.
ii r~ i 111 a ■wiiiiiiimi bi
pot filled with coarse sand and chlorine
powder, submerged in a water supply.
The chlorine seeps into the water sup
ply through holes in the container. Dif
fuser chlorinators have slow rates of
disinfection and are most effective in
wells or tanks not producing or holding
more than 100 litres/day.
of small stones. Cover this layer with a
layer of charcoal, over which put a thick
layer of sand. Another layer of gravel
can be put on top to stop the sand from
being disturbed when water is poured
in. The filtered water passes through a
tube from the bottom of the filter pot Boiling
into a collecting vessel. A similar ver Boiling is the best way of destroying
sion can be made from three or four germs in water. The water must be
clay pots standing on top of each other. brought to a good 'rolling' boil (not just
The pots, in turn from the top, contain simmering) and if possible kept boiling
gravel, and charcoal. In the four-pot
version the lowest pot is used for stor for ten minutes (this may need to be
age of the treated water. The filter is longer at high altitudes). Store the water
simple to make using local materials. in the container in which it has been
and can be kept working well by occa boiled, or. if pouring the water into
Storage______________________ sionally removing the top layers and
another container make sure that it is
Contaminated water can be made safer replacing them with fresh gravel and clean. There are certain issues to
to drink if it is stored for at least two charcoal.
consider when boiling water to purify it:
days. Within that time many harmful
Chemical disinfection____________ • Pathogen survival — some patho
organisms will die, and most of the dirt
gens (E coli and faecal coliforms)
will sink to the bottom of the pot. But Iodine — Iodine can be used for disin
and cysts such as giardia lamblia may
this will not kill all pathogens and is not fecting water and is excellent provided
the water is not too dirty. WHO recom
be killed at lower temperatures than
effective for very dirty water.
boiling point (about 50 - 64°C rather
Storage containers can be made of mend two drops of 2 per cent tincture of
than 100°C).
metal, glass, plastic, or glazed ceramic iodine per litre of water. If the water is
materials. The use of earthenware pots thought to be highly polluted then the • Cost — boiling water for ten minutes
or more may be impractical where
should be avoided if possible, because amount should be doubled — such
fuel is expensive or difficult to
of the risk of bacterial growth in the amounts are not harmful but will give
obtain. Boiling and cooling water
porous clay walls. Water can be purified the water a slightly medicinal taste.
also takes time.
by storage in the home using three pots. Iodine compounds, such as tetraglycine
Two big pots are used for fetching water potassium tri-iodide are supplied as • Recontamination — unless boiled
water is carefully stored and used, it
on alternate days. The first pot is tablets which are claimed to be effec
may be recontaminated by dirty con
allowed to stand for two days. Then the tive against amoebic cysts, and some
tainers, insects, dirty hands etc.
clear top water is carefully poured into viruses and bacteria.
another (smaller) pot for drinking. The Chlorine — Chlorine is a good disinfec Other methods
remaining water can be used for wash tant for drinking water as it is effective
Other methods have been used to
ing. When the first pot is empty it is against bacteria associated with water
purify water with differing levels of suc-l
cleaned and refilled, then it is allowed borne diseases. Bleaching powder con
cess. These include using sunlight,
tains
about
25-30
per
cent
chlorine.
to stand for two days again. Meanwhile
alum, ash, clay and traditional mate
the second big pot is used in the same (WARNING: Keep all kinds of bleach
rials such as seeds and plants. Some
way as the first. In this way each day’s away from children and out of eyes. Do studies have shown that exposing water
not
swallow.)
About
37cc
(2'/i
table
drinking water has been standing for at
to sunlight for several hours in a trans
least two days before it is used. Storage spoons) of bleaching powder dissolved parent container can reduce the
containers must be covered to prevent in 0-95 litre (1 quart) of water will give number of enteric pathogens. A recent
the water from becoming contami a one per cent chlorine solution. To study in Bangladesh showed that
nated, to stop algae from growing and chlorinate the water, add three drops of potash alum prevented bacterial
one per cent solution to each 0-95 litre
to prevent evaporation.
(1 quart) of water to be treated (2 table growth in ORS solution when used in a
Filtration_____________________ spoons to 32 imperial gallons), mix concentration of 0 05-0-1 per cent.
A sand filter will remove most of the thoroughly and allow it to stand for 20 More research is needed to study tradi
suspended organic material in water, minutes or longer before using the tional and alternative methods of
purifying water. The Editors would
but it will always let viruses and some water.
Alternatively, simple chlorinators, welcome letters from readers about
bacteria pass through. For this reason,
it is best, if possible, to boil or chlori which dispense chlorine at a constant their own experiences of treating water
rate into a water supply, can be bought using traditional methods.
nate water after it has been filtered.
Household sand filter — Using wide, or made with local materials. An exam For more detailed information about
earthenware pots, about 750mm high, 1 ple is a diffuser chlorinator which is the methods of water purification
litre of water can be filtered every used in non-flowing water supplies like described above, please write to
minute. Inside the pot put a thin layer wells, cisterns and tanks. It consists of a Dialogue on Diarrhoea at AHRTAG.
Dialogue on Diarrhoea, issue 30, September 1987.
11
Feeding and diarrhoea
Breast to family diet
Weaning does not refer only to the
stopping of breastfeeding. It is the
gradual process by which a baby be
comes accustomed to semi-liquid and
solid foods which increasingly comple
ment breastfeeding. It is complete
when the child is eating the regular
family diet and breastfeeding has com
pletely or nearly stopped. Phrases such
as “the baby should be weaned at six
months” can be very misleading.
Weaning is one of many changes that
all take place together. The weanling
child is becoming accustomed not only
to new foods but to a new environment
and to new physical and mental skills.
He is very vulnerable to illness at this
time.
When should weaning start?
The best way to wean varies according
to the circumstances of each family. If a
mother has to go out to work she may
have to start giving extra foods earlier
than is best for the baby, while continu
ing to breastfeed whenever she is at
home. Where sanitation and cooking
facilities are poor, she may be wise to
start weaning foods later than is ideal.
In general, breastmilk is perfectly
adequate until the baby is at least four
to six months old, or weighs about
seven kilograms. Other foods need to
be introduced about this time to com
plement breast milk. They are unneces
sary, and can be dangerous, if given
earlier.
What makes a good weaning diet?
Texture: At first, the baby needs liquid
foods. These become thicker until, by
his first birthday, he is able to chew
pieces of food. A good practice is to
start with a porridge or pap containing
the food ingredients mixed together
into a creamy consistency.
Quantity: Babies have very small
stomachs and are growing very fast.
They need small amounts of foods
which are rich in dietary energy. Little
and often is the rule. At first weaning
food is extra to breastfeeding; as time
goes on it becomes the main food, and
breastfeeding becomes less important.
The frequency of feeding should in
crease rapidly until the baby is soon
taking at least five meals a day plus
breastmilk. Feeding should continue at
this rate well into the baby’s second
year. Snacks, such as fruit, between
meals are useful — as long as they are
always clean.
Quality: Most weaning diets around the
world are based on starchy staple foods
such as rice, potatoes and cassava. This
is fine as long as certain precautions
are taken. Such staples are not nutriti
ous enough in themselves. A porridge
using the staple mixed with something
extra is excellent. The best additions
are peas and beans mashed with the
skins removed; milk; meat (finely
chopped) or other animal foods; plus
dark green leafy vegetables or yelloworange fruits such as papaya and
mango. Suitable recipes and methods
of preparing weaning mixes can be
found and developed in most cultures.
Energy supplement: Many weaning
porridges do not contain enough
energy for the baby’s needs. During
cooking, the starch used in the porridge
takes up water and becomes very
bulky. Extra oil added to the porridge
has two benefits: it adds energy (oil is
very rich in calories); and the oil
changes the consistency of the por
ridge, making it easier for the smallest
babies to swallow. Oil should be incor
porated in all weaning foods except
where obesity is a problem.
Two other ways of reducing the bul
kiness of weaning foods and making
them better and easier for the infant are
fermenting or roasting the staple
grains. This is done in some parts of the
world and can be of great benefit.
Economy: If people spend extra money
to buy special weaning foods they are
likely to give too little in order to make
it last. Weaning foods made at home
can be just as good as those bought
from shops. In fact, some products sold
for babies are very poor in nutritional
Diarrhoea Dialogue, issue 15, November 1983.
WHO photo
Weanlings are particularly vulnerable to infection. Michael
Gurney considers how this important time can be made safer
and more beneficial for the baby.
Small, frequent meals.
quality. It is usually best to rely on
foods available from the family pot.
Hygiene: Contaminated food is one of
the most critical problems during the
weaning period. In poor, unsanitary
environments it is very difficult to avoid
diarrhoea
in
young
children.
Breastfeeding provides a major protec
tion against diarrhoea. Good hygiene is
essential in preparing weaning foods
and keeping them until the next feed.
But it is difficult to feed a baby five or
more uncontaminated meals a day,
when the mother can only afford to
light the kitchen fire once. Local
technologies need to be used to resolve
the problem.
Utensils: Bottles and rubber teats are
difficult to keep clean. Moreover, in
order for a weaning porridge to pass'
through the teat it has to be very dilute,
therefore the baby risks not getting
enough food. It is best to keep suckling
from the breast, not the bottle. When
food is mashed for a baby, avoid using
sieves which are difficult to clean. A
cup and spoon are suitable for giving
weaning foods; this allows the mother
to change the food from liquid to semi
solid as the baby grows.
Breastfeeding: Breast milk is very nut
ritious and protects against infections.
It also provides the close, loving con
tact that encourages secure develop
ment. As far as possible, breastfeeding
should continue throughout the
difficult process of weaning.
Dr Michael Gurney, Nutrition Unit,
WHO, CH-1211 Geneva 27, Switzer
land.
12
Feeding and diarrhoea
Feeding the anorexic
child
Children with diarrhoea may not want to eat, yet feeding at this
time is particularly important. Shanti Ghosh suggests ways
to overcome this problem.
A child with diarrhoea may lose his
appetite (become anorexic) and, as a
result, be difficult to feed. Anorexia can
reduce the amount of food consumed by
up to 40 per cent. In many cultures,
deliberate withholding of food during
diarrhoea is very common and further
reduces intake. In addition, medical
advice often supports withholding of
food both duringand after diarrhoea, in
the belief that food is not absorbed and
that the bowel needs to be rested. This
leads to rapid worsening of the nu
tritional status of a child who may
already be malnourished.
crease dramatically when a child be
comes ill with diarrhoea. Therefore it is
important to continue breastfeeding,
even after the age of six months when
diarrhoea is more common. (After six
months breastmilk alone is not enough
for the total nutritional needs of the
child and additional semi-solid foods
should be given.) As far as possible, this
additional food should continue to be
given to the child with diarrhoea, even
though the appetite may be reduced. It
has now been shown that the ability of
the intestine to absorb nourishment is
not greatly diminished in diarrhoea.
Breastfeeding
Even the most dedicated mother may
find it difficult to feed an anorexic child;
she will have to use all her powers of
persuasion and ingenuity to make the
child eat. Often the child will turn its
head away when food is offered, and
may not want to eat the usual family
food. The anorexic child may find
chewing difficult as not enough saliva is
produced, so rolls the food around in its
mouth and either keeps it there or spits it
out. Small quantities of ‘soft’ foods,
which do not need chewing, and which
can easily be swallowed, should be
offered frequently. There are suitable
foods in every culture. For example,
porridge, gruel, boiled rice, a mixture of
rice and lentils, yoghurt, mashed bana
na, boiled potatoes or carrots. Fish and
eggs can be given where culturally
acceptable and available. A mother
needs plenty of patience not to get cross
with her child, especially if she is tired
and busy.
Photo by K Indirabai (DD photographic competition)
Fortunately, even an anorexic child will
usually breastfeed happily. This is be
cause, as well as nourishment, breast
feeding gives comfort and a feeling of
closeness to the mother which is particu
larly important when a child is unwell.
Studies have shown that the amount of
breastmilk a child takes does not de
Give the child the food it wants
Breastfeeding gives comfort as well as
nourishment to the sick child.
Some children may want to eat savoury
foods, and others may prefer something
sweet. Mothers should not be too par
ticular about what the sick child eats, as
long as it eats something. Many mothers
have their own ideas about which foods
are easily digestible and which are not.
They may insist that a child takes what
Dialogue on Diarrhoea, issue 23, December 1985.
they consider to be more suitable, while
an anorexic child may have its own
preferences. The child may not want to
eat bland or tasteless food, instead it
may prefer familiar foods that have
more flavour or are spicy. What is
important is that food is eaten, rather
than which food.
The bulkiness of cereal based foods
can be a problem, as a large volume may
contain little nourishment. This can be
even more of a problem for the anorexic
child. The bulk can be reduced by
roasting the cereal before cooking, oj«.
better still, by malting, a process involW
ing germination, drying and then roast
ing again. Adding some oil or butter will
increase the energy density.
During the recovery phase of diar
rhoea the appetite increases and the
mother should take advantage of this to
offer more food to the child. Extra food
at this stage is important as it helps a
child’s growth catch up some of the loss
which occurs during the illness.
Dr Shanti Ghosh, Al/18 Panchshila
Enclave, New Delhi 110017, India.
The feeding and care of infants and
young children, 1985. Ghosh S. Volun
tary Health Association of India
(VHAI), C-14 Community Centre, Safdarjttng Development Area, New Delhi
110016, India. Price: 14 rupees.
13
Feeding and diarrhoea
Vitamin A: preventing
blinding malnutrition
There is no real scarcity of vitamin A in many African and Asian
countries. Problems arise when fruit and vegetables
containing vitamin A cannot be conserved, or when it is not
culturally acceptable for or is difficult to get children to eat
vegetables.
Common sources of vitamin A
Ready-made
sources
Carotene
sources*
Meat
Green and yellow
vegetables (especially
dark green leaves)
Liver
Fish
Milk and
dairy produce
Eggs
Red palm oil
Yellow marrow,
pumpkin and squash
Carrot, mango and
papaya
Vegetables for sale in an Asian Market.
Vitamin A prevents
keratomalacia
Conserving vegetables
(containing vitamin A) out of
season
In areas where fruits and vegetables
may not be available all year round, sun
drying is a useful way of preserving
supplies. Perishable fruits are often lost
on the way to markets and can be trans
ported more easily in a dried form.
A simple sun dryer like the one
shown in the illustration can dry tip to
60 kilos of green vegetables a day in a
hot, sunny climate. A most important
point is that the vegetables must not be
exposed to direct sunlight since this de
stroys a lot of vitamin A. To avoid this,
a simple shade of reeds, stretched hes
sian or cloth can be supported over the
drying tray. This does not interfere
with the drying process as the drying is
accomplished by sun-heated air rather
than by direct sunlightfl>.
Dried green vegetables and suitable
root and fruit crops will provide con
centrated amounts of vitamin A.
*The body makes vitamin A from
carotene in the diet.
What is vitamin A?
Vitamin A is a fat-soluble substance.
Dialogue on Diarrhoea, issue 21, June 1985.
Reproduced fro
'rimary Child Care:
Book I' by Maur^e King et al.
In many areas where xerophthalmia is
prevalent there is an abundance of
fruits and vegetables that provide a
natural source of vitamin A. These are,
however, often not eaten, especially by
children, the main group who suffer
from blinding malnutrition. Many nut
rition education programmes are now
focusing specifically on children.
School children are an ideal target for
learning the importance of fruits and
vegetables to family health. There are
many ways of preparing green vegeta
bles to make them more acceptable to
children — for example, chopped and
mixed with lentils and other pulses,
minced meat, stews and soups. If chil
dren still refuse to eat greens, and the
family cannot afford the animal foods
containing vitamin A (see table), car
rots and coloured fruits are also useful
sources. It is important to note that vit
amin A cannot be satisfactorily ab
sorbed by the body unless there is
sufficient oil or fat in the diet.
retinol, found in animal foods and dairy
products. Carotene, the naturally oc
curring substance from which vitamin
A is made either by humans or animals,
is manufactured by plants, particularly
those with dark green leaves or with red
dish yellow roots or fruits. Dietary fats,
pancreatic enzymes and bile salts are all
important for the absorption of both
vitamin A and carotene, which are
transformed by the lining of the intes
tine into retinol. Most vitamin A is
stored in the liver as retinyl palmitate.
Free retinol is highly active but toxic
and it is therefore transported in the
body in combination with a retinolbinding protein. Retinol is essential for
the proper functioning of the photo
receptor cells which detect light strik
ing the retina at the back of the eye
Hence the night blindness in early vita
min A deficiency. It is also necessary
for the production of healthy new cells
to cover the eye and line the different
body systems like the gut and respirat
ory tract. Severe deficiency damages
the body’s defence against infections.
Line drawing showing some sources of
vitamin A.
Severe xerophthalmia and kerato
malacia only occur when liver stores of
vitamin A are extremely reduced.
(I) Appropriate technologies for tackl
ing malnourishment. Jim McDowell
CONTACT45, June 1978.
Further reading: Xerophthalmia Club
Bulletin. Produced by Mrs A Pirie,
Nuffield Laboratory or Ophthalmology,
Oxford, U.K.
14
Education and training
■■MrnwmTiiw—na—imh
i
Hl
Carrying out a survey on
attitudes to diarrhoea
• Would you like to learn how to treat
diarrhoea with a solution of salt and
sugar which you can make in your
home?
Mothers’ attitudes are critical to the success of ORT
programmes. A survey to find out their beliefs should,
therefore, be an essential step before developing a pro
gramme <1 and 2).
These questions were translated into
Haitian Creole and posed initially to
half a dozen mothers living in or near
the capital city. These mothers had
already heard of ORT, knew about
mixing a home-made solution of sugar
and salt, believed strongly in
continuing
breastfeeding,
giving
liquids (boiled and carefully handled).
and spoke of reducing heavy, fat foods
but not eliminating food altogether.
The families were also aware of the
danger of dehydration from diarrhoea
and knew they were dealing with a
potentially serious health problet
They generally recommended seeing
doctor and knew specific health
facilities where they could get help.
While the first interviews also
provided ideas on foods and liquids
that are traditionally considered good
and bad in treating diarrhoea
(diarrhoea is considered to be a “hot"
illness in Haiti so "cool” foods must be
given), the mothers had obviously
already had some exposure to modern
ideas.
• How do you know when your child
has diarrhoea?
• What causes it? What other names
do people use for diarrhoea?
• Is diarrhoea a disease? Can a child
die from it?
• Do you know a child who has died
from diarrhoea?
• What do you do when your child gets
diarrhoea?
• Should liquids and/or food be given
when your child has diarrhoea?
• Why or why not?
• What arc good foods/liquids for a
child who has diarrhoea?
• Should you continue breastfeeding a
child who has diarrhoea?
• Who in your community can help
you if your child has diarrhoea?
(doctor, health worker, traditional
birth
attendant.
leaf doctor.
traditional healer, etc.)
• Is there a particular medicine you
give your child when he has
diarrhoea? Which one9
hologr aph hv Michael MeQuestion
We recently received a study from
Haiti offering practical suggestions on
gathering information before starting a
national oral rehydration therapy
programme. The study was begun in
late 1981. For a year before then. Haiti
had been implementing a hospital
based ORT programme (,). Although
attempts had been made to teach
mothers about the use of oral
rehydration solution for several years.
community and home-based ap
proaches to oral rehydration therapy
were still new ideas.
The Research Section of the Division
of Family Hygiene, Department of
Public Health and Population dis
cussed the situation with public health
workers and drew up a list of simple
questions to ask mothers. The
questions were designed to give insight
into attitudes to diarrhoea in the
community and mothers’ beliefs about
its cause and cure. The questions
included:
Haitian mothers believe in continued breastfeeding when children have diarrhoea
Diarrhoea nialogue, issue 9. May 1982.
Survey in urban areas
Rural areas
Consequently, the next interviews
were with mothers in more isolated
rural areas. A total of 16 interviews
lasting between 10-30 minutes were
taped. Rather than transcribing all the
data, the cassettes were replayed
several times and notes taken on tf .
most relevant points. The fieldwork n.'
live different rural areas was done by
the Haitian Center for Applied
Linguistics, which was gathering data
tor a linguistic atlas of Haiti and offered
to cooperate with the Division of
Family Hygiene's Research Section
The age of the respondents varied
between 20 and 70 years. All the
women interviewed recognized diar
rhoea by the presence of liquid stools in
great quantity and most saw it as a lifethreatening disease. 'Hie majority said
that food intake should not be stopped
during diarrhoea, and generally had
reasonable ideas of the type and
quantity ot food to provide.
The eeneral consensus was that
breastfeeding should continue in order
to give the child strength and that
15
liquids (tea, juice, rice water, cow’s
milk) should continue as well. Half of
the respondents had already heard of
ORT.
The causes of diarrhoea mentioned
included teething and ‘spoiled’ mother’s
milk as well as some modern beliefs
related to poor hygiene. Treatment of
diarrhoea begins at home but many of
the mothers mentioned the need to
seek medical assistance.
Results
The main results of this small study
were confirmed in a larger nutrition
survey of almost 900 mothers which
included questions about their views on
the nature of diarrhoea, and feeding
practices to follow when it occurs. This
Supported a general feeling that
ithers in rural Haiti are very
lavourablc to the introduction of an
ORT programme. There do not appear
to be traditional attitudes and beliefs
that are obstacles to a national effort to
treat diarrhoea. Mothers seem to be
quite ready to take action when
diarrhoea strikes and are ready to
accept an appropriate technology.
In Haiti a complex magico-religious
system underlies views of health and
illness and what can be done to resolve
problems. While a simple study
focusing on practical issues in ORT did
not need to analyse this system in
detail, a sympathetic awareness of the
importance of traditional medicine
(often all that people in rural areas
have to help them in major crises) is
«ery important. The team who carried
">t the study described here plan
. ther work on this subject.
Study sent by Dr Janies Allman, Center
for Population and Family Health,
Columbia University and Dr Maryse B.
Pierre-Louis, Division of Family
Hygiene, Department of Public Health
and Population, Port-au-Prince, Haiti.
Rohde J E 1980 Attitudes and Beliefs
About Diarrhoea: The Mother's Role.
Diarrhoea Dialogue 2: 4—5
<2> Lozoff B, Kamath K R and Feldman
R A 1975 Infection and Disease in South
Indian Families: Beliefs About Child
hood Diarrhoea. Human Organization
Vol 34, No. 4:353-358
l3>Pape J 1981 Introduction and
Promotion of Oral Rehydration Fluids
in Haiti. USAID, Port-au-Prince,
Haiti.
General points to remember:
Many people dislike or distrust surveys. This is particularly true in poor communi
ties which are frequently studied but rarely see any results. Proper organization of
a survey and a sympathetic approach when carrying it out will make it far more
likely that the end results will be acted upon.
• Try to find out what problems people
feel are most important and see what
ideas they have for solving them.
• Only ask for the minimum amount of
information necessary for the
survey. Make sure that people
understand why you are collecting
the information.
• Talk to enough people to ensure
collection of a cross-section of
opinion from within the community.
The number of people you can reach
will obviously depend on the
questioners available. If you are
training questioners, it is very
important to spend time on this. An
unsympathetic, abrupt approach
when asking questions can produce
forced answers and ruin a survey.
• Try to ask questions in such a way
that people can learn something at
the same time as they answer. Avoid
asking leading questions and if a
person does not understand what to
reply, offer several different
possibilities including an open
response like ‘none of these
answers’.
• If possible, try to avoid using
questionnaires when talking to
people (small tape recorders were
used in the Haiti study).
However, you will need questionnaires/checklists at some stage to set
down the information gathered in a
logical way. Apart from the questions
listed on page six, the following topics
could also be included in a diarrhoea
survey:
• What household remedies are
available for diarrhoea?
• Does each household have a supply
of salt and sugar which could be used
for making oral
rehydration
mixture?
• What containers are available for
storing water, mixing up a solution
and measuring salt, sugar and water?
Your survey could also include the
local shops, pharmacies and the nearest
Diarrhoea Dialogue, issue 9, May 1982.
dispensaries and health centres. At
these places check:
• Which diarrhoea treatments are
used.
• How much stock is kept and the
turnover.
• Availability of packets of oral
rehydration salts (ORS).
• If alternatives are used what do they
cost and what is their chemical
composition?
It is also important to examine water
sources, storage of water and the use
and maintenance of sanitation.
Summary of the important steps in a
diarrhoea survey:
• Consider the questions that will
provide the necessary information to
improve the diarrhoea service.
• Set these out in a questionnaire and
test them with and on local people.
• Choose and train questioners.
• Survey a representative number of
people in the community.
• Summarize the results and apply
them to modify and improve the
diarrhoea prevention and treatment
services.
Useful further reading:
Barker DJT 1976 Practical Epi
demiology. Oxford University Press.
Bennett F J 1979 Community Diagnosis
and Health Action. The Macmillan
Press Ltd.
Cutting W A M et al 1981 A worldwide
survey on the treatment of diarrhoeal
disease by oral rehydration in 1979.
Annals of Tropical Paediatrics 1:4:
199-208.
McCusker J 1978 Epidemiology in
Community Health. African Medical
and Research Foundation, Nairobi,
Kenya.
Werner D, Bower B 1982 Helping
Health Workers Learn. The Hesperian
Foundation, PO Box 1692, Palo Alto,
California, USA.
16
Education and training
Getting the
message across
A health education programme that is to be effective, whether
nationally or locally, must use many ways of getting its
message across. Posters, puppets, cartoons, simple leaflets
and even magic are just some of the methods that can be used
to convey basic health messages. Where oral rehydration is
concerned, providing sachets of oral rehydration salts or
measuring spoons without appropriate instructions may do
more harm than good. This page shows three simple ways of
telling people about rehydration.
PIATA
Pl ATA-Mexico has developed a leaflet
on oral rehydration salts for use in the
National Health Programme. The
leaflet has been tested in rural areas,
especially among illiterate women. It is
used by auxiliary health personnel to
explain to mothers how to prepare the
solution, when to give it and how often
to give it. The importance of continuing
to breastfeed the child during the treat
ment is also stressed.
Cartoons
Professor C. Y. Chen of the Faculty of
Medicine at the University of Malaya
has adapted Jon E. Rohde's story of
Abdul and Seri into a local cartoon
book. The story shows how older
brothers and sisters and grandparents
can all help when younger members of
the family have to be treated for
diarrhoea. The story has also been con
verted into an audio visual set for use in
West Malaysia.
Local leaflets
Our illustration showing how to mix
oral rehydration solution is taken from
a simple course on common diseases
produced by the Programa Promotores
de Salud in Huehuetenango, Guate
mala. The leaflet also contains basic
advice on respiratory and stomach
infections and a chart for keeping a
record of the patient's health.
MAS LA CAHTIDAD DE
A 1a p*raon* deahldratada,. dAle trajultoa en eucharadltae da SUBRO
PARA rOMAR cada 5 alnutoa hasta qua •■piece a orinar QomalJMata.
Una paraona grande naeealta 3 a 6 lltroa al dfa. Un nldo chlqulto
□•caalta, por lo nenoa, 6 taaaa al d£a.
Diarrhoea Dialogue, issue 3, November 1980.
An illustration from the PIATA leaflet
which conveys the message about oral
rehydration in a simple way.
A copy of the pamphlet is given to
the mother with a packet of oral re
hydration salts and serves as a reminder
of the verbal instructions given by the
health worker. The pamphlet does not
contain words. A small version of the
leaflet is now available, the same size as
the packet of oral rehydration salts. If
you would like further information on
the design, testing or adaptation of
these materials, please contact PIATA
(Programa para la introduccion y
adaptation de tecnologia anticonceptiva) Shakespeare 27, Mexico 5, D.F.,
Mexico.
17
Education and training
Simple but not easy
Health education materials using only pictures are
needed in many countries. The end result may look simple
but the development and production process is complex.
Margot Zimmerman and Joan Haffey describe PATH’S*
work in this field.
PATH has been preparing illustrated
materials for non-literate audiences for
several years. Their first health-related
pamphlet, on how to mix and give oral
rehydration salts (ORS) solution to a
child with diarrhoea, was designed in
Mexico.
| Other PATH* projects to develop
instructional materials and packaging
to improve the understanding and
acceptability of ORS have been carried
out in Bangladesh, Indonesia, the
Philippines, and Thailand <*). A new
project was recently begun in Sri
Lanka.
Guidelines for production
readers. It is also usually the most
economical format for high-speed printing
presses.
• Initial print runs should be small, even if
the cost per copy is higher, so that changes
can be made following further evaluation
and before mass distribution.
• Understanding of the picture is greater
when a person’s whole body, rather than
just part of it, is illustrated.
• If the material will be printed in more
than one colour or will include simple
words, these choices should be pretested in
the same way the illustrations are tested.
Remember that certain colours have
different meanings in different societies.
• Using colour at all also adds to the
production cost, an important point to
remember.
• Non-literate people do not necessarily
look at pictures in the order intended. As
messages are being tested, it is useful to ask
several groups of people to arrange them
into the sequence that seems most logical to
them.
• The design and testing of simple
materials are more complicated and require
much more time than the development of
written materials. Simple does not mean
easy.
* The intended audiences should always
have the final say about the content,
illustrations, and sequences used.
• Not all kinds of technical information
can be transferred through illustrations.
Pictures can probably be used to teach
someone how to change a motorcycle tyre,
but it is doubtful they can be used to teach a
person to drive that motorcycle.
From its work in this field PATH has
developed
guidelines
for
the
production of instructional material for
non-literate communities:
• Keep pictures as simple as possible. A
crowded scene will divert attention from the
message being conveyed.
• Though excessive detail interferes with
understanding
of
the
message,
comprehension may also be reduced by
over-simplication.
• Content must be limited to the most
important messages. Only 8-12 major
.points can be effectively covered in a single
’pamphlet.
* Each picture and each page should have
a single, sharp meaning.
• Visual symbols should be as realistic as
possible.
* Pictures are more likely to be successful
if faces, clothing and buildings are based on
what is familiar locally.
• Use only familiar objects and symbols to
portray a message. For example, many
different kinds of light sources could be
used to signify night (a light bulb, a
kerosene lamp, a candle, a metal lamp).
The symbol chosen must be tested with
people from the intended audience to
ensure it is appropriate.
* Material
produced
for
national
distribution may not be equally appropriate
for all regions of the country.
• The ideal length for a pamphlet is usually
16 pages. This often corresponds both to the
space necessary to depict 8-12 major
messages and to the attention range of most
Broader lessons
Besides the detailed guidelines above,
PATH has also learned some broader
lessons. These apply to any efforts to
communicate information about health
or development.
Continuous field-testing and revision
As materials are prepared, continuous
Diarrhoea Dialogue, issue 14, August 1983.'
field testing and revision with the
intended audience are essential to
ensure that the materials are
understood and serving their purpose.
Multi-level approach When introduc
ing a new product or method, a broad
approach to providing information to
ail those who will come in contact with
it is best. Doctors, nurses, fieldworkers
etc. all have different information
needs, and materials should be appro
priate to the services they perform and
what they need to do their work more
effectively.
Involving the national programme early
A pilot project that is developing
materials intended for use on a wider
scale must involve the final distributor
of the materials at a very early stage.
PATH has seen from its • ow
experience that failure to do this ca
prevent even successful materials from
ever being used throughout a country.
Government staff must feel a part of
the project. This also helps to ensure
that elements of the message or
materials design will be appropriate to
mass distribution.
Unexpected findings Project staff
should realize that this work can lead to
unexpected findings. While evaluating
the Mexican ORS pamphlet, it was
found that, despite the scepticism of
both US and Mexican staff conducting
the research, both men and women
preferred a version of the pamphlet
showing active involvement of the
father in the care of the sick child to one
with only the mother. New projects will
teach new lessons to target audiences
and staff alike.
National self-sufficiency Pilot projects
that develop information materials by
using the methodology described here
also serve a broader purpose: project
staff will be learning skills that build a
national expertise in producing other
information materials. This can lead to
national self-sufficiency in this type of
education and communication.
Margot Zimmerman and Joan Haffey,
PATH, Canal Place, 130 Nickerson
Street, Seattle, Washington 98109,
USA.
*PATH — the Program for Appro
priate Technology in Health.
Reprints of a paper describing these
projects,
“ORS:
Promotion
of
Acceptability and of Safe and Effective
Use, ” are available from PATH.
18
Education and training
Evaluation of training
Birger Forsberg describes several methods for evaluating the
impact of training on the practices of health workers.
Training in programmes for the control
of diarrhoeal diseases (CDD) is very
much oriented towards changing health
workers' performance in supervisory
activities and their behaviour in the
treatment of diarrhoea. It is becoming
increasingly important to evaluate this
aspect as countries accelerate their
programme activities. Some countries
have started to develop methods for
evaluating the impact of training on the
practices of health workers.
Follow-up
In the United Republic of Tanzania, for
example, a series of clinical
management workshops was held in
1986. Supervisory visits are now being
made to participants, six to 12 months
after the training, to assess how they
are applying the skills taught at the
workshops. As one of the objectives of
the training was to teach participants
how to organise diarrhoea training
sessions, this area is given special
attention during the follow-up visits.
The trainees are given the opportunity
to explain their problems and the
assistance they need to successfully
promote proper diarrhoea manage
ment in their hospitals. This type of
follow-up is appropriate when a
training programme is focused on a
small group of persons who have a
major responsibility in the CDD
programme. It is not feasible for the
evaluation of large-scale training
activities.
Nepal provides an example of how
extensive
programmes
can
be
evaluated. The country is training
health workers in a new regionally
phased programme. During a CDD
programme review in 1986, the
practices and skills in the treatment of
diarrhoea of a random selection of
health workers were assessed (Table 1).
Records showed that children treated
at health posts in districts where the
staff had been trained were
significantly more likely to receive
ORS than those in ‘untrained’ districts.
There was little difference in the use of
antibiotics between the two groups.
Written guidelines for diarrhoea
treatment were available more than
twice as often in facilities with trained
personnel.
total numbers of visits, diarrhoea and
dysentery cases, and cases given
antibiotics, ORS, or both. Records
were checked before training in ORT,
and at intervals of one, six and 18
months after training. The results are
shown in Table 2.
The training appears to have had a
definite impact on the behaviour of the
health workers; ORS was prescribed
much more often and antibiotics less
often than before the workshops.
Evaluation is an important part of
training programmes. These examples
Table 1. Availability of written guidelines and frequency of treatment of diarrhoea
with ORS and antibiotics at health posts, Nepal
Health posts surveyed
Posts with treatment guidelines
Diarrhoea cases in under-fives
Cases treated with ORS
Cases treated with antibiotics
Comparing trained and
untrained health workers
Interestingly, interviews with health
workers did not reveal any differences
between trained and untrained health
post workers in knowledge of how to
assess and treat diarrhoea, primarily
because the untrained health workers
were fairly familiar with these skills
already. This suggests that the training
has been partially successful in
changing the practices of the health
workers with regard to the use of ORS.
Further efforts must now be made
during training to discourage the use of
antibiotics.
Dialogue on Diarrhoea, issue 29, June 1987.
Checking records
With trained staff
Percent
No.
—
13
54
7
—
219
71
156
178
81
With untrained staff,
Percent’
No.
—
13
23
3
—
103
47
48
93
96
illustrate some ways of evaluating the
impact of training on the actual perfor
mance of health personnel:
• follow-up visits including discussions
with trainees;
• interviews, observation and com
parison of trained and untrained health
workers; and
• checking and comparison of hospital
records before and after training.
Health staff in charge of CDD prog
rammes and Diarrhoea Treatment
Units (DTUs) could consider including^»
such methods in their training program-™
mes.
Birger Forsberg, MD, Evaluation
Officer, CDD Programme, WHO, 1211
Geneva 27, Switzerland.
Another example can be taken from
Sudan. A rural health training
programme was evaluated by a review DD would like to hear from readers
of daily attendance records at different about their own experiences with evalu
health stations. This involved counting ation of training.
Table 2. Diarrhoea and treatment with ORS and sulphonamides, Sudan
Before introduction of ORT
1 month after training workshops
6 months after training workshops
18 months after training workshops
No. of cases
ORS
1140
698
1981
4060
%
8
64
59
72
Sulphona
mides
%
76
45
38
22
19
‘Tfceme: (Dysentery
1 echnical Literature Update
on DIARRHEA
Technical Editor: Robert Northrup, M.D.
Managing Editor: Lisa Dipko
1992
Vol. VII, N54
DYSENTERY
As control of diarrheal diseases (COD) programs have begun to examine the impact of
their efforts, it has become apparent that dysentery and persistent diarrhea play an
important role, in some cases a dominant role, in mortality from diarrhea. The next two
issues of the Technical Literature Update focus on dysentery, responding to the recent
outpouring of articles on that problem in the published literature. Dysentery or bloody
diarrhea is more complex in its diagnostic and therapeutic pathways than dehydrating
watery diarrhea. It cannot be dealt with by a universal solution like ORT, and it falls prey
to a range of issues surrounding the use of antibiotics. The articles and commentaries in this
issue touch on the epidemiology of dysentery, as well as community and environmental
aspects of its control.
Dysentery is characterized by the frequent passage of loose stools with blood and mucus,
and often is accompanied by other symptoms such as fever, severe abdominal cramps, and
tenesmus (rectal pain following defecation). Unlike most watery diarrheal diseases, which
result from infection in the small intestine, dysentery results from infection in the colon,
resulting in inflammation and often in ulceration. Dysentery is often labeled either
''bacillary” (caused by bacteria, most commonly Shigella) or "amebic." The proportion of
dysentery which is bacillary or amebic is variable, but in general, bacillary dysentery is
much more common. Shigella is not the only cause of bacillary dysentery, but it is the most
common. Other bacterial agents that can cause dysentery include invasive E. coli,
Campylobacter, and probably Aeromonas and Plesiomonas. Shigella organisms are divided
into four species: S. dysenteriae, S. flexneri, S. boydii, and S. sonnei. S. flexneri is the most
common cause of endemic dysentery in developing countries while S. dysenteriae is frequently
associated with severe epidemic disease. S. sonnei seems to be unusual in developing
countries but is the most frequently isolated species in industrialized countries.
PRITECH—
Management Sciences for MeaCtfi
Address Correspondence to: Information Center, PRITECH. 1925 North Lynn Street, Suite 400, Arlington, VA 22209-1707, USA
Phone: 703-516-2555. Telex: 377-6735-WATERVIEW
A.I.D.-supported Contract # DPE-5969-Z-00-7064-00, Project * 936-5969
It can be extrapolated that another 191 patients
would have died without the services of the communityoperated hospital. Similar interventions may avert almost
all deaths in rural epidemics of shigellosis.
Islam, A.B.M.Q.; Siddique, A.K.; Mazumder, Y.; et
al. 'A STEEP DECLINE OF DEATH IN A SHIGELLOSIS
EPIDEMIC IN BANGLADESH BY A
COMMUNITY-PARTICIPATED INTERVENTION.”
Journal of Diarrhoeal Disease Research, vol. 6, nos.
3 and 4, September and December 1988,215-20.
Order#3256
Editorial Comment
This report describes a remarkable event, a
community responding to a devastating dysentery
epidemic by organizing a practical, close, and therefore
easily accessible, makeshift treatment center cum
hospital, and reducing subsequent mortality from the
epidemic from 11% to almost zero. The report shows
first of all the dramatic damage that dysentery can exert
in a community epidemic, enough to energize the
community and local doctors to stop everything else and
take action. I wondered what role the information
obtained by the routine diarrhea surveillance system
had in bringing this about. Scattered over a rural area,
would the community and responsible physicians have
known that an epidemic was taking place, and how
damaging it was, without that routine surveillance data? I
suspect it was quite important in providing a solid factual
basis for motivation toward action.
Summary
An epidemic of shigellosis began in Dimla,
Bangladesh on March 2, 1985.
People of the
community raised funds and requested assistance from
the local Health Administration and the Epidemic Control
Preparedness Programme (ECPP) of the International
Centre for Diarrhoeal Disease Research, Bangladesh to
operate a local, makeshift hospital. This facility, which
functioned in a school building from April 20 until the
end of the epidemic on July 14, was able to treat 40 to
50 patients at a time.
A physician assessed each patient twice daily.
Clinically diagnosed blood-dysentery patients were
rehydrated as necessary. Ampicillin by oral route (100
mg/kg/day) was given to all patients initially. For those
patients who did not show clinical improvement within 48
hours, nalidixic acid (55 mg/kg/day) was then given.
Patients were fed protein-rich meals three times per day.
Patients and attendants were given soap for washing
their hands before meals and after defecation, to avoid
spreading infection.
Second, the report dramatizes for me the fact that a
comprehensive approach to dysentery treatment is
needed to have such a positive impact. Good diarrhea
management, in particular assessment and treatment of
dehydration and aggressive feeding, was probably as
important as the antibiotic therapy, especially in that twothirds of the initial deaths were in children under 5, many
of whom were undoubtedly undernourished. With fully
6% of the specially studied group severely dehydrated,
and another 14% moderately dehydrated, keeping the
patients alive with fluids was a necessary first step to
allowing the antibiotics to eliminate the organism. The
extra attention to feeding may have been particularly
Data on patient numbers and deaths were collected
from the routine subdistrict diarrhea surveillance records
and from treatment charts. It was found that the interven
tion produced a 187-fold decrease in the case-fatality
rate, which dropped from 11.2% (70 deaths among 626
cases) before the hospital was established to 0.06%
(one death among 1,708 patients) during its existence.
Technical Literature Update
The TLU is produced by the PRITECH Project under
Contract #DPE-5969-Z-00-7064-00, Project #936-5969
with the Office of Health, Bureau for Research and
Development, of the United States Agency for
International Development (A.I.D.). The summaries and
editorial comments represent the opinions of the TLU
editorial staff and are not meant to represent A.I.D.
policies or opinions. Inclusion of an article in the TLU
does not denote endorsement or validation of the article
cited, but rather indicates that it is worthy of attention and
further critical appraisal.
A sub-group of 108 hospital patients was studied for
clinical and epidemiological characteristics. Only 22% of
stool cultures (taken from 65 of these patients) were
positive for Shigella. Although the organisms from 86%
of the cultured patients showed resistance to ampicillin,
70% of the 108 patients in the sub-group improved with
ampicillin treatment. Common dysenteric symptoms
included acute onset of diarrhea, fever, frequent
bloody-mucoid stools, and abdominal cramps. Most of
the patients had mild to no dehydration and had come to
the hospital within 5 days of onset. Conversely,
surveillance data showed that 80% of pre-intervention
deaths occurred after 5 days of illness.
Technical Literature Update
Copies of articles featured in the TLU are available
through the PRITECH Information Center, 1925 N. Lynn
St., Suite 400, Arlington, VA, 22209. Please use the
order number listed at the end of each title when ordering
articles. Your comments are welcome.
2
Vol. VII, N24
important in supporting healing of the intestine in what
was probably a generally malnourished group of children.
three primary sources: investigation of epidemics of
dysentery caused by Shigella dysenteriae type 1,
surveillance of endemic diarrheal disease in
communities, and hospital records. Investigations of
eight dysentery epidemics in various countries
worldwide between 1969 and 1984 showed overall
incidence rates ranging from 1.2% to 32.9%; attack
rates appeared to have been higher when active case
finding was used to detect cases than when passive
governmental reporting systems provided the
information. Overall case-fatality rates ranged from 0.6%
to 7.4%. In general, case-fatality rates during epidemics
were highest among infants (17% in one epidemic on an
island in Bangladesh) and were higher among both
children 1 to 4 years of age and persons over 50 years
of age than among other age groups.
Third, locating the treatment center in the community
and providing quick access allowed for early initiation of
treatment. The authors comment that prior to opening
the community center, the nearest source of care was a
rather distant government health center, 10 km from the
epidemic. In addition, the treatment there may have
been minimal; many rural health centers have shortages
of personnel and supplies, and monitoring of patients
may be difficult or impossible. The close and well-run
community treatment center allowed for earlier and better
treatment and patient monitoring.
Was the epidemic in fact shigella, despite the low Shi
gella positivity in the specially studied patients—only
22% ? I suspect it was because of the classic pattern of ill
ness and mortality. In developing countries, some 60%
of bloody diarrheas are caused by Shigella, and it is with
out question the most likely cause of epidemics of
bloody diarrhea such as this one. The authors attribute
the low positivity to the long period the specimens spent
in transport media before inoculation of culture media.
Although epidemic S. dysenteriae type 1 is the most
dramatic manifestation of shigellosis, the majority of
Shigella infections are due to endemic shigellosis
caused by other Shigella species. Information about
endemic shigellosis is available through the
Demographic Surveillance System maintained by the
International Centre for Diarrhoeal Disease Research,
Bangladesh in the rural district of Matlab. This system
has monitored diarrheal deaths in a population of about
200,000 since 1965. From 1975 to 1985, deaths
attributed to dysentery accounted for more than 20% of
deaths from all causes in the 1- to 4-year age group for
every year except 1981. Deaths due to dysentery
outnumbered deaths due to watery diarrhea by a ratio
ranging from 2.1 to 7.8. Using data from Matlab to
estimate nationwide mortality for dysentery and
shigellosis, one can calculate that in peak epidemic
years such as 1984, dysentery accounts for
approximately 150,000 deaths among children aged 1
to 4 years in Bangladesh, of which about 50%, or
75,000, are due to Shigella dysentery. In non-epidemic
years, an estimated 35,000 such children die from
dysentery.
Was ampicillin the reason for the patients' recovery,
despite the fact that 86% of the Shigella samples were
resistant to it? Here I wonder a bit more. The authors
state that patients with mucoid stool only were also
counted as "blood-dysentery" patients, despite the
name. How many of the patients who recovered with
ampicillin alone were in fact infected with Shigella? We
know that Shigella infections do recover spontaneously
in most patients. Would many of the patients have done
as well without ampicillin?
These questions demonstrate the importance of
careful documentation of both clinical and laboratory
characteristics of patients and organisms. It is not
possible to draw dependable conclusions from this study
regarding the effectiveness of ampicillin in cases of
Shigella dysentery which have been shown to be
resistant to ampicillin in vitro.
Information from the Dhaka and Matlab diarrhea
treatment centers, both of which provide in-patient care,
has also been analyzed. Hospital fatality rates for
patients admitted to the Dhaka unit with any species of
Shigella ranged from 13.9% in infants to 3.7% in
patients over 15, with an overall mortality of 9.1%. Data
from the Matlab field hospital (1983-84) indicated that
substantial mortality occurred following discharge. This
hospital admits all patients who come for care at least
overnight, thus admission does not imply severity or
complications. Nevertheless, 4.9% of patients admitted
with shigellosis died within 3 months following
admission, four-fifths of them after discharge from the
hospital. Because of its negative impact on nutritional
Bennish, M.L.; Wojtyniak, B.J. "MORTALITY DUE TO
SHIGELLOSIS: COMMUNITY AND HOSPITAL DATA."
Reviews of infectious Diseases, vol. 13, suppl. 4,
1991, S245-51.
Order #5040
Summary
Published data on the mortality associated with
shigellosis in developing countries are available from
Vol. VII, Na4
3
Technical Literature Update
malnutrition, shock). Is it appropriate to generalize that
Shigella dysentery, like measles, has long-lasting
effects on mortality (increased mortality during the 3
months after admission) from such a sample of cases?
Although hospital policy admits all cases that reach the
Matlab hospital, the patients who choose to seek care at
hospitals are already a highly self-selected and biased
group.
status, shigellosis may have a long-term effect on
mortality.
Three studies from Bangladesh have
demonstrated that dysentery has a greater effect on
growth than watery diarrhea, and that catch-up growth is
less likely to occur after recovery from the infection.
None of these types of data may represent the true
picture, for various reasons. The mortality rates from
epidemic disease are the most valid; the exact
quantitative contribution of endemic shigellosis to
mortality is less clear, although certainly substantial. It is
evident that prevention of deaths due to shigellosis will
require efforts directed at controlling both epidemic and
endemic shigellosis.
The authors of this review are not guilty of being
blind: they carefully describe the limitations of each of
the three types of data they present. Yet we the
readers, as "blind men," must be even more on guard to
avoid the unconscious tendency to conclude "Elephant
is like a rope," or "Dysentery occurs mostly in
malnourished children," after grabbing only one part of
the animal. All of the impressions of "elephant" are true,
but each is not the whole truth.
Editorial Comment
The impressions of Shigella dysentery one obtains
from these different types of data remind me of the story
of the group of blind men trying to understand
"elephant." One grabbed the tail and said, "Oh,
elephant is like a rope." Another felt the elephant's
side, and said, "No, elephant is like a wall"...you know
the story. This report shows nicely the "blindness" we
experience from different ways of looking at dysentery
and Shigella infections. Some investigations actively
seek cases in the community, and say, "Oh, shigella is
widely prevalent, everybody gets it, but only a small
proportion die." Others look only at cases which come
to health facilities, or more narrowly yet, at cases
admitted to hospitals, and say, "No, Shigella dysentery
affects only a small proportion of the population, but
case-fatality rates are high."
Henry, F.J. "THE EPIDEMIOLOGIC IMPORTANCE OF
DYSENTERY IN COMMUNITIES." Reviews of
Infectious Diseases, vol. 13, suppl. 4, 1991, S238-44.
Order H4&45
Summary
Various community studies in both urban and rural
Bangladesh have provided information on the
prevalence and incidence of dysentery as well as its
association with pathogens, nutritional status, persistent
diarrhea, and mortality. In one study, Shigella was
isolated from 50% of stools with blood, but was also
present in 19% of mucoid stools. In a comparative
longitudinal study in urban Zinzira and rural Mirzapur,
Shigella was recovered in 9.4% of urban dysenteric
(bloody) stools, and 28.3% of rural dysenteric stools.
The peak prevalence of watery diarrhea occurred at 6 to
11 months of age, while the peak prevalence of
dysentery occurred at 18 to 23 months. In another
study, children averaged one attack of bloody diarrhea
per 2-year period; these episodes lasted an average of
14.2 days. Several studies have shown that Shigella is
the dominant pathogen in cases of dysentery in
Bangladesh.
Further confounding these contradictory
impressions is the influence of varying treatment availa
bility and use. I cannot help but wonder, for example,
about the extent to which the availability and use of oral
rehydration in Matlab may reduce deaths from watery
dehydrating diarrhea and thereby make dysentery a
larger proportion of Matlab diarrheal deaths than it is
elsewhere in Bangladesh. In the same way, ORT may
reduce the proportion of diarrheal deaths overall among
all childhood deaths in Matlab. If one chose by chance
an elephant to investigate whose trunk had been cut off
in a logging accident, would one want to conclude
confidently that "elephant" was a short-nosed animal?
Looking at relative proportions of dysentery and
diarrheal deaths in Matlab may be like that.
Study results have also shown that cases of
dysentery are more likely to persist than cases of watery
or mucoid diarrhea, and that the prevalence of
dysentery, as well as Shigella isolation, is higher in
persistent diarrhea patients than in patients with acute
watery diarrhea. A Teknaf study showed dysentery
lasting a mean of 8.8 days, watery diarrhea 5.4 days. A
Matlab study found that 21% of Shigella illnesses lasted
10 to 19 days, and 16% continued more than 20 days.
The data from hospitalized cases are also
exaggerated in certain ways. Hospital admissions are
likely to be selected not only for severity of their
dysentery, but also for severity of underlying or
complicating factors (e.g., fever, pneumonia,
Technical Literature Update
4
Vol. VII, N24
In Teknaf, dysentery lasted significantly longer in
children with stunted growth. Similarly, height-for-age
was the most significant determinant of the duration of
dysentery. Several studies in Bangladesh have sug
gested that dysentery has a particularly strong negative
effect on linear growth. The reasons for this may be the
longer duration of dysenteric episodes than watery
diarrheal episodes, the greater likelihood of enteropathy
with protein loss in the stool (82% in dysentery versus
only 38% in watery diarrhea), or the fact that already
stunted children have longer dysenteric episodes.
Research in Bangladesh (ICDDR.B). Knowing the
special nature of the facilities there, one may wonder to
what extent quantitative results from Matlab are directly
transferrable to other sites. I have no doubt, however,
that the general conclusions are transferrable, and that
dysentery is a major challenge to CDD programs today,
even more so as dehydrating watery diarrhea is dealt
with by better rehydration treatment.
The review raises an important question facing those
who would investigate the epidemiology of diarrhea:
What word or words should be used to elicit the
presence of diarrhea?
Few reports describe in
adequate detail the word or words used in asking
families if their children have diarrhea or watery diarrhea
or just loose bowels or dysentery. Yet, in Bangladesh,
the responses to the word "diarrhea" may differ
substantially from the responses if the words amasha
(mucoid diarrhea) and rokto amasha (bloody/mucoid
diarrhea) are used. How many of the differences
reported from study to study are related to the
ignorance of the investigator regarding the different
words families use to describe their diarrheal illnesses?
Perhaps some of the early priority given to watery
diarrhea as a cause of morbidity and death may have
been due to insensitivity of interviewers to the fact that
the word "diarrhea" does not include dysentery in the
minds of a particular population. We seem to be seeing
an increase in the quantitative importance of dysentery.
Was it there all the time, but not detected, because the
words used by field interviewers to ask families about
diarrhea did not include bloody diarrhea?
An active surveillance study in Matlab found equal
mortality in children under 5 from acute dysentery and
acute watery diarrhea—5% of total mortality from each.
In another area of Bangladesh, however, child deaths
from dysentery were 1.8 times higher than deaths from
watery- diarrhea. Another report from Matlab showed
dysentery accounting for 20 to 50% of all
diarrhea-associated deaths; 56% of these
dysentery-associated deaths were due to acute bloody
diarrhea, and 44% to chronic dysentery. Comparing
various causes of diarrheal deaths, the Matlab
surveillance study found that acute watery diarrhea,
acute dysentery, post-measles dysentery, and
persistent diarrhea each accounted for 13% to 15% of
diarrhea-related deaths in children under 5. In contrast,
persistent diarrhea in association with malnutrition
caused 42% of diarrheal deaths.
Dysentery and Shigella infection can be prevented
by improved hygiene and water/sanitation. Installation
of latrines and tube wells reduced the prevalence of
bloody and mucoid diarrhea in one study area, but had
little effect on watery diarrhea. Other results showed
that handwashing with soap and water can also interrupt
transmission of Shigella infections.
The author's conclusion raises the question of the
appropriate balance between preventive and curative
services in CDD programs. Is the current emphasis on
case management likely to result in mortality reduction?
In countries such as Bangladesh, where the data
suggest that ORT alone will have only a limited effect on
mortality, would an educational stress on case
management of dysentery have a greater effect? Or are
the problems in the health system too great for the
system to effectively support good dysentery case
management? If families understand the principles of
dehydration and oral rehydration, they can prevent
death from dehydrating diarrhea at home. Practitioners
can similarly use available solutions if ORS packets are
not available. But for dysentery, antibiotics are needed
to prevent mortality in the severe cases. Can CDD
programs overcome the weaknesses in health system
logistics and drug management which make antibiotics
unavailable in many health facilities?
Since the largest single group of diarrheal deaths
occurs in malnourished children with persistent diarrhea,
most often associated with dysentery, CDD programs
which focus only on ORT are unlikely to have a major
impact on diarrheal mortality. Other important program
components should include improvement of nutrition,
weaning practices, personal and domestic hygiene, and
sanitation.
Editorial Comment
It is becoming ever more apparent that dysentery,
especially in combination with malnutrition, is at least an
equal, and in some localities a greater, cause of
diarrhea-related death than watery diarrhea. Many of the
data in this review are from Matlab, the field research
area of the International Centre for Diarrhoeal Disease
Vol. VII, N94
5
Technical Literature Update
though fly-control measures have not been demonstra
bly effective. This carefully done study shows that fly
control can effectively reduce both diarrhea (although
not statistically significantly) and Shigella infections. The
authors point out that outbreaks of diarrhea, and even of
Shigella, during the four periods of study, even when fly
control was good, suggested that flies were not the only
vectors or transmission mechanism. (The cases could
still have been caused by contaminated flies, however,
as fly control was never complete.) The clear-cut
differences in the development of antibodies to
Shigella, however, confirm the clinical epidemiological
data indicating the substantial role of flies in transmission
of diarrheal disease and of fly-control measures in
reducing this transmission.
Cohen, D.; Green, M.; Block, C.; et al. "REDUCTION
OF TRANSMISSION OF SHIGELLOSIS BY CONTROL OF
HOUSEFLIES (.MUSCA DOMESTICA')." The Lancet, vol.
337, no. 8748, April 27,1991, 993-97.
Order #4760
Summary
The effect of control of houseflies on the incidence of
diarrhea and shigellosis was evaluated in a prospective
crossover intervention study at two Israeli military field
camps several kilometers apart. On the intervention
bases, about 60 baited fly traps were placed around the
latrines, the field kitchen, and the mess tents, with bait
changed twice weekly. Spraying with pyrethrum as a sup
plementary measure was also carried out. Counts of flies
were made thrice daily by counting the number of flies on
a 2.5 meter segment of electric wire in two mess tents on
both control and intervention bases. Pooled samples of
ten trapped flies were ground up, emulsified, and
cultured for Shigella. Environmental samples from field
latrines were also cultured for Shigella. The intervention
was carried out for 11 weeks at one camp, with the other
serving as a control. After 11 weeks, the intervention was
stopped at the first camp, and started at the other, con
comitantly with the arrival of new recruits. This was done
for two consecutive summers (1988 and 1989).
Whether fly control could have a similar impact on
pediatric diarrhea and in villages of developing countries
is more uncertain. The military camp setting described in ■
this paper represented a situation in which most other
modes of shigella transmission were not present. Food
and water started out clean, and handwashing behavior
was ingrained. Hence, fly transmission from latrine to
food represented the major role of transmission.
Transmission in developing country settings, or where
children are involved, is likely to be much more complex.
Under these settings, fly control, while useful, may
influence a smaller proportion of all transmission. One
unique aspect of the military camp setting, for example,
was that food preparation was done in a single area, not
scattered over the area as it would be in an ordinary
village setting. This geographic concentration of food
allowed control measures, also concentrated, to be more
effective.
Results showed that fly counts were 64% lower on
the bases exposed to fly-control measures (p=0.024).
Clinic visits dropped by 42% (p=0.146) for diarrheal dis
eases (from 25.2% of soldiers to 14.6%) and by 85% for
shigellosis (p=0.015, from 4% of soldiers to 0.06%).
Rates of seroconversion also fell by 76% (p=0.024) for
antibodies to Shigella and by 57%(p=0.006) for antibod
ies to enterotoxigenic Escherichia coll. Cultures of 33
pooled fly samples revealed that 6% contained Shigella
sp. Cultures from 9% of the samples from latrines at both
intervention and non-intervention camps yielded S. sonnei or S. flexneri, indicating that flies in the area of the
latrines had access to human feces containing Shigella.
Should developing countries make fly control an
important part of their efforts to prevent dysentery, or
diarrhea? WHO/CDD recently reviewed this question 4
(Esrey WHO/CDD/91.37) and found that almost all the
published studies were inconclusive, that fly control was
difficult or impossible in many settings, and that the
evidence that changes in fly densities led to related
changes in diarrhea was not clear. Esrey concluded that
fly control was not a cost-effective measure for CDD
programs in developing countries which aim to control
diarrheal diseases in young children.
This study supports the contention that houseflies act
as mechanical vectors, transmitting Shigella and other
diarrheal infections. Analogous intervention studies
should be carried out in developing countries using a
combination of fly-control measures and improved
sanitation, particularly the VIP latrine, which is relatively
flyproof.
This study shows that fly control can be an effective
preventive measure in certain circumstances. Certainly
CDD programs should not discourage groups wishing to
control flies, but should keep in mind that other efforts to
prevent childhood diarrhea, such as handwashing and
exclusive breastfeeding, are likely to be more effective
for the same expenditure of effort, and certainly should
not be displaced by fly-control interventions.
Editorial Comment
I was delighted to see this article, as I had long been
convinced of the importance of houseflies as vectors, al
Technical Literature Update
6
Vol. VII, NB4
H^erne: (Dysentery
1 echnical Literature Update
on DIARRHEA
Technical Editor: Robert Northrup, M.D.
Managing Editor: Lisa Dipko
1992
Vol. VII, N55
Ronsmans, C.; Bennish, M.L.; Chakraboriy, J.; et al.
"CURRENT PRACTICES FOR TREATMENT OF
DYSENTERY IN RURAL BANGLADESH." Reviews of
Infectious Diseases, vol. 13, suppl. 4,1991, S351-56.
Order#4&43
Summary
The children with bloody diarrhea were more likely to
have received care from a medical practitioner. This like
lihood, however, was related to duration of illness rather
than to type of episode, as 71% of children with either
type of diarrhea who had been ill for more than 3 days
received some type
of medical care.
DYSENTERY
Allopathy was the
Dysentery that is
This issue continues last issue's discussion of
most common type of
primarily caused by in
outside care received
dysentery, particularly Shigella dysentery. The
fection with Shigella is
for both types of diar
responsible for the
articles presented here deal with the reality of
rhea. Patients with
majority of diarrheal
treatment in rural areas by often untrained practitioners,
bloody diarrhea were
deaths in Banglade
the changing nature of antibiotic therapy as resistance to
more likely to have
shi children.
This
cheaper antibiotics spreads, the belief structure
been treated by an al
study compared the
surrounding bathing and washing as key elements in the
lopath than those
type of care received
hygienic control of Shigella transmission, and the
with nonbloody diar
by children under 5
microbiology and pathology of Shigella. Underlying
rhea (62% vs. 43%).
with bloody diarrhea
many of these themes are the issues of practicality and
Most of these allo
to that received by
of integration of the science of dysentery into the reality
pathic practitioners
children under 5 with
of community concerns.
had little or no formal
nonbloody diarrhea,
all of whom had been
training; only 6%
ill less than 14 days.
were medical school
From May to November 1988, information on 960 pa
graduates.
Patients also received care from
tients (480 with dysentery and 480 with nonbloody diar
homeopaths (48% of children with bloody diarrhea and
rhea) was gathered by community health workers during
40% of children with nonbloody diarrhea), herbalists
bi-weekly home visits in the Matlab and Chandpur dis
(30% and 19%), and spiritualists (4% and 5%). No
tricts. This information included type and duration of
outside care was obtained in 32% and 42% of cases
the episode; name, type, and location of health care
respectively. In Matlab, community workers recom
providers used for the episode; and type of treatment
mended that all children with bloody diarrhea (240) be
received.
taken to the official treatment centers for treatment, but
only ten actually went.
~PRI TECH
Management Sciences for Meaitfi
Address Correspondence to: Information Center, PRITECH, 1925 North Lynn Street, Suite 400, Arlington, VA 22209-1707, USA
Phono: 703-516-2555. Telex: 377-B735-WATERVIEW
A.I.D.-supportad Contract 9 DPE-5969-Z-00-7064-00, Project # 936-5969
About a quarter (27%) of all patients with diarrhea in
Matlab received oral rehydration therapy, in all cases
ORS. In Chandpur only 15% received ORT, all but one
as homemade oral rehydration solution. Overall, more
children with nonbloody diarrhea received ORT than did
those with bloody diarrhea. In most cases, the amount of
solution was insufficient to prevent dehydration if the
purging rates had been high. Although the low level of
use is disappointing in view of the extensive CDD
program operating in Matlab for over 10 years, it may
indicate a perception that certain children are at lower risk.
In fact, none of the children with nonbloody diarrhea
became dehydrated.
nately, most of the drugs prescribed were not indicated,
and were given in ineffectively small quantities.
The authors comment that given the inevitably high
use of these local, easily accessible practitioners, CDD
programs must either make an effort to assist these prac
titioners to give more effective treatment, or give up hav
ing an impact on the case management of diarrhea,
either bloody or watery. Note how few families accepted
the recommendations of the community workers to go to
the official health facility for treatment. The authors sug
gest giving private practitioners a simple treatment algo
rithm. Such assistance must take into account, however,
the economic realities these practitioners face; they
must obtain their income from the sales of what they pre
scribe. Could a way be found, for example, to allow such
rural practitioners to make a satisfactory profit from selling
ORS packets, or a special diarrhea or dysentery food, or
other truly appropriate therapy? Without an approach
which responds to the practitioners' survival needs, it
may be difficult to convince them to adopt a different
treatment algorithm than the one they are now using.
Allopathic drugs were prescribed for 40% of the
children with bloody diarrhea and 22% of the nonbloody
diarrhea patients. Overall, 66% of children received a
prescription for one allopathic drug while 23% received
prescriptions for two, and 11% received prescriptions for
three or more drugs.
Furazolidone, trimethoprim
sulfamethoxazole, metronidazole, and ampicillin were
most frequently prescribed. The latter two drugs were
given more frequently to patients with bloody diarrhea
than to those with nonbloody diarrhea. Most prescrip
tions were for an inappropriately small quantity of drug
and most of the prescribed drugs were not indicated.
I was also struck by the authors' comment that
despite the low use of ORT in nonbloody diarrhea, and
the inadequate quantity of fluid given when it was used,
none of the patients became dehydrated. Most of our
CDD programs recommend giving ORT to every child
with diarrhea, from the first loose stool.
Mothers
appeared to decide that this advice was not sensible, or
was more work than was indicated by the child's
condition, and did not follow it. We know that a small
percentage of children will become dehydrated, even
though this report did not find them. What information
could be given to these mothers that would allow them
to more reliably identify those times, those episodes,
when dehydration is more likely to occur, or has already
occurred, so that they will be sure to use ORT then?
Editorial Comment
Rural Bangladesh appears to resemble India in its
care-seeking response to diarrhea and in the actions
taken by rural practitioners (see TLU, Volume V, Number
7). Rural families prefer to go to the non-physician
practitioners who are located close to their homes.
Despite the known high quality of care provided at the
ICDDR.B centers in Matlab, only a few families used them
for bloody diarrhea. As the duration of an episode
lengthened, however, families began to seek allopathic
care: the use of allopathic treatment went from only 45%
of children after 3 days of bloody diarrhea, to 80% after
14 days. About a quarter of all patients sought help from
more than one practitioner.
Technical Literature Update
The TLU is produced by the PRITECH Project under
Contract #DPE-5969-Z-00-7064-00, Project #936-5969
with the Office of Health. Bureau for Research and
Development, of the United States Agency for
International Development (A.I.D.). The summaries and
editorial comments represent the opinions of the TLU
editorial staff and are not meant to represent A.I.D.
policies or opinions. Inclusion of an article in the TLU
does not denote endorsement or validation of the article
cited, but rather indicates that it is worthy of attention and
further critical appraisal.
The report unfortunately does not indicate what per
cent of practitioners prescribed both a drug and ORS for
bloody diarrhea or nonbloody diarrhea. We do know that
less than 20% of bloody diarrhea patients received ORT,
while 40% received drugs. In comparison, nonbloody
diarrhea patients received more ORT and fewer drugs.
Given the fact that almost all rural practitioners make
their money from selling drugs, not from charging for
consultation, I actually was surprised that only 34% of the
drug-receiving patients had received two or more
drugs—two-thirds received only a single drug. Unfortu
Technical Literature Update
Copies of articles featured in the TLU are available
through the PRITECH Information Center, 1925 N. Lynn
St., Suite 400, Arlington, VA, 22209. Please use the
order number listed at the end of each title when ordering
articles. Your comments are welcome.
2
Vol. VII, NB5
review do not answer this critical question directly, but
reduction in morbidity with antibiotic use is so obvious
that this alone justifies treatment. Indeed the use of a
placebo cannot be justified currently in experimental
studies. Therefore, it seems very likely that antibiotic
use must lead to a reduction in mortality, even if the
studies themselves do not prove it. Yet in the real world
of community practitioners described in the previous
article (Ronsmans et al), there are many factors which
interfere with theoretical efficacy becoming real efficacy,
including availability of the right antibiotic in the rural
periphery, its cost as a barrier to use, the duration of the
prescribed course of drugs, the duration of the course
purchased by the parents and then actually given to and
consumed by the child, etc, etc. So it is not clear at all
whether making correct advice regarding sensitivity and
the correct antibiotic available to a particular population
will lead to a reduction in mortality from shigellosis.
Putting more emphasis on dehydration in messages,
stressing the observation and estimation of fluid losses,
conveying the signs of dehydration so mothers won’t
miss it, or will pick it up early (e g., irritability or
restlessness as an early sign of "some" dehydration) all
have been tried elsewhere. Which set of messages
would this population be best able to receive? Studies
trying such approaches certainly qualify as essential
national (and international) health research.
Salam, M.A.; Bennish, M.L. "ANTIMICROBIAL
THERAPY FOR SHIGELLOSIS." Reviews of Infectious
Diseases, vol. 13, suppl. 4, 1991, 5332-41.
Order#5031
Summary
In addition to rehydration therapy and nutritional
support, early initiation of effective antimicrobial therapy
is an important part of the strategy for reducing mortality
related to shigellosis. Clinical trials have shown that use
of antimicrobials shortens the duration of symptoms and
the excretion of pathogens. For a drug to be useful in
treating shigellosis in children in developing countries, it
should be inexpensive, safe for use in children, available
in an oral formulation, effective in vitro against the majori
ty of Shigella isolates in the area where the drug will be
used, and proven efficacious in controlled clinical trials.
It must be noted that the article reviews studies on
shigellosis, not dysentery. We know that Shigella
causes 60% or so of bloody diarrheas in developing
countries, thus it makes sense to manage dysentery as
if it were Shigella dysentery, since it is impossible in
places like rural Bangladesh to identify the specific
causative agent. This article speaks of "proven or
suspected shigellosis." The results of a particular
antibiotic in treating dysentery will vary, however, if the
agents causing the other 40% of dysenteries vary in
their sensitivity to that antibiotic.
Tetracycline and the sulfonamides alone are no
longer useful in treating shigellosis because the majority
of Shigella isolates are now resistant to these agents.
For the last 15 years, ampicillin and trimethoprim
sulfamethoxazole have been the drugs of choice to treat
this disease. They are inexpensive and widely available
in developing countries. However, in the last 5 years,
strains of S. flexneri, S. dysenteriae type 1, and S.
sonnei that are resistant to both drugs have been
identified in Asia, Africa, and North America.
An effective antibiotic for shigellosis is not always
easy to predict. Clearly, it should be one to which the
bacteria is sensitive in vitro. However, not all such
"sensitive" antibiotics are clinically effective, and the
clinical effectiveness can only be determined through
clinical trials.
Editorial Comment
An important characteristic of real world efficacy may
be the ability of an antibiotic to be effective in a short
course of therapy, since the majority of practitioners
prescribe such short courses. Cost is also critical,
especially for newer agents that are very expensive. We
face a big problem in the future with resistance now
widespread to the current, inexpensive, oral agents
such as ampicillin and trimethoprim-sulfamethoxazole,
and with manufacturers maintaining high prices for the
newer agents. Parenteral agents might be considered,
but they have no advantage and are not desirable in
developing countries because of the inconvenience,
cost and, more recently, risk of AIDS through injections
with contaminated needles.
Does treatment with an appropriate antibiotic lead to a
reduction in mortality? The studies used in this excellent
A critical factor in achieving reduction of mortality
through treatment is the integration of diarrhea
Nalidixic acid has been the most common alternative
for treatment of resistant cases of shigellosis, but
resistance to this drug is also increasing. Two other
alternative treatment options are the newer quinolines
and amdinocillin. Unfortunately, at this time, all three of
these alternatives have drawbacks (cost or questions
about safety in children). A possible future option that
should be explored is the use of second- and
third-generation cephalosporins.
Vol. VII, Na5
3
Technical Literature Update
management with the identification and management of
malnutrition. This is especially important in dysentery
management, because of the profound impact of
dysentery on growth. Building steps to detect the
stunted or wasted child into the approach used will be
critical in order to ensure closer attention, recommend a
return visit, and spend enough time convincing the
mother that she must feed the child aggressively and
talking with her about how to overcome anorexia. In
situations where it is procedurally feasible, doing
cultures and sensitivities on severely malnourished
children with dysentery would help to ensure that the
antibiotic chosen was likely to be effective.
In these two study communities, after defecation,
water from a small pot is used to wash the anal region
with the left hand. The hands are then cleaned using
ash, mud, or water. The left hand does not touch the
right one during this process. Cleaning a child after
defecation is generally done by the mother. Although
most people regard feces as pollutants, they do not
associate fecal contamination with the transmission of
agents that cause diarrhea. Muslims are also supposed
to wash the right hand and rinse the plate before meals,
keeping the left and right hands separated during meals
to maintain purity. However, people tend to use both
hands out of necessity when preparing food and
collecting drinking water, and children often do not
make the appropriate distinction between their left and
right hands.
The authors note that antibiotic treatment of watery
diarrhea caused by Shigella has not proven to be
effective. Using standard treatment recommendations,
patients with acute watery diarrhea would not be
considered for antibiotics initially, so this exception to
antibiotic efficacy in shigellosis would not become a
problem under field conditions.
Muslims perform ritual bathing before prayer five
times a day, as well as at other times. Both Muslims and
Hindus also take a daily bath if possible. This is
considered a cooling and cleansing act. Most people
who use soap buy the type produced for washing
clothes since it is cheaper and lasts longer. Body soap
is associated with luxury and beauty, a concept
reinforced by advertising. Because of this perception,
soap is rarely used for handwashing. In addition,
because of their cooling properties, both soap and
water are perceived as having potentially deleterious
effects, especially for children.
Zeitlyn, S.; Islam, F. "THE USE OF SOAP AND WATER
IN TWO BANGLADESHI COMMUNITIES:
IMPLICATIONS FOR THE TRANSMISSION OF
DIARRHEA." Review of Infectious Diseases, vol. 13,
suppl. 4, 1991, S259-64.
Order#4815
Summary
To change handwashing habits so that effective
cleaning occurs after defecation and before meals,
perceptions and practices must be altered. Possible
approaches include changing soap advertising so that it
stresses the use of soap in handwashing and its
benefits for children, and educating people about the
relationship between fecal contamination and diarrhea.
The pattern of fecal-oral transmission of microorgan
isms plays an important role in the transmission of Shi
gella. Regular handwashing with soap and water has
been shown to reduce such transmission. However,
before handwashing can be effectively promoted on a
wide scale, it is necessary to understand the percep
tions of cleanliness and the roles of soap and hand
washing at the community level. This study examined
these perceptions among 100 mothers of children un
der 5 in a rural village and an urban slum in Bangladesh.
Editorial Comment
This article is one more in the battery of evidence
showing how valuable, even essential, anthropology
and the information gathered by anthropologists is in
designing communication messages that will work. If a
Western-thinking person develops an advertisement,
poster, or community talk based on the idea that people
see feces as a source or cause of diarrhea, and are
washing to prevent diarrhea, they will probably develop
materials which won't work well because of the very
different assumptions and beliefs which surround
washing, bathing, and soap in other cultures. Only by
directly addressing such beliefs in the messages will
one be able to convince the listener that the ad
understands and proceeds from his or her world view,
and therefore must be taken seriously.
Both Bangladeshi Hindus and Muslims view water as
an important agent of purification. Although water's
religious significance differs between these groups,
both regard the simple act of pouring water over the
body or immersing the body in water as one of
purification. Water is also attributed with a capacity for
cooling, important in the system of ideas which classifies
many substances according to inherent "hot" or "cold"
properties. According to this belief system, a healthy
body must maintain a balance between heat and cold,
and illnesses may be caused by an extreme.
Technical Literature Update
4
Vol. VII, N®5
£
Anthropologists can also help to gather the subtle
details of current behaviors, needed in order to identify
why global or general messages may not work. In this
article, for example, we learn that people from this
culture generally do not rub their hands together when
they wash them, for fear that the left, or fecal, hand may
contaminate the right one. It will take a special message
to address this detail, and encourage people to rub
hands together so as to actually get better cleansing of
pollution from the feces.
Editorial Comment
How important is it for the practitioner to know what
organism is causing the diarrhea, or the dysentery? The
protocols for treating diarrhea are based on a progres
sive increase in detailed knowledge of the nature of the
illness. We start with the simple presence of diarrhea,
note that diarrhea by definition means fluid loss, and
recommend use of ORT in all cases of diarrhea. We
increase in complexity from there: presence of blood
with the diarrhea means dysentery. Dysentery has a
different time course, it won't respond to ORT alone, the
patient may have more severe nutritional problems, etc.
Knowing that it is dysentery will change both our
treatment and our expectations, or prognosis. The
problem is that various organisms may cause dysentery,
and there is no single medicine, like ORT, which will act
against all of them. So we seek more information.
Put more broadly yet, this article should reinforce our
conviction that communications messages and
campaigns cannot be designed by men from the
Ministry sitting around a table in the capital of the
country.
Echeverria, P.; Sethabutr, O.; Pitarangsi, C.
MICROBIOLOGY AND DIAGNOSIS OF INFECTIONS
WITH SHIGELLA AND ENTEROINVASIVE
ESCHERICHIA COLL" Reviews of Infectious
Diseases, vol. 13, suppl. 4, 1991, S220-25.
Order#5042
In developing country settings, knowing that the
disease is dysentery, i.e., that there is blood in the stool,
is a fairly good predictor that the cause is Shigella (50%
to 60% of the time), and therefore treatment with drugs
that usually work against Shigella is indicated. That
doesn't work in a different epidemiologic and
environmental setting, such as a developed country,
because Shigella is not as prominent as the cause of
dysentery. It also won't "work;" that is, won't lead to
effective treatment, if the Shigella strains prevalent in an
area are not sensitive to the usual antibiotics.
Summary
"The etiology of dysentery in Thailand and the
existing methods of diagnosing infections with Shigella
and enteroinvasive Escherichia coli (EIEC) are reviewed.
The four Shigella species (S. dysenteriae, S. flexneri, S.
boydii, and S. sonnei) are classically identified by culture
of fecal specimens on selective media and testing of
isolates for agglutination in species-specific antisera.
DNA probes have been used to identify both
lactose-fermenting and non-lactose-fermenting EIEC as
well as Shigella isolates that do not agglutinate in
antisera. These DNA probes are not necessary for the
identification of Shigella if a competent bacteriology
laboratory with shigella antisera is available. In Thailand
Shigella and EIEC are isolated more often from children
> 2 years of age than from younger children. The clinical
illness associated with EIEC infections is similar to
shigellosis. Fewer children with EIEC infections than
with shigellosis, however, have occult blood in stool
(36% vs. 82%) and more than 10 fecal leukocytes per
high-power field (36% vs. 67%). Standard bacteriologic
methods and testing of E. coli isolates for hybridization
with the shigella/EIEC probe are currently the most
sensitive means of diagnosing infections caused by
these enteric pathogens. A more rapid method of identi
fying Shigella and EIEC infections in a situation where a
bacteriology laboratory is not available will probably
involve immunologic assays." [Published Abstract]
Vol. VII, N25
The practitioner takes a practical way out: the
therapeutic test. Treat the patient with an approach that
can be expected to work, use a combination of
treatments to cover various less likely possibilities, and
see what happens. If the patient gets better, then the
"diagnosis” (in fact, the treatment used, whatever the
real diagnosis) was correct. If not, then try something
else. This approach is practical, but patients and
practitioners still want to know the cause. At the heart of
the process is a fundamental human need—to name the
devil. In general we humans feel much better if we can
name the enemy we are struggling with, even If so
naming the devil does not affect our
response.
This article explores the complexities of naming the
devils that cause diarrhea, particularly dysentery.
Certainly there are other benefits from knowing the
organism, the species, even the strain, of the organisms
which are causing an individual case, or are the
predominant endemic strain, or are causing an
epidemic. For research purposes, it may be the central
focus of attention. But for therapeutic purposes it is
possible to initiate sensible treatment without knowing
5
Technical Literature Update
epithelial cells leading to ulceration; and exudates of in
flammatory cells into the lumen of the rectum. Electron mi
croscopy showed actual invasion of the epithelium by
Shigella, migration of bacteria through cell walls, and dam
age of organelles within cells, such as destruction of mitochondriae in crypt cells. In the crypts, there was depletion
of mucus and increased mitotic activity, presumably to re
place epithelial cells being lost at a more rapid rate.
the specific causative agent. It must be kept in mind also
that identifying an etiologic organism by ELISA or DNA
probe still will not definitively predict whether it will
respond to a particular antibiotic. Because of this, the
therapeutic trial remains an important part of the practical
response to dysentery' in the individual patient.
The article points out that use of a microscope to
detect fecal leukocytes, combined with the knowledge
that there is blood in the stool, can be used to predict
Shigella as the cause of illness. Microscopes are
important in developing country health facilities for a
variety of purposes, and have a low recurrent cost. This
gives microscopes advantages over facilities and
supplies for bacteriologic culture, which require
refrigeration, become dried out or contaminated after a
period of time, and require much more training to use
effectively. Only bacteriologic facilities can run the
antibiotic sensitivity tests which will predict the
effectiveness of various antibiotics against a particular
patient's organism however. Work is going on to develop
simplified methods of doing ELISA type tests and other
rapid procedures in field settings. These development
efforts are of equal or greater importance in comparison
to the more basic work, such as that reviewed in this
article, to develop new approaches to identification and
characterization of etiologic organisms.
in deeper layers (the lamina propria), examination
revealed congestion, edema, and scattered hemor
rhages, with an overall increase in cellularity consisting of
both polymorphonuclear leukocytes and plasma cells.
There also were changes to the blood vessels suggestive
of damage by Gram-negative bacterial endotoxin.
In patients with symptoms for greater than 1 week, the
investigators found more eosinophils, degranulation of
eosinophils and mast cells, an increase in plasma cell
activity, and activated lymphocytes, suggesting that
cell-mediated cytolysis may contribute to persistence of
symptoms of shigellosis. The only difference between
patients from whom the Shiga bacillus was isolated and
patients from whom other Shigella species were isolated
was a higher prevalence of epithelial cell detachment and
exudate into the lumen of the rectum.
Editorial Comment
1 point out these various considerations to emphasize
that the purpose of identifying organisms must be clear.
Is it to determine treatment of an individual patient? If so,
simple clinical information plus, perhaps, the examination
of a stool for leukocytes, combined with previous
knowledge of antibiotic resistance patterns in the locality,
may be sufficient to prescribe treatment which will be
effective most of the time. Going beyond this in accuracy
of identification may require much more cost than the
benefit in treatment effectiveness would justify.
These findings are certainly consistent with the large
numbers of white blood cells, along with red blood cells, in
the stools of patients with Shigella dysentery. For me the
most interesting finding was the evidence by electron mi
croscopy of activated lymphocytes causing destruction to
neighboring cells, presumably activated by immune mech
anisms and possibly related to prior sensitization from pre
vious infections. Is it possible that the frequent colon
ization of the intestine in contaminated tropical environ-(
ments may augment or extend the symptoms of dysentery
when it occurs, through this immune mechanism? Are
cells being destroyed as "innocent bystanders" in a pro
cess similar to that seen in some autoimmune diseases?
Mafhan, M.M.; Mathan, V.l. "MORPHOLOGY OF
RECTAL MUCOSA OF PATIENTS WITH SHIGELLOSIS."
Reviews of Infectious Diseases, vol. 13, suppl. 4,
1991,5314-18.
Order #5034
The evidence of active cell reproduction and replace
ment, with immature cells migrating up from the crypts,
suggests how malnutrition may prolong the course of ill
ness by slowing cell reproduction, thereby delaying heal
ing and return to normal functioning of the epithelial cells
(and therefore, digestion and absorption). The toxic ef
fects of the bacteria on cells described in this report places
a major challenge on the crypts as sources of new epithe
lial cells which, without an adequate supply of nutrients as
building blocks, they will meet only poorly. In light of this,
the prolonged impact of dysentery on mortality, even after
recovery from acute symptoms, is understandable.
Summary
Biopsy specimens of rectal mucosa from 46 consecu
tive patients with dysentery, from whom Shigella was iso
lated, were examined. Thirteen of the patients had
Shigella dysenteriae type 1 (the Shiga bacillus). Micro
scopic examination of the 46 specimens showed inflam
mation of the epithelium, with infiltration by polymorpho
nuclear leukocytes; damage to and detachment of the
Technical Literature Update
6
Vol. VII, N95
‘Tftcmc: Jfcahft Communications
Technical Literature Update
on DIARRHEA
Guest Editor: William A. Smith, Ed.D.
Technical Editor: Robert Northrup, M.D.
Managing Editor: Eileen Hanlon
1992
Vol. VII, N!6
Fox, K.F.A. “SOCIAL MARKETING OF ORAL
REHYDRATION THERAPY AND CONTRACEPTIVES IN
EGYPT.” Studies in Family Planning, vol. 19, no. 2,
March/April 1988, 95-108.
Order #2541
family members could be caregivers of sick children.
Health workers, however, were targeted separately to
receive diarrhea case-management training.
-'Social marketing is a set of strategies — product,
price, availability, and
promotion — to con
Summary
Guest Editor William A. Smith, Ed.D.
vince the public to
/in 1983, the Nation
adopt a product or be
William A. Smith is Executive Vice President of the
havior. /In the case of
al Control of Diarrheal
Academy for Educational Development, a nonprofit
the N^DD’s campaign,
Diseases (NCDD) pro
organization with extensive experience in development
the product was a local
ject, part of the Egyp
communication and social marketing. Dr. Smith received
ly produced brand of
tian Ministry of Health,
his Ed.D from the University of Massachusetts, where
ORS, eventually made
began a social market
he focused on rural consciousness-raising. During his
in only one size. The
ing campaign for ORS.
subsequent career, he moved from consciousness-raising
affordable price was set
First, the NCDD hired
into social advertising and finally into social marketing
by the government, but
local consulting firm to
and development communications. He has recently
free ORS was available
conduct marketing re
written on behavior change and sexually transmitted
through health facilities.
search. Data were col
diseases, and on social marketing and narcotics
ORS was made widely
lected on the public's
education, adding to his earlier work on oral
available commercially,
exposure to the media
rehydration therapy and immunization programs.
through wholesalers
and on mothers’ atti
and retailers, as well as
tudes and practices
through health serv
about diarrhea. The
ices. Finally, a media campaign showing the symptoms
firm also pretested logos, ORS packaging, media mes
of diarrheal dehydration and how to mix ORS was devel
sages, and promotional materials. After initial analysis,
oped and disseminated through radio, television, and
the NCDD decided not to segment the public into differ
print materials.
ent audiences: all children could receive ORS, and all
PRI TECH
Management Sciences for MeaCth
Address Correspondence to: Information Center, PRITECH, 1925 North Lynn Street, Suite 400, Arlington, VA 22209-1707, USA
Phone:703-516-2555. Telex: 377-8735-WATERVIEW
A.I.D.-supported Contract * DPE-5969-Z-00-7064-00, Project # 936-5969
ISSN 1063-7486
overlooked aspect of successful behavior change — it
matters what behavior you are trying to change. The
health education field badly needs a classification
system of behaviors and the corresponding optimal
intervention strategies. Such a system would help
program managers not only select better interventions,
but establish more realistic goals for their programs,
based on our best understanding of behavioral change.
The campaign was enormously successful. During
one year, the percentage of mothers who could
(—. recognize dehydration rose from 32% to 90%; and the
\/ f
percentage of mothers who had ever used ORS rose
'
from 1% to 50%. /
-
Meanwhile, the Family of the Future, a family
planning nonprofit organization, began their social
marketing campaign for contraception. This campaign
was not as successful as the ORS campaign.
Contraception is more difficult to market, as it involves
advertising several products at once, without being able
to explain visually their use, as well as involving culturally
sensitive issues. While ORS was quickly accepted and
adopted, rates of contraceptive use have been slower
to rise.
Briger, W. “MASS MEDIA AND HEALTH
COMMUNICATION IN RURAL NIGERIA.” Health
Policy and Planning, vol.5, no. 1, 1990, 77-81.
Order #3695
Summary
This study examined the media habits of adult men
and women living in two villages in Oyo state, Nigeria.
Survey questions focused on the availability and use of
four mass-media channels: radio, television,
newspapers, and magazines. Open-ended questions
sought information on the recall of health messages, the
types of programs preferred, and sources of information
on AIDs, yellow fever, ORT, and immunizations.
The need for ORS and family planning will not
diminish in the near future. Two other factors point to
the sustainability of social marketing in Egypt. First,
Egyptian nationals are now well trained in social
marketing, and their skills may now be used for other
products. This progress does not mean that ORS
marketing will decrease, as the use of social marketing
for the promotion of other related issues can be used to
improve diarrheal disease control.
For example,
campaigns aimed toward physicians about inappropriate
drug use during diarrhea, and messages aimed at the
public about infant feeding and hygiene practices can
use social marketing strategies, while continuing to
promote messages from the earlier ORS campaign.
Second, while U.S. aid will not always be available, and
Egyptian public funds are limited, social marketing can
become seif-funding.
The commercial firm that
produces ORS has already begun to funnel some of its
profits back into the NCDD.
One town, Eruwa, had a population of 45,000 and
had electricity, piped water, a hospital and health
centers, a factory, and access to national newspapers
and magazines. The second town, Idere, was an
agricultural town of 10,000 residents and did not have
access to electricity or piped water. Both towns were in
range of the national and state radio and television
stations.
Technical Literature Update
Editorial Comment
The TLU is produced by the PRITECH Project under
Contract #DPE-5969-Z-00-7064-00, Project #936-5969
with the Office of Health, Bureau for Research and
Development, of the United States Agency for
International Development (A.I.D.). The summaries and
editorial comments represent the opinions of the TLU
editorial staff and are not meant to represent A.I.D.
policies or opinions. Inclusion of an article in the TLU
does not denote endorsement or validation of the article
cited, but rather indicates that it is worthy of attention and
further critical appraisal.
This is one of the landmark ORS studies of the world.
The Egyptian experience is an almost textbook field
application of social marketing to ORS. While many
lessons emerged from this program, perhaps one of the
most important is the interaction of various programming
decisions, such as the type of ORS to promote, where
to make it available, and what to say about it. Each
question was answered through field research on
mothers and answers were integrated into a single
comprehensive program. This project deserves our
continued attention and should be a focus of regular
follow-up.
Copies of articles featured in the TLU are available
through the PRITECH Information Center, 1925 N. Lynn
St., Suite 400, Arlington, VA, 22209. Please use the
order number listed at the end of each title when ordering
articles. Your comments are welcome.
The comparison of ORS with family planning
messages in this paper highlights an important but often
Technical Literature Update
2
Vol. VII, N96
Editorial Comment
14-year period.
Several top university research
contractors provided the objective evaluation data cited
in this publication.
It is impossible for this editor to be objective about
this particular document, given my many years of
involvement with the project. It does appear to be one
of the few comprehensive attempts, over time and
across many cultures, to assess the role of modern
communication in the promotion of ORS. Given that fact
alone, it represents an almost unique resource to
program managers trying to understand how and when
to use communication strategies for child survival. The
program was also blessed with a unique partnership with
the U.S. Agency for International Development (A.I.D.),
which provided (competitively awarded) funding over a
Yet even this comprehensive program leaves many
important questions unanswered.
Several of the
studies were truncated due to political or natural
disasters. Other studies suffered changes in design
that interfered with the clarity of the research results. But
this document presents in a readable and persuasive
manner the major lessons emerging from an important,
and probably landmark, program that continues today
under A.I.D. guidance.
PRITECH announces the publication of two
new reports:
> The Ciclope Innovations in Rural
Communication: Reaching the
Unreachable Villages in Mexico —
describes a health education
intervention in Mexican rural markets.
Order #6011.
■ Integrating Diarrhea Control Training
into Nursing School Curricula in the
Sahel — outlines the steps taken to
develop nursing-school modules. Order
#6012.
Vol. VII, N®6
7
Technical Literature Update
TLU Survey Results
In April 1992, we conducted a survey to determine how readers use the TLU
and with whom they share it. Eight percent (or 822) of those contacted by mail
returned the survey. Many readers asked for more information about health
education. We hope that this issue is useful to you in your work. Here are
other results from the survey:
■ 46% of respondents reported that reading the TLU has changed the way
they teach by keeping them updated with the latest scientific
information. Many reported using the TLU as a reference for
preparation of lectures and as reading material for students.
■ 43% of respondents stated that the TLU has changed the way they manage
diarrheal disease cases. Respondents reported that their use of drugs and
IV therapy had decreased, while their commitment to ORS and
promotion of feeding during diarrhea had increased. Some readers
indicated that the TLU had helped them prepare for the cholera epidemic
in South America.
■ 43% of respondents stated that the TLU is their primary source of
information about diarrheal diseases. In addition, 84% of respondents
share their copy of the TLU with others, 32% with more than five
people. Because of your interest, the TLU mailing list has grown to more
than 12,500 readers around the world.
Printed on recycled paper
Technical Literature Update
8
Vol. VII, Na6
Technical Literature Update
on DIARRHEA
Technical Editor: Robert Northrup, M.D.
Managing Editor: Karen White, M.L.S.
1993
Vol. VIII, N22
Oladepo, O.; Oyejide, C.O.; and Ok®, E.A.
“TRAINING FIELD WORKERS TO OBSERVE
HYGIENE-RELATED BEHAVIOR.” World Health
Forum, vol. 12, 1991,472-475.
Order#5825
The process by which investigators selected and
trained a group of field workers to observe accurately
behaviors related to the prevention of diarrhea is
described. The trainees selected were women, thereby
meeting local cultural requirements, and all spoke the
local language. Some were experienced in field studies
and from Ibadan, others were from the villages. Training
took place in three phases:
examined each variable until there was agreement on
an operational definition. The questionnaires were tried
in homes, with investigators and field supervisor being
present, and comparing notes afterwards. Again,
trainees worked in pairs with separate recording until
they achieved 95% agreement. The supervisor spent
two extra days with trainees whose performance was
comparatively poorer.
The subsequent performance and data recording of
the trainees in the actual study were regularly monitored
and found to be consistent with their training. Mothers
rated the trainees' communication as satisfactory.
Editorial Comment
(1) Lectures and discussions on behavior, expected
roles of observers working in a village setting, and
diarrhea, particularly the different terms used for diar
rhea and its symptoms. Graduated practice in observing
was given, from general observing to eventually
observing hygiene-related behavior in an outpatient
department without asking structured questions.
(2) Role-playing with trainees acting as family and as
the visitor observer, followed by field training in a poor
urban community, with trainees working in pairs for two
weeks observing the behavior of women and children in
homes. Observations of each were compared until they
achieved 90% agreement.
(3) Data collection using draft structured question
naires involving both questions and observations
related to food preparation, feeding episodes,
defecation episodes, and child behavior. Discussions
It has become clear to all those working in CDD that
detailed information on actual behaviors potentially
related to diarrhea incidence is needed if effective
messages regarding prevention of diarrhea are to be
designed and delivered,zThe 1987 study of Clemens
and Stanton1 showed the necessity of targeting
communication efforts to the specific behaviors
responsible for diarrhea in a particular setting. This
exquisite report provides an ideal description of the
kind of detailed training needed by field workers who
1 J. Clemens and B. Stanton, "An Educational Intervention for Altering
Water-Sanitation Behaviors to Reduce Childhood Diarrhea in Urban
Bangladesh: I. Applications of the Case-control Method for Development of
an Intervention," American Journal of Epidemiology, vol. 125, no. 2,1987,
284-291; B. Stanton and J. Clemens, "An Educational Intervention for
Altering Water-Sanitation Behaviors to Reduce Childhood Diarrhea in
Urban Bangladesh: II. A Randomized Trial to Assess the Impact of the
Intervention on Hygienic Behaviors and Rates of Diarrhea," American
Journal of Epidemiology, vol. 125, no. 2.1987, pp. 292-300.
P RITE CH—
Management Sciences for O^ealtfi
Address Correspondence to: Information Center, PRITECH, 1925 North Lynn Street, Suite 400, Arlington, VA 22209-1707, USA
Phone:703-510-2555 Fax: 703-525-5070
Ad.D.-supported Contract « DPE-5969-Z-00-7064-00, ProjectW 936-5969
ISSN 1063-7466
—
are going to be collecting this kind of data. While it
seems long and complex, program managers must keep
in mind that the effectiveness of their communication
campaigns depends on the quality and appropriateness
of the messages which it delivers. These will be only as
good as the data on which they are based, which in turn
depends on the quality of the observers collecting it.
the diseases they cause (dysentery and cholera) should
be treated with antibiotics. It is these reasons that justify,
at least partly, the use of a procedure to confirm the
microbiologic etiology of a clinical diagnosis. Routine
management of individual cases in poorly equipped
facilities can proceed well on the basis of “diagnosisby-epidemiology” alone: there is no need to confirm the
microbiologic cause.
Islam, D.; Tzipori, S.; Islam, M.; and Lindberg, A.A.
“RAPID ISOLATION AND DETECTION OF SHIGELLA IN
FAECES BY O-ANTIGEN SPECIFIC MONOCLONAL
ANTIBODY COATED IMMUNOMAGNET1C BEADS."
In: Adram, D.S.; Hasan, H.; Agboatwalla, M.;
Jalaluddin; and Tahir, Ali S, sds. Reflections on
Diarrhoeal Diseases and Nutrition of Children:
Proceedings of the Sixth Asian Conference on
Diarrhoeal Diseases, December 11-13, 1992,46-53.
Public health workers seeking to manage an epidemic
of diarrhea in a community, however, often need to
identify its microbiologic cause, and could benefit from
use of procedures of this type. In the past, cholera could
be identified rapidly using a dark-field microscope on a
stool specimen, often following brief incubation in
enrichment broth to increase the numbers of bacteria.
Today, procedures of the types reported here may be
more feasible. Once the reagents are prepared, the
ELISA procedure reported here is very easy to perform,
and may be more feasible than obtaining an expensive
microscope. We should reiterate, however, that the care
of routine diarrhea patients does not require a
microbiologic diagnosis, and therefore would not require
the use of tests of the sort reported here.
A method for detecting the presence of Shigella in
diarrheal stool using immunomagnetic particles coated
with monoclonal antibodies (IMS) was compared with
latex agglutination (LA), indirect immunofluorescence
(IFS), and routine microbiological culture. The IMSA
assay detected 100% of the samples which were
positive in culture. It showed positive results later in the
clinical course of diarrhea in some samples which were
negative on culture because of treatment. LA showed
false negatives in 28% of culture-positive samples. IFS
was 95% sensitive for detection of Shigella flexneri, and
100% sensitive for Shigella dysenteriae type 1.
Excler, J.L.; Standaert, B.; Ngendandumwe, E.; Piot,
P. “MALNUTRITION ET INFECTION A HIV CHEZ
L'ENFANT EN MILIEU HOSPITALIER AU BURUNDI.”
Pediatrie, vol. 42,1987, 715-8.
Order If 1716
Summary
Ramamurthy, T.; Bhattacharya, S.K.; Uesaka, Y.; et
al. “EVALUATION OF THE BEAD ENZYME-LINKED
IMMUNOSORBENT ASSAY FOR DETECTION OF
CHOLERA TOXIN DIRECTLY FROM STOOL
SPECIMENS.” Journal of Clinical Microbiology, vol.
30, no. 7,1992,1783-1786.
This study followed 40 children, aged 2 to 29 months,
hospitalized for malnutrition in Burundi to determine the
role of HIV in childhood malnutrition, and to describe the
clinical differences between malnourished HIV positive
Technical Literature Update
A bead ELISA was evaluated for direct detection of
cholera toxin (CT) from stool specimens of patients with
acute secretory diarrhea. Culture detected Vibrio
cholerae in 59 of 75 stool specimens. The bead ELISA
was positive in 50 of the 59 (85%) culture-positive
specimens, and an additional 3 specimens negative for
culture.
The TLU is produced by the PRITECH Project under
Contract #DPE-5969-Z-00-7064-00, Project #936-5969
with the Office of Health, Bureau for Research and
Development, of the United States Agency for
International Development (A.I.D.). The summaries and
editorial comments represent the opinions of the TLU
editorial staff and are not meant to represent A.I.D.
policies or opinions. Inclusion of an article in the TLU
does not denote endorsement or validation of the article
cited, but rather indicates that it is worthy of attention and
further critical appraisal.
Editorial Comment
These two papers describe promising techniques to
detect important pathogens in diarrhea patients rapidly
and with a high degree of sensitivity—100% in the
Shigella test, 85% in the cholera procedure. Both these
agents are of importance in epidemics of diarrhea, and
Technical Literature Update
Copies of articles featured in the TLU are available
through the PRITECH Information Center, 1925 N. Lynn
St., Suite 400, Arlington, VA, 22209. Please use the
order number listed at the end of each title when ordering
articles. Your comments are welcome.
2
Vol. VIII, N22
infections. Indeed the authors suggest that in this envi
ronment, failure of a malnourished child to respond to an
appropriate therapeutic feeding regimen suggests the
presence of HIV infection, especially when accompanied
by other evidence suggesting HIV infection such as hep
atomegaly, adenopathies, and skin and mouth lesions.
children and malnourished children who are HIV
seronegative. Anthropometric measurements and HIV
tests were taken, and treatment included a fortified, high
protein-energy diet plus any medications needed.
Eighteen of the 40 children (45%) were HIV positive,
but all five infants under six months of age in this study
were HIV positive. Vertical transmission accounted for 15
(83%) of the 18 cases; blood transfusions accounted for
three (17%).
As with diarrhea, the poor response of these children
to therapy will doubtless discourage both parents and
practitioners from making an intensive effort to help
them. This may lead to children not infected by HIV
failing to get treatment for malnutrition due to the
premature assumption of HIV infection.
The malnutrition cases seen in the HIV positive group
were more often complicated by other problems.
Protein-energy malnutrition started at an earlier age in
this group. And other symptoms characteristic of HIV
infection were also seen, such as thrush, labored
breathing, skin lesions, and swelling of lymph nodes and
the liver. But no difference was seen between
seropositive and seronegative children concerning fever
’or diarrhea. Finally, HIV positive children did not respond
as well to the improved diet given as therapy: seven HIV
positive children did not gain weight.
Keusch, G.T.; Thea, D.M.; Kamenga, M. et al.
"PERSISTENT DIARRHEA ASSOCIATED WITH AIDS."
Acta Paediatrica, supplement, vol. 381, 1992,45-8.
Order #6271
Summary
Preliminary analysis was carried out of an ongoing
prospective longitudinal study of 469 babies born to HIV
seropositive and seronegative mothers in Kinshasa,
Zaire. The objective of the analysis was to determine the
incidence of diarrhea and the proportion of cases in
which diarrhea persisted for more than 14 days. During
the first 6 months of observation 269 episodes of acute
diarrhea were observed. The mean duration of diarrhea
was 5 days. Sixteen (5%) of the 269 acute episodes of
diarrhea became persistent. The persistent diarrhea rate
in HIV+ infants was over 6 times that of infants bom to HIV
seronegative mothers, and three of the four babies who
died with persistent diarrhea were HIV+. The persistent
diarrhea rate in HIV- infants born to HIV+ mothers was
intermediate: 3.6 times the risk of HIV- babies.
Editorial Comment
This report gives a foretaste of what lies ahead in
countries in which AIDS is added to an already difficult
situation for children. While the sample selection of this
study is biased (admissions to hospital for malnutrition,
not a community population), the disproportionately large
percentage of HIV+ children (45%, as compared to the
proportion of HIV seropositive women in prenatal clinics
of only 11%-28%) suggests that HIV infection is rapidly
debilitating.
This is borne out by the earlier onset of malnutrition in
these children, suggested by the large number of infants
■under 6 months who were HIV seropositive (5) compared
to no seronegative malnourished infants under 6 months
who required hospital admission. Given the likely high
prevalence of breastfeeding in this population, it may be
that breastfeeding during this first 6 months of life was
not effective in protecting these infants from malnutrition,
due to the detrimental effects of their HIV infections,
although the authors unfortunately did not report
information about breastfeeding.
Surprisingly, no association of persistent diarrhea was
seen with breastfeeding before or during the diarrhea,
water source, preparation of formula, use of boiled water,
antecedent malaria or measles, or use of antibiotics. Fifty
percent of the deaths in the babies were due to acute or
persistent diarrhea, and were strongly associated with
HIV infection. The article also reviewed other aspects of
overall morbidity and mortality and of diarrhea disease rel
ative to HIV status, based on reports from other centers.
We see also that many of these HIV-infected children
responded poorly to the high protein-energy feedings
provided by the hospital, in contrast to the seronegative
children. Possible reasons would include inadequate
intake of the feedings, inadequate absorption of
nutrients due to morphologic abnormality or intestinal
malfunction, or a higher rate of energy consumption or
metabolism due to their ongoing opportunistic
Vol. VIII, NB2
Editorial Comment
This report, unlike most of the literature on diarrhea
related to HIV/AIDS, focuses on children, the population
with the highest non-AIDS diarrhea rates and the empha
sis of control of diarrheal disease (CDD) programs. We
note a relatively low incidence of diarrhea overall—0.6
3
Technical Literature Update
Combining the data from these four reports shows
that the risk of an infant contracting HIV infection from
breastfeeding alone is 29% (95% confidence interval
16-42%).
episodes per infant in 6 months or 1.2 episodes per year,
compared to general figures of 2.5 to 3.5 episodes per
year in under-fives overall. This low incidence may be due
to high rates of breastfeeding in this population, although
this preliminary analysis does not report an analysis of
overall diarrhea incidence relative to breastfeeding.
The additional risk of transmission through
breastfeeding, when breastfeeding follows exposure of
the fetus to a seropositive mother in utero during
pregnancy and subsequently during the delivery
process, was estimated by comparing breastfed infants
with exclusively bottlefed infants born to mothers known
to be HIV positive. Six studies provided the data for this
summary analysis. The additional risk of breastfeeding in
such cases was 14% (95% confidence interval 7-22%),
with extremes from the six studies being from a high of
33% (Australia) to a 5% lower risk of HIV in breastfed
infants (Miami), compared to bottle-feeding infants.
Yet the persistent diarrhea rate in the HIV+ infants was
high: six times that in the HIV- infants from HIV- mothers.
Seeing this, we might immediately jump to the conclusion
that the persistent diarrhea results from immunosuppres
sion, but it may well relate to other factors in some of the
infant-mother pairs, as the persistent diarrhea rate is high
er also in HIV- infants who have HIV+ mothers. Those
infants may also be immunosuppressed, but perhaps
from measles or malnutrition, not from AIDS. Also, as the
authors note, HIV+ mothers, some of whom doubtless are
suffering from AIDS infections, may be less able to care
for their infants because of their illnesses, or because of
living situations associated with HIV infection (for
example, prostitution, poverty, or husband not at home).
Editorial Comment
Since we last discussed this issue in the TLU (vol. V,
no. 4), a number of careful studies have been published,
and much discussion of policy has taken place. This
careful metaanalysis of two sets of studies summarizes
what we know at present. It confirms that breastfeeding
by a HIV+ mother puts the child at substantial risk of be
coming infected with HIV: 29% in mothers seronegative
at birth, 14% in mothers seropositive at birth.
The number of cases upon which these comparisons
are based is quite small, only 16 cases of persistent
diarrhea overall, due to the limited six-month period of
data collection so far in this prospective study. We will
look forward to a fuller analysis in the future, when more
data become available. In the meantime, this important
study draws our attention to the fact that AIDS will add to
the diarrhea problem in children both directly, by means of
infection and immunosuppression in HIV+ children, and
indirectly, by its effect on parents, the home environment,
and parental responsiveness to their children.
Why should the second rate be lower? The authors
point out the possibility that IgG antibody may be
transmitted to the infant via the placenta during
pregnancy and protect the child from infection by viruses
transmitted during the traumatic birth process, also that
mothers with antibody may be less likely to have viremia
than mothers who are newly infected and have a period
of intense viremia during breastfeeding prior to their own
antibody response to the virus.
Dunn, D.T.; Newell, M.L.; Ades, A.E.; Peckham, C.S.
“RISK OF HUMAN IMMUNODEFICIENCY VIRUS TYPE 1
TRANSMISSION THROUGH BREASTFEEDING.” The
Lancet, vol. 340, September 5, 1992, 585-8.
Order#6034
What should CDD programs recommend regarding
breastfeeding? The most difficult aspect of this is the fact
that most infected mothers in developing countries do
not know that they are infected, and few developing
countries would be able to do HIV serology on all
pregnant women. In such circumstances recent
computer modeling of risks indicate that, in most
developing countries, breastfeeding is still the safer
alternative, as alternatives to breastfeeding (milk, formula)
are not safe in a contaminated non-hygienic environ
ment. Discouraging breastfeeding in such circumstances
would, according to these calculations, increase mortali
ty, despite the risk of HIV infection and certain death from
it. This would be true unless HIV prevalence in women is
high, and infant mortality rates are low, a situation which
does not currently exist in developing populations.
Summary
This article estimates the rate of HIV infection of infants
through breastfeeding based on four published studies
that met the following criteria designed to ensure that
transmission took place after delivery: (1) mothers were
infected with HIV through a blood transfusion after
delivery, or (2) repeated serological testing of mothers
shown to be seronegative at the time of delivery and
subsequently becoming seropositive. Children in one
study (Kigali) born to mothers who seroconverted too
rapidly after delivery (within 3 months) were excluded from
the analysis.
Technical Literature Update
4
Vol. VIII, N22
ITERATURE || PDATE
A MONTHLY REPORT OF CURRENT LITERATURE ON DIARRHEAL DISEASES & RELATED HEALTH ISSUES
Technic?.! Editor: Robert Northrup, M.D.
Technical Writer: Karen White, M.A., M.LS.
Managing Editor: William Amt
February 1989
Vol. IV, No. 2
.
PRITECH is a USAID-funded project which assists countries in implementing national diarrheal
disease control programs. PRITECH publishes the TLU, a monthly bibliographical listing of selected
annotated articles and other Information which our Technical Editor, Dr. Robert Northrup, feels
should be circulated to Individuals concerned about diarrheal diseases and related health issues.
Inclusion in a listing does not mean that we endorse or validate the article cited; rather, that it is
worthy of your attention and further critical appraisal, particularly when It has already been published
In a well-known journal. The summaries and editorial comments represent the opinions of the TLU
editorial staff, and are not meant to represent USAID policies or opinions. Copies of the articles
featured In this Issue are available by writing to the PRITECH Information Center. Your comments
are welcome.
Molla, A.M.; Molla, A.; Rohde, J. et al.
"TURNING OFF THE DIARRHEA: THE
ROLE OF FOOD AND ORS." J. Ped.
Gastroent. Nutr, 1989, vol. 8, 81-84.
Summary
"Ninety-three boys aged 5 years or less who had
diarrhea due to Vibrio choierae were randomly as
signed to treatment with glucose oral rehydratlon salt
(ORS) or rice-based ORS. For the first 24 hfours],
ORS only was given to all the patients. During the
next 24 hfours], ORS and normal food were given.
The efficacy of the two types of ORS was compared
in terms of ORS Intake, stool output, change In
hematocrit reading, serum specific gravity, and In
crease In body weight. At the end of the first 24
hfours] of treatment, a 50% reduction In ORS intake
and stool output was observed In the 47 patients ran
domly assigned to receive rice ORS as compared
with the 46 patients who received glucose ORS.
During the second 24 hfours] of treatment, a sig
nificant reduction In the stool output was noticed in
the glocuse ORS group, making the efficacy of
glucose ORS equal to that of rice ORS. The study
suggests that normal food can Impart some of the su
periority of 'super’ ORS to standard glucose ORS
with regard to reduction of stool volume." [Journal
abstract]
Editorial Comment
The exciting core of this report is, FOOD IS AN
ANTIDIARRHEAL DRUG, or, paraphrasing the
authors, food Is the real "super4' ORS.
I haveWor some time been saying that food is as
Important In diarrhea treatment for Its role in rehydra
tlon, as for Its role In maintaining nutrition and
promoting more rapid healing of the Intestinal cells.
PUTSCH—
Technologies for Primary Health Care
Address Correspondence to: Information Center, PRITECH, 1655 North Fort Myer Drive, Suite 700, Arlington, VA, 22209, USA
Phone: 703-841-0680. Telex: 3792632-PARK PL.
USAID-supported Contract #DPE-5969-Z-00-7064-00, Project #936-5969
rhea required admission to the medical ward,, as op
posed to only 8% of those with acute diarrhea.
However, patients with persistent diarrhea were less
llkdly to be dehydrated.
/ In contrast to children with acute diarrhea, those
with diarrhea lasting more than 2 weeks were more
likely to have bloody or mucoid stools, a history of
previous antibiotic use, night blindness, vitamin A
deficiency, and malnutrltlon/welght/height F% of the
median of the NCHS standard). Pathogens found In
the stool were not slgnflcantly different from those
found among acute diarrhea patients./Breastfeeding
was found to be less common among those suffering
from persistent diarrhea:
The authors cite several limitations of the data:
reliance on recall of the parents for information on
duration of diarrhea, antibiotic use and dietary his
tory; inability to separate cause from effect in many
of the cases; collection of fecal specimens late in the
Illness; and use of patients with acute diarrhea as a
control group.
This report begins the job of demonstrating that
hypothesis.
During the first 24 hours, when no food was given,
the children given the ORS based on rice starch had
a real reduction In stooling, compared to the glucoseORS group. With the addition of food during the
second '24 hours, the two groups became indistin
guishable. To state that another way, the data sug
gests that giving food along with glucose ORS has
the same effect as giving rice-based ORS - both ap
proaches appear to reduce stooling.
Now, to be rigorous, the study design does not
permit us to go so far as saying, “food plus
electrolytes and water Is as effective In rehydratlon as
glucose-ORS or rice-ORS." There was no group In
the experiment that received only water as the fluid.
But two of the authors (AMM and JR) have studied a
couple of patients making that sort of comparison,
and their results do not contradict that hypothesis.
We hope a full study will be carried out soon.
I do not wish to Imply by my remarks that we
should be aiming at doing away with ORS, and just
using water along with food plus electrolytes: not at
all.
ORS provides a uniform mixture of water,
electrolytes, and the absorption-stimulating substrate.
Food plus salt with water would almost Inescapably
not be so uniform. First would come the fluid, then
the food and salt - what reahed the small intestine
would doubtless vary quite a bit In composition, and
therefore in stimulating absorption, despite the
mixing that would occur In the stomach.
Add another cosideration: using ORS keeps the
user focused on rehydratlon, on the Importance of
replacing the fluid that has been lost, volume for
volume. That focus, that emphasis might bezlost If
we switched to a food plus water approach/Using a
rice-based ORS, this study suggests, would allow us
to keep the emphasis on fluids and rehydratlon, while
getting the addition'al anti-diarrheal benefits of a food
based approach/jRSN]
Shahid, N.; Sack, D.; Rahman, M. et al.
"RISK FACTORS FOR PERSISTENT DIARRHOEA." British Medical Journal, October
22, 1988, vol. 297, 1036-1038.
Editorial Comment
A study of this sort using ICDDR.B patients may
show substantial differences In the proportions of
various characteristics from the actual situation In the
community. This Is because of the general selection
bias from using patients seeking care at a health
facility.
It may be further skewed in this case,
however, because of the perception of ICDDR.B as
the "cholera hospital", a place to go if you have the
acute rapidly-dehydrating type of diarrhea familar to
the public as cholera.
Nevertheless, it Is Interesting to note that 61% of
those with persistent diarrhea did have some degree
of dehydration on presentation, despite the fact that
only 53% had watery stools. That more of the persist
ent diarrhea patients than the acute were not
dehydrated Is easy to understand-ln contrast to the
acute patients, they probably came because their
diarrhea was persistent, not because of dehydration
and its symptoms.
I was surprised that amoeblasis was not even men
tioned as an etiologic agent, and glardla was present
In only 4% of the persistent patients (the same as in
the acutel). Is this real, or does it result from the
stool examination procedures used?
Fully 16% had evidence of vitamin A deficiency
(night blindness or conjunctional xerosis) compared
with only 6% in the acute group. And 8% were
wasted (F% wt/ht) compared to 3% in the acute
group. While the retrospective nature of the data
limits the possible concluslons/it seems highly likely
that pre-existing vitamin A deficiency and malnutrition
played a role in, the gut falling to heal, and the diar
rhea persisting/
The authors note that In Matlab, where availability
of treatment for dehydration Is excellent, 50% of diar
rhea-related deaths are now from persistent diarrhea.
Certainly, this Is an Increase from the probable 2030% of the general population. But, why is it not sub
■
Summary
Studies have shown thatmore than half the deaths
due to diarrhea can be attributed to chronic, or per
sistent, diarrtjg/ The authors undertook a retrospec
tive analysis o/perslstept diarrhea (defined as lasting
more than 14 days)/of a systematically sampled
group of patients aged 5 years or less attending the
ICDDR.B clinical research center during the period
1983-85. Of the 4,155 children who participated In
the study, 10% suffered from persistent diarrhea, with
no detectable differences In sex or season. In terms
of treatment, 18% of the patients with persistent diar
Technical Literature Update
2
February 1989
stantially higher? With excellent care, hardly any
patients should ale with acute watery diarrhea. Is
dehydration still the cause of some of those 50% of
deaths from acute diarrhea? [RSN]
area without cholera. The incidence of cholera was
particularly high In the study year.
The second constraint Is the need for a perfectly
run Immunization program to achieve those excellent
results. Three doses, and a perfectly run cold chain:
how close can the usual routine immunization
program, with its Inevitable problems and often high
drop-out rates, come to achieving these results?
Third Is the fascinating finding that the mortality
reduction was not among the children, the group like
ly to have the highest diarrhea Incidence, but rather
among adult womenl The authors suggest that this
may be due to the delays In a conservative area like
Matlab In taking women for treatment of diarrhea.
Without Immunization, some of the women died.
With vaccinating them, the reduction In diarrhea
severity resulted In saved lives. Children, presumably
more rapidly taken for help, did not show a sig
nificant mortality reduction from the vaccine. We
might broaden that observation to note that easy ac
cess to effective diarrhea treatment, such as Is avail
able In Matlab, may eliminate any observable mor
tality reduction from diarrhea vaccines like these.
We should probably note that the three-dose re
quirement may make this vaccine rather useless as a
rapid epidemic-control action. In an endemic setting,
less than three doses may have a useful booster ef
fect, at least In persons with previous exposure. Still,
however, vaccination Is not an appropriate response
to a cholera epidemic/Ensuring easy access to ef
fective treatment, and telling the public about ORT,
are two methods much more likely to prevent mor
tality In such epidemics than vaccination, even with
effective vaccines like these.^"Unfortunately, we still
hear of governments wasting scarce resources on
emergency vaccination programs as their major
responses to a cholera epedemlc. [RSN]
Clemens, John D.; Harris, Jeffrey R.;
Khan, M.R.; et al. "IMPACT OF B SUB
UNIT KILLED WHOLE-CELL AND KILLED
WHOLE-CELL-ONLY ORAL VACCINES
AGAINST CHOLERA UPON TREATED
DIARRHOEAL ILLNESS AND MORTALITY
IN AN AREA ENDEMIC FOR CHOLERA."
The Lancet, June 18, 1988, 1375-1378.
Summary
/The impact of B subunit killed whole-coll (BS-WC)
and killed whole-cell-only (WC) oral cholera vaccines
was assessed in a randomised double-blind trial In
rural Bangladesh. 62,285 children aged 2-15 years
and women aged over- 15 Ingested three doses of
one of the vaccines or placebo. During the first year
of follow-up. there was a 26% reduction of all visits
for treatment of diarrhoea in the BS-WC group and a
22% reduction in the WC group. The reduction of all
admissions for fatal or severely dehydrating diar
rhoea was 48% In the BS-WC group and 33% in the
WC group. Overall mortality rates were 26% lower In
the BS-WC group and 23% lower In the WC group
during the first year, and reductions of mortality were
observed only In women vaccinated at ages over 15
years/ However, no differences In cumulative mor
tality were evident at the end of the second year of
surveillance." [Journal abstract]
Editorial Comment
Levine, M.; Harrington, D.; Losonsky, G.
et al. "SAFETY, IMMUNOGENICITY, AND
This paper takes vaccine trials In diarrhea preven
tion to the next logical and programmatically critical
level, beyond the ability of the vaccine to prevent
cases of diarrhea, to its ability to reduce the need for
treatment (l.e., severity) and mortality.
From a CDD program’s point of view, that is the
major objective of a preventive program like vaccina
tion, Most CDD programs are still primarily con
cerned with eliminating diarrhea deaths, and have
not yet succeeded in that enough to switch to the ob
jective of reducing diarrhea Incidence only because it
is an inconvenient nuisance.
The discussion section of this paper Is particularly
cogent, noting a number of reasons why these find
ings must be conservatively extrapolated to
programs. The most obvious constraint is the limita
tion of usefulness to areas with lots of cholera: al
though the vaccine with the B-subunlt of cholera
toxin (BS-WC) does cross-protect against toxigenic
Escherichia Coll (LT-ETEC), even It would not be like
ly to have neatly the impact seen in this report In an
Technical Literature Update
EFFICACY OF RECOMBINANT LIVE ORAL
CHOLERA VACCINES, CVD 103 AND CVD
103-HGR." The Lancet, August 27, 1988,
467-470.
Summary
/In an effort to develop a new cholera vaccine that
Is safe, easy to administer, inexpensive, and highly
protective after a single dose, researchers conducted
a volunteer study of two live vaccines administered
orally, strains CVD 103 and CVD 103 HgR. Taking a
classic cholera bacterial strain, the authors deleted al
most all of the genes (54%) responsible for making
the toxic piece of the cholera toxin molecule. The
resulting strain (CVD 103) was further attenuated and
a marker was added, producing strain CVD 103-HgR.
Given orally to volunteers In a single dose, both
3
February 1989
.
strains elicited strong antibacterial and antitoxic
serum antibody responses, and provided substantial
protection of the volunteers against a challenge dose
of pathogenic Vibrio cholera,e/ Strain CVD 103
caused mild diarrhea In 5 of 46 recipients, with mild
cramps in only one; CVD 103-HgR bacteria lyophil
ized produced no side effects In 18 volunteers, and
was excreted In the stool in only 28% of volunteers,
less than with CVD 103.
Editorial Comment
/WHO has given top priority to efforts to develop
an effective cholera vaccine. These results look bet
ter than those obtained with another preparation, a
killed vaccine- given orally along with a purified toxin
subunit (By More volunteer challenges were done
with volunteers Immunized with the CVD 103 strain.
Protection was good, and/faven In those 5 volunteers
who did get clinical cholera, they did not have severe
ly dehydrating diarrhea./So the approach was suc
cessful In preventing "severe disease, while allowing
infection and Immunogenic stimulation to occur. The
next step Is to take these strains to endemic areas,
first to test their safety and the incidence of side ef
fects, such as mild diarrhea in healthy adults and
children. If the results from this are good, a field trial
tg,-test protectiveness can be done.
/ Clearly, these vaccine strains do themselves
produce diarrhea in some persons, despite the ef
forts to remove their toxic component^ These will
have to be weighed by committees first, later by
volunteers, then by parents, against the protection
they confer against potentially fatal cholera./fn con
trast to the experience with the remarkably safe and
protective viral vaccines such as mumps and meas
les, or diphtheria or tetanus toxoids, cholera vaccine
researchers are having a much more difficult time get
ting a strain which provides adequate Immunity In the
gut (the old approach of Injecting killed bacteria did
not), and produces enough of an Infection to stimu
late this immunity without stimulating diarrhea as
well. It seems that the bacterial factors (toxins, ad
herence, etc) which make a bacterial strain able to
'take," that Is, to cause an Immunogenic Infection,
may be also the factors which cause diarrheal/RSN]
Technical Literature Update
4
February 1989
Health Systems Research
Competition: winning article
A. Joseph, S. Abraham, S. Bhattacharji,
J. Muliyil, K.R. John, N. Ethirajan, K. George,
& K.S. Joseph
Improving immunization coverage
A study was made on the causes of unsatisfactory progress in
immunization coverage in an area of Tamil Nadu, southern India. The
fmoings led to the appointment of additional community health workers,
the improvement of their supervision, the enhancement of accessibility to
services through an increase in the number of peripheral clinics and the
organizing of temporary clinics, and the concentration of effort on
underprivileged groups. As a result, immunization coverage was more
than doubled.
The Communin' Health and Development
Proiect in Tamil Nadu, southern India, is a
primary health care programme covering
128 square kilometres and serving 68
villages with a population of approximately
t>:i i.'UO. The region is semi-arid and
predominantly rural, the economy being
heavily dependent on agriculture and related
industries. In 1981 the programme
functioned with a base hospital and 3~
peripheral clinics. The base hospital dealt
Dr A Joseph is Professor and Head. Dr Abraham is
Assoc.ate Professor. Dr Bhattacharji and Dr Muliyil are
Readers Dr John. Dr Ethirajan and Dr George are
Lecturers, and Dr K.S. Joseph is Research Officer in
the Department of Community Health, Christian
Meoical College. Vellore. Tamil Nadu. India 632 002.
33»
with about 100 outpatients and 40 inpatients
daily and with 60 deliveries every month.
The peripheral clinics were conducted on a
weekly basis by community health nurses; a
doctor was in attendance at each clinic
every second week. At the grass-roots level,
community health workers each served a
population of some 1500 and were
supervised by auxiliary nurse midwives, who
each covered about 5000 people. At the next
level, for approximately every 15 000 people
a community health nurse and a doctor were
available. Immunization was given on a
routine basis at the peripheral clinics, and,
in addition, mass immunization campaigns
were conducted periodically. The health
education and rural development
components of the programme were
Wuna Heal’?’Fo'u^’
Vo> 9
1988
Improving immunization coverage
Table 1. Coverage of population under five years
of age with third dose of diphtheria
pertussis-tetanus vaccine
Year
Population under
five years
% population
given third dose
1981
1984
8571
9048
37.1
51.4
raised were further considered by the
supervisory staff. Studies were carried out to
clarify doubtful issues. Statistical analyses
were performed to test hypotheses that
emerged during the discussions.
The process of identifying problems
through review’ meetings was continued
subsequently. The staff of each sector met
monthly to discuss the effect of any changes
that had been implemented. Operational
flexibility was thus achieved at the periphery
through partial decentralization of the
decision-making process. These meetings
also provided feedback on deficiencies in the
programme.
implemented by staff who supervised
workers in the villages. Two to three years
after this strategy was mounted there were
clear indications that it was not yielding
dividends at the expected rate. Table 1
shows the improvements in immunization
coverage that occurred between 1981 and
1984, and Table 2 the changes in the
utilization of diphtheria-pertussis-tetanus
vaccine from 1981 to 1986. A quarter of the Results
children who received an initial dose of this
Poor immunization coverage was caused by
vaccine in 1984 failed to take the second
various factors, the influence of any one of
dose and more than a third did not
which appeared to differ from place to
complete the course of immunization. An
place. Nevertheless, it was possible to
investigation was therefore made into the
/identify the following critical elements.
causes of the inadequate improvement in
immunization coverage.
• Inadequate supervision of community
health workers/'
Methods
The reasons for nonacceptance or dropout
were discussed with staff and various
members of the community. A special effort
was made to obtain the views of staff
working at the periphery, particularly the
community health workers.
The area was divided into four sectors. The
community health workers, auxiliary nurse
midwives, community health nurses and
other development staff in each were
brought together, and the community health
workers were required to identify the
specific factors affecting immunization
coverage. Discussions were initiated in
mothers’ clubs and youth clubs and in
meetings with village leaders. The matters
Wond Health Forum
Vol 9
1988
Table 3 shows that although-'coverage with
diphtheria-pertussis-tetanus vaccine was
better in villages with community health
workers than in those without them/the
Table 2. Utilization of immunization services
1981-1986
Year
1981
1982
1983
1984
1985
1986
DPT--2
No of
doses
given
DPTa-3
%
compliance
for
DPTa-3
72.1
74.4
73.7
74 7
80.8
86 5
499
637
1016
969
1382
1625
48.5
58.7
66 7
58 5
68.3
70 7
No of
doses
given
DPTa-1
No of
doses
given
DPT--2
%
compliance
1030
1085
1523
1657
2024
2299
743
807
1123
1238
1621
1989
for
* Diphthena-penussts-tetanus.
337
Health Systems Research
Table 3. Immunization coverage in areas with and
without community health workers, 1981
and 1984
1981
No
1984
%
No
%
/• Difficulty of access to health services /
Villages with community health workers
Population under
five years
6138
—
6461
—
Completed DPT"-3
2391
38 9
3452
53 4
improvement
14.5%
Villages without community health workers
Population under
five years
2433
—
2587
—
Completed DPTa-3
792
32 6
1202
46.5
improvement 13 9%
- D.phtheria-pertussis-tetanus
improvement between 1981 and 1984 was
similar in both categories of village. This
was attributed to poor supervision of and
support for the community health workers.
The programme had envisaged their
supervision by auxiliary nurse midwives,
who, however, were mostly unmarried
young women not residing in the areas
where they worked. It proved difficult to fill
these posts, and the programme suffered
because of a high staff turnover. The
community health nurses, who each
supervised 10 community health workers,
could spend only about rwo hours a week
with each worker, which meant that support
was inadequate.
• Scattered communities/
Villages in which the houses were clustered
together were better acceptors of health
messages than were those with houses
scattered over large areas, which required a
relatively massive effort for the achievement
of the desired impact/tlf the 12 villages
having the poorest coverage with the third
dose of diphtheria-pertussis-retanus vaccine,
seven had more than half their populations
33S
scattered over large areas. In contrast, of the
12 villages with the best coverage, none had
their populations scattered to a similar
extent.
It had been assumed that people would
travel up to two kilometres in order to avail
themselves of the immunization service, but
this proved not to be the case. Table 4
illustrates how, in a given area,
./immunization coverage fell with distance
from the peripheral clinic/
fi^Low economic and educational status^
The more educated, progressive groups
invited the health team and extended all
possible support, whereas poorer groups,
among whom traditional beliefs held sway,
gave much less cooperation. In consequence,
significantly better service was obtained by
the former groups. This was especially
marked within villages, where people of
comparatively high caste and socioeconomic
status had a much better record of health
service utilization than people of lower caste
and socioeconomic status. Thus the
better-off people improved their lot further
whereas the poorer people, in greater need
of health care, failed to benefit
proportionately. Clearly, the villages that
gained most from the health services were
the ones that cooperated with the
programme and appointed community
health workers to work for them/
Changes and benefits
In the light of the above observations, the
following measures were taken.
• The number of community health workers
was increased from 42 in 1984 to 57 in
WoriQ Health Forum
Vo' 9
1988
Improving immunization coverage
Table 4. Immunization coverage in relation to distance from peripheral clinic
Presence (+)
or
absence (-)
of community health
worker
Village, year
Kantyambadi, 1984
Kamyambadi Kattupadi. 19S4
Kanryambadi Pudur 1984
-
Kilarasampet. 1984
Kilarasampet, 1987
Palavanzath. 1984
Palavanzath. 1987
Clustered
or scattered
population
Distance
from clinic
(km)
Coverage
with DPT'-3
(%)
65.5
66 7
-
Clustered
Clustered
-
Clustered
< 0.5
<05
1-2
+■
+
'4 scattered
’/> scattered
2
< 0.5
+
+
Clustered
Clustered
2
<0 5
49 2
29 5
63.2
46.7
79 8
J Dipnihena-penussis-tetanus.
1987, by which time all the villages were
covered. The method of selection,
involving community participation, was
modified so that the persons chosen were
acceptable to all sections of the villages.
programmes, using film shows, drama,
adaptations of folklore, and so on.
Mothers’ clubs, youth clubs, and village
leaders were brought into the process.
• The post of auxiliary nurse midwife was
abolished and a new category of staff was
introduced to link the communit}' health
worker and the community health nurse.
The persons chosen for this role were
married women who were resident in the
areas where they worked and had
completed their secondary education.
They were designated “health aides’’ and,
after intensive training, each supervised
the work of three or four community
health workers.
Table 5 shows the improvement in
immunization coverage between 1981 and
1987 and Table 2 indicates the increase in
the use of diphtheria-perrussis-tetanus
vaccine which occurred between 1981
and 1986. Between 1984 and 1987,
immunization coverage increased by 30% as
against 14.3% between 1981 and 1984. The
level of immunization among children aged
between 6 and 36 months in 1987 was over
80%. Periodic checks on the data were
carried out by a team of field workers not
involved in the programme. Cluster
sampling techniques were also used to check
the coverage.
• The number of peripheral clinics was
increased from 37 to 45, and temporary'
clinics were held in areas with poor
immunization coverage.
• Efforts were made to improve the service
given to economically and socially
underprivileged areas. Often this involved
the screening of a health education film
twice within the same village on the same
day so that both the higher and lower
castes could benefit.
• Greatly increased efforts were made to
improve the health awareness of the
people, by means of health education
Wo'io Hea>:n Forum
Voi 9
1988
The altered strategy was intended to benefit
not only immunization coverage but also the
Table 5. Changes in immunization coverage,
1981-1987
Year
No. under
five years
% population
given DPTa-3
1981
1984
8571
9048
37.1
51.4
1987
8445
81 4
* Diphtheria-pertussis-tetanus.
339
Health Systems Research
other primary health care programmes of the
Community Health and Development
Project, andTavourable effects were seen in
antenatal care, compliance with chronic
disease treatment, surveillance and
monitoring,/and other areas.
As a result of the study, immunization
coverage was more than doubled. The gains
realized from the deployment of community
health workers were consolidated through
better supervision. Accessibility to health
services was enhanced by increasing rhe
number of peripheral clinics and holding
temporary clinics where necessary. An
increased effort was made in villages with
scattered populations. The programme was
reorganized so that the socioeconomically
weaker sections of the population received
special attention. /
Said at the 41st World Health Assembly
WHO — the way ahead
The World Health Organization has emerged unscathed from the
scrutiny which is being cast on all the United Nations system and has
been judged as one which is doing a good job and moving in the right
direction
— Dr H. Nakajima, Director-General Elect in his
acceptance speech. Fifth plenary meeting,
4 May 1988
Dr Nakapma has demonstrated his dedication to the high goals of the
World Health Organization and his commitment to the promotion of
health and the control of disease. His effectiveness as a physician and
as administrator are well known. We are confident that, under
Dr Nakajima's leadership, this Organization will continue to make
significant contributions to the improvement of health of people
everywhere, in pursuit of WHO's noble goal of health for all.
—Mr D Newman (USA), one of the 88 delegates who
took the floor to welcome Dr Nakajima's election as
Director-General. Fifth plenary meeting. 4 May 1988
340
World Health Forum
Vol 9
1988
Missed Opportunities for
immunization s
Hiraniiimauimnze aiii Everry Oppoirtianimnt^/’'
Highlights
./ O Many opportunities to immunize women and children are
missed when:
— Immunizations are not offered at every contact.
— Immunizations are denied because of false contraindications.
— Only one vaccine is given when the child is eligible for more
than one.
— Mothers are not being immunized when the child is immunized. /
© Actions to reduce missed opportunities:
— Identify missed opportunities by examining the health center
records and immunization cards.
— Perform surveys to measure missed opportunities.
— Check the immunization status of every woman and chilcl at
each clinic visit. Those in need should be immunized before
leaving.
— Immunize children even a,tcenters_no£specifically_ designated as
immunization clinics, such as clinics for sick children.
— Use every. visit. niade_.by_.a woman to a health facility as a
chance toJnamunizeJiemwith-tetanus-toxoid.
— Avoid fals£_contraindications_to. immunization^There are few
real contraindications. Incorrect use of contraindications denies
life-saving immunizations to many infants.
IMMUNIZATIONS IT T< > I’AII ON ARRIVAL
How opportunities are missed. Illis figure sllows'lhe results of a
typical "missed opportunities survey": three quarters of those who attended
a clinic for sick children were not up to dale for immunizations on arrival.
Only 7‘o of those who needed immunizations received any by the time they
left tile clinic.X
WORLD HEALTH ORGANIZATION
The Problem
Many women and children in need of
immunization do not come to immuniza
tion clinics but are seen at clinics treating
sick people. This valuable chance to im
munize is too often neglected by clinic
staff. Even at immunization clinics,
women and children are not being
offered all of the antigens for which
they are eligible.
An opportunity Io immunize is missed
when:
& Immunizations are not offered AT
EVERY CONTACT,/" women and
children make with health facilities such
as attendance at an outpatient depart
ment. a hospital or an antenatal session
in a maternity clinic.
O Immunizations are denied because of
FALSE CONTRAINDICATIONS or
improper immunization schedules. Mild
fever, cough, diarrhoea or weight loss
are not valid reasons for withholding life
saving immunization.
• ONLY ONE VACCINE IS GIVEN
when the child is eligible for more than
one vaccine (such as BCG and polio vac
cine at birth)/Mothers and children who
present at the right time for immunization
are being turned away because vaccines
art? out of stock or the vaccinator thinks
loo few children are present to justify
opening a new vial of vaccine. It is worth
opening a vial for even one child; it may
be their only chance Io be immunized/'
© MOTHERS ARE NOT BEING
IMMUNIZED WHEN THE CHILD IS
IMMUNIZED. Tetanus toxoid should be
given to all women of child bearing age
at all opportunities. Whenever a child is
immunized, the mother should be im
munized with tetanus toxoid if she is not
up to date/
How to Measure the Size of the Problem
/ Inspect Routine Data First
An examination of routine data may
be enough to indicate whether a missed
opportunity problem exists/
It is necessary Io know only the date of
the clinic visit, the birth date and the
dates when immunizations were given.
This information may be available in
health records, immunization or "road to
health" cards.
Also immunization coverage survey
analysis may show whether all needed
vaccines have been given at the earliest
possible time.
Table 1.
Missed Opportunities al Clinics
,,
Country oj study
Pakistan. 1984
India. 1985
Nepal. 1985
Honduras. 1987
Indonesia. 1987
Thailand. 1987
Zimbabwe. 1987
Comoros. 1988
Egypt, 1988
Ethiopia, 1988
Pakistan. 1988
Turkey. 1988
Children needing but not receiving
vaccine
69 %
57%
54%
45%
76%
68%
0%
58%
30%
41%
45%
49%
Missed Opportunity Survey —"
There is a simple survey to measure
missed opportunities for immunization at
a health facility, ft is based on interviews
with parents and guardians as they leave
a health facility. It shows if a child or
mother failed to receive a needed vac
cine. and the method is available from
EPl.
( Zimbabwe has developed an effective
system for reducing missed opportunities
at paediatric clinics. Each ill child is
screened by a nurse tor immunization
status and the necessary immunizations
are given even before the child is seen .hy
the physician. In two clinic studies in
1987. this system reduced missed oppor
tunities to zer{/
/" Clinics where sick children are seen
miss more opportunities to immunize
than immunization clinics. One study in
1988 showed that 91% of eligible
children did not receive immunization at
a clinic for sick children compared with
only 31% at an immunization cliryp/
Illness of the child was the commonest
reason given by health workers for not
immunizimjf
Interviewing the staff will demonstrate
why eligibles did not receive needed
doses of vaccine. They may not have
been screened, not refered, not immuniz
ed, or incompletely immunized.
/'
SA f
'
]
Use Every; Opportunity; for Immunization
O Check the immunization status
of every child and womarr /
Screening of every woman and child
for immunization status should be done
as a routine at e^ery contact with a
health facility/ Reducing missed oppor
tunities is the cheapest way to increase
EPI coverage^
Action:
Immunization cards should be
issued to every woman and child.
Immunization cards should be
checked at every visit to every
health facility.
O Immunize children at clinics
treating sick persons.
The most common reason for a missed
opportunity is the belief by health
workers and mothers that sick children
cannot be immunized. Mild fever.
malnutrition, diarrhoea and other minor
diseases are not/talid contraindications
to immunizations There is no increased
risk of side effects from the vaccines in
these children? I lowever. in such children
the risk of severe disease. particularly
measles, is increased/
When children come for treatment of
an illness, preventive services should also
be offered^' When they are seen at clinics
for medical problems, it is important., (bat
other needs of the patienTand famiLy-are
rfrel al the same time. These should in
clude immunization for the child and
mother/
^/infectious diseases can be transmitted
at clinics where sick children and unim
munized children wait in the same areqg/-'
For example, following a measles
epidemic in Cote d'Ivoire, it was
estimated that two thirds of the measles
cases seen at a paediatric clinic had ac
quired the disease during a previous visit
to the same clinic/If the unprotected
children were immunizedythis would
cease to he a problem^/
Action:
Review national policy on contra
indications.
Encourage doctors to provide
preventive as well as curative services.
Educate mothers as to the importance
of immunizations.
Immunize eligible children on
admission and discharge from
hospitals.
O Administer all appropriate
antigens at each clinic visit.
Different vaccines can be given at the
same timeZA child should receive all
eligible vaccines at the same visit,/
.clion:
Review the immunization schedule.
Open a vial of vaccine even for a
single eligible woman or child.
Table 3.
Recommended immunization schedule to
.provide protection at the earliest age
Age
Birth
6 weeks
10 weeks
14 weeks
9 months
Vaccine
BCG and OPV
DPT andOPV
DPT and OPV
DPT and OPV
Measles
Table 2.
Summary of Indications and Contraindications to EPI Vaccines
1. Immunize children who are malnourished or mildly ill.
2. Immunize all women of child bearing age with tetanus toxoid. Early pregnancy
is not a contraindication.
For children who have an illness requiring hospitalization, the decision whether
or not to immunize should be made by the doctor admitting the child.
Give OPV. DPT and measles vaccines to children infected with Human Im
munodeficiency Virus (HIV) or who have AIDS/
Do not give BCG to children who have a symptomatic infection with HIV.
6. Do not immunize children who have had a previous severe event after a
previous dose of the vaccine/
~--v;
s \
V-'
z'
0 Immunize all women of child
bearing age at every opportunity.
The problem of missed opportunities is
particularly important Jor the prevention
of neonatal tetanus./l'he worldwide
coverage is 23% (or pregnant women
with two doses of tetanus toxoid. In
many developing countries it is less than
10 %. z
A 1986 study in Indonesia indicated
that only 21% of those who had attend
ed antenatal clinics twice or more had
received the necessary two doses of
tetanus toxoid. If all opportunities to im
munize had been used. I I 2 coverage
would have been al least 68%.
“My mum needs immunizing too.”
Women of child bearing age will fre
/ Action:
quently accompany their children to an
immunization session or an outpatient
clinic. In a recent study in Ethiopia. 99%
Giue women two doses of TT with an
of women who accompanied children to
interval of at least 4 weeks.
clinics to seek treatment for their child's
Immunize mothers when they
illness weic in need of tetanus immuniza
accompany their children to an
tion but did not receive it. Immunization
immunization clinic.
services should be offered to the women
Immunize women,when they are seen
at both of these occasions as well as at
at, or accompany others to, a clinic
maternal and child health clinics.
for treatment of an illness.
Actions to Reduce Missed Opportunities
© Review the national immunization
schedule to ensure that it provides
optimal protection at the earliest age.
© Review the national immunization
policy on contraindications. Most sick
children and pregnant women can be
safely immunized.
© Make immunization available at all
clinics including clinics for sick children
and maternal and child health clinics.
• Make sure all eligible women and
children have an immunization card and
that they bring the card to every clinic
visit.
• Check the immunization cards oL
eyer^wornan and child at every clinic
• Ensure that all women and children
receive all vaccines that they are eligible
to receive.
Think of immunizing a child even when
being seen for another problem.
• Immunize on admission and
discharge~from hospitals.
I
BAC/DDC/78.1
A'ORLD HEALTH ORGANIZATION
ORIGINAL} ENGLISH
DIARRHOEAL DISEASES CONTROL PROGRAMME
ORAL THERAPY FOR DEHYDRATION IN ACUTE
DIARRHOEAL DISEASES WITH SPECIAL REFERENCE TO
THE GLOBAL DIARRHOEAL DISEASES CON TROL PROGRAMME
ftr
Dti. I«. Finhkro,
Monlcftorc Hospital and Medical Center.
New York, USA
Dlt. D. MAHALANAIliS,
Kothari Centre of Gastroenterology,
Tiie Calcutta Medical Research Institute
Calcutta, India
ami
Dr. D. Naijn,
Centre for Vaccine Development, Division of Infections Diseases,
University of Maryland School of Medicine,
Baltimore, Maryland. USA
1. Ir.trodEr.lfoa
Oral therapy for diarrhoea) dehydration has a major roic in the currently expanding global
programme to reduce diarrhoea related mortality amlpnalitutrition.|Empirical clinical findings led
to therapeutic recommendations and usage of oral tehydration in mldly dehydrated infants in the
early 1950’s,1’’ and subsequent elucidation of the physiological mechanisms influencing intestinal
absorption gave impetus to btdttncc studies which have confirmed its utility in the treatment of acute.
watery diarrhoea of all etiologies and in all age groups.3 The clfectiveness of oral therapy in the
rehydration of patients with mild or moderate dehydration and in the maintenance of hydration
following intravenous rehydration of severely dehydrated patients is firmly based on many published
reports of its use in hospitals and other treatment centres.
' Much remains to be accomplished, however, before mortality due to diarrhoeal dehydration
ptr re can lx: reduced to an achievable level of less than one per cent, particularly in develop
ing countries where resources are scarce and basic health services me limited. For example, there is a
need to consider the best means of ensuring the safety and efficacy of oral therapy when extending’
. its use from treatment centres to simpler rural facilities (c.g. health posts, sub-centres) and to the
'/ 0 Y home. Variations in local conditions, including the standard of education of the population, the
availability of ingredients, the quality of medical supervision and the accessibility of backup facilities
for referral need to be considered in devising programmes that will be perceived ns beneficial by the
community and by those responsible for evaluation, z'
I
page 3
To provide guidance for the development of impiementatioft strategies for the (dotal diar
rhoeal diseases control programme, an attsmpt has beep. m^r.rwmmripe-Its ^ijrlsitt^vqlwd
in the composition of erni fluid for rehydtation and la the use of oral rehydration therapy according
to patient age, and to tonite recommendations for the application of oral therapy atld related research.
2. CHOSOE CP OaAL iti^ORATlON SOLUTION (ORB)
Many questions have arisen regarding the formula that should be recommended for die
oral rehydratitm solution and on the best means for delivering oral rehydration therapy to those who
need it most/Sincc 1971 WHO has recommended the use of a single solution (hereafter referred to
ORB) conialiihg 3.5 g of Nad, 1.5 g of F-CL, 2.3 g of NaHCOt and 20 g of glucose in 1 liter
QJx of water, yielding the Pdlcwlng concentrationst Na: 90 mtnol/1, K: 20 mmol/t, Cl: BO mmol/1,
HCOe: 30 tmr.ol/1 dtet glucose: ill mmol/L/From the organizational and administrative point of
view having a single formulation has the Hear advantage of simplifying manufacture and distribution
of the required ingredients and preventing confttsion associated with multiple products. Howeve.’,
there needs to be fiailbillty In th?, use of ibis solution, particularly in infants who have unique require
ments such us the need for more plain water.
The available controlled data regarding the use of oral rehydration have been derived
chiefly from patients attending treatment facilities, and it would bo prudent for programmes Initially
to emphB.tiz.c activities that liave been recommended on the basis of such data. Future studies may
yield new data permitting recommendations on tiro most suitable methods for initiating oral therapy
in the home. For the present it is recommended that national programmes be based on the existing
health care facilities for use as diarrhoea treatment centres where simplified therapy can be supervised
by personnel who Itave received training.ftfalucatfon of the mothers on proper nutritional practices,
measures for the prevention of diarrhoea, and practical aspects of continued oral rchydration therapy
at home should be given when therapy for dehydrated patients is initiated at such centres, Village
health workers (VHW) must alro be trained to initiate and supervise oral rehydration therapy and
should likewise be able io educate mothers to continue tire administration of ora! rehydration at
home in addition to providing guidance on dietetic management, when to seek-mtdlcal care, and
how to prevent the recurrence of diarrhoeal episodes. Health centres and trained local health personnel
(VHB) should form pert oian integrated referral system t» provide backup faclHtia for tile treatment
of difficult or comp!!m ted casw^/
/
3. FttlN01?tEf. 52? THERAF?
/ Fluid and electrolyte therapy is given to remedy or prevent the physiological disturbances
which accompany acute diarrhoeas of all etiologies. Water, mineral salts and a source of food energyare the ingredients. Except for the route of administration, the principles of ora! hydration are the
same as those for parenteral hydrationt provision of water and mineral salts (electrolytes) to (1) replace
prior losses (deficits), (ii) provide ongoing replacement ofobiigatory metabolic losses, and (iii) replace
any losses produced by the continuing disease process^/
There are t ho three main principles that must be considered in attempting to use a single
oral solution In allsi nations. First, the presence of dehydration—that is, having a duficii—may require
a solution with constituents different from those needed when pmitntfon vf deficit—i.e,, wnitimtta) of the
hydrated state after repair—are the objectives, For example, deficit replacement (notation) necessi
tates more salt than duen maintenance. A disparity may also, arise If during the illness there has been
intake of either excccs water or excess electrolytes by the patient.
W& .i
SsgontHy, teoe v*i sg< cfote patient im'tedisa te proportionate-roqulrecnent fur water
as nietebtsik water fowl st': x teut'na cf aaftrjy. expenditure. An Hf/k-it (defined here arbitrarily as
a child-tawtet « y.£a,ra olagtt) prate®-and expends heat energy, per uftit mass, at 5 times she rate of
:<■; adult. The sfe-adcr 'he bite- is. te greater is the disparity. Cll'.lhhs-i (2 years u» puberty) foil Inbetween, Th!- iimdstnr.ntei difference, liupsted by sire and the te;:w?hcrr>i!<- nature of mamnte,
■ .-imitates wre water per unit tnfww for infaiils than .for children of adults; thus a net lower cohc ttration of tatote, which is rhe snun of the total euh.V.e divided by told water ddaffnistered In the
,; me nxrfod- !?. desirable for the Inline AttcrriaHvely, one con’d rerentnnend an 0RR With st lower
-a <tce-.tfr-itrm of ingrt:-diet>'-:<} but in t.didts tins would require Ingestion of inordinately large, probably
unpractical volumes of the duid to restore electrolyte loss®.adequately.
Thirdly, diarrhoea? diseases in genera* show great variability hi fate of stool Ims and ceaseq-iently in concent! arion of sodium (range front 5-140 mtnol/1) and potassium (lff-70 rnmol/1).
5.1
Xefanto
h; order to deal with test’ consideration’ and still retain the simplicity of a single formulatmn, specifically different instructions are needed for the use of ORS in Infants with ncn-cholem
disorders, /sr«ar&f(}- those under 6 months of age or under 7 kg. body woightyfn this regard some
comments about the ingredienb of OKU ate to order.
Glucnse; The glucose serves two functions: first, it facilitates sodium absorption via a coupling
mechanism in the litrnll intestine, and accord, It provide?, carbohydrate calories and thus has a protein.
sparing effect and prevent* ketosis. The glucose concentrate', of ’ll mmul/i ir probably ths minimum/wceaary for tuese functions; more «mid pnter.tia'i/ induce greatoi stool Joss 'ty.au osmotic
effect. Infants have incurred nc special problems with th,r level of glucose.
Sodium: The sodium concentration of 90 iniroi/i together with its accompanying anion
presents the infant with i\ very high renal solute load. Experience has shown that an infant, parti
cularly a small one (under 7 fo;), ingesting only ■>. sofution oi that conwntrathn may become hyper
natraemic, especially li'it Is under stress, lies fever, is hypervc'.ittlasing, or is living in high evnricntnental
temperatures or arid, surroundings where insensible water losses may be high.
/OMrr ainsMkritls: The other constituents, namely potassium, blcarbonftte and chloride, are
proper replacement ions to i.ruintain cellular function and extracellular fluid composites; the can rentration'. arc suitable for s wide range of encountered physiological, disturbances.
To avoid b.yeernatrnetnis ftmn use of ORS for this age group, it is generatty necessary to
provide additional water. One usefu* regirnen for rchydralion and maintenance has breti to give
10f' ml/iet/day of OKS ap:i 50 ml/kg/day of plain water, Interspersing the feedings at the ratio of
2 ofORS to I nrwate^TAn niternative of further diluting the reconstituted OKS itself may yield suit
able :;nditt)n ctmceitetteis but suboptlmal concentrations of the other ingredients thus reaming the
addition of potassium, bicariwiuite and glucose. In replacing losses In cases with a severe deficit.
iiowever, the full strength ORS may be used in an amount to meet the estimated deficit; thi: mnlutcnrmr.f regjmcn for such, crises should ir.ciudc the addition of plain water as described above (i.e.
'.? to I regimen) except in profuse cholera-like diarrhoea where the ORS per se should be continued.
Rehydmtfon iir’wpy should inelude not only the safeguard of giving additional plain water
but also the appreciation of the need for ft distinct endpoint of therapy, however aimpliflr.d, based on
the patient’s clinical appearance, ft is most important to avoid both insufficient or excessive ora!
therapy with resultant untirrlivdratioti or ovcrhydratlotf fk-nhh auxiliaries, and ss shown in seme
studies, even toothers, can be taught to differentiate sunken, norma! and puffy eyes and to asses-; skit!
elasticity and/or turgor. Wher. the patient’s activity, strength and 'aitertness, as well as appearance of
the eyes, skitt clastety and iurgor return to nortna?, and diarrhoea volume has dinteshecl, fejdings
i 9AC/»Dq/?B.i
. jjajje 4
st the breast or with diluted milk cast be 3ti6Hfti&ii for OKS and the patient tifestf*'ed. If proibse
• watery dlarrhoett reeurs. OKS cun be r&iim&l or sbfcdlitgs alternated with OHS. Infitnu old enough/
to take locally available foods other than mttk should be encouraged to do w» as soon as they dafere^./
During hydration therapy, dehydrated infants may not take enough volume because of
anorexia or intractable vomiting. Under these eircumstanees recourse should be had to parenteral
therapy, However, a smalt amount of vomiting should not lead, to discontinuation of oral hydration
therapy; instead the infant should, be observed for 10 to IS minutes to allow gastric emptying and'
oral rejiydraiion resumed in small voluntas.
Mothers whose infants need to continue ora! therapy tit home should be given Instructions
for proper mixing and administration and should be made to repeat these instructions before being
allowed to leave the health facility. They should a’fo receive instructions about breast feeding and diet
during and after diarrhoea, particularly with regard .to food items other than milk fwtanlng foods
in the appropriate age goup).
v
3.2
©Ider age gtwraps!
Older children and adults have higher stool r,odium concentrations (and lower potassium
concentrations) and can be safely treated with OR.S with extra water given when the patient desires.
Petients with more severe diarrhoeas and in shock—e.g., cholera—should receive initial intravenous
rehvdratioii to restore blond pressure followed by OUS to complete replacement of the deficit fiehydratlnn) and to replace continuing losses (maintenance); for niaititciuince therapy up to 1.3 times the
volume of karts hi diarrhoea and vomiais may he required to compasate for relatively higher stool
tlcctrolvte concentration:-.-Older children hiay rieed 250-590 tnl/h and adults Up to 7l?d->0CG mlih
during peak purging periods.
Most mild or moderately dehydrated cases can be rehydrated within 6 to 8 hours with the
□RS atone in volumes equivalent to 5-3% of body weight. This amount can be repeated if diarrhoea
continues. Patients who vomit during the course of therapy shoulil be maftaged as described for infants.
Diet erm usually lie resumed as soon as rehydratidh is complete; thus food should be offered
:arly in the maintenance stage.
I.
DiST!U8UTXCN O.?' ORS
Prepackaging of Ingredients (pharmaceutical grade to ensure a iong shelf-life) for n. volume
bnt corresponds to that of readily available local vessels is, in our view, the best method for cihlributiuu
)H5. When possible, packets should be prepared locally or on a regional bash. Large hospitals and
rcatment centres that are equipped with an adequate pharmacy and have the ingredients available
nn weigh, them and prepare the oial solution in bulk for daily use. Estimates of ORS teauirements
ased on the existing demand and projected need should be made prior io embarking on such an
ndertaking to maintain a continued supply,
t
A. small-sized packet for a proportionately small volume of fluid (e.g., 500 cc) may be more
ppropriate for infants under <5 niontlis of age. This will offer n better control oi the quantity of oi«l
uid administered to infem?, help prevent possible salt overload and nve.id the use of left-overs.
Sait-sugar preparations made at home by mothers using such methods as ' pinch and scoop”,
secial spoons, tlotnesti-" spoons, etc... should not be widely applied at present until further fi-.ld studios
sve determined the variability in the composition of such preparations and their safety and effeotivs:■ss for infants. Such methods should be subjected to rigorous evaluation with appropriate methoslogy (sec section 5).
BAC/DDC/79.1
page 5
5.
RESEARCH nSCW.5iWEW»ATION8
5.1 Varioiv ..'.ya of preparation of oral solutions at home by the "pinch and scoop” method,
or by special spoons, need to be carefully evaluated with particular reference to composition and
efficacy.
5.2 The hn: act of early, including home, management of diarrhoea with ORS in reducing
hospital referrals,
-tality and diarrhoea-related malnutrition needs further elucidation.
5.3 There i" a rrcat need for studies of various methods of communication for tcaclung and
training personnel ar varii./s levels, including mothers.
5.4 More sit; .bes on oral rehydration therapy of neonatal diarrhoeas arc required to establish
the basis for optimum recommendations for its use in this age group.
5,5 The use of amino acids such as glycine ns substrates in conjunction with glucose to
improve the absorption of ORS and reduce stool volume is an attractive field of study.
5.6 /A ser.rcl; fo- bescs or base precursors other titan bicarbonate—e.g., lactate, citrate,
acetate, etc., with particular reference to their efficacy and shelf-life when packaged with other
ingredients, would be mem .
5.7 Further e.viilua'T i of ORS composed of sr-dimn chloride, potassium citrate or acetate,
and glucose (without bicarbonate) is another research area of interest since it would reduce the
number of ingredients to three.
5.3 The absorption cTmagnesium and phosphate from oral hydration fluids in malnourished
children would be a useful
for research.
6.
SUMMARY ANT CONCLUSIONS
/ 6.1 Widespread use of oral rehydration therapy should form the major strategy in the
global diarrhoeal di;■ v control programmCyBnrkup facilities should be available for treatment of
the few severely dehydrated or otherwise complicated patients who require parenteral therapy.
6.2 From an administrative viewpoint there is a clear advantage in having a single formula
tion for the oral rehyurn’inn fluid. The WHO recommended composition is suitable for use in all age
groups and in all acute wafcry diarrhoeas. It may be used in infants provided it is given appropriately
with additional plain w: ter and stopped at the proper timd^Education and training ofbcallh personnel
nt all levels is essential to ensure proper use of oral therapy which should include dietetic management
dining and after an <;p;:t.de of acute diarrhoea, particularly in infants. /
6.3 Packaged ingredients for an appropriate volume is the best method of distribution of
ORS. Whenever possible, these should be prepared locally from plmrinaccuticul grade ingredients.
.Large treatment centres mr.y prepare the oral rchydration solutions in bulk, anti need not use packets.
A small-sized packet for • p> opo, ‘innately small volume of fluid may be better for use in infants.
6.4 A number of research priorities exist. The most important area is field evaluation of the
accuracy of mixing, safety and efficacy of oral solutions made from household salt and sugar by
mother* in the home.
&AG'DDC/79.i
page 6
1.
Harrison, H.(1954): *I1ie treatment of diarrhoea in infancy. Pedin!. Cth:. tf, A.-rw.> 11 335- "48.
2.
Harrison, H. £, & Finberg, L. ()959>: Hypernatremic dehydration, Pettial. Clin. N. Amer., 6» 193-199.
3.
Naitn, D. P,. & Cash. R. A. f 2974): Oral therapy for cholera. Jn.‘ Barna,! ). & B.h kiw.i, W. (eds) Chsbra. Philadelphia,
VV.B. Saunders Co., pp. 253-2fi1.
•‘. Nfllin, D. R. ft ai, (1979) Oral rrhydrndon and msiatHfinnec of chilrfrai with rotavirus and b»r<erh4 dtr.rrhoow.
(Ml. ml Hlth. Org f 37: No. 3 (m r«
DIARRHOEA
□a So you think that diarrhoea is a simple ordinary disease
not worth bothering about I Do you know that a child dies of it
every six seconds somewhere in the worid? In India, 1.5 million
children die of diarrhoea everyyear. Miss 2 turns to think about
this killer disease.
00
Well, I am not surprised that you have diarrhoea today.
That vendor's stall may look very tempting with those beauti
fully cut slices of water melon and fruit chaat. But did you
notice the flies? Go back 4 steps.
00 Advance 5 steps for motivating people in the village to
cover their toilet with earth as cats do. When these toilet 'piles'
dry, they are broken up and scattered by the wind and the rain
contaminating uncovered food and water.
00
People die of diarrhoea because they do not have enough
water left in their bodies. They die of dehydration I Advance 4
steps to the areas where there is diarrhoea epidemic.Encourage
people along your route to take enough fluids and salt to make
up for the fluids and salt lost with each watery stool.
□ 0 You have noticed that your younger brother, Ramu, often
one glass of water, put a pinch of salt and one tablespoon of
sugar. If you have a sour lime, a lemon, squeeze in a few drops.
has diarrhoea. Advance 2 steps to the hospital laboratory tak
ing with you a specimen of his stools. He may have a worm
infection. Those suffering from intestinal worms often have diar
rhoea.
00 You have diarrhoea, and yet you are happily eating
□ 0 There are several cases of diarrhoea in this hostel. Miss
pakoras, samozas and tikki. Don't you know that oily food is
not good for someone suffering from diarrhoea ? Miss a turn.
2 turns to prepare three jugs each of rice water, buttermilk and
nimbu pani. Add some salt to each jug. Encourage those suf
fering from diarrhoea to choose any one of these three drinks
and to sip it very slowly at intervals during the day.lf they gulp it
down ordrink it quickly, it could start a bowel movement.
00 Miss a turn to learn howto prepare the ORT solution. In
EE Did you get diarrhoea after taking those tetracycline tab
lets? Miss 2 turns to tell your doctor this. Certain drugs cause
diarrhoea as a side effect. Watch out for this.
00 Several children in this holiday camp have diarrhoea. I
notice many eat without washing their hands. And the cook,
does he wash his hands ? Go back 4 steps. YOUR negligence
is the cause of diarrhoea among the children.
00 Yes, many bottle fed babies suffer from diarrhoea. Why
aren't you advising mothers to breast feed their babies instead
of bottle-feeding them? Go back 5 steps.
□ 0 Go back 3 steps. Don't you know that severely malnour
ished children find it difficult to digest milk ? Why give them milk
when it can cause them diarrhoea? Dilute the milk if you must
give them some.
0 0 Have another turn if you can name 4 causes of diarrhoea.
00
Have you stopped drinking water, or any other fluid, be
cause you think you will have more watery stools? You are
making a huge mistake. Miss a turn. Continue to take fluids
otherwise you will get dehydrated. Remember, however, to take
only a few sips at a time.
0E3 As you are fortunate to live in a place where coconuts are
easily available and inexpensive, give the patient tender coco
nut water. It is the most sterile and nutritious drink you could
give him. Move 4 steps ahead to collect half a dozen coconuts
for him.
0H
as Boil a few well-washed guava leaves in 2 cups of water.
Continue to boil these until the water is reduced by half. Ad
vance 4 steps to tell everyone about this good remedy for diar
rhoea.
as
Bravo ! Your ORT stall at Allahabad railway station during
the Kumbha Mela and at the pilgrimage site did marvels to help
hundreds of pilgrims suffering from diarrhoea. Have another turn
as a reward.
as
Grandmas once said that anyone having watery stools
should not eat. Todaywe realize that we MUST eat. Take soft,
boiled unspiced non-greasy foods : rice, dal, porridge, arrow
root, sago pudding or apples boiled with cloves and sugar. Miss
a turn to spread this message.
Miss a turn to look at a serious case of dehydration at
the hospital. The eyes are sunken and dry.The tongue is also
dry. The skin has lost its elasticity. He is cold and his breathing
is deep and rapid. He has not passed urine for several hours.
He is drowsy as well.
H H Advance one step forward to buy some over- ripe bananas
00 Move ahead 3 steps to show people how to make this
for your neighbour who has diarrhoea. Over-ripe bananas are
good fordiarrhoea. But unripe fruit can cause diarrhoea.
00
You are inviting trouble by eating sweets from the ven
dor’s cart around which buzz dozens of flies. Go back 5 steps.
Coax the vendor to cover the sweets he sells ? He could then
continue to earn a living without spreading illness with his sale
of contaminated sweets.
00 You did well to tell people about yet another natural rem
edy for diarrhoea. Congratulations! Move three steps forward. A
teaspoonful of a mixture of poppy seeds and crystasI sugar
helps to check diarrhoea.
H0
Miss 2 turns if you cannot explain why it is very impor
tant to keep drinking while you have diarrhoea. If you can, you
may move ahead 4 steps.
good remedy for diarhoea. Roast 2 tablespoons of raw rice in a
pan. Then boil the roasted rice in 2 cups of water until there is
just half the quantity of liquid left in the pan. Cool it and then sip
it slowly.
□0
Move forward 2 steps to spread the message that black
tea made with a little ajwain is also good for diarrhoea.This is
yet another natural remedy for diarrhoea.
□ 0 Roast a teaspoonful each of methi seeds, jeera and ajwain
in a pan and then powder it. Divide the powder into three doses,
mixing each with a cup of curd. Add a little salt. Take it thrice a
day. Move 4 steps back telling people about this remedy for
diarrhoea.
□El My mother gave me a cup of curd mixed with a teaspoon
of dry ginger powder and some salt. That put an end to the
diarrhoea. I now feel well enough to jump 4 steps forward.
000 Have another turn if you can explain why salt should
be added to the ORT solution orto any fluid taken by someone
suffering from watery stools. Miss 2 turns if you cannot.
EJ 00 Move ahead 4 steps if you can repeat any 4 natural
remedies for diarrhoea. If you cannot, miss 2 turns.Try to listen
carefully when these are read out as the game continues.
00Q Excellent! You have noticed that the soft spot in the
centre of the baby's forehead is sunken. This is a sign of dehy
dration. If you can rememberthe other signs of dehydration you
can move ahead 5 steps ahead.
ana
You have now been on Oral Rehydration Theraphy
forfive full days and you still have watery stools and fever. Miss
a turn to have a stool test. You may either have typhoid, amoe
bic dysentry or intestinal flu.
00Has a chemist are you only concerned with selling your
stock of medicines ? Are you not concerned about people's
health ? How can you still sell Mexaform, Lomotil, Intestopan ?
These anti-dairrhoeal drugs have been banned as they have a
harmful effect on those who take them. Move back 3 steps.
HHEO Run ahead 5 steps and distribute these leaflets on
SMON - a disease people developed aftertaking several tablets of
anti-diarrhoeal drugs over a period of time. They went blind and
slowly became paralyzed. People should know the risk they
run when they take adti-diarrhoeal drugs.
000
Move ahead 5 steps. Tell everyone that the victims of
SMON in Japan took Ciba Geigy to court in Japan and made the
company pay them compensation for the disability they suf
fered as a result of taking the anti-diarhoeal drugs marketed by
the company. However, Ciba Geigy continued to sell Mexaform
in India despite this case in Japan. It claimed that our bodies
were different I
000
Why are you encouraging the use of anti-diarrhoeal
drugs ? Move back 3 steps. Don't you realize that these medi
cines seem to cure you and stop your watery stools almost
immediately. However,they hide the body loss of fluids ?
- Media
SDA-RF-CH-3.3.pdf
Position: 2841 (3 views)