Impact of vitamin A supplementation to rural children on morbidity due to diarrhoea.

BACKGROUND AND OBJECTIVES: a number of studies have shown the association between vitamin A deficiency and the increased risk of diarrhoeal and other childhood morbidities and mortality. However, some studies have raised controversies regarding the reduction of the incidence of diarrhoea after vitamin A supplementation to children. This study was undertaken to evaluate the effectiveness of vitamin A supplementation to young rural children in reducing the incidence of diarrhoea. METHODS: a double-blind randomized intervention trial was carried out amongst 404 rural children between 6-59 months of age to assess the impact of vitamin A supplementation on morbidity due to diarrhoea. Children aged 6-59 months were enrolled and allocated to receive either 200,000 or 50,000 IU of vitamin A and the same dose was repeated after six months. Morbidity due to diarrhoea was observed by twice-a-week household surveillance, during the subsequent one year of follow up. The incidence of diarrhoea was compared between the two supplemented groups. In addition, the overall incidence of diarrhoea n the two supplemented groups was also compared with the incidence observed during the year preceding supplementation. RESULTS: the incidence of diarrhoea was similar in the two supplemented groups (Incidence Rate Ratio = 1.05. 95% C. I. 0.79-1.40). However, the overall incidence of diarrhoea among all the children in the two supplemented groups (0.56 episodes/child/year) was significantly lower than the incidence before supplementation (1.15 episodes/child/year). The Incidence Rate Ratio was 0.49 with 95% C.I 0.40-0.59. INTERPRETATION AND CONCLUSIONS: the results of this study indicate that vitamin A supplementation in a dose of 200,000 IU, has no additional advantage over 50,000 IU, at least when the aim is to reduce the incidence of diarrhoea. For control of morbidity due to diarrhoea, vitamin A supplementation in a dose of 50,000 IU every six months appears to be adequate, cost effective and suitable for younger children.

Maternal knowledge on risk behavioural practices and it's association with diarrhoea in a rural community of West Bengal, India.

Knowledge of rural mothers related to five diarrhoeagenic risk behaviours, identified in an earlier study, was ascertained. A high proportion of mothers (67%-79%) had knowledge about risk of bottle feeding, non-use of soap for cleaning feeding containers, storage of drinking water in wide-mouthed vessels and indiscriminate disposal of children's faeces. However, only around 31% of mothers were aware about danger of using pond water for cleaning feeding containers. Risk behavioural practices were less amongst mothers who had knowledge about them. Risk of diarrhoea amongst children of mothers having risk practice without knowledge as compared to those who utilised their knowledge to avoid risk practice was found significantly higher (p < or = 0.005) except for bottle feeding (p = 0.330). The results of this study indicate that children can be protected significantly from diarrhoea if mothers' diarrhoeagenic behaviours can be altered through educational intervention.

Risk behavioural practices of rural mothers as determinants of childhood diarrhoea.

Maternal behaviours related to certain child care practices which possibly have a contributory role in causation of diarrhoea in children were studied. Comparison was made between behaviours of mothers in 108 families having diarrhoeal children (Case families) with mothers of 72 families having age and neighbourhood matched non diarrhoeal children (control families) using a logistic regression model. Five risk behaviours were identified and these are bottle feeding (OR-2.87; CI-1.30 to 6.34), non-use of soap for cleaning feeding container (OR-2.61; CI-1.30 to 5.23), water storage in wide-mouthed container (OR-2.75; CI-1.27 to 5.96), use of pond water for the same (OR-2.36; CI-1.15 to 4.84) and indiscriminate disposal of children's stool (OR-1.99; CI-0.97 to 4.08). Around 83 per cent of diarrhoeal families could be predicted using these five variables only. The first three of these five risk behaviours were responsible for occurrence of significantly higher incidence (3 or more episodes) of diarrhoea in the case families. All these risk behaviours are amenable to change if suitable intervention is initiated. The result of this study would be helpful in reducing diarrhoea associated morbidity to a substantial level.

PIP: A number of studies have documented the existence of a relationship between certain behavioral practices at the family level and an increased incidence of diarrhea among children. Findings are reported from a study in which mothers' behaviors in diarrheal and control families were compared to selected child care practices which may help cause diarrhea in children. The authors compared the behaviors of mothers in 108 families having children with diarrhea (case families) with mothers of 72 families having age and neighborhood matched nondiarrheal children (control children) using a logistic regression model. The following risk behaviors were observed: bottle feeding, non-use of soap for cleaning feeding containers, water storage in wide-mouthed containers, the use of pond water for the same, and the indiscriminate disposal of children's feces. 81.5% of diarrheal families could be predicted using only these 5 variables. The most significant risk behavioral practices of mothers were bottle feeding, non-use of soap for cleaning feeding containers, and drinking water storage in wide-mouthed containers. All of these risk behaviors are subject to change if exposed to the appropriate interventions.

Value of faecal leucocyte count as an indicator of invasiveness in mucoid diarrhoea.

Importance of faecal leucocyte count as an indicator of invasiveness in mucoid diarrhoea was studied. A total of 290 faecal specimen, 170 from mucoid diarrhoea and 120 from watery diarrhoea were examined for faecal leucocyte count under high power field (hpf) from rural children below four years of age during the period from November 1992 to October 1995. Faecal leucocyte count > 10/hpf was noted in 45.9% of mucoid diarrhoea as against 19.2% of watery diarrhoea (p < 0.0001) samples. From faecal samples with > 10 faecal leucocyte count, invasive pathogens could be recovered in 19 (24.5%) to none of 23 patients with watery diarrhoea (p < 0.006 Fisher exact test). This sample test appears to be of value as an indicator of invasiveness in mucoid diarrhoea in the absence of culture facility.

Isolation of Escherichia coli to detect faecal contamination of infants and their mothers in West Bengal.

The present study was undertaken to gain insight into the sources of faecal contamination of infants in rural Bengal. It was carried out in three villages near Calcutta, India, from June 1993 to August 1995 among 148 infants and their mothers. Escherichia coli was used as an indicator of faecal pollution. A total of 725 samples, including hand rinsings of children and mothers, feeding utensils and leftover food were examined. The total isolation rate of faecal E. coli was 30%. The isolation rates from hands of children and mothers were 17% and 40% respectively. The germs from 30% of utensils and 59% of leftover food and drinks were recovered further. The study highlights the precarious hygiene in rural Bengal.

Investigation of the outbreak of cholera in Alleppey & Palghat districts, south India.

In May 1996, a massive outbreak of cholera occurred in Alleppey district of Kerala which spread to Palghat district by July 1996. Of the 575 patients hospitalized at the Alleppey Medical College hospital between May 1 and August 2, 1996, 30 deaths occurred with a case fatality rate of 5.2 per cent while of the 638 diarrhoea patients admitted at Agali PHC of Attapadi area in Palghat district, 30 (4.7%) deaths were recorded. Clinically, the patients had profuse watery diarrhoea with vomiting. The epidemic of cholera in Alleppey and Palghat districts was caused by V. cholerae O1 of the EITor biotype, Ogawa serotype which possessed both the ctxA and tcpA genes when examined by multiplex PCR. Gross contamination of water sources was incriminated as the cause of the epidemic.

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.

Epidemiological and clinical profiles of acute invasive diarrhoea with special reference to mucoid episodes: a rural community-based longitudinal study.

A study was carried out in 3 villages near Calcutta, India, having a population of 5464, between August 1992 and December 1994. A cohort of rural children below 4 years of age was prospectively observed to determine the clinico-epidemiological aspects of mucoid diarrhoea and examine propensity to invasiveness. Overall, the incidence of diarrhoea was 1.7 episodes/child/year, and that of mucoid and bloody dysentery was 0.8 and 0.2 episodes/child/year, respectively. Children aged 6-11 months had a higher incidence of mucoid diarrhoea (1.3 episodes/child/year) and the peak season occurred in June and July. Multivariate analysis using logistic regression showed that mucoid diarrhoea and bloody dysentery were closely similar in both clinical and laboratory findings, including raised faecal leucocyte count (> 10/high power microscope field [hpf]). However, abdominal pain occurred more frequently in bloody dysentery than in mucoid diarrhoea. Faecal leucocyte count (> 10/hpf) can therefore be used as an indicator for invasiveness of mucoid diarrhoea at the community level.

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.

Epidemic of Vibrio cholerae 0139 in Calcutta.

As one of large outbreaks of cholera-like illness in the Indian subcontinent, Calcutta and its neighbouring areas experienced an unprecedented epidemic due to a new strain of V. cholerae non-01, designated as V. cholerae 0139 Bengal, since January 1993. This epidemic predominantly affected the adult population of Calcutta as evidenced by the hospitalization of more adults at the Infectious Disease Hospital, Calcutta (IDH), which bore the main brunt of the epidemic in and around Calcutta. During the peak of the epidemic about 180 to 300 diarrhoea patients were admitted daily at the IDH. Of the 807 patients screened, 407 were positive for V. cholerae 0139 and majority (82.8%) of the cases were > 10 yr of age. Severe dehydration was recorded in 85.5 per cent of the cases.

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.

Implementation of ORT: some problems encountered in training of health workers during an operational research programme.

During an operational research study on implementation of oral rehydration therapy in a block of West Bengal, India, amongst a population of 2, 16,805, a total of 171 Community Health Guides and 152 Anganwadi Workers were initially trained for one working day by lectures and slides about diarrhoea case management at the community level. The training was evaluated after two months and found to be inadequate. The workers were then retrained with modern approach using a module (prepared in local language) as suggested by World Health Organisation. The level of retention of the imparted knowledge of Health Workers for different items 2-3 months after training with lectures and slides ranged between 5-25% except preparation of ORS which was 80%. With the use of modules, 47-98% of health workers could retain the same knowledge 3 months after the training. The knowledge thus acquired were sustained even after 12 months of training to a level which was still much better than that retained 2 months after training with slides and lectures. However some of the items like indication of use of Home Available Fluids, dosage of ORS and when to refer a diarrhoea case to health facility were more difficult to recall after one year. This possibly indicates need for in-service training of grassroot level health workers at suiTable interval.

PIP: In India, the National Institute of Cholera and Enteric Diseases implemented an operations research project on oral rehydration therapy in the rural block of Polba of Hooghly district in West Bengal. Its physicians used lectures and slides to train grassroot level health workers about dehydration signs, management of diarrhea, referral of patients with diarrhea to the Primary Health Center, and how to educate mothers in the community about early management of diarrhea. Each health worker received a reference booklet, prepackaged oral rehydration salts (ORS), and a 1-liter standard plastic container. Two months after the initial training, their knowledge was reevaluated and they underwent retraining. A module in Bengali was used for the retraining. It consisted of individual readings, examples and exercises of simulated conditions, discussions, role playing, and demonstration of ORS preparation. The workers were reevaluated at 3 months and 1 year post-retraining. Other than preparation of ORS (80%), few grassroot workers retained the messages delivered via the lecture and slides approach (5-25%). For example, only 5% could correctly identify the signs of dehydration. On the other hand, many more health workers retained the messages delivered via the modular approach 3 months after retraining (47-98%). At 12 months post-retraining, dosage of ORS, referral, and use of home fluids were more difficult to recall than were signs of dehydration, indication of ORS, and preparation of ORS (18-29% vs. 48-87%). These results show that periodic refresher training increases knowledge to a sustained level. The researchers concluded that simple booklets in local scripts facilitate efficient training of health workers in diarrheal treatment services. Each worker should have his/her own personal copy.

An outbreak of acute diarrhoeal disease amongst tribal population in Tripura.

A massive outbreak of acute diarrhoeal diseases occurred during March-April, 1992 in the north district of Tripura. Investigation of the outbreak revealed Vibrio cholerae 01 biotype ElT or as the main etiologic agent in 50 per cent of patients. The outbreak which started amongst the tribal population might have spread due to prevailing illiteracy, poverty, low personal and domestic hygiene and vulnerable water sources (chhara water).

Prevalence of diarrhoeal diseases amongst tribals of Car Nicobar Island, India.

In a cross sectional study of total 14514 tribal Nicobarese people of Car Nicobar Island, an union territory of India, situated in Bay of Bengal, morbidity, mortality and treatment practices of diarrhoeal diseases of under-five children were surveyed. The incidence of diarrhoea (0.2 episode/ch.year), Crude death rate (3.6/1000) and IMR (31/1000 live births) were exceedingly low as compared to SouthEast Asian Countries including mainland of India. ORS utilisation rate was high (41%) as compared to the National figure (12.0%). This is the first study of it's kind carried out in this island and amongst the Nicobarese tribe in India. A preliminary study carried out among the mothers of the hospitalised children indicated that protective behaviours like breast feeding, hand washing, use of chlorinated water and proper disposal of stool were regularly being practiced by the community traditionally. An in-depth study on risk factors of diarrhoea in this island can yield useful clue for describing the same.

Occurrence of multi-resistant Salmonella typhimurium infection in a pediatric hospital at Calcutta.

Salmonella typhimurium was isolated from 55 (15.9%) of the 347 hospitalized diarrheal children and 14 (11.1%) of the 126 non-diarrheal controls. All the 98 asymptomatic children attending hospital outpatients were negative. Six (3.7%) of the 162 samples of different categories examined from the hospital were positive for S. typhimurium. Finger washing of one female food handler, feces of two cats of the wards, surface of wash basin, lavatory seat and shelf yielded positive isolations. In vitro antibiotic sensitivity testing showed majority of the strains were resistant against commonly used antimicrobial agents while they were uniformly sensitive to norfloxacin and ciprofloxacin. The present study points to cross-infection by multi-resistant S. typhimurium strains in the hospital wards.

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.

Global review on ORT (oral rehydration therapy) programme with special reference to Indian scene.

This communication is an attempt to review the status and implementation of the Oral Rehydration Therapy in the programme for Control for Diarrhoeal Diseases. The Global and the Indian situations are separately discussed, with more emphasis on the latter. Use of Home Available Fluids (HAF), Salt Sugar Solution (SSS). Commercial packets of ORS and the Government supplied packets of ORS are also assessed.

PIP: The WHO Global Diarrhoeal Disease Control (CDD) Programme has been implemented in at least 110 member countries. It encourages oral rehydration therapy (ORT) as the chief means to reduce child mortality caused by diarrhea. Despite relatively high ORT access rates ORT (20%-70% in Africa and South East Asia respectively, 1989), oral rehydration solution (ORS) use is inadequate (12.1-26.7% Africa and Eastern Mediterranean respectively, 1988) as well as ORT use (19.2-39.8% Africa and Eastern Mediterranean respectively, 1988). These poor results could be a factor of diminished knowledge and inadequate numbers of trained staff. Yet 58 countries now produce ORS and worldwide production increased from 100-350 million 1 between 1983-1987. In India, however, at least 75% of ORS brands do not meet WHO standards. Further 0.5-1 million 5 year olds succumb annually due to diarrhea (25% of all deaths among 5 year olds). In addition, about 500 million episodes of diarrhea occur each year. ORT is required in 50-100 million of these episodes and hospitalization is needed for 5 million. The Indian CDD program has reduced child mortality from diarrhea by 50% between 1981-1990. It operates under a 3 tier strategy including home management with ORS, and hospital management with ORS and/or IV fluids. This strategy faces several obstacles. For example, mothers in some villages do not know the village health guides who teach mothers how to make ORS. Besides few are motivated at the village level to teach this to mothers. According to government studies, ORT use varies in India from 36-96.3%, but according to operational research by the National Institute of Cholera and Enteric Diseases, ORT use in the best health facilitate is only 11-12%.

Effectiveness of oral rehydration salt solution (ORS) in reduction of death during cholera epidemic.

An extensive outbreak of acute gastroenteritis involving all age group of patients occurred during July-September, 1978 in the Central district of Manipur state. A total of 4469 cases occurred during the period. 45.7% of diarrhoea cases sampled and 47.6% of water samples collected from rivers were found to be positive for V.cholerae biotype EITor. Case fatality rate in this epidemic was exceptionally low (0.8%) which was attributed to the early domiciliary use of oral rehydration salt solution (ORS) in the affected villages. Utility of ORS in drastic reduction of case fatality rate during any epidemic situation was first of its kind in the Indian scene.

PIP: Between July-September 1978, an outbreak of gastroenteritis among all age groups (total of 4469 reported cases) occurred in various villages in the Central District of Manipur State, India including Imphal. Upon notification of the epidemic, health workers distributed oral rehydration salt solution (ORS) generously so people could begin taking ORS as soon as any diarrhea appeared. Researchers from the National Institute of Cholera and Enteric Diseases investigated 92 active cases who were either in the hospital or the community. They collected the data from records of the Regional Medical College, the Directorate of Public Health in Imphal, Primary Health Centers in Thoubal and Kakching, and by visiting active cases at home. 45.7% of fecal samples and 47.6% of river water samples tested positive for Vibrio cholerae biotype ElTor. The case fatality rates fell significantly during the 3 months from 2% for 5 year old children to 0.7% to no deaths at all and 1.9% for 5 year old people to 0.6% to no deaths (p.05). The overall case fatality rate was just 0.8% (36 deaths), it was higher for 5 year old children than it was for 5 year old people (1% vs. 0.7%). Data on earlier cholera epidemics in Manipur were not available, but the researchers found the case fatality rates in cholera epidemics (ElTor) before ORS varied from 22-24%. In fact, they believed this cholera epidemic to be the 1st use of ORS under field conditions which happened to result in a case fatality rate of 1%.