A reassessment of the cost-effectiveness of water and sanitation interventions in programmes for controlling childhood diarrhoea.

Cost-effectiveness analysis indicates that some water supply and sanitation (WSS) interventions are highly cost-effective for the control of diarrhoea among under-5-year-olds, on a par with oral rehydration therapy. These are relatively inexpensive "software-related" interventions such as hygiene education, social marketing of good hygiene practices, regulation of drinking-water, and monitoring of water quality. Such interventions are needed to ensure that the potentially positive health impacts of WSS infrastructure are fully realized in practice. The perception that WSS programmes are not a cost-effective use of health sector resources has arisen from three factors: an assumption that all WSS interventions involve construction of physical infrastructure, a misperception of the health sector's role in WSS programmes, and a misunderstanding of the scope of cost-effectiveness analysis. WSS infrastructure ("hardware") is generally built and operated by public works agencies and financed by construction grants, operational subsidies, user fees and property taxes. Health sector agencies should provide "software" such as project design, hygiene education, and water quality regulation. Cost-effectiveness analysis should measure the incremental health impacts attributable to health sector investments, using the actual call on health sector resources as the measure of cost. The cost-effectiveness of a set of hardware and software combinations is estimated, using US$ per case averted, US$ per death averted, and US$ per disability-adjusted life year (DALY) saved.

PIP: Cost-effectiveness analysis indicates that some water supply and sanitation (WSS) interventions are very cost-effective in controlling diarrhea among children under age 5 years, as cost-effective as oral rehydration therapy. These include relatively inexpensive interventions such as hygiene education, the social marketing of good hygiene practices, regulation of drinking water, and monitoring of water quality. Such interventions are needed to ensure that the potentially positive health impacts of WSS infrastructure are fully realized in practice. The perception that WSS programs are not cost-effective has grown out of the assumption that all WSS interventions involve building physical infrastructure, a misperception of the health sector's role in WSS programs, and a misunderstanding of the scope of cost-effectiveness analysis. WSS infrastructure is usually built and operated by public works agencies and financed by construction grants, operational subsidies, user fees, and property taxes. Health sector agencies should provide project design, hygiene education, and water quality regulation. The cost-effectiveness of various water and sanitation interventions to control childhood diarrhea is estimated, using US$ per case averted, US$ per death averted, and US$ per disability-adjusted life year saved.

Breastfeeding promotion and priority setting in health.

An increase in exclusive breastfeeding prevalence can substantially reduce mortality and morbidity among infants. In this paper, estimates of the costs and impacts of three breastfeeding promotion programmes, implemented through maternity services in Brazil, Honduras and Mexico, are used to develop cost-effectiveness measures and these are compared with other health interventions. The results show that breastfeeding promotion can be one of the most cost-effective health interventions for preventing cases of diarrhoea, preventing deaths from diarrhoea, and gaining disability-adjusted life years (DALYs). The benefits are substantial over a broad range of programme types. Programmes starting with the removal of formula and medications during delivery are likely to derive a high level of impact per unit of net incremental cost. Cost-effectiveness is lower (but still attractive relative to other interventions) if hospitals already have rooming-in and no bottle-feeds; and the cost-effectiveness improves as programmes become well-established. At an annual cost of about 30 to 40 US cents per birth, programmes starting with formula feeding in nurseries and maternity wards can reduce diarrhoea cases for approximately $0.65 to $1.10 per case prevented, diarrhoea deaths for $100 to $200 per death averted, and reduce the burden of disease for approximately $2 to $4 per DALY. Maternity services that have already eliminated formula can, by investing from $2 to $3 per birth, prevent diarrhoea cases and deaths for $3.50 to $6.75 per case, and $550 to $800 per death respectively, with DALYs gained at $12 to $19 each.

PIP: During April 1992 to March 1993, in Santos, Brazil, in San Pedro Sula, Honduras, and in Mexico City, Mexico, interviews were conducted with 200-400 women in each of three hospitals and at their homes at 1 month and at 2-4 months postpartum as part of a study of the cost and effectiveness of three breast feeding promotion programs in hospital-based maternity services. The hospital in Mexico and, in the past, the one in Brazil used infant formula, while the hospital in Honduras and the hospital in Brazil removed infant formula. Various nutrition and policy specialists estimated the costs and impacts of these programs to develop cost effectiveness measures and then compared them with other health interventions. At a net incremental cost ranging from about US$0.30 to US$0.40 per birth, infant feeding programs with formula feeding in nurseries and maternity wards can reduce diarrhea cases for about US$0.65 to US$1.10 each, prevent diarrhea-related deaths for US$100 to US$200 each, and reduce the burden of disease for about US$2 to US$4 per disability-adjusted life year (DALY). On the other hand, by investing US$2 to US$3 per birth, maternity services that no longer provide infant formula can prevent diarrhea cases and deaths for US$3.50 to US$6.75 per case and US$550 to US$800 per death, respectively, and gain DALYs at a cost of US$12 to US$19 each. The estimates obtained indicate that breast feeding promotion in hospitals competes very closely with measles and rotavirus vaccination as the most efficient option for diarrheal disease control and is markedly more cost-effective than oral rehydration therapy and cholera immunization even when infant formula is no longer offered. In fact, investments in breast feeding promotion are among the most cost-effective health interventions. The cost effectiveness of breast feeding promotion programs improved as programs became institutionalized. These findings show that such programs are a very efficient way of improving the health status of children.

A double-blind clinical trial comparing World Health Organization oral rehydration solution with a reduced osmolarity solution containing equal amounts of sodium and glucose.

OBJECTIVE: To compare the safety and efficacy of an oral rehydration solution (ORS) containing 75 mmol/L of sodium and glucose each with the standard World Health Organization (WHO) ORS among Egyptian children with acute diarrhea. METHODS: One hundred ninety boys, aged 1 to 24 months, who were admitted to the hospital with acute diarrhea and signs of dehydration were randomly assigned to receive either standard ORS (311 mmol/L) or a reduced osmolarity ORS (245 mmol/L). Intake and output were measured every 3 hours. RESULTS: In the group treated with reduced osmolarity ORS, the mean stool output during the rehydration phase was 36% lower (95% confidence interval, 1%, 100%) than in those treated with WHO ORS. The relative risk of vomiting during the rehydration phase was significantly lower in children treated with reduced osmolarity ORS (relative risk, 2.4; 95% confidence interval, 1.2, 4.8). During the maintenance phase, stool output, mean intake of food and ORS, duration of diarrhea, and weight gain were similar in the treatment groups. The relative risk of treatment failure (need for unscheduled administration of intravenous fluids) was significantly increased in children receiving standard WHO ORS (relative risk, 7.9; 95% confidence interval, 1.1, 60.9). The mean serum sodium concentration at 24 hours was significantly lower in children receiving the reduced osmolarity ORS solution (134 +/- 6 mEq/L) than in children receiving the standard WHO ORS (138 +/- 7 mEq/L) (p < 0.001). The relative risk of the development or worsening of hyponatremia was not increased in children given the reduced osmolarity ORS, and urine output was similar in the treatment groups. CONCLUSION: The reduced osmolarity ORS has beneficial effects on the clinical course of acute diarrhea in children by reducing stool output, and the proportion of children with vomiting during the rehydration phase, and by reducing the need for supplemental intravenous therapy. These results provide support for the use of a reduced osmolarity ORS in children with acute noncholera diarrhea.

PIP: Between July 1993 and March 1994, clinical researchers in Egypt enrolled 190 male children aged 1-24 months with acute diarrhea at the Abu El Reeche Hospital in Cairo in a randomized double-blind clinical trial to evaluate the relative efficacy of a reduced osmolarity oral rehydration solution (ORS) containing 75 mmol/l of both sodium and glucose (total osmolarity, 245 vs. 311 mmol/l for the standard ORS recommended by the World Health Organization and UNICEF) for treating acute noncholera diarrhea. They measured intake and output every three hours. Over the entire course of the study, the mean stool output was significantly lower in the reduced osmolarity ORS group than the standard ORS group (4.3 vs. 5 g/kg/hour; p 0.05). During the rehydration phase, the mean stool output was 36% lower in the reduced osmolarity ORS group than in the standard ORS group (p 0.05). The proportion of children vomiting during rehydration was much lower in the reduced osmolarity ORS group than the standard ORS group (17% vs. 33%; relative risk [RR] = 2.4; p 0.01). During the maintenance phase, the two groups shared similar stool output, mean intake of food and ORS, duration of diarrhea, and weight gain. Treatment failure was significantly more common in the standard ORS group than the reduced osmolarity ORS group (8% vs. 1%; RR = 7.9; p 0.01). The mean serum sodium level at 24 hours were much lower in the reduced osmolarity ORS group (134 vs. 138 mEq/l; p 0.001) but remained within the normal range in both groups. Children in both groups developed hyponatremia or their hyponatremia worsened at the same rate. Urine output was about the same in both groups. These findings suggest that the reduced osmolarity ORS has advantages over the standard ORS as a treatment for acute noncholera diarrhea. This safe and effective rehydration treatment reduces stool output and vomiting during rehydration as well as reduces the need for supplemental intravenous therapy.

Quality assurance of a diarrhoea control programme in northeastern Brazil.

In this study quality assurance methods were used in an evaluation of a programme for Control of Diarrhoeal Diseases (CDD) in northeastern Brazil. Seventy-eight randomly selected public primary care facilities in four states were assessed by trained surveyors. Problems observed in the facilities were lack of information on target population and coverage, lack of equipment to permit rehydration in the premises, and frequent unavailability of trained professionals. Health workers showed deficiencies in history taking, physical examination and knowledge on diarrhoea management. Many caretakers had difficulties in recalling information given to them in the health facilities. Eighty-four percent of the cases were treated with oral rehydration, but 90% were sent home immediately and not kept in the facilities to practice rehydration under guidance as recommended by the national CDD programme. An overuse of the medical treatment was observed. More than two-thirds of health professionals gave wrong indications for use of antibiotics. The study showed that oral rehydration therapy is well established in the government health services in the region but that the CDD programme needs to take early action to correct deficiencies in logistics, case management and health education.

PIP: The 9 states in the northeast of Brazil were divided into 4 groups based on population size and geographical distribution. In the capital cities of each state, 5-8 health units treating children with diarrhea were chosen at random. Overall, 78 health care units were studied. University-trained nurses evaluated each health care unit regarding diarrhea management and conducted interviews using questionnaires for the data collection. The survey team was split into groups of 4, each group covering 1 state. The field-work was carried out in May 1989 and took 4-6 weeks to complete. 88% of facilities surveyed were health centers, while the rest were outpatient departments in hospitals. In 40% of the facilities, the number of monthly consultations of children was known, while only 22% had information on the number of children attending for diarrhea each month. 62% of facilities had a special oral rehydration therapy (ORT) place for children. Utensils for administration of ORT were available in only half of the facilities. In 1/5 of the facilities the sugar-salt-solution packets were never or seldom available. In 32 of 65 facilities, the most recent shipment of ORS packets had arrived in the last month. 10 facilities had not received ORS for more than 6 months. In 67 facilities (86%) a physician, and in 9 a health auxiliary, was responsible for managing childhood diarrhea. 75 visits for childhood diarrhea were observed in 42 health facilities. 58 of the attendances (77%) were managed by doctors, 12 by health auxiliaries, and 5 by nurses. 90% of the patients were sent home, while the rest were treated. In 84% of cases oral rehydration therapy was prescribed, usually oral rehydration salts (ORS). Antimicrobial drugs were prescribed in 21% of the cases. Other drugs like metochlopramide, caolin-pectin, aspirin and vitamins were prescribed in 41% of the cases.

Growth charts only marginally improved maternal learning from nutrition education and growth monitoring in Lesotho.

A study done in Lesotho in 1985-1986 assessed whether growth charts increased the impact of nutrition education and growth monitoring on maternal learning about weaning practices and diarrhea. Seven hundred and seventy six mothers were given three monthly sessions of group nutrition education along with growth monitoring of children and individual counseling. Growth charts, which were taught to one of two groups, fostered learning but only on issues related to diarrhea and only among new clinic attendants, mothers with less than secondary schooling and mothers of malnourished children. These benefits, however, were small (differences less than 10%) compared with the overall impact of the nutrition education and growth monitoring intervention (increases between baseline and post-intervention were greater than 50% for some questions). Our findings suggest that well-designed clinic-based nutrition education and growth monitoring can have a significant impact on maternal nutrition knowledge. Teaching growth charts to mothers may not be necessary for obtaining such results in programs conducted under ideal conditions. More research is needed to determine under what circumstances, for what purposes and for whom growth charts may be beneficial.

PIP: Between December 1985 and November 1986, before and after 3 monthly sessions of group nutrition counseling and individual counseling about weaning and diarrhea management at 9 primary health clinics in Lesotho, researchers compared data on 575 mothers who received a growth chart to monitor their 2-year old children's growth with data on 201 mothers of 2-year old children who did not receive a growth chart. They wanted to learn whether growth charts promoted maternal learning and whether the growth charts better served some mothers than other mothers. Growth monitoring intervention improved knowledge of diarrhea management but not weaning practices. This improvement in learning about diarrhea management was limited to new clinic attendants, mothers with less than high school education, and mothers with malnourished children, however. Yet the differences in benefits between these 2 groups were 10% and insignificant. Nutrition education interventions had significantly improved knowledge of weaning practices and diarrhea management for both groups of mothers (range of improvement 3-119.2%; p.05). The greatest improvements occurred in correct responses to continuous feeding of solid foods during diarrhea (119.2% for mothers who did not receive charts and 85.2% for those who did) and to introduction of protein rich vegetables to children's diet (42.6% and 58.9%, respectively). Thus use of growth charts contributed only slightly to increased effectiveness of nutrition education. It appeared that the quality and specificity of educational projects and proper use of weight information during individual counseling contributed the most to improved maternal learning. Nevertheless further research is warranted to learn the circumstances, purposes, and target audience under which use of growth charts would bring the most benefits.

Breast-feeding, nutritional status, and other prognostic factors for dehydration among young children with diarrhoea in Brazil.

Early identification of children at high risk of diarrhoea-associated dehydration would be of great value to health care workers in developing countries. To identify prognostic factors for life-threatening dehydration, we carried out a case-control study among under-2-year-olds in Porto Alegre, Brazil. Cases were 192 children admitted to hospital with moderate or severe dehydration, while controls were children matched to controls by neighbourhood and age, who experienced nondehydrating diarrhoea in the week preceding the interview. The following variables were significantly associated with an increased risk of dehydration, after adjustment for age and other confounding variables: absence of the father from the home; low paternal education level; young age; maternal age 25-29 years or less than 20 years; mother of mixed race; high birth order; short birth interval; low birth weight; stunting, underweight and wasting; lack of breast-feeding; presence of other under-5-year-olds in the home; families with 4-5 members; lack of antenatal care; less than three doses of diphtheria-pertussis-tetanus or poliomyelitis vaccine; previous admission to hospital; use of medicines during the fortnight prior to the episode; and living in an unclean home. The associations were particularly strong (P less than 0.001) for the child's age, birth weight and other anthropometric indicators, birth interval, and feeding mode. In terms of their sensitivity and specificity, however, these prognostic factors were not as effective as early signs and symptoms for predicting the outcome of the episode.

PIP: During the primary diarrhea season (December 1987-April 1988) in metropolitan Porto Alegre in southern Brazil, researchers compared 192 children aged less than 2 years who were admitted to a hospital with moderate or severe dehydration with 192 neighborhood- and age-matched controls who had a diarrhea episode without dehydration during the seven days before the interview. They aimed to identify factors predicting life-threatening dehydration. When the researchers controlled for age and other confounding variables, the following factors were significantly related to an increased risk of dehydration: no father in the household, low paternal education level, young age, maternal age 25-29 years or less than 20 years, mixed race mother, high birth order, short birth interval, low birth weight, stunting, underweight and wasting, non-breast milk, children aged less than 5 in the household, family size of 4-5, no prenatal care, less than three doses of diphtheria-pertussis-tetanus or poliomyelitis vaccine, previous admission to a hospital, use of medicines during the two weeks before the diarrhea episode, and living in an unsanitary household. The strongest factors associated with an increased risk of dehydration (p 0.001) included young age, low birth weight and malnutrition, short birth interval, and non-breast milk. These factors were not as effective at predicting an increased risk of dehydration as early signs and symptoms. Specifically, their sensitivities were lower than those of early signs and symptoms. Notwithstanding, these findings support current efforts towards promotion of breast feeding, prevention and treatment of malnutrition, and birth spacing since they contribute to the prevention of diarrhea-related dehydration.

The rural market: a unique communication medium.

PIP: In January 1990, the Health Secretary asked the Technologies for Primary Health Care (PRITECH) project to facilitate access to the many small villages with 500 people in Mexico since PRITECH had assisted the diarrhea disease control program. 1st PRITECH had Ministry of Health staff train trainers which would eventually spread the information to the rural areas. This strategy was effective only for those people who did not live in remote areas. The same reasons for remote people being at high risk of disease also limited this strategy: isolation, lack of education, limited diets, lack of access to services, and limited fluency in Spanish. PRITECH hired a local consulting organization, CICLOPE, to develop a new strategy. CICLOPE limited its activities to the states of Hidalgo and Vera Cruz for 8 months. 1st CICLOPE staff provided proper diarrhea management training including emphasis on oral rehydration therapy (ORT) to rural health auxiliaries. They used a gourd painted to look like an infant with holes and other modifications to depict the workings and results of diarrheal dehydration. The staff then sent the auxiliaries to their own communities to use the gourd dolls to teach mothers about ORT and correct diarrhea management. The staff conducted follow-up activities to monitor the auxiliaries' progress. This training approach allowed the auxiliaries to realize the abilities of the mothers and their active role in learning. The auxiliaries conducted the training at markets where women living in remote areas came weekly. The local radio announced market day events in which the auxiliaries participated and aired dramas about diarrhea management. CICLOPE staff and the auxiliaries sat up a booth at these markets to promote proper diarrhea management. They used a flip chart, comic books, a lottery game, and entertainment to impart education messages.^ieng

Cholera in Africa: lessons on transmission and control for Latin America.

In January, 1991, epidemic cholera emerged in Peru and spread to 7 other countries of Latin America. Cholera was introduced 20 years ago to Africa, where it spread rapidly to 30 of the 46 countries of the region and by 1990 accounted for 90% of all cases reported to the World Health Organisation. Many lessons from the cholera epidemic in Africa are relevant to efforts to control the disease in Latin America. Public health practices from the past--quarantine and cordon sanitaire to halt introduction of cholera by travellers, and vaccination and mass chemoprophylaxis to control epidemics--are ineffective in preventing spread of the disease. Cholera can be transmitted not only by contaminated water but also by food. Social phenomena such as mass migrations and burial practices may play a greater role than previously understood. While efforts to prevent the spread of cholera have been ineffective, cholera-associated mortality can be decreased with rehydration therapy. Since the current pandemic is unlikely to retreat soon, new strategies are urgently needed to control the spread of cholera through sanitary and behavioural interventions or improved vaccines.

PIP: Latin America had been free of cholera for 70 years until January 1991 when the 7th pandemic of El Tor cholera struck Peru. It killed 1500 people and affected 200,000 people within 6 months. It soon spread to at least 7 other Latin American countries. 20 years earlier the it reached Africa. Foci of infections in Africa included markets, fairs, funerals, and refugee camps. Scientists doubted that vaccination or quarantine would have prevented its introduction into Africa. Yet, in Latin America, public health officials should earnestly reconsider chemoprophylaxis (tetracycline) of family contacts in families with high rates of illness. Presently no such data exist in Latin America. In addition, health workers should test the new oral vaccine in Latin America since there is no preexisting immunity and the people are exposed to high levels of contamination. Little epidemic research was done in Africa to pinpoint modes of transmission so health workers could learn what types of intervention were warranted. It should be done in Latin America, however. As for quarantine, symptomatic and mild to moderate cholera cases can outnumber severe cases as much as 100 to 1, so confining cases would not prevent the spread of the disease. Latin America should broaden diarrheal disease control programs to include adults so they will accept oral rehydration therapy (ORT). It should be used in mild to moderate dehydration cases and intravenous rehydration therapy for severe cases. If the environmental factors are not known and understood and if feces contaminate water supplies, foods, and fisheries, cholera may become endemic in Latin America. In conclusion prompt disease reporting, surveillance, and implementation of control measures could prevent the endemicity of cholera in Latin America.

Cholera: ancient scourge on the rise. WHO announces global plan for cholera control. (25 April 1991).

PIP: Vibrio cholerae spreads quickly via contaminated water and food, especially in areas with a poor health and sanitation infrastructure. Its enterotoxin induces vomiting and huge amounts of watery diarrhea leading to severe dehydration. 80-90% of cholera victims during an epidemic can use oral rehydration salts. A cholera epidemic is now spreading through Latin America threatening 90-120 million people (started in January 1991), particularly those in urban slums and rural/mountainous areas. As of mid April 1991, there were more than 177,000 new reported cases in 12 countries and 78% of these cases and more than 1200 deaths were limited to 5 countries: Brazil, Chile, Colombia, Ecuador, and Peru, WHO's Global Cholera Control Task Force coordinates global cholera control efforts to prevent deaths in the short term and to support infrastructure development in the long term. Its members are specialists in disease surveillance, case management, water and sanitation, food safety, emergency intervention, and information and education. WHO's Director General is asking for the support of the international community in cholera control activities. These activities' costs are considerable. For example, Peru needs about US$ 60 million in 1992 to fulfill only the most immediate demands of rehabilitation and reconstruction of the infrastructure. Costs of infrastructure capital throughout Latin America is almost US$ 5 thousand million/year over the next 10 years. It is indeed an effective infrastructure which ultimately prevents cholera. Cholera is evidence of inadequate development, so to fight it, we must also fight underdevelopment and poverty.^ieng

Cholera in the Americas.

PIP: The cholera epidemic 1st hit South America in January 1991 in the coastal town of Chancay, Peru. In 2 weeks, it spread over 2000 km of the Pacific coast. By the end of the 1st month, it had already reached the mountains and tropical forests. By August 1991, cholera cases were reported in order of appearances in Ecuador, Colombia, Chile, Brazil, the US, Mexico, Guatemala, Bolivia, and El Salvador. Health authorities still do not know how it was introduced into South America. The case fatality rate has remained at a low of 1%, probably due to the prompt actions of health authorities in informing the public of the epidemic and what preventive cautions should be taken. This epidemic is part of the 7th pandemic which originated in Celebes, Indonesia in 1961. Cholera can spread relatively unchecked in Latin America because sewage in urban areas is not treated even though they do have sewage collection systems. The untreated wastewater enters rivers and the ocean. Consumption of raw seafood is not unusual and has been responsible for cholera infection in some cases. In fact, many countries placed import restrictions on marine products from Peru following the outbreak at a loss of $US10-$US40 million. Municipal sewage treatment facilities, especially stabilization ponds, would prevent the spread of cholera and other pathogens. In rural areas, pit latrines located away from wells can effectively dispose of human wastes. Most water supplies in Latin America are not disinfected. Disinfection drinking water with adequate levels of chlorine would effectively destroy V. cholera. If this is not possible, boiling the water for 2-3 minutes would destroy the pathogen. Any cases of cholera must be reported to PAHO. PAHO has responded to the outbreak by forming a Cholera Task Force and arranged transport of oral rehydration salts, intravenous fluids, antibiotics, and other essential medical supplies.^ieng

Environmental health conditions and cholera vulnerability in Latin America and the Caribbean.

PIP: Epidemic cholera reached South America in January 1991 and later spread to Central America and the United States. It afflicted 312,000 people and claimed 3200 lives. Since cholera had not been in Latin America for almost 70 years, health authorities allowed environmental health barriers to cholera collapse. For example, the Governments of the Region agreed in 1961 to abide by the Charter of Punta del Este to provide water and sewerage to 70% of the urban population and 50% f the rural population by 1971. They did not achieve their goals for the rural population. In fact, at the end of 1988, water was piped to 79% of the urban households and an additional 11% of the urban population had access to a public water source. Sewerage services served 49% of the urban population and, with other methods of excreta disposal, 80% of the population had adequate excreta disposal. On the other hand, only 55% of rural inhabitants had access to either piped water or public standpipes. Further sanitary excreta disposal services only covered 32%. Besides the water quality of existing water supply systems was poor. Since feces of infected people have as many as 1 billion Vibrio cholerae and , in some of Vibrio, up to 80% of carriers exhibit only mild symptoms or no symptoms at all, it is easy to understand how cholera took hold in Latin America. Researchers identified the points of contamination responsible for the cholera outbreak in Piura and Trujillo, Peru to be wells, distribution systems, and house. Annual population growth in Latin America at 2.6% poses specific problems to providing enough water and sanitation services to all in need, especially those in marginal areas around the cities (who will make up 40% of the population by 2000).^ieng

[Control of diarrheal diseases in Mexico and Latin America]. / El control de las enfermedades diarreicas en México y Latinoamérica.

Oral rehydration therapy (ORT), has been considered the major advance in the treatment of the diarrheal diseases, and has been the single most important factor in the decrease of mortality and decreased morbidity in childhood diarrheal. ORT, is not limited to the administration of oral rehydration solution; it also includes feeding techniques and community education and participation. In order to promote ORT, national programs have been developed and promoted in educational centers in strategic areas of the Latin America countries, where medical and paramedical staff attend. In México there have been two national surveys to evaluate the ORT program. This policy has allowed for participating countries to reduce the cost of treatment of diarrheal disease.

PIP: Gastrointestinal infections are the most frequent causes of illness and death in children under 5 in most Latin America countries and in other developing countries. The simple and effective techniques now available to prevent death from diarrhea offer promise therefore of lowering overall pediatric mortality rates. Oral rehydration therapy is the single most effective treatment for control of diarrheal disease in children because most diarrhea deaths are directly related to dehydration. The discovery during the 1960s that intestinal absorption of glucose, sodium, and salt by the small intestine continued during diarrheal episodes gave scientific support to oral rehydration therapy. The World Health Organization estimates that up to 67% of diarrheal deaths can be prevented with oral rehydration therapy. Oral rehydration therapy can help prevent harmful treatments such as fasting and requires no laboratory controls. By the late 1980s, diarrheal control programs were in effect in over 90 countries, including all of Latin America except Chile. 20% of children with diarrhea receive modern treatment, thus avoiding an estimated 600,000 deaths annually. The World Health Organization formula for oral rehydration has been proven effective and safe for treatment of dehydration caused by diarrhea at any patient age. Early experience with oral rehydration therapy in Mexico and elsewhere demonstrated that it resulted in shorter episodes of diarrhea with fewer effects on nutritional status. The reduced need for hospitalization is another significant benefit or oral rehydration therapy. An estimated 60% of the population of Latin America has access or oral rehydration therapy. In late 1985 the rate of use was estimated at 20% for Latin America as whole but only 9% in Mexico. Research in Mexico indicated that the product name and packaging of oral rehydration packets were unattractive and intimidating to mothers. The new packaging has pictures of a healthy baby and the tree of life, a statement of indications for use (avoid dehydration due to diarrhea), and logos of institutions in Mexico's health sector. The package also provides simple instructions for preparation and use. In 1986-87 greater emphasis was placed on clinical training in use of oral rehydration therapy, communication, and increasing access. Selected personnel from each of the 32 Mexican states and territories received training in oral rehydration therapy in a hospital in Mexico City and returned to act as multipliers in their home states. Over 1700 health professionals were trained in 6 priority states. In 1986, efforts were initiated to promote use of oral rehydration therapy directly in the home. A 2nd survey showed that by 1987 the rate of use of oral rehydration therapy in Mexico had increased from 9 to 24%, but that some harmful practices persisted.

The programme for combating diarrhoeal diseases in Haiti.

PIP: A national program for controlling diarrhea and promoting breastfeeding was launched by the Haitian Government in July 1983 with the aim of reducing the diarrhea mortality rate by 50% over a 3-year period. After almost 2 years of operation, the program is judged to have been successful in terms of the implementation of activities, the preparation and distribution of educational materials, and the mobilization of health workers and volunteers. In 1984, 6875 medical and paramedical personnel, 5500 national scouts, and 5283 people on the community level were trained in oral rehydration techniques. Over 600,000 packets of oral rehydration serum were sold or distributed by a total of 2311 distribution sites. Successes achieved are considered to be due to a combination of institutional, community, multisectorial, and commerical approaches. Although the statistics from 1984 suggest significant program activity, the results of such activities have not been evaluated. For example, the program's impact on the incidence of diarrhea and dehydration or mortality caused by diarrhea remains unknown. Moreover, the 2md aspect of the program--promotion of breastfeeding--has been neglected to date and will be the focus of a separate campaign scheduled to begin in June 1985. There is some evidence that other priorities of the Ministry of Public Health and Population, including vaccinations, nutrition, family planning, and the fight against tuberculosis and malaria, received dwindling attention during the period of the campaign against diarrhea. This seems to reflect the phasic approach of health authorities.^ieng

Doxycycline prophylaxis of travelers' diarrhea in Honduras, an area where resistance to doxycycline is common among enterotoxigenic Escherichia coli.

Daily doxycycline (DX), known to be effective prophylaxis against travelers' diarrhea (TD) in areas of the world where enterotoxigenic Escherichia coli (ETEC) are sensitive to the drug, has not been extensively studied in geographic areas where antibiotic resistance is common. Therefore we studied 44 U.S. Peace Corps Volunteers during their first 5 weeks in Honduras, which is such an area. During the first 3 weeks, volunteers took daily either 100 mg DX or placebo (PL) in a double-blind, randomized fashion. All 22 taking PL developed TD during the first 3 weeks, compared to 7 of 22 (32%) taking DX (P less than 0.001; 68% protection). ETEC were isolated from 39% of episodes of TD. From the PL group, ETEC from 7 of 13 stool samples (54%) were resistant to DX, whereas from the DX group, ETEC from 10 of 11 stool samples were resistant (P less than 0.05). TD that developed in persons taking DX was also found to be less severe, as judged by length of illness (P less than 0.01) and frequency of stools (P less than 0.05). This study demonstrates that DX 1) significantly prevents TD even in areas where antibiotic resistance is common, although it does not prevent TD caused by docycycline -resistant ETEC, and 2) significantly diminishes the severity of illness.

PIP: This study analyzed the effect of doxycycline prophylaxis of travelers' diarrhea in Honduras, an area where antibiotic resistance is common among enterotoxigenic Escherichia coli (ETEC). 44 newly arrived US Peace Corps volunteers were given either 100 mg of doxycycline/day or a placebo. All 22 subjects who received a placebo developed travelers' diarrhea within 3 weeks compared to 7 of 22 subjects (32%) who received doxycycline. ETEC were isolated from 39% of the travelers' diarrhea episodes. In the placebo group, ETEC from 7 of 13 stool samples (54%) were resistant to doxycycline. In the doxycycline group, ETEC from 10 of 11 stool samples (91%) were resistant. Volunteers who took doxycycline had a shorter diarrheal illness than controls and a less severe disease, as measured by the peak numberof stools/day. No clinical adverse drug effects were noted. The protective effect of the drug lasted only while the drug was being taken. This study demonstrates that prophylactic doxycycline significantly reduces the severity of illness among those who experience travelers' diarrhea and can provide a 60-70% protection rate even in countries where ETEC are resistant to antibiotics. Antibiotic prophylasix should be viewed as a temporary measure, however, until safer and perhaps more effective methods such as vaccines or nonpharmacologic agents become available.

Interventions for the control of diarrhoeal diseases among young children: promotion of personal and domestic hygiene.

PIP: The effects of improving personal and domestic hygiene on diarrhea morbidity are reviewed using data from studies in hospitals, day care centers, and communities. There is evidence that low educational attainment and certain religious customs predispose to diarrhea, presumably because of behavioral factors. The specific hygiene related behavior that has een most studied is handwashing. Hospital studies suggest that enteric infections can spread via contaminated hands and that hands can be decontaminated by washing with soap and water. 3 studies from Bangladesh, US, and Guatemala on the impact of hygiene education programs on diarrhea are reviewed in detail. Reductions in diarrhea incidence rates of between 14-48% were documented in these studies. Little is known of the impact of hygiene education programs on diarrheas of specific etiology or of their impact on diarrhea mortality. Information is lacking on the optimal design of such programs, on costs, and on their dependence on preexisting levels of sanitary facilities. The available evidence suggests that hygiene education programs may be a cost effective intervention for diarrhea morbidity reduction. Research is necessary to fill the current gaps in understanding and to clarfiy the operational aspects of these programs. (author's modified)^ieng