THE MANAGEMENT OF DIARRHOEA AND USE OF ORAL REHYDRATION THERAPY
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THE MANAGEMENT
OF DIARRHOEA AND
USE OF ORAL
REHYDRATION THERAPY - extracted text
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THE MANAGEMENT
OF DIARRHOEA AND
USE OF ORAL
REHYDRATION THERAPY
OZ&n
The World Health Organization is a specialized agency of the United Nations with
primary responsibility for international health matters and public health. Through this
organization, which was created in 1948. the health professions of some 165 countries
exchange their knowledge and experience with the aim of making possible the attainment
by all citizens of the world by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life.
By means of direct technical cooperation with its Member States, and by stimulating
such cooperation among them, WHO promotes the development of comprehensive health
services, the prevention and control of diseases, the improvement of environmental
conditions, the development of health manpower, the coordination and development of
biomedical and health services research, and the planning and implementation of health
programmes.
These broad fields of endeavour encompass a wide variety of activities, such as
developing systems of primary health care that reach the whole population of Member
countries; promoting the health of mothers and children; combating malnutrition;
controlling malaria and other communicable diseases, including tuberculosis and leprosy;
having achieved the eradication of smallpox, promoting mass immunization against a
number of other preventable diseases; improving mental health; providing safe water
supplies; and training health personnel of all categories.
Progress towards better health throughout the world also demands international
cooperation in such matters as establishing international standards for biological
substances, pesticides and pharmaceuticals; formulating environmental health criteria;
recommending international nonproprietary names for drugs; administering the
International Health Regulations; revising the International Classification of Diseases,
Injuries, and Causes of Death; and collecting and disseminating health statistical
information.
Further information on many aspects of WHO’s work is presented in the
Organization’s publications.
THE MANAGEMENT
OF DIARRHOEA AND
USE OF ORAL
REHYDRATION THERAPY
A Joint WHO/UNICEF Statement
Second edition
RARY
ind
AND
DOCUMENTATION
K
)
UNIT
WORLD HEALTH ORGANIZATION
Geneva
1985
First edition (unpublished), 1983
Second edition, 1985
z^' /,/ i q fl nZ’ /
/ c
ISBN 92 4 156086 X
© World Health Organization 1985
Publications of the World Health Organization enjoy copyright protection in
accordance with the provisions of Protocol 2 of the Universal Copyright Con
vention. For rights of reproduction or translation of WHO publications, in part
or in toto, application should be made to the Office of Publications, World
Health Organization, Geneva, Switzerland. The World Health Organization
welcomes such applications.
The designations employed and the presentation of the material in this
publication do not imply the expression of any opinion whatsoever on the part
of the Secretariat of the World Health Organization concerning the legal status
of any country, territory, city or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does
not imply that they are endorsed or recommended by the World Health
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Errors and omissions excepted, the names of proprietary products are
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- 3 -
CONTENTS
Page
Definitions • •...............................
5
Introduction
.................................
6
The scientific basis of oral rehydration
therapy .....................................
9
Programme recommendations .....................
18
National responsibility and external support
23
Selected reading
.............................
•
25
"The discovery that sodium transport and
glucose transport are coupled in the small
intestine so that glucose accelerates
absorption of solute and water was potentially
the most important medical advance this
century" (Lancet, 1978, ii, 300).
5
DEFINITIONS
Dehydration.
Loss of water and dissolved salts from
the body, occurring, for instance, as a result of
diarrhoea.
Rehydration.
The correction of dehydration.
Oral rehydration therapy (ORT).
The administration
of
fluid by mouth
to
prevent
or
correct
the
dehydration that is a consequence of diarrhoea.
Oral rehydration salts (ORS).
Specifically, the
standard
WHO/UNICEF
recommended
formula,
which
consists of four constituents:
1. Sodium chloride
3.5 grams
2. Trisodium citrate, dihydrate
2.9 grams
or
Sodium hydrogen carbonate
(Sodium bicarbonate)
2.5 grams
3. Potassium chloride
1.5 grams
4. Glucose
20.0 grams
to be dissolved in one litre of clean
drinking water
ORS is generally provided pre-packaged in a dry form
to be reconstituted when required.
6
INTRODUCTION
In 1980, an estimated five million children
under 5 years of age - about 10 every minute - died
as a consequence of diarrhoeal disease.
These
deaths were an outcome of the some 1 000 million
episodes that occurred in the developing countries
(excluding China) among the 338 million children in
this age group and were undoubtedly more frequent in
poorer families.
An estimated 60-70% of diarrhoeal deaths are
caused by dehydration.
Oral rehydration therapy
(ORT) can prevent and correct this dehydration and
thus prevent many of these diarrhoea-associated
deaths.
This
technological
breakthrough
offers
important new possibilities for reducing the number
of deaths in children because it can be used
throughout the health care system and can even be
administered in the home by family members.
ORT can be provided in the form of prepackaged
salts or as home-prepared
solutions;
both have
important roles
to play in
the management
of
diarrhoea. The present annual supply of ORS packets
(about 200 million) is only enough to treat some 10%
of all childhood diarrhoeal episodes.
There is an
urgent need to accelerate the production of ORS and
to disseminate more information about the early
treatment of diarrhoea in the home.
Diarrhoea is also a major factor
in
the
causation or aggravation of malnutrition. This is
because the diarrhoea patient loses his appetite and
is unable to absorb food properly, and because it is
a common practice to withhold fluids and
food
(including breast-milk) from him.
Such malnutrition
is itself a contributing cause to the high number of
deaths
associated
with diarrhoea
in
childhood.
Thus, continued feeding, both during and after a
diarrhoea episode, is an important part of the
proper management of diarrhoea, complementing ORT.
7
ORT is a simple, inexpensive, and effective
therapy; ensuring that it is widely available and
widely used is a major public health challenge. WHO
and UNICEF,
as well as numerous international,
bilateral,
and
voluntary
agencies,
are
now
collaborating with many countries in establishing
national primary health care services which include
diarrhoeal disease control programmes with ORT as
their cornerstone.
As more and more experience is
gained with ORT, the best types of solution to use
in different situations are becoming clearer.
This statement presents WHO’s and UNICEF’s
joint views on ORT in the light of experience to
date.
It should be borne in mind that it has been
written at a time when new scientific knowledge and
practical experience are being acquired at a rapid
rate.
The
paper
deals
in
particular
with
scientific, programmatic, and operational issues in
relation
to
ORT
which
are
important
in
the
development and strengthening of national diarrhoeal
disease control programmes.
It is not intended as
operational guidelines for the implementation of
these programmes; such guidelines would need to
address many other issues, such as the provision of
information to a wide range of
audiences,
the
training of health and other workers at various
levels,
the
nutritional
aspects
of
diarrhoea
management and prevention, and the use of water
supply and sanitation facilities and good hygiene
practices.
This statement views ORT in the context of
wider
national
diarrhoeal
disease
control
programmes,
which
are
themselves
an
integral
component of primary health care and need to be
linked
with
other
essential
elements
such
as
immunization and other maternal and child care
activities, including nutrition and birth spacing,
and
the
provision
of
essential
drugs.
These
activities have in common the need to reach the
family and strengthen community responsibility, and
require
supporting referral and other
services.
Making ORT, along with these other essential primary
health
care
interventions,
accessible
to
all
families requires managerial, organizational, and
financial
support.
Because
diarrhoea
is
so
frequent,
the
implementation
of
ORT
delivery
services offers an excellent entry point for the
strengthening of primary health care.
- 9 THE SCIENTIFIC BASIS OF ORAL REHYDRATION THERAPY
Principles of therapy
A person with acute diarrhoea-^- begins
to
lose essential water and salts from the onset of
illness.
Unless
these are adequately replaced,
dehydration will develop.
Prevention of dehydration
is therefore the first appropriate response to
diarrhoea.
Once a person is dehydrated^ he needs
to be treated in two phases:
(1) the rehydration phase - replacement of the
accumulated deficit due to fluid and salt
losses in stools and vomitus.
(2) the maintenance phase - replacement of
ongoing abnormal losses due to continuing
diarrhoea and vomiting, and replacement of
normal
losses
due
to
respiration,
sweating,
and
urination,
which
are
particularly high in infants.
Fluid replacement by injection into the veins
(intravenous
therapy)
was
first
used
for
the
treatment of dehydration from diarrhoea in the
mid-nineteenth century.
This technique, however,
requires sophisticated equipment, is costly, and
^’’Acute" diarrhoea is an attack of sudden onset,
which usually lasts 3 to 7 days but may last for up
to 10 to 14 days.
^The signs and symptoms that allow one to assess
the degree of dehydration and fluid deficit are
described in Treatment and prevention of acute
diarrhoea.
Guidelines for the trainers of health
workers.
Geneva, World Health Organization, 1985.
10 -
calls for specially trained workers.
The concept of
replacing fluid losses by mouth began to receive
attention in the 1960s, when a major breakthrough
was made with the successful use of an oral solution
containing glucose and essential salts to treat
cholera cases with very severe diarrhoea.
The
scientific evidence to explain the success of ORT
included the demonstration that the presence of the
sugar in ORT solution (glucose) made it easier for
the intestine to absorb water and sodium, a process
that remained unimpaired during acute diarrhoea.
Some 25
pathogenic bacteria,
viruses,
and
parasites have so far been identified as causes of
diarrhoea.
The mechanisms by which they produce
diarrhoea are varied:
some cause little or no
change in the lining of the walls of the intestine,
while others cause considerable damage to some areas
of the wall.
However, it is now firmly established
that, regardless of the causative agent or the age
of the patient, an ORT solution containing glucose
and essential salts is adequately absorbed and
replaces both previous and continuing fluid and salt
losses.
ORT does not stop the diarrhoea, but the
diarrhoea usually continues for only a limited time.
Composition and use of ORT
A rational response to diarrhoea is as follows:
(a)
To
prevent dehydration using
solutions
prepared from ingredients commonly found
in the home ("home remedies"); this should
be the first response.
(b)
To correct dehydration using a balanced,
more complete, glucose-salt solution; ORS
is the universal solution of this type
recommended by WHO and UNICEF;
- 11 -
(c)
To correct severe dehydration
(usually
defined as loss of 10% or more of body
weight)
by
intravenous
therapy;
this
method should also be used in patients who
are unconscious or unable to drink.
Prevention
of
dehydration.
Intensive
promotion by health and other workers of the use of
home remedies for the early treatment of diarrhoea
can be expected to result in fewer cases developing
dehydration during diarrhoea.
The use of
such
remedies should thus decrease the number of visits
to health facilities and community health workers
and the need for ORS packets.
Further studies are
needed to clarify the extent of these benefits.
There are two groups of home remedies:
(a)
"Household food" solutions - fluids or
liquids that are normally available in the home and
are appropriate for the early home treatment of
acute diarrhoea.
Such solutions are often prepared
from
boiled
water,
thus
ensuring
safety
for
drinking, and contain sodium, sometimes potassium,
and a source of glucose - such as starches - that
can facilitate the absorption of
salts in the
intestine; they also may contain other sources of
energy.
Two examples are rice water, often found in
homes in Asia, and various soups - e.g., carrot
soup, often found in homes in North Africa; other
less robust examples include juices, coconut water,
and weak tea.
There is a need to identify other
appropriate "household food" fluids in different
regions of the world.
(b)
"Salt and sugar" solutions - consisting
of white sugar (sucrose) and cooking salt (sodium
chloride).
In a few countries molasses or unrefined
sugar is used in place of white sugar; it has the
advantage of containing also potassium chloride and
sodium bicarbonate
More than 20 different recipes
joV' LIBRARY
and
OCUMdNTATION
UNIT
> o
r
) “
12 have so far been suggested for these solutions, and
methods for their preparation include hand measures
(e.g.,
"pinch
and
scoop"),
household
spoons
(metallic or home-made), and specially manufactured
double-ended plastic measuring spoons.
Each of
these methods has advantages and disadvantages, but
the proper use of all of them requires considerable
training of health workers and mothers and the
availability of sugar and salt, which may not be
affordable in the poorest homes.
Costs, seasonal
shortages, and varying quality of sugar or salt have
made it difficult to promote and implement the use
of "salt and sugar" solutions in the home in some
areas; in such cases the use of "household food"
solutions should be considered.
The
comparative
safety
and
efficacy
of
"household food" and "salt and sugar" solutions in
the prevention of dehydration are important subjects
that require further intensive study.
As these home remedies may have a varied
composition and usually lack or have insufficient
amounts of the ingredients in ORS (particularly
potassium and citrate or bicarbonate - see below),
they are not ideal for the treatment of dehydration
at any age.
However, they certainly should be used
at the onset of diarrhoea to prevent dehydration and
in situations where the complete formula is needed
but is not available.
The proper management of diarrhoea in the home
also includes, along with the administration of ORT,
the promotion of appropriate child feeding, both
during and after a diarrhoea episode, to prevent
excessive and uncompensated loss of nutrients.
In
many societies the parent’s remedial response to
diarrhoea is to withhold food and fluid, including
breast-milk, in the mistaken belief that this will
stop the diarrhoea and ease the strain on the
intestine.
This
"treatment"
only adds
to
the
dehydration and malnutrition caused by the illness.
- 13 -
Treatment of dehydration.
The treatment of
dehydration
requires
the
use
of
a
balanced
glucose-salt solution.
Much experience has been
gained in the use of ORS for the treatment of
dehydration in hospitals, clinics, and homes.
This
solution (see definitions for composition), which
WHO and UNICEF began to recommend and make available
in 1971, was selected because it is universal i.e., it can be used to treat dehydration from
diarrhoea of any cause, including cholera, in all
age groups.
The adoption of a universal solution
simplifies the production and distribution of the
solution (or
its
ingredients)
as well as
the
training of health care personnel at all levels.
This increases the availability and assures safer
use of ORT.
From the outset, ORS was envisaged for
use both to correct dehydration (the rehydration
phase) and to maintain hydration during continuing
diarrhoea
(the
maintenance
phase).
Extensive
experience has repeatedly demonstrated the safety
and efficacy of ORS as a universal ORT solution when
used correctly.
Some doctors have expressed concern about the
sodium concentration of the ORS solution because it
is substantially higher than that of some commercial
solutions marketed primarily in the industrialized
countries.
Many of these commercial solutions are,
however, recommended for maintenance phase therapy
only, and not for rehydration.
Experience has shown
that the use of ORS very rarely causes a blood level
of sodium above normal and that even when it does,
it
is usually very brief and of no clinical
importance.
Even in the newborn, ORS has been
proved safe provided that additional fluid is given
during the maintenance phase of treatment.
Thus,
young infants receiving ORS solution should be fed
breast-milk,
juices, weak tea,
or plain water.
While
ORS
with
a
substantially
lower
sodium
concentration can be used for treating most cases of
diarrhoea in infants, it is not suitable for use as
14 a universal solution; for example, it cannot be used
for rehydration treatment in cholera.
The
presence
of
potassium
in
ORS
is
particularly
important
for
the
treatment
of
dehydrated children, in whom potassium losses in
diarrhoea are relatively high.
Studies have shown
that
undernourished
children
who
have
suffered
repeated bouts of diarrhoea are especially likely to
develop a blood level of potassium below normal if
the potassium is not replaced during rehydration.
The citrate or bicarbonate in
for
the
treatment
of
acidosis,
frequently with dehydration.
ORS is
which
needed
occurs
Glucose
is
included
in
the
solution
principally to help the absorption of sodium and not
as a source of energy. Ordinary sugar (sucrose) can
be substituted for glucose with near equal efficacy,
though
twice
the
amount
of
sugar
is
needed.
Increasing the amount of sugar in the formula as a
means of improving palatability or increasing its
nutritive value is potentially dangerous as it can
worsen the diarrhoea.
Because ORS is sometimes considered by mothers
or health workers to have an unpleasant taste, a
number of other substances have been proposed as
additions to ORS to improve its flavour.
The
addition of any of these would substantially raise
the cost of manufacturing
the
product
without
increasing its efficacy.
Unflavoured ORS tastes
rather like tears, though a little less salty, and
is
acceptable
to
almost
all
infants,
whereas
flavoured solutions do not have a universal taste
appeal.
- 15 -
Use of QRS at treatment centres.
From studies
during the past decade, the following conclusions
may be drawn about the use of ORS in hospitals and
clinics:
(a)
About 90-95% of all patients with acute
watery diarrhoea, including infants, can
be
treated
with
ORS
alone;
in
the
remainder,
most
of
whom
have
severe
dehydration or are unable to take fluids
orally, intravenous therapy is required to
replace the deficits rapidly.
Hospitals
and health centres that have introduced
ORS have substantially reduced the costs
of treating diarrhoea cases, due to a
large decrease in the use of intravenous
fluid
and
in the number
of
hospital
admissions.
The average cost of treating
one patient with intravenous therapy can
be more than $5 as compared with less than
JO.50
with
ORS.
In
contrast
to
intravenous
therapy, ORS can be given
under
simple
conditions
and does
not
require any special equipment or highly
skilled personnel; thus there is increased
access to rehydration therapy.
(b)
In some hospitals, the use of ORS has
resulted in a substantial decrease in the
number of deaths from diarrhoea; this is
probably due to an increase in overall
concern regarding diarrhoea management and
a
decline
in
the use
of
intravenous
therapy and its associated risks.
(c)
While the use of ORS may initially require
more health workers’ time to train mothers
to give ORS to their children, in the long
term it frees hospital and health centre
staff
for
other
duties.
Of
greater
importance, ORS involves parents directly
16 -
in the care of their children and presents
an
excellent
opportunity
for
health
workers to communicate important health
education messages on diarrhoea prevention
and nutrition.
(d)
ORS is associated with very few side
effects.
Stool losses have been observed
to increase by up to 10% in severe cholera
cases (though this is of no major medical
significance),
but
are
not
usually
increased in diarrhoea from other causes.
Vomiting, when it occurs, usually does not
prevent
the
successful
use
of
ORS.
Over-hydration may occur occasionally, but
probably
much
more
rarely
than
with
intravenous therapy.
Thus, ORS has been
found to be remarkably safe.
Use of ORS at the community and household
level.
Since all the ingredients of ORS can be
readily packaged, it became apparent during the
1970s that ORS was extremely suitable for use as
part
of
primary
health
care
services
in
the
community and in the home.
The reasons are as
follows:
(a)
Community
health
workers
and
mothers
readily accept ORS for the treatment of
acute diarrhoea.
This has been shown in
many settings where
standard
diarrhoea
treatment
practices
had
previously
involved only the administration of often
useless drugs and referral to clinics and
hospitals for intravenous therapy.
(b)
In a number of research studies the use of
ORS for treating dehydrated children at
the community level has
decreased
the
number of deaths from diarrhoea by as much
- 17 as 50-60% over a one-year period.
(The
rates for longer time periods are not yet
known.)
(c)
The
delivery
of
messages
recommending
early and continued feeding together with
the administration of ORS by community
health workers has been associated, in
some settings,
with the prevention of
weight loss and with better weight gain in
young children.
It is not certain whether
this is because of more rapid correction
of the salt deficits by the ORS, resulting
in improved appetite and a
sense
of
well-being, or is a consequence of the
improved nutritional practices resulting
from the advice provided at the time ORS
is distributed.
18 PROGRAMME RECOMMENDATIONS
Comprehensive programme approach
Successful
prevention
and
treatment
of
dehydration
from
acute
diarrhoea
requires
a
comprehensive programme approach at the national
level which includes efforts on three fronts:
(a)
improving the outreach and effectiveness
of diarrhoea management throughout the
health system;
(b)
using
all
available
channels
to
disseminate knowledge, impart skills, and
encourage
the
practice
of
better
management of diarrhoea; and
(c)
producing
and
distributing
appropriate
supplies and equipment for the management
of diarrhoea.
Use of health system for delivery of ORT
Efforts need to be directed at three levels:
the household, the community, and the clinic or
hospital.
Early home
therapy is
important
to
prevent dehydration, ORS is needed to treat most
cases of dehydration, and intravenous therapy is
required
to
treat
severely
dehydrated
cases.
Efforts must be directed at strengthening health
delivery
services
and
enlisting
community
participation to support activities at all three
levels. More specifically:
(a) In the home, mothers and other members of
the family should be informed and trained (i) to
recognize diarrhoea in infants and children as an
illness requiring early treatment; (ii) to prepare
and give a "home remedy" by mouth; and (iii) to
recognize when they should seek additional care,
- 19 including ORS. The type of household solution to be
used and its method of preparation must inevitably
vary from country to country and even within regions
in the same country, depending on such factors as
cultural practices, the food normally used in the
home, the price and availability of salt and sugar,
the ability of mothers
to prepare a
solution
accurately,
the
presence
of
standard
measuring
utensils, and the extent of outreach of the health
delivery system.
Any of the approaches indicated
above for the preparation and use of home remedies
can
be
adopted,
though
in
most
areas
some
operational research may be needed to determine
which of the approaches is most feasible, safe, and
effective.
It is recommended that, if possible, the
home
remedy
should
have
sodium
and
glucose
concentrations that are between 50-100 mmol/1.
The
presence of even a small amount of potassium (e.g.,
that provided by fruit juices) can be beneficial.
Making ORS packets routinely available for home use
is probably feasible and desirable in only a few
(usually
small)
countries;
in the majority
of
countries the goal should be to have ORS packets
readily accessible in the community for those who
need them and who have had Instruction in their use,
which means distribution to the most peripheral
level of the health services as possible.
b)
The first-level health worker, e.g., a
community health worker, has a crucial role to play
in disseminating knowledge and
skills
for
the
management of diarrhoea, as regards the use of both
home remedies and ORS.
ORS packets should be
available in adequate supply at this level and
throughout the entire health system. If this is not
possible, maximum efforts should continue towards
this end and,
in the meantime, as complete a
formulation as possible should be used, recognizing
its
limitations.
When potassium is
a
missing
ingredient, patients should be encouraged to drink
fluids that are rich in potassium (e.g., juices).
- 20 -
For the preparation of ORS solution the safest water
available should be used.
(c) In
clinics
and
hospitals
having
the
appropriate equipment and trained staff, intravenous
fluids
should
be
used
to
rehydrate
severely
dehydrated
cases
and
the
few
other
diarrhoea
patients (e.g., those with vomiting that is not
responding to treatment) for whom it is required.
Efforts are needed to improve the use and quality of
intravenous therapy, especially for young children.
Other aspects of the management of diarrhoea
Two other aspects must complement ORT:
Feeding.
Experience shows that food should
not be withheld from infants and children with acute
diarrhoea.
Depending
on
their
feeding
status,
children should first receive breast-milk or diluted
milk feeds; in cases of dehydration, these should be
offered as soon as initial rehydration therapy has
been completed.
Appropriate locally available foods
(e.g., cereals) should be offered as soon as the
appetite returns.
After the diarrhoea ceases, more
than the usual amount of food should be given for a
short period. The routine use of any special infant
formulae (e.g., lactose-free products) for diarrhoea
cases should be strongly discouraged as they are
only rarely necessary and are costly.
Other drugs.
Selected antibiotics should be
judiciously
used
for
the
treatment
of
severe
dysentery and cholera; otherwise, there is no need
for other pharmaceuticals in the routine treatment
of acute diarrhoea.
Use of communication channels
Often
a
contributory
cause
of
childhood
dehydration and consequent death is the objection of
- 21 the
mother
to
providing
fluids
to
her
child
suffering from diarrhoea.
There is an urgent need
to understand her present attitudes, perceptions,
and practices regarding diarrhoea as well as those
of
health
and
other
community
workers.
Sociocultural research, group interviews and proper
pretesting are indispensable tools for the design of
messages
that
will
motivate
her
to
a
more
appropriate and timely response at the first sign of
diarrhoea. To change her attitude to the management
of diarrhoea,
and enhance her capacity for
it
requires a considerable but sensitive effort in
effective
person-to-person
and
mass
media
communication.
Appropriate educational and training materials
need to be prepared to transmit priority messages on
the preparation and administration of ORT solutions,
the importance of continued feeding, and the need
for referral if the child’s condition worsens.
Lessons on the causes and treatment of diarrhoea
should also be given in primary schools.
Mothers require individual instruction and
often need to observe a practical demonstration and
practise mixing a number of times in order to
prepare
ORS
or
’’salt
and
sugar”
solutions
correctly.
Separate guidelines
for
the management of
acute diarrhoea need to be prepared for first-line,
mid-level, and senior-level health workers.
These
should be based on well-established practices, but
adapted to meet local needs.
Production and distribution of appropriate supplies
There is a need for prepacked ORS
in a
suitable quantity for mixing in an appropriate,
’’universally" available measuring container.
Such
packets can be manufactured Industrially on a large
- 22 -
scale
by
government
or
private
pharmaceutical
companies using laminated aluminum foil to prolong
their
shelf-life,
or
produced
by
a
"cottage
industry" approach using less expensive packaging
material.
The seasonal character of diarrhoea in
the country should be borne in mind when timing both
the production and distribution of packets.
The use
of trisodium citrate in place of sodium bicarbonate
allows the use of cheaper packaging materials.
Any
packets produced locally should bear instructions
for
their
use
in
the
local
language(s),
and
preferably be accompanied by inexpensive pictorial
and printed material.
In
clinics
and
hospitals
with
even
the
simplest pharmacies, ORS can be prepared in bulk for
administration to visiting patients, and in simply
made packets for immediate use at home.
In view of
the need for greatly increased supplies of ORS, such
cost-saving measures should be implemented whenever
possible, and efforts should be made to develop
appropriate small-scale production technology.
The marketing and distribution of supplies of
prepacked
ORS
through
commercial
and
non-governmental channels should also be promoted.
Where a large enough demand can be generated through
widespread promotional efforts, it will be possible
to distribute ORS on a commercial basis, as has been
demonstrated in some countries.
In establishing programmes the production and
distribution of other supplies besides ORS, such as
intravenous fluids,
weighing
scales,
containers,
measuring spoons, and educational materials also
need to be considered.
- 23
NATIONAL RESPONSIBILITY AND EXTERNAL SUPPORT
The promotion of the proper management of
diarrhoea with emphasis on ORT depends on
the
government's decision and support in each country.
While the health services are the major instrument
for
implementation,
educational
channels,
communications media, non-governmental organizations
(especially
women’s
organizations),
and
other
sectors and agencies will also need to be involved.
External
cooperation,
both
technical
and
material,
from
international,
bilateral,
professional, and other non-governmental sources has
been an important factor in the progress made so
far.
If the goal of a much wider application of ORT
technology is to be achieved, this cooperation will
need to be increased and coordinated, especially in
view
of
the
present
very
difficult
financial
situation in the developing countries.
At the international level, WHO will
- promote an exchange of views with doctors
and the diffusion of technical information;
- support and encourage research to find new
drugs
and
vaccines and
to develop,
if
possible,
a
less
costly and
even
more
effective and stable ORS product; and
- organize
courses.
managerial
and
technical
training
At the country level, WHO and UNICEF will work
together in their respective spheres to support
- planning
and
evaluation
of
national
diarrhoeal
diseases
control
programmes,
bearing
in
mind
their
importance
and
relationship to the development of primary
health care services;
- 24 -
- training of community-based workers;
- development of communication and information
materials
on
ORT,
including
diarrhoeal
management at home; and
- establishment of ORS production at cottage
industry or manufacturing level, development
of appropriate production technology, and
provision of ingredients for ORS in bulk
supplies or packets.
Both
agencies
will
continue
to
support
operational
research,
including
social
and
behavioural studies, to identify the most suitable
and
effective
approaches
for
promoting
the
administration of ORT at the household and community
level.
This remains one of the most important and
pressing issues relating to research on primary
health care systems.
25
SELECTED READING
Oral rehydration therapy: an annotated
bibliography, 2nd ed. Washington, DC, Pan
American Health Organization Sci. Publ. No. 445
(1983).
Oral rehydration therapy (ORT) for childhood
diarrhea. Population Reports, Series L, No. 2
(revised 1984).
Oral therapy for acute diarrhoea.
615-617 (1981).
Lancet, ii,
Finberg, L., Harper, P.A., Harrison, H.E. & Sack,
R.B. Oral rehydration for diarrhoea. Journal of
Pediatrics, 101: 497-499 (1982).
Hirschhorn, N. The treatment of acute diarrhoea in
children: a historical and physiological
perspective. American Journal of Clinical
Nutrition, 33: 63?-663 (1980).
Mahalanabis, D., Merson, M.H. & Barua, D. Oral
rehydration therapy - recent advances. World
Health Forum, 2.: 245-459 (1981).
Snyder, J.D. & Merson, M.H. The magnitude of the
global problem of acute diarrhoeal disease: a
review of active surveillance data. Bulletin of
the World Health Organization, 60: 605-613 (1982).
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Oral rehydration therapy is simple,
inexpensive, and effective, but ensuring
that it is readily available and widely
used in developing countries is a major
public health challenge.
This booklet presents the views of
WHO and UNICEF in the light of expe
rience so far. It deals with scientific,
programmatic, and operational issues in
relation to oral rehydration therapy that
are important in the development and
strengthening of national diarrhoeal
disease control programmes. It does not
provide operational guidelines for the
implementation of these programmes.
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