Occurrence of diarrhoeal diseases in relation to infant feeding practices in a rural community in West Bengal, India.

In a rural community-based prospective study, diarrhoea in relation to the feeding patterns of a cohort of infants was studied. A total of 148 infants between the ages of 0 and 2 months were enrolled and followed until the completion of 1 year of age. Survival analysis showed that by the fourth month of age exclusive breastfeeding dropped by 75%. The proportion of complementary breastfeeding increased from 18.6 to 52.9% during the same period and to 83.7% by the eighth month. This study clearly highlights the tendency for early switch over from exclusive breastfeeding to complementary breastfeeding. Early weaning was associated with an incidence rate ratio (IRR) of 3.02 (95% CI 1.043-8.802). The IRR of 3.02 and its confidence limits (1.043-8.02) suggest a significant protective effect of exclusive breastfeeding against diarrhoea in infants. The results of this study indicate that promotion of exclusive breastfeeding has a potential role to reduce the incidence of diarrhoea amongst infants. The findings of this study will be useful for Diarrhoeal Disease Control Programme in reducing diarrhoeal morbidity.

Intestinal parasitism: a childhood problem in rural Bengal.

A study was undertaken to assess the parasitic infection rate in a rural community of West Bengal amongst children below four years of age suffering from gastrointestinal complaints. A total of 221 faecal samples were examined during November 1992 to April 1994. G. lamblia (17.2%) and E. histolytica (8.1%) were the predominant protozoas, whereas E. vermicularis (12.2%) and A. lumbricoides (8.1%) were found to be common amongst helminthic infection. A significantly lower infection rate was observed in children below one year (24.4 per cent) as compared to older age groups (66.4 per cent).

Epidemiology of Vibrio cholerae O139 with special reference to intrafamilial transmission in Calcutta.

A total of 27 families of hospitalised patients (index case families) suffering from acute watery diarrhoea caused by Vibrio cholerae O139, and 14 neighbourhood families were bacteriologically screened for 4 consecutive days to determine the extent of V. cholerae O139 infection amongst healthy contacts and other suspected vehicles of transmission at the intrafamilial level. V. cholerae O139 was isolated from faeces of 14.6% of healthy contacts in index case families as compared to none in neighbourhood families (P = 0.002). The organism could be recovered from 3.7% of handwashings of contacts of index cases and also from stored drinking water (8.0%), open well water (28.6%), flies (3.8%) and pond water (25.0%) used by the index case families and none from neighbourhood families. The large number of asymptomatic infected persons indicate an epidemiological similarity to that of eltor cholera. The organisms may be carried on hands and may act as a potential source of infection to other inmates through contamination of stored drinking water, open wells etc. The results will be useful in formulating strategies for intervention of transmission of V. cholerae O139 at the community level.

Review on development and community implementation of oral rehydration therapy.

The review of the current status and implementation of Oral Rehydration Therapy at the community level have been presented in this communication with special emphasis on its development, ORS access rate, ORS use rate and home available fluids. The global ORS supply has gone up an increased eleven folds since 1981. Similarly the ORS access rate has also increase from 46% to 68% in 1991. However, the global ORS use rate was low (21%). The major constraints during ORT implementation which have been reported by several scientists are also discussed.

PIP: Dehydration is the major reason children die from diarrhea. The key element of the WHO Diarrhoeal Disease Control (CDD) Programme is implementation of oral rehydration therapy (ORT). ORT implementation includes production and distribution of packets of oral rehydration salts (ORS), training of medical and paramedical personnel and education of mothers, and operational/health services research for identification of suitable strategies for implementation. Most ORT-related research has been done in hospitals. Community health workers in India have been given ORS packets to use to treat diarrhea cases at home. Operational research in India shows that volunteer health guides can train mothers to give available and culturally acceptable home fluids to children with mild diarrhea before dehydration develops. Use of home available fluids greatly reduces the need for ORS packets. Another possible alternative to ORS was sugar salt solution (SSS) or household formula, but research shows that mothers tend to prepare SSS inaccurately. The success of the CDD program depends on ORS production and proper distribution. In India, more than 100 companies produce about 130 different commercial ORS products, indicating a need for quality control. The best indicators to evaluate India's CDD program are ORS access and ORT use rates. In India, the 1991 ORS and ORT use rates were only 7% and 14%, respectively. The approach to ORT in India is mothers should treat children with diarrhea with no dehydration, village level workers should manage dehydrated patients with ORS, and health professionals at the nearest health facility should treat severely dehydrated patients with either ORS or intravenous fluids. ORT has reduced child mortality in India from 1.9% to 0.6%. Major barriers to ORT implementation are scarcity of resources, lack of political commitment, managerial and organizational problems, and problems related to community participation, health personnel, and dissemination of information.

Maternal behaviour and feeding practices as determinants of childhood diarrhoea: some observations amongst rural Bengalee mothers.

PIP: In India, epidemiologists followed 980 rural families with children less than 3 years old living near Calcutta in West Bengal to identify determinants related to maternal behavior and feeding practices of childhood diarrhea. They identified 570 families with diarrhea cases and 410 families with no diarrhea cases. Children with diarrhea were more likely to live in Kuchcha housing (44.7% vs. 33.9%; p = 0.0006), to have a family income of less than Rs.500/month (44.2% vs. 36.6%; p = 0.016) and a mother who was illiterate (53.5% vs. 45.4%; p = 0.013). Nondiarrheal families were more likely to have a sanitary latrine (63.9% vs. 50.5%; p = 0.000031) and have soap (for ablution, 22.9% vs. 14.4%; p = 0.0005 and, before food handling, 7.1% vs. 3%; p = 0.0046). Mothers with children who did not have diarrhea were more likely to space their births at least 4 years apart than those with children who did have diarrhea (20.5% vs. 14.7%; p = 0.018). Mothers with children who did not have diarrhea were also less likely to practice poor hygiene. Specifically, they would tend not to use leftover food for the next feeding (19.1% vs. 38%; p = 0.02), to have children whose body and clothes were dirty (19.1% vs. 40%; p = 0.01), to dispose of stools indiscriminately (55.3% vs. 73.7%; p = 0.02), to share a common latrine with other villagers (15.9% vs. 36.2%; p = 0.008), and to stop drinking water in a wide mouth container (66% vs. 84.8%; p = 0.008). Mothers with children who did not have diarrhea were also more likely to wash the container used for feeding the children with soap (48.9% vs. 30.4%; p = 0.03).^ieng

An operational study on implementation of oral rehydration therapy in a rural community of West Bengal, India.

An operational study of a 3-tier strategy for implementation of oral rehydration therapy (ORT) was conducted in a block of West Bengal with 216,825 population through the existing health services facilities. All the grassroot level, health workers including their supervisors at various levels were trained regarding the management of patients of diarrhoea with mild to moderate degree of dehydration, by ORT. Another block in the same district with similar demographic features where this intervention was not provided served as control. After 22 months of observation, it was evident that despite adequate training, the performance of Community Health Guides (CHGs) and Anganwadi Workers (AWWs) was not encouraging because of the low utilization of both home available fluids (32.0%) and oral rehydration solution (18.0%) in the study area. Similarly, diarrhoea associated mortality could not be reduced significantly. Lack of motivation and failure to maintain sustained level of skill by the CHGs and AWWs constitute the major bottlenecks for the successful implementation of the programme at the community level.

PIP: Between April 1985-January 1987, researchers conducted a 3 stage operational study of oral rehydration therapy (ORT) implementation in 2 rural blocks of Hooghly district in West Bengal, India. ORT implementation only occurred in 1 block. The stages included training of community health guides (CHGs) and Anganwadi workers (AWWs); monitoring, supervision, and logistic support; and health and practices surveys. Home available fluids (HAF) usage rate increased from 31-53% in the study block, but fell to only 32% by January 1987. In fact, the initial and final HAF usage rates for the study block were comparable to those of the control block (31% vs. 28.4% and 32% vs. 30%, respectively). Moreover the corresponding figures for oral rehydration solution (ORS) use stood at 13% vs. 8% and 18% vs. 18%). Despite several CHG and AWW training sessions on informing mothers to use ORT in adequate amounts as early as possible during a diarrheal episode, only 12.4% of mothers ever educated by a CHG/AWW knew to do so. In fact, none of the mothers administered ORT early or in adequate amounts. Furthermore diarrhea related mortality remained essentially the same in the study area throughout the study (2-2.8) and indeed the lowest rate (1.7) was in the control area in April 1986. Even though mothers in the study block were significantly more likely to know about oral rehydration solution (ORS) and the availability of free treatment for diarrhea in the village (57% vs. 26% and 34% vs. 13% respectively; p.05), no difference in use of HAF and ORS during diarrhea occurred (26.8% vs. 20% and 11% vs. 12% respectively). The researchers concluded that the major obstacles for improvement of HAF and ORS use were lack of motivation and the CHGs and AWWs inability to maintain a sustained skill level.

Report of an outbreak of diarrhoeal disease caused by cholera followed by rotavirus in Manipur.

An outbreak of acute diarrhoeal disease between August and October 1985 in 3 districts of Manipur state was investigated amongst 9,29,077 population at risk. The overall attack rate and case fatality rate were 0.2% and 0.9% respectively. Hospital records revealed that 58.8% of cases occurred amongst older children above 5 years of age. V.cholera was isolated from 25.3% of cases sampled. Interestingly, increased frequency in weekly admission of cases amongst children during first two years of life increased in the beginning of October when the original peak of diarrhoeal outbreak was about to decline. The October peak was caused by rotavirus which could be detected from 50.0% of diarrhoeal children in this age group. This possibly reflected beginning of the usual rotavirus diarrhoea season in the locality.

PIP: Between August 24-October 20, 1985, an outbreak of acute diarrheal disease occurred among 1833 children in Imphal, Bishenpur, and Thoubal districts in Manipur State in India for an overall attach rate of 2/1000. 17 children died, a case fatality rate of 9/1000. Hospital and health center personnel treated 1711 cases with rehydration therapy (oral or intravenous fluids). Local, mainly unqualified, practitioners treated the remaining 122 cases with antidarrheal drugs. Children treated at home were more likely to die than those treated at health facilities (case fatality rates 0.6% vs. 4.9%; p.001). Nevertheless these case fatality rates were lower than those in a 1973-1974 outbreak of gastroenteritis in Manipur, perhaps because the health authority distributed oral rehydration solution packets during this 1985 epidemic. The leading symptoms were watery diarrhea (82.5%), vomiting (67.5%), and abdominal pain (37.5%). Children 5 years old tended to experience severe dehydration more so than younger children (31.3% vs. 12.5%). 58.8% of hospitalized cases were older children who suffered the highest death rate. (1.9%). Peak admissions occurred the last week of September ending on October 2. Yet during the decline phase, the admission rate of children 2 years old rose. 25.3% of cases sampled recovered V. cholerae with the highest isolation rate (30.8%) found in older children and adults. 50% of fecal samples of children 6-23 months old tested positive for rotavirus. The researchers did not find any obvious epidemiological link between the 3 areas. They concluded that the rotavirus epidemic which peaked the week after that of cholera represented the beginning of the usual rotavirus diarrhea season.

Comparison of selective media for primary isolation of Aeromonas species from human and animal feces.

Five selective media were evaluated for their effectiveness in the primary isolation of Aeromonas spp. from human patients with acute diarrhea and from healthy domestic animals. Sheep blood agar with 30 mg of ampicillin per liter (ASBA30) yielded a significantly higher percentage of positive specimens as compared with the four other media. The effective combination of two selective media with which 98% of all isolates were detected and with which all of the three human-associated Aeromonas spp. could be isolated was ASBA30-DNase-toluidine blue agar. ASBA30 was the most sensitive medium since it permitted more growth of Aeromonas colonies and effectively suppressed competing microflora. We recommend the use of ASBA30-DNase-toluidine blue agar for investigations in which an attempt is made to assess the significance of Aeromonas spp. in the etiology of human diarrhea.

Effect of doxycycline on transmission of Vibrio cholerae infection among family contacts of cholera patients in Calcutta.

Doxycycline was used among the family contacts of hospitalized cholera patients in Calcutta to determine its effectiveness in controlling transmission of V. cholerae infection. A total of 137 such contacts were given a single oral dose of doxycycline in graded doses according to age. A similar group of 139 contacts received a single dose of multivitamins as placebo. All 276 contacts were examined bacteriologically daily for 10 days for the presence of V. cholerae in their stools. The results showed that doxycycline was effective in significantly reducing the load of V. cholerae infection for up to 5 days following treatment.