Use Of Oral Rehydration Therapy Research Articles

Other bacterial diarrhoeas

Diarrhoea is the major manifestation of bacterial infection of the gut. These bacteria range from the mundane to the exotic, from the inconsequential to the lethal. As each year passes new organisms are found to be pathogens, and old ones are found to have new tricks that cause disease. This chapter’s purpose is to provide the reader with current information and thinking on the clinical syndromes associated with specific bacterial pathogens. Diarrhoea remains one of the leading causes of death in the world, despite progress in the use of oral rehydration therapy and antimicrobial drugs. Bacillary dysentery and chronic diarrhoea in the malnourished may well lead to more deaths than acute, dehydrating watery diarrhoea in many locales. Resistance to antimicrobial drugs is rampant in the developing world, and increasingly prevalent in the developed world. The challenges to the medical and public health establishments posed by these trends should not be underestimated. Old approaches to preventing and treating diarrhoea are being replaced as new ones evolve. It is useful to consider whether diarrhoea is watery, bloody or chronic, appreciating that the underlying molecular pathogenic mechanisms are usually mediated by toxins, adherence factors or invasion of the gut. The ecological balance of the gut microflora can become altered, and this alteration in and of itself can contribute to disease.

Tropical Pediatrics

Tropical pediatrics often is more a study of the consequences of poverty than of exotic infections. Pediatricians involved with the care of children in or from the tropics must deal with poverty, place an appropriate emphasis on preventive medicine, and seek to bridge their own cultural and linguistic barriers. Malaria, diarrheal disease, and malnutrition account for a large part of pediatric morbidity and mortality in tropical countries. P falciparum can cause severe malarial disease. Treatment must be initiated promptly; resistance to antimalarial drugs is possible. Hygienic and nutritional prevention of diarrhea must be coupled with widespread use of oral rehydration therapy for acute cases of diarrhea. Identification and early treatment of mildly malnourished children can prevent some of the mortality of overt marasmus and kwashiorkor.

Tropical pediatrics.

Tropical pediatrics often is more a study of the consequences of poverty than of exotic infections. Pediatricians involved with the care of children in or from the tropics must deal with poverty, place an appropriate emphasis on preventive medicine, and seek to bridge their own cultural and linguistic barriers. Malaria, diarrheal disease, and malnutrition account for a large part of pediatric morbidity and mortality in tropical countries. P falciparum can cause severe malarial disease. Treatment must be initiated promptly; resistance to antimalarial drugs is possible. Hygienic and nutritional prevention of diarrhea must be coupled with widespread use of oral rehydration therapy for acute cases of diarrhea. Identification and early treatment of mildly malnourished children can prevent some of the mortality of overt marasmus and kwashiorkor.

Impact of Selective Primary Care on Childhood Mortality in a Rural Health Zone of Zaire

Following the introduction of intensified child survival activities, use of health services for children increased markedly: measles vaccination reached 74% of children aged 12-23 months, and the use of oral rehydration therapy for the treatment of diarrhoea had increased. During the same period, childhood mortality declined by 33% for children aged 1-4 years. Data on cases of measles in the local hospital reveals that the pattern of measles epidemics characteristic of the years preceding programme implementation was altered in the years following programme implementation. The mean annual number of inpatient measles cases declined from 108 before the programme to 36 after its start. The high correlation between the number of inpatient measles cases and mortality at ages 6-35 months suggests that the programme reduced mortality largely by reducing the incidence of measles. Primary health care activities, supported in part by the Combatting Childhood Communicable Diseases Project, is estimated to have reduced mortality at ages 6-35 months by at least the 18-23% associated with the change in the incidence of measles and may have been responsible for the full 28% reduction recorded between 1980-1984 and 1985-1989.

A strategy for evaluating the mortality impact of child survival programmes in Africa: Combatting Childhood Communicable Diseases Project.

The Mortality and Use of Health Services surveys were designed to measure the mortality impact of the Combatting Childhood Communicable Diseases programmes which are based on childhood vaccinations, prenatal immunization against tetanus, home-based use of oral rehydration therapy, and presumptive treatment of malaria. The survey design includes pretest and post-test surveys in programme and non-programme areas. The questionnaires are designed to collect information on use of health services and on pregnancy histories to provide retrospective reporting of child mortality. When combined with data from surveillance systems (particularly information on cases of measles cases seen at clinics and health centres), these data should provide reasonable estimates of programme impact.

Mortality associated with acute watery diarrhea, dysentery and persistent diarrhea in rural North India

Mortality associated with diarrhea was investigated in a longitudinally followed cohort of children under six years of age in rural North India. During the follow-up, 1663 episodes of diarrhea and 23 diarrhea related deaths were recorded in 1467 children followed up for 20 months. The case fatality rate was 0.56% for acute watery diarrhea, 4.27% for dysentery and 11.94% for non-dysenteric persistent diarrhea. Most of the episodes lasted less than a week; 5.2% became persistent (duration > 14 days). The case fatality rate was similar in episodes of one and two weeks' duration (0.64% and 0.8%) and increased to 13.95% for persistent episodes. Of the total 86 persistent episodes, 22.1% were dysenteric; the case fatality rate for such dysenteric persistent episodes was 21.1% and for watery persistent diarrhea 11.4%. Diarrheal attack rates were similar among different nutritional groups, but diarrheal case fatality rates progressively increased with increasing severity of malnutrition, these were 24 times higher in children with severe malnutrition (7.48%) compared to those normally nourished (0.31%). With availability and use of oral rehydration therapy, dysentery and persistent diarrhea emerge as major causes of diarrhea related mortality, with underlying malnutrition as a key associated factor.

Use of Non Medicated Oral Rehydration Therapy to Treat Diarrhea and Scouring in The Young Calf

Diarrhea and scouring are still major problems associated with rearing of calves. Calf mortality in the dairy herd may be as high as 15% and much of this is attributable to deaths as a result of dehydration, electrolyte imbalances and physiological starvation, associated with digestive disturbances (diarrhea & scours). Although the use of oral rehydration therapy has been advocated for a long time producers have been slow to move away from reliance on antibiotics to treat diarrhea.
 Most oral electrolyte products simply aim at replacement of lost ions and perhaps replenishment of some energy with dextrose. Many of these electrolytes have severe imbalances in tonicity resulting in reduced absorption of ions. In addition, few electrolyte products slow rate of passage to prevent further excessive loss of ions through the feces.
 With these problems in mind, an oral rehydration product (ORP*) was developed and tested in clinical situations.
 The ORP consisted of a number of ingredients which are common components of diets and oral rehydration products for both animals and humans. These included: energy sources - dextrose, corn syrup solids, lecithin; fibers - to absorb water and slow flow rate in the gut; vegetable gums - to increase viscosity of gut contents to slow rate of passage and aid in suspension of insoluble fibers; electrolytes - sodium, potassium, magnesium.
 The formulation is proprietary but ingredients were: dextrose, apple flakes, oat hulls, dried corn syrup, xanthan gum, guar gum, vegetable fat, sorbitol, lecithin, sodium bicarbonate, salt, potassium chloride, ascorbic acid, calcium pantothenate, potassium phosphate, dried whey product, magnesium sulfate, polysaccharide complexes of icon, zinc manganese, copper and cobalt, fumaric acid, citric acid, calcium propionate, sodium propionate, potassium sorbate, ethylenediamine dihydriodide, silicon dioxide.

Epidemic cholera in the Americas.

Cholera returned to the Americas after a 100 year hiatus in Peru in January 1991. Fecal contamination of water caused this epidemic. Even though health authorities informed the public about cholera early in the epidemic holdups to providing safe water permitted its spread. By the end of 1991 there were 391000 cases and 4000 deaths in 15 countries. The use of oral rehydration therapy kept the case fatality rate much lower (1%) than it had been in the past (>20%). This epidemic is a continuation of the 7th cholera pandemic begun in Asia in 1961 with the new Vibrio cholerae 01 El Tor biotype. In Chile the vehicle for transmission of cholera was uncooked vegetables irrigated with raw sewage. Public health authorities forbade the sale of such vegetables and informed the public to cook all vegetables. A decline in the incidence of cholera and typhoid followed these measures. In Ecuador contaminated shellfish spread cholera. US cholera cases were infected in either affected Latin American countries on the airplane returning to the US or from contaminated seafood they brought to the US. Cholera control measures are often difficult to implement. For example the Americas need to invest >US $200 billion over 12 years to provide safe drinking water and adequate sewage disposal. Until funding arrives however governments can repair existing water distribution systems and chlorinate water supplies. In areas not provided with such services authorities can promote use of small mouthed water containers and/or boiling or chlorinated household water. Further health educators can encourage people to wash their hands to cook contaminated foods and to avoid food/beverages prepared by street vendors. Research is accelerating in developing an effective cholera vaccine such as the promising killed whole cell vaccine (subunit B). The epidemic in the Americas is expected to spread to the Caribbean the Amazon Basin and the Atlantic Coast.

Centrally processed weaning foods for use in developing countries

Abstract Many approaches are needed to improve child survival and growth in developing countries. Among these are improved sanitation, breast‐feeding promotion, immunizations, diarrheal disease control, and the provision of safe and nutritious weaning foods. This review considers weaning food developments in the context of aggregate data on changes in the nutrition situation in developing countries. Infant and child mortality and growth data are reviewed. These data reveal that progress has been made in many regions of the developing world in reducing infant and child mortality over the last 20 years. Less success is apparent in reducing the prevalence of linear growth retardation of preschool children. The importance of breast‐feeding and improved sanitary practices is stressed. This review is focused on the important role weaning foods can play in addition to other cultural and health inputs in improving growth and child survival in the developing world. Following a brief introduction to the weaning period, breast‐feeding and weaning practices in all regions of the developing world are reviewed. Weaning food developments, including compositional and processing alternatives, are then discussed in the context of nutritional requirements. Particular attention is devoted to various technologies to increase the energy density of weaning foods. In the context of all these factors, product specifications for weaning foods, as promulgated by the Codex Alimentarius Commission, are presented and discussed. Finally, studies in which supplementary feeding programs have been evaluated are reviewed. The data discussed in this review suggest strongly that the timely introduction of properly prepared weaning foods has an important role to play in improving child survival and growth in the developing world. Emphasis in this review is placed on the advantages of centrally processed weaning foods, but clearly home/village‐prepared foods also have an important role to play. The review emphasizes elementary principles of home sanitation in the proper use of weaning foods. Also, other elements of successful child health programs need to be present, including encouragement of breast‐feeding, child spacing, immunization, growth monitoring, and provision of and instruction in the use of oral rehydration therapy when needed.

Does ORT reduce diarrhoeal mortality?

Researchers analyzed 1976-88 data from rural Matlab in Bangladesh to examine changes in diarrhea and in acute watery diarrhea mortality among infants and children before and after the implementation of an oral rehydration therapy (ORT) program. Overall diarrhea mortality among infants increased consistently (3-13) in both the area with maternal and child health-family planning (MCH-FP) services and the comparison area (p<.001). Mortality from acute watery diarrhea among infants also rose in both areas (1-7; p<.001). Trends in diarrhea mortality among children were not as straightforward however. It peaked in 1983-84 due to a dysentery epidemic. 92% of mothers in both areas knew about the benefits of glucose and oral rehydration salts (G-ORS) packets or homemade ORT solutions but most mothers (78% in MCH-FP area and 85% in comparison area) incorrectly believed ORT would stop diarrhea. Only 58% of G-ORS local distributors had G-ORS packets on the day the community health worker visited. Infants with severe acute watery diarrhea ingested a mean of 400 ml of ORS during the 1st 2 days of illness which is inadequate to treat infants with severe dehydration or high purging rates. ORT promotion and home distribution of G-ORS did not decrease infant and child deaths from acute watery diarrhea. Possible reasons for this phenomenon are suggested: complications other than dehydration the small amounts of ORS used and reduced reliance on hospitals and increased delays before taking severely ill children to the hospital. The question of whether the relative increase in diarrhea deaths among infants was due to the decline in infant mortality from other diseases thus making diarrhea a predominant replacing disease in the Matlab was considered. The results indicated that health educators should work toward formulating clear messages which promote correct use of ORT. Health workers should consider ORT as 1 component among others in diarrheal disease control programs.

Cost effective strategy for promotion of appropriate case management of diarrheal diseases — Establishment of DTUs

Oral rehydration therapy (ORT) is one of the essential components of child survival technologies which are currently being utilised to reduce morbidity and mortality on account of common illnesses. ORT has made it possible to undertake a global effort to reduce deaths from dehydration and diarrhea associated malnutrition. Appropriate case management can also combat deaths from dysentery and persistent diarrhea. During the last decade considerable success has been achieved by incorporating this simple, effective and economic therapeutic intervention in the primary health care package. However, the ultimate objective of improved case management of diarrhea including the use of ORT at all levels of health care system is yet to be achieved. Patients with dysentery need antimicrobial therapy apart from ORT. Clinical experience has shown that with ORT and appropriate dietary therapy, most patients with persistent diarrhea can be managed effectively. Unfortunately, injudicious use of intravenous fluids and irrational prescription of antibiotics and anti-diarrheal agents is quite common even in the hands of pediatricians. The training of mothers visiting health facilities is poor for ORT and feeding. Establishment of diarrhea training and treatment units (DTUs) is aimed to improve current practices in the teaching hospitals and to promote appropriate case management of diarrhea by all health personnel.

Oral rehydration program evaluation by quality assurance sampling in rural Haiti.

An oral rehydration program in rural Haiti was evaluated by quality assurance sampling. The quality assurance sampling method and its application are described. The indicators measured were knowledge of the oral rehydration salts packet, knowledge of preparation of the solution from the packet, oral rehydration therapy use, and knowledge of preparation of the solution from salt and sugar. Coverages of the first two indicators were adequate, coverages of the latter two were inadequate. The method is a useful low-cost approach to evaluation of program coverage.

Economic Barriers to the Use of Oral Rehydration Therapy

Diarrheal dehydration is a highly prevalent condition among young children and is readily prevented and treated with oral rehydration therapy. We report a death due to hypernatremic dehydration caused by rotavirus diarrhea of a 9-month-old infant whose mother attempted to purchase oral glucose-electrolyte solution in a pharmacy but was unable to afford it. While efforts such as the National ORT Project should help to promote the proper at-home treatment of this condition, we conclude that oral rehydration therapy will not be used optimally by the parents of children living in poverty until the economic barriers to its use are removed.

Economic barriers to the use of oral rehydration therapy. A case report

Diarrheal dehydration is a highly prevalent condition among young children and is readily prevented and treated with oral rehydration therapy. We report a death due to hypernatremic dehydration caused by rotavirus diarrhea of a 9-month-old infant whose mother attempted to purchase oral glucose-electrolyte solution in a pharmacy but was unable to afford it. While efforts such as the National ORT Project should help to promote the proper at-home treatment of this condition, we conclude that oral rehydration therapy will not be used optimally by the parents of children living in poverty until the economic barriers to its use are removed. (<i>JAMA</i>. 1991;265:1724-1725)

Use of Oral Rehydration Therapy in Acute Watery Diarrhoea

Various foods and fluids have been used in traditional treatments for diarrhoeal illnesses in infants and children for centuries. During the last 2 decades, however, with the advent of an improved scientific understanding of oral rehydration, effective treatment of dehydrating diarrhoea has been improved, expanded and simplified. The appropriate use of oral rehydration solutions depends on an appreciation of the physiological mechanisms of diarrhoeal illness. Since dehydrating diarrhoea is such a common cause of morbidity and mortality, and because oral rehydration therapy is inexpensive, effective and adaptable, it has become a powerful intervention for improvement in health care for all ages. Newer formulations using starches, cereals and/or amino acids promise to make oral rehydration therapy even more efficacious and acceptable. Nearly all developing countries now have active national diarrhoeal control programmes which facilitate rehydration therapy as the first treatment of diarrhoea while discouraging the use of other diarrhoea medicines (e.g. kaolin and pectin, antispasmodics, etc.). Industrialised countries are also increasingly using oral rather than intravenous fluids. For most patients with lesser degrees of dehydration (up to about 8%) or no detectable dehydration, oral rehydration therapy is the only form of hydration needed. The 'standard' oral replacement solution recommended by the World Health Organization has the advantage of wide experience, demonstrated safety and effectiveness and wide availability. However, rehydration is only part of the management of diarrhoea, and nutritional management (including electrolytes and glucose, alternative substrates to glucose, inclusion of starches and proteins in the solution if possible, etc.) must also be integrated into programmes for diarrhoea control.

Oral Rehydration Therapy for Invasive Diarrhea

Current guidelines for the management of diarrheal diseases focus on the use of oral rehydration therapy (ORT). Clinically evident dehydration of a moderate degree is not uncommon with invasive diarrhea, and when it occurs, the response to ORT is satisfactory. Studies from hospitals and the community each document the effectiveness of ORT for rehydration of patients with invasive diarrhea. This has been confirmed in a clinical trial of oral rehydration solution (ORS) for the treatment of diarrheal diseases in children less than 5 years of age. Children with moderate dehydration benefited most from ORS, especially those who had culture-proven invasive diarrhea. Significant early weight gain was observed for this group of patients alone after rehydration with ORS. In developing countries, there is no reason to withhold ORT at the first signs of watery or dysenteric diarrhea regardless of the cause and independent of the decision to treat the patient with antimicrobial agents.

Brazil: System of health care for the poor

In Brazils poor regions the infant mortality rate approaches 200/1000 live births (compared to a national average of 68/1000) and close to 25% of the children are severely malnourished. To redress this imbalance in health resources a primary health care experiment has been launched by the National Bishops Conference of the Catholic Church outside of Florestopolis. The project which was begun in 1984 trained 176 volunteers from the poorest communities in the basic principles of child health: prenatal care advantages of breastfeeding measurement of weight and infant development vaccination promotion and use of oral rehydration therapy. By 1985 the infant mortality rate in the pilot project area has declined by 50% and hospital admissions for diarrheal diseases were down by 70%. Given the success of this project a national organization Pastoral da Crianca was set up by the Church to implement the scheme in other poor regions of Brazil. To date over 6000 groups coordinated by a trained community member have been established across the country. The leader who is most often a mother weights and assesses the development of all infants in her group of 10- 15 families and reports the results to a district organizer. The district organizer is responsible for providing ongoing training and supervision to the community volunteers. Outgrowths of this project in addition to improvements in child survival include community vegetable gardens cooperative pharmacies and political mobilization for social change at the municipal level. There are plans to extend this program to other Latin American countries.

Rotavirus

Since their discovery in the 1970s, the human rotaviruses have been recognized as the most important cause of acute infectious gastroenteritis among infants and children worldwide. Rotavirus has been found to infect almost all mammalian and avian species tested, and is primarily a disease of the young. In humans, rotavirus is the most frequent gastrointestinal pathogen in infants and children less than 2 years of age. In developing countries, the attack rate peaks at 6 months of age, whereas in developed areas of the world the virus is most commonly found among children 6–12 months of age. Rotavirus displays a marked seasonality in temperate climates, with the number of cases peaking in the colder winter months. In tropical climates, this seasonality is not as apparent, and infection may occur year round. Symptoms of rotavirus infection are non-specific and include vomiting and diarrhoea, occasionally accompanied by a low grade fever. Dehydration is more common with rotavirus infection than with most bacterial pathogens, and is the most common cause of death related to rotavirus infection. Treatment is non-specific and includes the use of oral rehydration therapy, especially in developing countries where malnutrition is common. Strategies for the prevention of rotavirus infection are dependent on advances in the understanding of the molecular biology of the rotavirus. The genetic structure of the virus has been extensively studied, and a number of the structural proteins have been identified. The neutralization antigens, located on VP4 and VP7, may be important in conferring immunity to rotavirus in vivo. Two animal-derived and several reassortant rotavirus vaccines are currently being evaluated in field studies, and a number of other candidate vaccines are being tested in vitro and in animal studies.

Community Health Assessment of a “Repopulated” Village in El Salvador

A community health assessment was carried out in San Jose las Flores, a village in rural northern El Salvador “repopulated” entirely by former refugees who returned to their area of origin in June 1986. In a survey of randomly selected households, knowledge of hygienic practices was documented among mothers, despite low levels of literacy and education. A campaign stressing sanitation and health education, conducted by village health promoters, and the use of oral rehydration therapy were associated by the health promoters with a decline in diarrheal mortality in children. Anthropometric measurement of children under five, however, showed an increase in acute undernutrition compared to survey data reported from the region in 1978. Respondents reported a high rate of total child mortality (255 of 1,000 live births), with cause of death attributed to actions of the Armed Forces of El Salvador (FAES) in 43% of cases. War‐related mortality of family members was also high (a mean of 7.1 per respondent), again with the leading cause of death (91 %) reported to be actions of the FAES.

UPDATE ON THE WORLD'S CHILDREN

Less than 5% of the poor world's children were being immunised at the start of the decade. Now the proportion is over 50%. The UN target is 85% vaccination coverage by the end of 1990. China is expected to achieve this by the end of this year, and India, with 20% of the world's infants, is now passing the 60% level. Immunisation saves lives and reduces morbidity—poliovaccination prevents 190 000 cases every year. But only 25% of pregnant women are vaccinated against tetanus, which kills 800 000 infants annually. Improvemments in transport and cool storage of vaccines have extended the reach of immunisation programmes. Almost half the developing world's children are not protected by immunisation—another 2-3 million lives could be saved and 240 000 cases of poliomyelitis could be prevented a year. Rapid spread of knowledge about family planning, especially birth spacing, is a major break-through. Births that are "too many or too close" or to mothers who are "too old or too young" cause up to a quarter of all maternal and infant deaths world wide. Sensible spacing of births could save the lives of 3 million children and 200 000 mothers every year. The use of oral rehydration therapy saves almost a million children annually and has been a success story. But another 1.6 million child deaths from diarrhoea could be saved if use of this simple and cheap technigue could be extended.