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Zinc treatment to under-five children: applications to improve child survival and reduce burden of disease.
Journal of Health, Population, and Nutrition. 2008 Sep; 26(3):356-65.Zinc is an essential micronutrient associated with over 300 biological functions. Marginal zinc deficiency states are common among children living in poverty and exposed to diets either low in zinc or high in phytates that compromise zinc uptake. These children are at increased risk of morbidity due to infectious diseases, including diarrhoea and respiratory infection. Children aged less than five years (under-five children) and those exposed to zinc-deficient diets will benefit from either daily supplementation of zinc or a 10 to 14-day course of zinc treatment for an episode of acute diarrhoea. This includes less severe illness and a reduced likelihood of repeat episodes of diarrhoea. Given these findings, the World Health Organization/United Nations Children's Fund now recommend that all children with an acute diarrhoeal illness be treated with zinc, regardless of aetiology. ICDDR.B scientists have led the way in identifying the benefits of zinc. Now, in partnership with the Ministry of Health and Family Welfare, Government of Bangladesh and the private sector, the first national scaling up of zinc treatment has been carried out. Important challenges remain in terms of reaching the poorest families and those living in remote areas of Bangladesh.
Paediatric and Perinatal Epidemiology. 1998 Apr; 12(2):176-181.In children, the treatment of acute diarrhoea with the World Health Organization (WHO) standard oral rehydration solution (ORS) provides effective rehydration but does not reduce the severity of diarrhoea. In community practice, carob bean has been used to treat diarrhoeal diseases in Anatolia since ancient times. In order to test clinical antidiarrhoeal effects of carob bean juice (CBJ), 80 children, aged 4±48 months, who were admitted to SSK Tepecik Teaching Hospital with acute diarrhoea and mild or moderate dehydration, were randomly assigned to receive treatment with either standard WHO ORS alone or a combination of standard WHO ORS and CBJ. Three patients were excluded from the study because of excessive vomiting. In the children receiving ORS + CBJ the duration of diarrhoea was shortened by 45%, stool output was reduced by 44% and ORS requirement was decreased by 38% compared with children receiving ORS alone. Weight gain was similar in the two groups at 24 h after the initiation of the study. Hypernatraemia was detected in three patients in the ORS group but in none of those in the ORS + CBJ group. The use of CBJ in combination with ORS did not lead to any clinical metabolic problem. We therefore conclude that CBJ may have a role in the treatment of children's diarrhoea after it has been technologically processed, and that further studies would be justified. (author's)
Geneva, Switzerland, WHO, Programme for Control of Diarrhoeal Diseases, 1993.  p. (WHO/CDR/93.4; UNICEF/NUT/93.2)The International Code of Marketing of Breastmilk Substitutes has been in place for more than a decade, and much effort to protect breastfeeding from commercial influences has followed. One requirement for being "Baby Friendly" is that a facility shall not accept or distribute free samples of infant formula. However, even mothers who initiate breastfeeding satisfactorily, often start complementary feeds or stop breastfeeding within a few weeks of delivery. All health workers who care for women and children after the perinatal period have a key role to play in sustaining breastfeeding. Many health workers cannot fulfill this role effectively because they have not been trained to do so. Little time is assigned to breastfeeding counselling and support skills in the preservice curricula of either doctors, nurses or midwives. Hence there is an urgent need to train all health workers who care for mothers and young children, in all countries, in the skills needed to both support and protect breastfeeding. The purpose of "Breastfeeding counselling: A training course" is to help to fill this gap. The materials are designed to make it possible for trainers with limited experience of teaching the subject to conduct up-to-date and effective courses. The concept of `counselling' is new, and the word can be difficult to translate. Some languages use the same word as `advising'. However, counselling means more than simple advising. Often, when you advise people, you tell them what you think they should do. When you counsel a mother, you help her to decide what is best for her, and you help her to develop confidence. You listen to her, and to try to understand how she feels. This course aims to give health workers listening and confidence building skills, so that they can help mothers more effectively. (excerpt)
Is a 2 : 1 ratio of standard WHO ORS to plain water effective in the treatment of moderate dehydration.
Journal of Tropical Pediatrics. 2003 Oct; 49(5):291-294.Increased amounts of plain water have been recommended ad libitum during rehydration treatment with oral rehydration solutions (ORS) in moderately dehydrated cases in order to decrease the hypertonicity of ORS. However, we could not encounter any study demonstrating its effectiveness objectively. In this study, moderately dehydrated children admitted to Hacettepe University Ihsan Dogramaci Children’s Hospital Diarrheal Disease Training and Treatment Unit were administered either standard WHO ORS treatment or two parts of standard WHO ORS and one part of plain water alternately at a dose of 100 ml/kg, according to the period they were admitted to the center. The frequency of vomiting, stool purging rate, and unscheduled intravenous treatment rate of the two different regimens were compared. There were 51 children in the standard ORS group and 79 children in the 2 : 1 ratio ORS group. The admission characteristics of the children were similar. The children with a stool purging rate over one per hour during treatment was higher in the standard ORS group (29.4 vs. 15.2 per cent, p = 0.051), as well as the children with vomiting (56 vs. 30 per cent, p = 0.007). The children who required unscheduled intravenous treatment was also higher in the standard ORS group (20 vs. 14 per cent, p = 0.2). A regimen of two parts of WHO ORS and one part of plain water may be an alternative treatment for moderately dehydrated children with non-cholera diarrhea in areas where hypotonic ORS is not yet available. (author's)
BMJ. British Medical Journal. 2003 Apr 12; 326(7393):782.WHO believes that as much as a third of the world’s total burden of disease is caused by environmental factors. Children under 5, who comprise only 10% of the world population, currently bear 40% of the global disease burden. (excerpt)
[Geneva, Switzerland], WHO, 1994. , 17 p. (WHO/CDD/94.49)The clinical diagnosis of bloody diarrhea refers to any diarrheal episode in which the loose or watery stools contain visible red blood. This does not include episodes in which blood is present in streaks on the surface of formed stool, is detected only by microscopic examination or biochemical tests, or in which stools are black due to the presence of digested blood. The health practitioner may diagnose the presence of bloody diarrhea in a child by either asking the mother whether the child's stool contains red blood or by looking at the stool, but the former approach is usually more efficient than waiting for the child to pass a stool and as equally sensitive and precise. All infants and children with bloody diarrhea should be treated promptly with an antimicrobial effective against Shigella. Such antimicrobials include ampicillin, TMP-SMX (cotrimoxazole), nalidixic acid, pivvmecillinam, newer quinolones, and ceftriaxone. Dehydration when detected in children with bloody diarrhea should be treated at the health facility. Children with bloody diarrhea and signs of dehydration are at increased risk of complications and should be re-evaluated two days after treatment. The caretakers of all children should be encouraged to offer increased amounts of suitable fluids at home. Moreover, the continued provision of nutritious food is important for all children with dysentery, even though they may have to be coaxed to eat. Appetite usually improves after 1-2 days of effective antibiotic therapy. Frequent small meals with familiar foods are usually better tolerated than a few large meals. Furthermore, mothers should be advised to breastfeed as often and as long as their children want, while children convalescing from dysentery should be given an extra meal each day for at least two weeks. Severely malnourished children with bloody diarrhea are at very high risk of complications and should be referred immediately to hospital after starting treatment for shigellosis.
Geneva, Switzerland, WHO, . 28 p. (WHO/CDD/SER/87.11)This manual provides an overview of the nature of acute diarrhea and its treatment, especially through the use of oral rehydration therapy (ORT), for pharmacists in developing countries. The composition of oral rehydration sales (ORS) is covered as is how to treat dehydration with ORS solution and how to prevent dehydration. The booklet also stresses that antimicrobial and antidiarrheal agents are not recommended for the routine treatment of acute diarrhea. The information presented in the main text is then reviewed in a series of questions and answers, and the World Health Organization's Diarrhoeal Disease Control Programme is described. Finally, a series of guidelines suggest that pharmacists: 1) persuade mothers to use ORT when necessary, 2) supply ORS packets and ensure that mothers know how to prepare and use the solution, 3) prepare ORS solutions in the pharmacy on a daily basis if packets are not available, 4) explain to mothers how household food solutions or sugar/salt solutions can be used to prevent dehydration, 5) persuade mothers not to purchase expensive and ineffective medication, 6) ensure that all cases of severe diarrhea and dehydration are taken to an appropriate health facility, 7) give advice on ways to prevent diarrhea, 8) participate fully in the diarrheal diseases control program of their country, and 9) advocate the teaching of ORT in pharmacy schools and continuing education programs.
[Unpublished] 1990. 12 p. (WHO/CDD/90.33)Findings from the 11th meeting of the Technical Advisory Group (TAG) of the Diarrheal Diseases Control Program are reviewed. Progress made in health services during 1988-1989 include training in supervisory skills for an estimated 17% of the staff and in case management for 11% of the staff, endorsal of breast feeding and rational drug use, 61 countries producing oral rehydration salts (ORS), a 60% access rate to ORS and 34% rate of use of oral rehydration therapy, increased communication activities, and improved assessment for diarrheal management. Major research progress includes determining the effectiveness of rice-based ORS, continued feeding, and breast feeding in diarrheal management. Revisions in research management include the utilization of multi- disciplinary research teams and the replacement of Scientific Working Groups (SWG) with experts to review research priorities, determine study methods, review proposals, and confer with investigators on research design. Research priorities are vaccine development and childhood diarrhea which involves case management research by employing clinical trials, epidemiology and disease prevention, and determining cost effectiveness and optimal delivery of intervention methods. 1995 goals are increased production of ORS, improved supervisory skills training, and improved case management of oral rehydration therapy. During 1988- 1989, the program had access to US$ 20.9 million. US$ 4.7 million carried over at the end of 1989 into 1990. The 1990-1991 overall budget was reduced by 26% because increased contributions were not acquired. Recommendations for the health services component of the program include program implementation which utilizes effective diarrheal assessment tools, focuses on lowering childhood mortality due to diarrhea in 24 countries, and correcting the misuse of antibiotics and antidiarrheal drugs; training for the medical profession in diarrheal management, improved training materials and additional training units; increased accessibility to ORS; improved communication which involves promoting diarrheal treatment in the educational system; and preventing diarrhea by encouraging breast feeding. Recommendations for research includes revised research management guidelines and close collaboration between TAG and investigators.
CDD UPDATE. 1989 Mar; (5):1-3.Rotavirus diarrhea, most common in children 6-24 months of age, accounts for 20-40% of cases of severe diarrhea in the Third World and is involved in 40-60% of diarrhea cases requiring hospitalization. Since rotavirus is the organism most often involved in cases of severe dehydrating diarrhea in young children throughout the world, vaccine development is an important goal. Such a vaccine could reduce diarrhea- related deaths in the 6-24-month age group by 30% and prevent 500,000-1 million deaths each year. The ideal vaccine should: 1) induce substantial, longterm protection against rotavirus diarrhea in young children after a single dose, and 2) be administered at 2-3 months of age. At present, there are 5 candidates for live, attenuated oral vaccines: bovine, rhesus, bovine-human reassortant, rhesus-human reassortant, and nursery strain. Efficacy trials have found that the rhesus-human serotype 1 reassortant confers significant protection. Other vaccines have been ineffective or associated with side effects in preliminary trials. The World Health Organization's Program for Control of Diarrheal Diseases continues to provide support to research into the efficacy of these vaccines, as well as genetically-engineered vaccines. The Program is further investigating the feasibility of simultaneous administration of rhesus-human rotavirus and oral poliovirus vaccines in the event that multiple doses of the rotavirus vaccine are needed.
CDD UPDATE. 1989 Mar; (4):1-4.Persistent diarrhea, defined as an episode of at least 14 days' duration, is associated with a deterioration in child nutritional status and a significant risk of death. In developing countries, various surveys have found that 3-20% of acute diarrheal episodes in children under 5 years of age become persistent. Most persistent diarrhea occurs in the last 3 years of life and is more frequent in children who have had a prior history of this condition. The risk factors for persistent diarrhea include: age under 12 months, poor nutritional status, impaired immunological status, previous infection, receipt of animal milk, and enteropathogenic bacteria in the feces. Oral rehydration salts are effective in the majority of cases of persistent diarrhea. The exception is cases of infants with sever, watery diarrhea in which carbohydrate absorption is severely impaired; here, intravenous fluids and electrolytes may be required. Continued feeding, including breastfeeding, is another important component of the management of acute and persistent diarrhea. Food mixtures should be energy-rich, with low viscosity and osmolality. The present recommendation is that antibiotics should be administered in persistent diarrhea only when a specific enteropathogen warranting treatment has been isolated or dysentery is present. In children with a marked weight loss and a purging rate greater than 5 ml/kg/hour, hospitalization may be necessary.
Geneva, Switzerland, WHO, 1988. ii, 119 p.The 6th report of the World Health Organization's (WHO) Control Program (CDD) describes the activities of the program during 1986 and 1987. The program consists of health services, a research component, and information services. Program review bodies are discussed, as are resources and obligations. New publications and documents are listed. 7 appendices are given: 1) diarrheal diseases control--resolution of the World Health Assembly, May 15, 1987; 2) WHO CDD estimates of oral rehydration salts (ORS) access and ORS/oral rehydration therapy (ORT) use rates by country and region, 1986; 3) new research projects supported by the program (from January 1, 1986 to December 31, 1987); 4) publications arising out of program-supported research; 5) collaborating centers; and 6) financial status. Health service program activities include planning and implementation, and training. Also important is increasing the availability of ORT. Health education and communication are important in the health services program. Program progress must be evaluated. The program's research component consists of biomedical and epidemiological, and operational (health) services research. Research projects include improved ORS formulations and ORT; feeding during and after acute disease; drugs in diarrhea therapy; persistent diarrhea; epidemiology of specific diseases; studies on risk factors for diarrhea and related interventions; development, evaluation, and improvement of diagnostic procedures for diarrhea; and development and testing of vaccines. Research also consists of collaborating with industry and other organizations.
[Unpublished] 1989 Mar. 21 p. (WHO/CDD/89.32)This is a review report on the 10th annual meeting for the Technical Advisory Group (TAG) of the Diarrheal Disease Control (CDD) Program. The participants took particular notice of the external review report issued in 1988. It was noted that the health service component had retained proper case management, which was composed of ORT, proper feeding during and after diarrheal, and judicious use of intravenous fluids and anti-microbials. For the research component, 32 new projects were launched in 18 countries in 1988 alone, and of the total program projects, 77% were stationed in the developing countries. TAG reviewed the reports from the regional advisory committees and noted developments in 6 WHO regions. Great emphasis was placed on problem solving activities needed to overcome specific constraints that hinder effective implementation of individual national CDD programs. In addition, 13 key indicators were selected for continuous monitoring and evaluation of the CDD programs. Current research strengthening activities include short-term training fellowships, workshops for proposal developments and provision of technical support during site visits. Conclusions and recommendations were given in the following areas: basic program implementation, training, communication, monitoring and evaluation, research component, epidemiology and disease prevention, implementation, research, immunology, microbiology and vaccine development.
Geneva, Switzerland, WHO, 1989. 54 p. (WHO/CDD/89.31)This is an interim summary report of the Diarrheal Disease Control Program (DDC) activities during 1988; it addresses in detail the health service component, the program management and review, and new publications of the DDC. With regards to the health services, it was revealed that 1) the total countries with DDC plans remained unchanged, 2) training in program management, supervisory skills, and diarrhea case management received priority attention, 3) the need to increase access, production, and exchange of information on oral rehydration therapy was emphasized, 4) a guide to assist CDD program managers in planning, implementing and evaluating communications activities was produced, 5) continuation of data collection and storage continued, and 6) there was a higher increase in activities which focused on diarrheal prevention. The DDC continued to support biomedical and epidemiological research topics which emphasized treatment methods, identification of interventions for prevention of diarrheal diseases, and vaccine development and evaluation. In addition 3 annual review meetings took place for the technical advisory group, management and review committee and a meeting of interested parties. New publications from the DDC for 1988 included articles in management, an overview of diarrheal disease, a manual on prevention guidelines, national program reports and technical papers on scientific research activities.
[Unpublished] 1988. 21 p. (WHO/CDD/88.29)The Technical Advisory Group (TAG) of the Diarrheal Disease Control (CDD) Program had its 9th meeting in March 1988. This report on that meeting describes TAG's view on the status of CDD (globally and regionally), the research in case management, related activities of other WHO programs, the global medium-term program for 1990-1995, the plans for the development of the Acute Respiratory Infections (ARI) Control Program, the revised 1988-89 budget and the preliminary budget for 1990-91, and TAG's conclusions and recommendations on all of these activities. TAG commended the progress by CDD which has most likely averted 700,000 diarrhea deaths in 1986 alone. TAG also found satisfaction with the Program's intention to increase activities related to the reduction of diarrhea incidence, but recommended greater emphasis on research to define an improved approach for the treatment of dysentery. TAG commended CDD's emphasis on coordinating multilateral and bilateral agencies in diarrheal disease control efforts and endorsed its policy of strengthening national CDD programs. TAG had several recommendations for the training of supervisory and case management personnel. It also recommended that more specific training goals be defined. TAG urged further exploration of ways to strengthen and support CDD activities by regional, subregional, and particularly country WHO offices. The association between CDD and ARI was strongly endorsed.
Communication: a guide for managers of national diarrhoeal disease control programmes. Planning, management and appraisal of communication activities.
Geneva, Switzerland, WHO, Diarrhoeal Diseases Control Programme, 1987. vii, 78 p.When the World Health Organization's Diarrheal Diseases Control Program (CDD) began in 1978, it concentrated on producers and providers of oral rehydration salts. Communication efforts were directed at informing health care providers and training them to treat patients. The time has come for CDD programs to put more emphasis on enduser-oriented approaches, and it is to facilitate that aim that this guide for CDD program managers on enduser-directed communication has been developed. The guide is divided into 3 parts. Part 1 deals with nature and scope of communication in a CDD program. The 1st step is research and analysis of the target population -- find out what the target audience does and does not know and what are some of their misconceptions about the use of oral rehydration therapy (ORT) and the Litrosol packets. Communication can teach mothers how and when and why to use ORT, but it cannot overcome lack of supply and distribution of the salts; it cannot be a substitute for trained health care staff; and it cannot transform cultural norms. Part 2 deals with the communication design process. Step 1 is to investigate the knowledge, attitude and practice of both the endusers and the health care providers; to investigate what communication resources are available; and to investigate the available resources in terms of cost, time, and personnel. Step 2 is communication planning, in terms of: 1) definition of the target audience; 2) identification of needed behavior modification, and 3) factors constraining it; 4) defining the goals of the communication program in terms of improving access to and use of the new information; 5) approaches to change, e.g., rewards, motivation, and appeal to logic, emotion, or fear; 6) deciding what mix of communications methods is to be used, i.e., radio, printed matter; 7) identifying the institutions that will carry out the communicating; 8) developing a feasible timetable, and 9) a feasible budget. Step 3 is to develop the message to be communicated and to choose the format of the message for different communications media. Step 4 is testing, using a sample of the audience, whether the messages are having their intended effect in terms of acceptance and understanding by the target audience, and revision of the messages as necessary. Step 5 is the actual implementation of the communication plan in terms of using a media mix appropriate to the audience, phasing the messages so as to avoid information saturation; and designing the messages so that they are understandable, correct, brief, attractive, standardized, rememberable, convincing, practical, and relevant to the target audience. Step 6 is to monitor the program to be sure the messages are reaching their intended audiences, to evaluate the program in terms of its actual effects, and to use the results of the monitoring and evaluation to correct instances of communication breakdown. Part 3 deals with the CDD manager's role in communication. The manager must select a suitable communications coordinator, who will have the technical expertise necessary and the ability to call upon appropriate government and private information resources and consultants. The manager must brief the coordinator in the scope and objectives of the CDD program; and he must supervise and monitor the work of the coordinator.
[Unpublished] 1986. 6 p. (WHO/CDD/CMT/86.1)This article presents an overview of current therapeutic practice as recommended by the World Health Organization (WHO) Diarrheal Disease Control Program. The recommendations apply solely to acute diarrheal disease in infants and children. Therapy for such cases is primarily concerned with the prevention or correction of dehydration, the maintenance of nutrition, and the treatment of dysentery. The various approaches to treatment considered are: 1) oral rehydration, which is highly effective for combating dehydration and its serious consequences, but does not diminish the amount or duration of diarrhea; 2) antimotility drugs, none of which are recommended for use in infants and children because the benefits are modest and they may cause serious side effects, such as nausea and vomiting; 3) antisecretory drugs, only a few of which have been properly studied in clinical trials, virtually all of which have important side effects, a low therapeutic index, and/or only modest efficacy. Consequently, none can at present be recommended for the treatment of acute infectious diarrhea in infants and children. 4) aciduric bacteria, on which conclusive evidence is still lacking; 5) adsorbents: kaolin and charcoal have been proposed as antidiarrheal agents in view of their ability to bind and inactivate bacterial toxins, but the results of clinical studies have been disappointing. 6) improved Oral Rehydration Salts (ORS): this may turn out to be the most effective and safest antidiarrheal drug. 7) antibiotics and antiparasitic drugs for a few infectious diarrheas (e.g., cholera). Antibiotics can significantly diminish the severity and duration of diarrhea and shorten the duration of excretion of the pathogen. No antibiotic or chemotherapeutic agent has proven value fort the routine treatment of acute diarrhea; their use is inappropriate and possibly dangerous. It is concluded that oral that oral rehydration is the only cost-effective method of treating diarrhea among infants and children.The Inter-African Committee's (IAC) work against harmful traditional practices is mainly directed against female circumcision. Progress towards this aim is achieved mostly through the efforts of th non governmental organizations (NGO) Working Group on Traditional Practices Affecting the Health of Women and Children and the IAC. In 1984 the NGO Working Group organized a seminar in Dakar on such harmful traditional practices in Africa. The IAC was created to follow up the implementation of the recommendations of the Dakar seminar. The IAC has endeavored to strengthen local activities by creating national committees in Benin, Djibouti, Egypt, Ethiopia, Gambia, Ghana, Kenya, Liberia, Mali, Nigeria, Senegal, Sierra Leone, Somalia, Sudan and Togo. IAC activities in each country are briefly described In addition, the IAC has created an anatomical model, flannelgraphs, and slides to provide adequate educational material for the training of medical staff in teaching hospitals and to make village women aware of the harmful effects of female circumcision. The IAC held 2 African workshops at the Nairobi UN Decade for Women Conference. The African participants recognized the need for international solidarity to fight female circumcision and showed a far more definite and positive difference in their attitude towards the harmful practice than was demonstrated at the Copenhagen Conference/ Forum of 1980. At the United Nations level, female circumcision is receiving serious consideration. A special Working Group has been set up to examine the phenomenon. Finally, this article includes a statement by a sheikh from the Al Azhar University in Cairo about Islam's attitude to female circumcision.
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.
Report of the third meeting of the Scientific Working Group on Bacterial Enteric Infections: Microbiology, Epidemiology, Immunology, and Vaccine Development.
[Unpublished] 1984. 17 p. (WHO/CDD/BEI/84.5)The scientific topic discussed in detail by the Scientific Working Group (SWG) was recent research advances in the field of cholera. The SWG reviewed new knowlenge in areas such as epidemiology and ecology, phage-typing, pathogenesis, immunization, and related pathogens, and made recommendations for future research. The Diarrhoeal Disease Control Pragramme was continuing to emphasize the implementation of oral rehydration therapy as a means of reducing diarrheal mortality, and research aimed at an improved case-management strategy. The Steering Committee granted support to a number of projects aimed at clarifying the epidemiology of diarrhea and the pathogenesis of bacterial agents of acute diarrhea. Support was provided by the Steering Committee to projects aimed at, or closely related to the development of new vaccines against typhoid fever, cholera, and Shigella dysentery.
Who Chronicle. 1984; 38(5):212-6.This article highlights the conclusions and recommendations of the 5th meeting of the Technical Advisory Group of the World Health Organization (WHO) Diarrheal Diseases Control (CDD) Program held in March 1984. On the basis of clinical trials supported by the CDD Program, WHO has endorsed use of oral rehydration salts (ORS) containing trisodium citrate dihydrate in place of sodium bicarbonate. Although the bicarbonate formulation remains highly effective and may continue to be used, the citrate formula results in less stool output and is more stable under tropical climatic conditions. At its meeting, the Technical Advisory Group expressed satisfaction with progress in the health services and research components of the program's activities. By 1983, 72 countries or areas had formulated plans of operation for national CDD programs and 52 had actually implemented programs. Training courses directed at program managers, first-line supervisors, and middle-level health workers are held on a regular basis. 38 developing countries are now producing ORS. Another area of activity has involved development of a management information system to monitor progress toward the target of increased access to and use of oral rehydration therapy for diarrhea in children under 1 year of age. Data from 40 countries indicate that access to ORS was 6-10% in 1982 and usage was 1-4%. There have been reviews of 10 national CDD programs, 7 of which utilized a joint national-external team to collect and analyze information on the management and impact of the CDD program. During 1983, 71 new research projects were funded by the CDD program, bringing the total number of projects supported to 231 (59% in developing countries). Biomedical research has focused on development of more stable and effective ORS; the etiology and epidemiology of acute diarrhea: and development and evaluation of new diagnostic tests, vaccines, and antidiarrheal drugs. In 1982-83, the CDD program received US$1.4 million from WHO and about US$11 million from voluntary contributors. The 1984-85 budget has been set at US$19.7 million.
Report of the third meeting of the scientific working group on viral diarrhoeas: microbiology, epidemiology, immunology and vaccine development, [held in] Geneva, 1-3, February 1984.
Geneva, Switzerland, WHO, . 19p.The current status of the Scientific Working Group Program is reviewed, showing an expansion of activities in both its health services component (planning, implementation and evaluation of national diarrheal diseases control programs) and its research component (biomedical and operational). Submission of research proposals is encouraged by the Steering Committee (SC), namely those investigating the etiological role of viral agents in diarrheal disease and the epidemiology of these agents. Recently, the SC has made a particular effort to stimulate research in the area of immunology of viral enteric infections, which has been a generally neglected area. Other important areas of Program activity include site visits to review progress made by its projects, to participate in the initial design or the analysis of studies, or to stimulate general interest among research workers in the activities of the SWG. Workshops have also been initiated and conducted in WHO regions. The SWG notes with satisfaction the progress of the Program and commends the SC's efforts to stimulate and support research activities. SWG recommendations bear on the need for more data on the etiology and epidemiology of diarrhea in the community and the encouragement of further community-based studies. Particular attention should also be given to the preparation of reagents for the serotyping and subgrouping of rotaviruses. Moreover, the Group recommends that research strengthening workshops be continously held. In addition to the review of the meeting and recommendations, this paper includes a report on active and passive immunity to viral diarrheas. Special attention is given to rotavirus diarrhea as it tends to be common and quite severe. Its epidemiology is briefly presented, showing its incidence, seasonality (winter) in temperate climates, age-specific occurrence (most severe in infants and young children) and transmission (fecal-oral, person-to-person). Neonatal ans sequential postneonatal rotavirus infection are addressed ans issues for further investigation clarified; e.g., the relationship between low birth weight and the occurrence and severity of infection. Much remains to be elucidated regarding the serotyping-specific epidemiology of rotaviruses. The Group notes that further immunological studies of rotaviruses are essential to elucidate the role of passive protection. The other area of study in which research activities need to concentrate is vaccine development.
[Geneva, Switzerland], WHO, . 2 p. (WHO/CDD/SER/84.7)In 1982-1983 the Who Diarrhoeal Diseases Control (CDD) Programme supported laboratory studies to identify a more stable ORS composition, particularly for use in tropical countries, where ORS has to be packed and stored under climatic conditions of high humidity and temperature. The results of these studies demostrate that ORS containing 2.9 grams of trisodium citrate dihydrate in place of 2.5 grams of sodium bicarbonate was the best of the formulations evaluated. 7 clinical trials were undertaken in which the efficacy of ORS-citrate and ORS-bicarbonate was compared. All but 1 of these trials had a double-blind study design. 4 of these studies were undertaken in children below 2 years of age with moderate to severe noncholera diarrhea. The ORS-citrate was received by 128 children and found to be uniformly as effective as ORS-bicarbonate in correcting acidosis. In 3 of the 4 studies from which preliminary data are available, there was a trend towards a reduction (8-14%) of diarrheal stool output in children receiving the ORS-citrate. Countries should have no hesitation in continuning to use ORS-bicarbonate, which is highly effective. However, because of its better stability and apparently greater efficacy, WHO and UNICEF now recommend that countries use and produce ORS-citrate where feasible.
Geneva, Switzerland, WHO,  27 p.This is the 1st interim report issued by the Diarrhoeal Diseases Control (CDD) Programme, summarizing progress in its main areas of activity during the previous calendar year. Most of the information is presented in the form of tables, graphs and lists. Other important developments are mentioned briefly in each section. The information is presented according to major program areas; health services; research; and program management. Within the health services component, national program planning, training, the production of Oral Rehydration Salts (ORS), health education and promotion are areas of priority activity. Progress in the rate of development of national programs, participants in the various levelsof training programs, and the countries producing their own ORS packets and developing promotional and educational materials are presented. An evaluation of the health services component, based on a questionnaire survey to determine the impact of Oral Rehydration Therapy (ORT), indicates significant decreases in diarrheal admission rates and in overall diarrheal case-fatality rates. Data collected from a total of 45 morbidity and and mortality surveys are shown. Biomedical and operational research projects supported by the program are given. Thhe research areas in which there was the greatest % increase in the number of projects funded were parasite-related diarrheas, drug development and management of diarrheal disease. Research is also in progress on community attitudes and practices in relation to diarrheal disease and on the development of local educational materials. The program's organizational structure is briefly described and its financial status summarized. The report ends with a list of new publications and documents concerning health services, research and management of diarrheal diseases.
Washington, D.C., National Academy Press, 1981. 22 p. (Contract AID/ta-C-1428)2 essential direct interventions in management of acute diarrheal diseases, oral rehydration and continued feeding, are summarized. Recent estimates of the global problem are that more than 500 million episodes of diarrhea occur yearly in infants and children under 5 years of age in Asia, Africa, and Latin America. 5 million deaths from diarrhea have been reported each year. Dehydration is the major cause of the immediate morbidity and mortality of children with diarrhea. Oral rehydration techniques may assist and reverse progression to severe dehydration and thereby are highly efficient in managing diarrheal disease. Formula selection, preparation of ingredients, distribution of oral rehydration solution, economic considerations, and cost-effectiveness of therapy programs are the primary concerns for those using oral rehydration. Formula selection should take into account the quantity of sodium, potassium, bicarbonate, and glucose in the formula. Preparations should be made so they can be done in the household rather than in national agencies. Centralized national packaging is recommended to standardize the salt/sugar mix. Measuring spoons and containers are also important in the packaging. Distribution should be accomplished by government or private agencies. The home preparation is the most economical. The effectiveness of the program is an important consideration. It is recommended that 2 different formulas be introduced into the community: a simpler lower sodium formula for home preparation and the more complex World Health Organization solution for supervised use in the health center. Continuation of feeding is important during and after diarrheal illness. Anorexia, nausea, vomiting, and abdominal cramps, may accompany acute infection. Cow milk may help produce symptomatic fermentative diarrhea, however breastfeeding should be continued. Fruits, vegetables, and sources of protein should also be fed to patients with diarrhea. Deleterious effects may occur if a patient fails to continue eating. A community system of surveillance and education should be developed to control diarrheal disease.
[Unpublished] 1980. 10 p.This paper briefly reviews the development of the highly effective and universally applicable ORS (oral rehydration solution) recommended by WHO, and tested world wide during the past decade. ORS is prepared by adding appropriate amounts of glucose, sodium bicarbonate, and potassium chloride to drinking water to give the optimum concentration for intestinal absorption of electrolytes and water to replace acute diarrhoeal losses. Many studies conducted in developing countries attest to the enormous success of programs extending the delivery of oral rehydration therapy to the village and to the household level, thus significantly reducing infant mortality. The paper also describes the physiological basis of oral rehydration, and its nutritional benefits.
Report of the WHO/UNICEF Consultation on the National Production, Packaging and Distribution of Oral Rehydration Salts (ORS), Bangkok, January 23-26, 1979.
Geneva, Switzerland, WHO, 1979. 33 p. (ATH/79.1)The conclusions and recommendations reached by the participants at a joint WHO and UNICEF sponsored consultation on the national production, packaging, and distribution of ORS (oral rehydration salts) were presented. Also provided were separate country reports on the status of ORS production and distribution in Bangladesh, Costa Rica, Egypt, India, Indonesia, Mozambique, Pakistan, Philippines, and Thailand. The purpose of the consultation was 1) to identify the problems involved in national efforts to produce and distribute ORS and 2) to develop guidelines for the production, packaging, and distribution of the ORS. Oral rehydration therapy provides an effective method for treating all but the most serious types of diarrhoeal diseases and the treatment can be administered at home without medical assistance. Many countries are engaged in the production of ORS and at the present time there is considerable variation in the formulation, packaging, cost, and quality of the products. Recommendations were 1) the product should be packaged and identified as a drug in order to inspire confidence in the product; 2) national standards for the quality control of pharmaceuticals should be applied to the production of ORS; 3) eventually international standards for the formulation and quality control of ORS should be established; 4) bulk packaging of separate ingredients for use in large facilities is preferred; 5) efforts should be made to make ORS widely available especially in rural and isolated areas; 6) efforts should be directed toward developing a product with a long shelf-life; 7) all levels of health personnel should be trained in oral rehdyration therapy; and 8) evaluation of production and distribution systems should be promoted.