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Geneva, Switzerland, WHO, 1985. 101 p. (WHO/CDD/85.13)The Diarrheal Diseases Control (CDD) Program, initiated in 1978, is a priority program of WHO for attainment of the goal of Health for All by the Year 2000. Its primary objectives are to reduce diarrheal disease mortality and morbidity, particularly in infants and young children. This report describes the activities undertaken by the Program in the 1983-1984 biennium. During this period, the Program collaborated with more than 100 countries in the implementation of national diarrheal disease control and research activities. The biennium has witnessed a growing interest of other international, bilateral, and nongovernmental agencies in diarrheal disease control; their financial support and commitment have contributed in a large measure to furthering the development of CDD programs and related research in many countries. During the biennium, the services component continued to expand both the quantity and scope of its activities at global, regional, and national levels. This is readily seen from the increase in global acess to Oral Rehydration Salts (ORS) packets from less than 5% in 1981 to 21% in 1983. Other significant developments were a substantial increase in the number of countries planning and implementing programs and the initiation of a new management course in supervisory skills. Successful implementation of national primary health care systems was recognized as necessary for the achievement of the Program's objectives. Efforts of both developing and industrialized countries must continue in a joint endeavor to reduce the problem of diarrheal diseases, especially cholera, the most severe diarrheal disease. The following areas are discussed: the health services component; the research component; information services; program review bodies; program resources and obligations; and program publications and documents for 1983-1984.
PEDIATRIC INFECTIOUS DISEASE JOURNAL. 1993 Jan; 12(1):5-9.Each year diarrheal disease causes an estimated 3.2 million deaths worldwide in children under 5 years of age. Reported attack rates in developing countries range from 1 to 12 episodes per child per year, with a global average of 3 episodes per child per year. Diarrhea is associated with 1/4 of all deaths in children under 5 years in developing countries. Oral rehydration therapy (ORT) is the cornerstone of global efforts to reduce mortality from acute diarrhea. The World Health Organization (WHO)/UNICEF ORS formula contains glucose and sodium in a molar ratio of 1.2:1. Potassium chloride is added to replace potassium lost in the stool. Trisodium citrate dihydrate (or sodium bicarbonate) corrects metabolic acidosis caused by fecal loss of bicarbonate. The WHO case management strategy for children with diarrhea consists of: prevention of dehydration through early administration of appropriate fluids available in the home; treatment of dehydration with ORS solution; treatment of severe dehydration with an intravenous electrolyte solution; continued feeding during, and increased feeding after the diarrheal episode; and selective use of antibiotics and nonuse of antidiarrheal drugs. The WHO/UNICEF formula is also suitable as a maintenance fluid when given with equal amounts of water, breast milk, or low carbohydrate juice. Despite the unquestioned success of ORT in developing countries, physicians in the United States, the United Kingdom, and other industrialized countries have been slow to adopt ORT. Guidelines for case management call for patient assessment. The physician evaluating a child with diarrhea should inquire about clinical features including its duration and the presence of blood in the stool. Thus, a reliable treatment plan can be made without need of laboratory tests. Most diarrheal episodes are self-limited and do not benefit from antimicrobial therapy. Children with bloody diarrhea should be treated for suspected shigellosis with an oral antibiotic.
CENTRAL AFRICAN JOURNAL OF MEDICINE. 1992 Jul; 38(7):314-5.Participants at a 1992 WHO/UNICEF consultation meeting on HIV transmission and breast feeding weigh the risk of death from AIDS with the risk of death from other causes. Breast feeding reduces the risk of death from diarrhea, pneumonia, and other infections. Artificial or inappropriate feeding contributes the most to the more than 3 million annual childhood deaths from diarrhea. The rising prevalence of HIV infection among women worldwide results in more and more cases of HIV-infected newborns. About 33% of infants born to HIV-infected. Some HIV transmission occurs through breast feeding, but breast feeding does not transmit HIV to most infants HIV-infected mothers. Participants recommend that, in areas where infectious diseases and malnutrition are the leading causes of death and infant mortality is high, health workers should advise all pregnant women, regardless of their HIV status, to breast feed. The infant's risk of HIV infection via breast milk tends to be lower than its risk of death from other causes and from not being breast fed. HIV-infected women who do have access to alternative feeding should talk to their health care providers to learn how to feed their infants safely. In areas where the leading cause of death is not infectious disease and infant mortality is low, participants recommend that health workers advise HIV-infected pregnant women to use a safe feeding alternative, e.g., bottle feeding. Yet, the women and their providers should not be influenced by commercial pressures to choose an alternative feeding method. Health care services in these areas should provide voluntary and confidential HIV testing and counseling. Participants stress the need to prevent women from becoming HIV-infected by providing them information about AIDS and how to protect themselves, increasing their participation in decision-making in sexual relationships, and improving their status in society.
WORLD HEALTH FORUM. 1993; 14(2):207-9.An analysis conducted by WHO in 1991 and 1992 indicated that death rates from diseases related to diet and life-style (heart conditions, cancer, and diabetes) have increased significantly in many countries during the past 30 years, largely owing to changes in diet and life-style. 40 high-income countries have diet-related disorders, and as many as 80 middle-income nations may have both undernutrition and overnutrition problems. Undernutrition is widespread in some 50 low-income countries and is associated with a high incidence of stunting and micronutrient deficiencies (especially iron, iodine, and vitamin A). Diet-related deficiencies affect 2000 million people. WHO scientists reviewed data from 26 developed and 16 developing countries from the period 1960-89: 20 countries showed increases ranging up to 160% in death rates from diet-related and life-style-related causes. The biggest decreases were in Australia, Canada, Japan, and the USA where education advised people to limit intakes of fat, saturated fat, and salt as well as to increase exercise and reduce smoking. Data on food availability for 1988-90 showed that an estimated 786 million people in developing countries were chronically undernourished. Hunger and malnutrition affect many of the 123 million people living in 11 countries where the food situation is critical. Some 192 million children <5 years of age suffer from protein-energy malnutrition characterized by retardation of physical growth and lowered resistance to infections. 55 million of these underweight children are in south Asian countries. In these countries, about half of all deaths occur before 5 years of age, and the majority of these deaths are caused by diarrheal disease. It is estimated that up to 70% of diarrhea cases are food-borne in origin. There are 1500 million episodes of diarrhea annually in children <5 years of age, killing 3 million of them.
DIALOGUE ON DIARRHOEA. 1991 Sep; (46):4.Artificial feeds constituted with contaminated water and unclean bottles are the leading cause of diarrhea in infants. Companies market artificial feeds globally as infant formula (a substitute for breast milk) and follow-up formula (a complement to breast milk). Breast milk is best for all 0-12 month old infants. Breast-fed infants do not need any formula even follow-up formula. Indeed >6-month old infants require solid healthful foods and breast milk. Like infant formulas, follow-up formula made with contaminated water or bottles can cause the infant to become ill with an infection, and offering follow-up formulas to infants impedes weaning and is costly. Follow-up formulas do not complement breast milk, but instead tend to replace it. The 1986 WHO World Health Assembly has even declared that, in some countries, provision of follow-up formula is not necessary. WHO fears mothers could use follow-up formula instead of infant formula because it has a higher protein and mineral content thus increasing the risk of dehydration during diarrhea. Follow-up formula can result in an unbalanced diet. Since the International Code of Marketing of Breastmilk Substitutes does not address formulas marketed as a complement to breast milk, formula companies market follow-up formulas in both developed and developing countries. Most mothers do not know the risks of using follow-up formulas, however. Governments have several alternatives to stop the marketing of these formulas. They can design and implement a code that defines breast-milk substitutes as any formula perceived and used as a breast milk option even if promoted as a breast-milk complement. They can also amend an existing code. WHO offers technical assistance to any member government who wishes to design, implement, and monitor such a code.
AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 1986 Jan; 35(1):1-2.A paper by Hazlett et al. is of particular importance because it addresses the question of the role of acute respiratory infections (ARI) as a cause of morbidity and especially mortality in 3rd world children. Diarrheal disease and malnutrition are generally thought to be the major killers of these children, and until recently little attention was paid to ARI. Recent data suggest that ARI are more important than realized previously and almost certainly are the leading cause of death in children in developing countries. It is estimated that each year more than 15 million children less than 5 years old die, obviously most in socially and economically deprived countries. Since death usually is due to a combination of social, economic, and medical factors, it is impossible to obtain precise data on the causes of death. It has been estimated that 5 million of the deaths are due to diarrhea, over 3 million due to pneumonia, 2 million to measles, 1.5 million to pertussis, 1 million to tetanus, and the other 2.5 million or less to other causes. Since pertussis is an acute respiratory infection and measles deaths frequently are due to infections of the respiratory tract, it is becoming clear that ARI are associated with more deaths than any other single cause. The significance of this is emphasized when the mortality rates from ARI in developed and underdeveloped nations are compared. Depending on the countries compared, age group, and other factors, increases of 5-10-fold have been reported. These factors raise the question of why respiratory infections are so lethal for 3rd world children. The severity of pneumonia, which is the cause of most ARI deaths, seems to be the big difference. Data are accumulating which show that bacterial infections are associated with the majority of severe infections and "Streptococcus pneumoniae" and "Haemophilus influenzae," infrequent causes of pneumonia in developed world children, are the microorganisms incriminated in a large proportion of cases. The increase in severity of ARI in 3rd world children has been associated, at least in port, with malnutrition, diarrheal diseases, an increased parasite load, and more recently with air pollution. Crowding and other factors associated with poverty doubtless also play a role. How these various factors contribute to increased severity and lethality is not well understood. The increasing recognition of the important role played by ARI as causes of mortality in 3rd world children is encouraging. The UN International Children's Emergency Fund (UNICEF) has joined the World Health Organization in the battle against ARI in developing countries, and the 2 organizations recently issued a joint statement on the subject in which they pledged to collaborate to integrate an ARI component into the primary health care program.
Proceedings of the International Conference on Oral Rehydration Therapy, June 7-10, 1983, Washington, D.C.
Washington, D.C., Agency for International Development [AID], Bureau for Science and Technology, 1983. 210 p. (International Conference on Oral Rehydration Therapy, 1983, proceedings)With over 600 participants from more than 80 countries, the International Conference on Oral Rehydration Therapy (ICORT) was a testimony to the international health community's recognition of the seriousness of diarrheal disease, the value of oral rehydration therapy, and the commitment to primary health care. The conference, initiated by the Agency for International Development, was cosponsored by the International Center for Diarrheal Disease Research, Bangladesh, the United Nations Children's Fund, and the WHO. The conference focused on oral rehydration therapy, an important treatment of diarrhea. 1 out of 10 children born in developing countries dies from the effects of diarrhea before the age of 5. A 70% reduction in the mortality rate can result from ORT--a major breakthrough for primary health care. Excellent laboratory investigation, well-conducted clinical studies, and careful field observation have led to this effective therapy. Many papers presented at the conference demonstrated the effectiveness of ORT. Participants agreed on the best formula for ORT in terms of electrolyte content and on the need for an international commitment to expand implementation of ORT. Problems in implementing oral therapy programs are discussed. Possible areas of investigation include: 1) improving the solution through the addition of glycine, other amino acids, or cereal-based substrates; 2) developing methods for teaching ORT; and 3) investigating better methods of program evaluation. Innovative approaches to informing the public about the use and benefits of oral therapy were also discussed. Participants, recognizing that problems are shared among many different programs and nations, exchanged ideas and addresses, pledging to keep each other abreast of their ORT research and implementation efforts. The conference closed with a strong call for action to attain near universal availability of ORT in the next 10 years.
American Journal of Tropical Medicine and Hygiene. 1983 May; 32(3):437-46.Following an overview of the less developed countries (LDCs) and their health problems, attention is directed to what pharmaceutical companies have been doing to develop tropical disease medicinals: past and current programs for the development of pharmaceuticals; the relationship of pharmaceuticals to other health problems; criticisms of the pharmaceutical industry; problems and constraints in developing drugs by pharmaceutical firms, particularly for tropical diseases; and strengthening incentives to pursue tropical medicine research in the future. There are 31 countries in the less developed category and they have 4 things in common: poverty; a high birthrate; a young population, and a low life expectancy. At the top of the list of the major health problems in developing countries are malaria, diarrheal diseases, and malnutrition. For malaria, there is a need for something new for chloroquine resistant infections, but research looks promising. Meanwhile, the use of presently available medications in much of the world would go far towards alleviating suffering and death from this disease. For diarrheal diseases and malnutrition the principal problems lie elsewhere than with development of new pharmaceuticals. For tuberculosis and leprosy, the 4th and 5th major health problems, therapy has improved markedly in recent years, yet there is room for improvement. Of the sexually transmitted diseases, only for sexually transmitted herpes is the industry missing a solution. On balance, it seems clear that the need for new pharmaceuticals, although important, is not as critical as some of the other needs of the LDCs. If this individual is correct in maintaining that the most important problems in the LDCs are pure water, adequate food, basic sanitation, and a distribution system for already available pharmaceuticals, then the question is why is the drug industry singled out for so much criticism. The principal charges, which are discussed in detail, are as follows: inadequate research on the endemic diseases of the developing and least developed countries; the practice of "dumping" drugs in developing countries that do not sell or sell for different indications at home; labeling of products differently than in the US; permitting over the counter sales of drugs that a prescription only goods in the US; selling products whose stated expiration date has passed; and charging high prices and reaping excessive profits. The critics are the UN agencies, consumer groups, trade unions, and media writers. Much of what is said is in defense of the pharmaceutical industry. but shortcomings are also noted.