Dialogue on Diarrhoea - Issue no. 1 - May 1980
version of this Issue
There is much information in this issue that is valuable
and useful. Online readers are reminded, however, that treatment guidelines and health
care practices change over time. If you are in doubt, please refer to
WHO's up-to-date Dehydration Treatment
- Diarrhoea Dialogue Online Issue 1 - May
Diarrhoea Dialogue Online Issue 1 May 1980
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Diarrhoea Need Not Kill
The diarrhoeal disease scenario
Diarrhoeal disease has long been recognized as the greatest killer of infants and young
children in the developing world. Well over 500 million episodes of diarrhoea in
children under five are estimated to occur annually in Asia, Africa and Latin America. At
least five million children die. Diarrhoeal disease is a major contributory factor to malnutrition. Recurrent diarrhoea
coupled with inadequate feeding results in impaired body defence mechanisms. Malnourished
children have up to a 50% higher incidence of diarrhoeal disease and suffer more severe
attacks than normally nourished children. Although diarrhoeal diseases are most often lethal among the very young, they are a
major cause of ill health and of death among children and adults of all ages, adding to
the huge burden of the many communicable diseases prevalent in the developing world Long term and short term remedies Diarrhoeal diseases are usually transmitted by faecal contamination of food and water,
so a vital long term objective is improvement of water supplies and sanitation. The global
improvement of nutrition is as essential to break the link between diarrhoea and
malnutrition. More urgently, measures can and must be adopted to enable prompt treatment
and control of diarrhoea All diarrhoeas lead to dehydration and if untreated, progressive
dehydration is fatal. It has been known for decades that replacement of salt and fluid
losses in sufficient quantity can prevent diarrhoeal deaths, but, until about 1970,
conventional treatment was rehydration by intravenous infusion, which is expensive and
requires skills and facilities found only in well staffed and equipped clinics and
hospitals. Fluids by mouth do work Treatment by oral rehydration therapy (ORT) - a drink comprising glucose, sodium and
potassium chlorides, sodium bicarbonate and water - was first used on a large scale among
refugees from the 1971 India-Pakistan war. In the camps, the mortality rate dropped from
30% to 1%. Since then, ORT has been widely used with great success. The Infectious
Diseases Hospital in Calcutta and the hospital of the International Centre for Diarrhoeal
Diseases Research in Bangladesh now use only 20% of the amount of intravenous fluid
previously used for diarrhoeal diseases treatment. Controlled studies in Indonesia,
Pakistan, Costa Rica and the Philippines have all shown major reductions in
diarrhoea-related deaths since the introduction of ORT. The main advantage of ORT is that
as an inexpensive and simple procedure it can be prepared and given by primary health care
workers or mothers, therefore avoiding the necessity of treatment in large hospitals. Constraints to implementation Although ORT has been shown to be effective, some constraints have to be resolved
before the treatment can be universally available. These include manufacturing and
packaging the oral rehydration powder as cheaply as possible whilst maintaining quality
and shelf life; the arrangement of efficient delivery systems to ensure continuity of
supply, especially to remote rural areas; and the need to find the safest and most
effective methods of treatment for mothers and health workers to use, when the complete
oral rehydration formula is not available, or when a substitute is needed for an
ingredient such as glucose which is expensive and hard to obtain in some countries. These
problems of supply and delivery are inevitable but by no means insoluble and should not
deter any country from implementing a national ORT programme. Global interest in oral rehydration Interest in the use of oral rehydration therapy has been growing rapidly on the part of
numerous national governments (with the backing of the World Health Organization, which
has a specific diarrhoeal diseases control programme, and the United Nations Children's
Fund); of many non-government organizations and voluntary agencies engaged in primary
health care work; and of clinicians involved in research and teaching THE ROLE OF DIARRHOEA DIALOGUE
This newsletter is about the latest developments, new ideas and solutions to problems,
the organization and results of controlled field studies and the establishment of new
national and local programmes in diarrhoeal diseases control in developing countries. We
hope to provide not just facts and news but also a forum for opinion and comment. The main
article in this first issue of Diarrhoea Dialogue considers some of the
controversial questions that are being asked about oral rehydration therapy. Please help
us to answer them. Diarrhoeal disease is not only treatable but largely preventable. This
newsletter will also present some of the new ideas on water supplies and sanitation
technologies which the forthcoming UN Water Decade is certain to provoke. The December
1980 issue will concentrate on the relationship between water and diarrhoea. Later issues
will discuss the place of feeding in the management of diarrhoea, the role of drugs and
traditional remedies in treatment and future possibilities for immunisation. Debate not dispute Diarrhoea Dialogue is intended to be a place for debate rather than dispute.
While detailed scientific arguments can be pursued in academic journals, this newsletter
will focus on promoting the exchange of practical information and experience related to
the effective prevention and treatment of diarrhoea. Diarrhoea Dialogue is meant
for everyone who cares about unnecessary suffering and deaths. Your ideas, experience and
constructive criticism are needed to make it into a genuine dialogue.
K.E. and W.A.M.C.
|With this issue . . .
- we introduce Diarrhoea Dialogue
- we outline and explore some of the main issues
- we look to you, the readers, for ideas, comment, questions.. . and more readers!
Diarrhoea Dialogue Online Issue 1 May 1980 1
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A study in Nigeria
"The pattern of infant feeding and attitudes of the mothers towards breast
feeding, morbidity and mortality of a sample of the Nigerian Igbo tribe was studied. The
result showed that:
- Ninety-four per cent of all mothers breast fed their infants for at least six months.
The duration was longer among the non-educated than the educated mothers.
- The size of the family decreased with increases in educational attainment. Eighty per
cent of the mothers gave their babies supplementary food between three and seven months of
age. A special weaning diet was used by 49 per cent of the educated mothers and 27 per
cent of the non-educated mothers.
- Twenty per cent of the children have at least one attack of diarrhoea before the age of
six months. One out of every eleven children was admitted at least once to the hospital
before the end of six months.
"The prevalence of diarrhoea, malnutrition and possible death could be attributed
to a number of factors. These include: the introduction of supplementary food too early in
unsanitary conditions, the ignorance of the mothers of what the weaning diet should
constitute, the large number of children in the family, and the unhygienic
environment." From Kazimi L. J. and Kazimi H. R. (1979) Infant feeding practices of the Igbo,
Nigeria. Ecology of Food and Nutrition 8 (2) - abstracted in Tropical Diseases Bulletin,
February 1980. Villagers can save their children
An important study was carried out in Bangladesh in which the diarrhoeal death rate in
two similar rural communities was compared over 24 months, from January 1977 to December
1978. An oral rehydration (OR) programme was started in one village community, Shamlapur,
using volunteer depot holders. They stocked oral rehydration salts (ORS) packets and were
trained in the preparation and administration of the oral rehydration fluid. There was one
depot holder for about every 800 people and his house was identified by a white flag This
service was well publicized locally.
West African mother and baby
Photograph by Dr Michael Reinhardt The other community at Bordil did not ask for specific help because they already had
access to a diarrhoea treatment centre only seven miles away, where ORS packets were
available. The diarrhoea attack rates were similar in both groups, 123 and 118 per
thousand person years respectively.
However, the diarrhoeal case fatality rates were 0.5 per 100 episodes in Shamlapur, the
OR village, and 2.4 in the control village, Bordil. The difference was most striking among
children under one year of age. More than twelve times as many children in this very young
age group died in the village without the programme. For some years there has been good evidence that OR is effective treatment for
diarrhoea in supervised clinical situations. This study suggests that following initial
intervention by health personnel, trained lay volunteers can use the technique to
significantly decrease deaths from diarrhoea, especially among infants and young children. The Lancet 1979, 2: 802-812 Oral rehydration workshop
A workshop on the integration of oral rehydration therapy into community action
programmes was held in Washington D.C. from March 19-21, 1980. The participants in this
workshop were representative of American, private and voluntary organizations (N.G.O.'s)
which sponsor programmes in the less developed countries. The history, development and current research into oral rehydration therapy was
presented by Drs. Hirschhorn, Black and Merson. Ms. Sullesta, Dr Mahalanabis, Dr Sayaad
and Mr Charkraborty related their experiences in using oral rehydration therapy in the
Philippines, India, Egypt and Bangladesh. The participants then worked in small groups to discuss the issues of home and village
level distribution, training and community education. The workshop was sponsored by USAID and organized by the Centre for Population
Activities, the Pan American Health Organization and the National Council for
International Health. Requests for a copy of the workshop report should be sent to the Centre for Population
Activities, 1717 Massachusetts Avenue N. W., Suite 202, Washington D.C. 20036, USA. Antibiotic resistance to cholera
For the past decade, a representative sample of vibrio specimens collected from
patients attending the Dacca Hospital and the Matlab Field Station of the International
Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR B) have been screened for
antibiotic sensitivity. Recently, five of 28 isolates tested from the Matlab field area in
the previous six weeks were found to show multiple antibiotic resistance. To confirm these initial observations, 167 additional vibrio specimens obtained from
patients of the Matlab Field Station were tested. The percentage of isolates demonstrating
resistance increased from 5% in the first month of the epidemic to 13%, 28%, 36% and 15%
in the four subsequent months. While antibiotics are not essential to the treatment of cholera, they shorten the
duration and volume of purging, the duration of excretion of vibrios and the amount of
fluid replacement required, Patients not responding to tetracycline will require more oral
and/or intravenous therapy than other cholera patients. Initial results from the study suggest that over-use of antibiotics is probably not
responsible for the emergence of multiple drug resistance. It also appears that while this
outbreak was first identified in Matlab, an area under intense microbiological
surveillance, the organism is probably more widely spread. Further epidemiologic and
microbiologic studies are underway. From a paper released by members of the Matlab Field Station, the Disease
Transmission Working Group, and the ICCDR B. January 31, 1980.
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Small hands to the pump in a Peruvian village. Clean water is
essential if diarrhoeal diseases are to be avoided
Public health authorities world-wide attribute much of the lower morbidity and
mortality of the developed world to improved hygiene and sanitation. Adequate water
supplies are an essential component of this and it is vital that we learn how to measure
the volume of water necessary to promote health and, conversely, the adverse effects of in
During a severe drought, Port-au-Prince, Haiti, lost hydroelectric power for ten weeks,
which led to water shortages in some areas of the city. In a study of the impact of water
restriction on disease, 400 families were randomly selected from two urban areas
differentially affected by the water shortage.
Diarrhoea rates were seen to be higher for children from homes using less than one can
of water per person per day, as were rates of scabies, febrile illness and malnutrition
That diarrhoea, which is related to both water quantity and quality, occurred in the same
pattern as the other illnesses - conditions related to only water quantity - suggest that
a major determinant of illness in this study was a reduction in water quantity. From The Lancet 1980, 1: 471-473 Viral diarrhoea - a big step forward
Clean utensils and the hygienic handling of food help to
prevent diarrhoea, in adults as well as children.
We know that a substantial percentage of acute diarrhoeal disease, especially in small
children, is caused by viruses. Antibiotic treatment does not work against viruses and
many children die. Vaccines are needed to protect them but to develop a vaccine, the
infecting agent must first be grown under laboratory conditions. Viruses can only grow
inside cells, unlike bacteria, so the culture medium must contain cells which the virus
Ever since the discovery by electron microscopy of rotaviruses (wheel-shaped particles)
in the faeces of young mammals, including babies, with acute diarrhoeal disease and the
recognition of these as the cause of the disease, strenuous efforts have been made to
cultivate them for thorough study. The success announced in SCIENCE on January 11, 1980,
has taken us a big step forward in the fight against diarrhoeal disease. Three laboratories in the USA announced that human rotavirus Type 2 (Wa) had been grown
in cultures containing African green monkey kidney (AGMK) cells. Specimens of faeces from
children known to have rotavirus diarrhoea provided the inoculum for a complicated series
of laboratory procedures aimed at producing a viral strain that would grow successfully in
tissue culture and retain the power to stimulate antibody production. Such a
culture-adapted human rotavirus now exists together with a test which demonstrates its
antibody - producing capability. It should therefore be possible to manipulate the Wa
strain in vitro in order to develop attenuated mutants for use in preventing a
serious diarrhoeal disease of human infants. From SCIENCE 1980, 207: 189-191 Egyptian programme
A pilot oral rehydration therapy project was carried out in Egypt from May to October
1977 with the aid of WHO and UNICEF. The therapy was initiated at maternal and child
health units and continued at home. It was found that most dehydrated children attending
MCH units were mild to moderate cases which could be effectively managed with oral
rehydration therapy. In 1978 it was decided to expand the oral rehydration programme
nationwide and there is now an extensive network in Egypt of some 3000 primary health care
units administering the therapy. One rural health unit serves a population of 5-15000 and
an urban MCH centre over 50000. From the weekly Epidemiological Record 1979, 51/52: 393-395
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|Diarrhoeal control ... opportunities and constraints
Issues in oral rehydration
In this feature, Norbert Hirschhorn examines some of the
most important issues in the planning and implementation of an oral rehydration therapy
programme. In an engineer's jargon, an answer to a problem is called "robust" if it can
be applied in several variations or adapted to several contingencies; be secure from total
failure because of failure at a single point; and show cost-effectiveness. Glucose-electrolyte fluid, with a universal composition to be taken by mouth, has
proved a far more robust product for rehydration in diarrhoea than intravenous fluids of
varying compositions tailored by age, diagnosis, bio chemical status of the blood, etc.
But the development of an oral rehydration therapy (ORT) delivery programme requires
considerable thought and research to discover the most robust methods. I can tentatively identify the various components of a delivery system and suggest some
areas where known opportunities and constraints make a potential delivery system more or
less robust or indicate our lack of knowledge. Six components come to mind: selection (of
ingredients), production, distribution, preparation, use and evaluation. Selection Sucrose or glucose?
Sucrose is cheaper but is somewhat less effective than glucose, especially at higher
concentrations. Sucrose absorbs less moisture, perhaps allowing use of non-foil packaging,
but at humidity over 85% and in warm climates moisture absorption is substantial.
Bazaar-bought sucrose is sometimes adulterated with water to increase selling weight, and
during recent years sucrose prices have fluctuated dramatically. How do glucose or sucrose and salts interact when stored as a powder together?
If the extra cost of glucose (plus foil package) is the limiting factor to a delivery
system, then sucrose is a more robust product. Potassium or no potassium?
No potassium would be cheaper, but the cumulative effect of unreplaced potassium loss
is known to be detrimental to appetite, behaviour, muscle and renal physiology. This is no
longer a researchable issue, but much data can be obtained from earlier studies. Bicarbonate or no bicarbonate?
If renal function is quickly restored, perhaps there is no need for bicarbonate, yielding
a cheaper product; but a number of cases will be detrimentally affected by prolonged,
albeit mild, acidosis. How much sodium?
We now know that a single concentration of sodium - 90 meq/L - is suitable for all
ages and most degrees of severity (except high output cholera in adults). This is the most
robust level. Production Salts and sugar combined in packets at some central points, or procured individually
at local bazaars?
Packet combined chemicals allow for greater safety, as bazaar salt is likely to be coarse
and sucrose may be adulterated. Bazaar-bought chemicals may be more often available (not
always: shortages of salt and sugar occur in the poorest countries), or perhaps cheaper.
Packeted chemicals are regarded more highly as "medicine" while salt and sugar
are regarded as food. The quantity of "energy" required to teach, procure and
use either set of chemicals and the quantity of "entropy" (loss of the message
and actions) are not yet known. Packets produced centrally, or regionally, or assembled at each health centre?
A more robust answer has production decentralised and not dependent on a single source,
but then some quality control is necessary. High technology or simple technology of packaging?
One person can manually measure out salts and sugar by spoon-measures to make up
100-300 packets per day. A $5,00 - $10,000 mixing machine can dispense thousands of
packets per day automatically. Distribution Hospital or health post?
It can be argued that most of the deaths and cases of prolonged diarrhoeal illness are
seen in hospital, that oral rehydration therapy will have the larger impact, and that
illness presenting to health posts is generally mild and self-limited. However, oral
rehydration therapy may have a longer-term preventive impact when given to milder cases.
The greater cost of distributing through health posts can be offset by not using
non-specific drugs and unnecessary antibiotics, but considerable retraining of staff
and families is required. Village health worker delivery scheme (government-employed), or village resident?
Mothers tend first to go to neighbours for help. If one of them is a supply point for oral
rehydration therapy, the trip to the health post may be averted, but if other things occur
at a health post (education, weighing, immunisations), this short-circuit may be
undesirable. Commercial channels and over-the-counter sales?
The private sector is brilliant at distribution, promotion and sales of drugs, but can the
price be low enough to prevent the "two penicillin tablet" syndrome? The
occasional packet bought over the counter is unlikely to cure and will bring the method
into disrepute. Preparation Measuring spoons or pinch-method for bazaar-bought chemicals?
Marked variations exist in different parts of the world in the quantity of a
"pinch" of salt. Cheap (plastic) measuring spoons are readily broken or lost.
English mothers often used heaped spoonfuls of milk powder in making up bottle
feeds, even when instructed to use level spoonfuls. Manufactured standard container or locally used container for dissolution of
Marked variations in local containers exist and larger measures (litre) are generally less
available or reliable than smaller measures. Cheap standard containers are easily
available in some places or can be cheaply made. Packets for one litre, half litre or quarter litre solutions?
One litre packets are cheaper, but more waste and bacterial overgrowth of standing
solutions may occur. Quarter litre packets may be hoarded as readily as half litre packets
by health workers, or fewer may be bought by the mother than needed (so treatment would be
inadequate). A robust answer might be the manufacture of a sturdy plastic bag, containing
the salts and sugar, which can then be filled to stretching point by an appropriate volume
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|Diarrhoeal control ... opportunities and constraints
worker giving out a packet of ORS.
Reproduction courtesy of UNICEF news
Who should get ORT?
If every child with diarrhoea got oral rehydration therapy, the costs (either in packets
or in interaction with the mother) would be astronomical (one thousand million children
under five, one episode each annually, $0.10/packet, three packets per episode = $300
million). Alternatively, should only those coming to a health post or health worker -
10-50% of total episodes - get oral rehydration therapy? Or, only those under three years
of age? Who makes the choices? It seems a difficult area of design, the decisions being
not entirely medical, or even controllable. How much is given on the first visit?
If packets are used, should mothers be required to return daily? If not, how many packets
should be given at a time? Bazaar-bought chemicals overcome this problem. However, will
the mother need daily reminders, especially when by day three, the salts have not
"cured" her child? What water is used to mix the chemicals? Boiled? But what if fuel is pitifully
scarce? In tea, perhaps? Or in just whatever is available?
Some useful description of what does happen is needed. What is the effect on a
child with diarrhoea getting more contaminated water? The wider the use of oral
rehydration therapy, the more this will occur. What about the nutritive message?
The message may be weakened or lost as - delivery moves closer to the village level.
Food may be seasonally scarce in any case. The salt-sugar solution may be viewed magically
and the food message overlooked. If the child is on cow's milk, should cow's milk be
stopped? Or only in those over one year old? There is no excuse to stop breast feeding.Glucose and electrolytes neutralise the bad effects of lactose. How are cultural blocks overcome?
In many cultures, sugar and salt are thought to be bad for diarrhoea; packets of sugar and
salt, however, gain remarkably rapid acceptance even in highly traditional societies. The major cultural block impeding use of oral sugar-electrolyte fluids and feeding in
diarrhoea is from the Western- based training of paediatricians. "Health
education" of government decision-makers may be as necessary as "education"
of mothers. Evaluation Should it be done?
It may be necessary that at least bedside demonstration of ORT takes place at teaching
hospitals to convince professors. Evaluation of impact at a community level is difficult,
costly and confounded by numerous selection, diagnostic and seasonal variables. A
double-blind control study is impossible and a closely surveyed control group (getting notherapy) may be unethical. Evaluation should be based on certain operational indicators. Remember that there are
two parameters of a delivery system: one, the system is rational, and two, it is being
properly executed. Five rational indicators may be listed as follows:
- Access Can children in need get to where the therapy is? Excessive cost is
considered a block to access.
- Availability Are the ingredients and means of mixing them properly available (and
- Acceptability Do mothers and children accept oral rehydration therapy? (Good data
for standards are now available.)
- Awareness Do mothers need to know scientific medical physiology
to use oral rehydration therapy effectively? (Data from the Philippines suggest not.)
- Adequacy Spot checks of how preparations are taught, how made up and how given
and whether children are being fed will be good indications of how the delivery system is
Conclusions A robust approach
Flow diagrams of the likely combinations of
selection-production-distribution-preparation and use will help establish a few choices,
especially when existing cost and effectiveness data from around the world are used.
Necessary data that must and can be easily obtained relate to stability, moisture
absorption, interactions and simplest packaging for sugar-electrolyte salts. A robust
approach will employ two or three means of manufacture and delivery of oral rehydration
therapy to high-risk groups with operational evaluation of each. Leadership from WHO
should continue. Gresham's Law applied to diarrhoea control
This basic law of economics states that bad money drives out good money. In medicine,
insisting that all report forms be filled out will guarantee that the really necessary
ones will be done as badly as the rest. In diarrhoea control, insisting to Ministries of
Health that all elements must be pursued with equal vigour (surveillance,
sanitation, water supply, education, nutrition, fluid therapy) will guarantee that those
things which can be undertaken now will be neglected both at the central and
peripheral levels. Norbert Hirschhorn, The John Snow Public Health Group, Inc., Boston, Mass., USA.
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|World Health Organization
Diarrhoeal diseases control programme
Acute diarrhoeal diseases have long been recognised as one of the major causes of
infantile and childhood mortality and morbidity in the developing countries. In 1978,
responding to the rising concern of its member states about the problem and as part of the
Organization's overall commitment to primary health care, WHO launched a global Diarrhoeal
Diseases Control (CDD) Programme, with the support and continued cooperation of UNICEF. The development of this global programme has been motivated by significant recent
developments in the treatment and control of diarrhoeal diseases. These include the
recognition of the role of new viral and bacterial agents of diarrhoea, an understanding
of the pathogenesis of acute diarrhoea and the demonstration that dehydration in all
diarrhoeas except the most severe can be safely and effectively treated by oral
rehydration therapy with a single glucose/salts solution. In addition, it has been found
that early oral rehydration together with proper feeding contributes to better weight gain
in children, thus reducing the ill effects of diarrhoea on nutritional status. As an immediate objective, the CDD programme seeks to reduce diarrhoea related
mortality and malnutrition in children by widespread implementation of oral rehydration
therapy and improved feeding practices. A major reduction of morbidity is an important
long term objective to be achieved through the improvement of child care practices, the
provision and use of water supply and sanitation( linking the programme closely
with the International Drinking Water and Sanitation Decade), epidemiological surveillance
and epidemic control. The programme has two main components. Firstly, an implementation component to
incorporate existing knowledge on diarrhoeal disease into national primary health care
programmes, and secondly a research component to support both field and laboratory
research in the development of new methods and approaches of treating and preventing
diarrhoeal disease. Implementation National CDD programme formulation
In this area, activities have been focused on cooperation in the, development of national
CDD programmes. As a global target, it is hoped to make oral rehydration salts (ORS)
accessible to at least 25% of children under five in the developing countries by 1983. To
date, some 70 countries have shown interest in developing national CDD programmes as an
integral part of primary health care. Initially, these programmes stress oral rehydration
therapy as a means of reducing diarrhoea related mortality. WHO is providing information
to country programme managers about activities in other countries and recent technical
Composition of oral rehydration
mixture recommended by WHO.
Sodium chloride (table salt)
Sodium bicarbonate (baking soda)
Dissolve in one litre of potable water
A management course and operations manual are being developed to strengthen national CDD
programmes, especially as regards planning and evaluation. Technical training manuals are
also being prepared on the treatment and prevention of diarrhoeal diseases, the control of
cholera epidemics and simplified procedures for laboratory diagnosis of enteric
infections. Also, with the support of the United Nations Development Programme (UNDP), a
number of Asian institutions are to be strengthened to provide a nucleus of training
centres in that region. Logistics
A major problem in the development of national CDD programmes has been organizing adequate
supplies of oral rehydration salts (ORS). With the support of the United Nations
Children's Fund (UNICEF) a major international effort is being made to meet requirements
through the provision of prepackaged ORS and help with national production. It is
estimated that 13 developing countries are now undertaking large-scale production of ORS
and guidelines for local production are being prepared Research
The research component of the programme is linked to the needs of the national CDD
programmes. Several meetings have been held over the past two years, in which scientists
from 27 countries have reviewed available knowledge and recommended research priorities.
Global Scientific Working Groups are soon to be established to coordinate and guide the
programme's basic research activities. Also, operational research on health services
delivery, environmental health and child care practices is to be carried out. Research on
vaccine and drug development and related epidemiological aspects is being supported by
UNDP, in collaboration with the World Bank. Some of the priority operational research areas will be:
- determination of the epidemiological patterns of the known aetiological agents of
diarrhoeal disease and identification of new agents.
- comparisons of different methods of preparation and packaging of ORS and delivery
systems at the primary health care level
- comparisons of alternative compositions of sugar/salt mixtures for oral rehydration with
the WHO formulation of already proved effectiveness (ORS).
- identification of infant feeding and child care practices that can best reduce diarrhoea
related malnutrition and mortality.
- determination of the best methods of environmental intervention to reduce the
transmission of diarrhoeal disease agents.
A special effort is now being made to identify suitable research workers and
institutions in the developing countries and to provide them with appropriate support,
Continuing support is going to the WHO Collaborating Centres and to other internationally
recognized centres such as The International Centre for Diarrhoeal Diseases Research,
Bangladesh The periodic distribution of annotated bibliographies and summaries of new
research is also planned
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A national experience in oral rehydration therapy
In the Philippines, diarrhoeal disease is the main cause of death among children under
five. The Philippine government and the World Health Organization collaborated in field
studies to test the effects of oral rehydration therapy (ORT) when administered in health
centres and at home. On the basis of the encouraging results received from the studies, a
national programme was developed. Field studies
In the urban study, the WHO glucose-electrolyte solution
(Oresol) was given at home to
464 children with diarrhoea. A greater average weight gain was observed both during an
attack and over a seven month period when compared to a control group. The longer term
effect on weight was more pronounced in children with recurrent diarrhoea. The Oresol was
dispensed from health centres where diarrhoea patients were first seen by a doctor.
Assistant health workers then collected the necessary data, discussed treatment with the
mothers and followed up cases in the home.
health worker demonstrating the use of Oresol
The seven villages selected for the rural study had no easy access to the organized
health delivery system and one village was only partially accessible to transport.
Meetings were first held with local officials to obtain their approval. Later, community
talks were held about oral rehydration and the villagers then selected their own OR
deliverers who were given basic training by project staff.
There was a high acceptance rate of ORT in both studies. Mothers were enthusiastic
about the treatment, sought it out and claimed it had improved the general state of health
and appetite of their children. They also realized the value of continued feeding during
diarrhoea. Both studies showed a highly significant decrease in morbidity and mortality rates. In
the rural study, the local delivery system was well accepted and worked effectively. A key
factor in the success of this type of system is selection of sympathetic and responsible
deliverers. One problem was finding an easily available measuring device. This was resolved when
everyone agreed that local beer bottles were to be found in almost every home. Later, a
drinking glass, originally the container for a popular coffee brand, was found to be more
practical. Incorrect mixing of Oresol by mothers occurred throughout the year. National programme
Encouraged by these results, WHO, UNICEF and the Ministry of Health sponsored a two day
national seminar workshop. Participants discussed the obvious value of ORT in treating
diarrhoeal diseases and national pilot projects were planned. A four member national team
was created to coordinate and monitor these. Inevitably, coordination problems increased
with the nationwide implementation of the programme. One major difficulty was that the
team could not rely on getting enough regular and accurate incoming reports to make a
valid evaluation of the programme. ORT outside the Ministry of Health
- International Institute for Rural Reconstruction (IIRR)
In IIRR communities, traditional healers carry out ORT, reporting back to the medical
officer at headquarters about once a month.
- Institute of Maternal and Child Health (IMCH)
Under the direction of a prominent national paediatrician, the IMCH encourages ORT at its
hospital and community projects, using a more diluted solution for infants and
- National Nutrition Council of the Philippines (NNCP)
The NNCP receives 12,000 packets of Oresol each month which are distributed by
"barangay nutrition scholars" throughout the country. Some critics doubt whether
these extension workers have enough training in ORT, and their poor record-keeping makes
Recommendations Mother giving her child Oresol to drink
The success of a national programme depends on the coordination and supervision of
education, training, distribution and supply. The system of education and training should
reach everyone involved in the delivery of health care and the enthusiasm of a national
coordinator is crucial. The Philippine experience in oral rehydration therapy revealed strengths and weaknesses
which could benefit other countries, not as a model, but as a reference on which to base
the strategies for their own national programmes. Enriqueta O. Sullesta, Supervising Public Health Nurse, Bureau of Quarantine,
Ministry of Health, Manila, Philippines.
Diarrhoea Dialogue Online Issue 1 May 1980 7
Points Feedback and discussion
In future issues, your letters and comments will be welcome on this page and we anticipate
that it will become a lively forum. While we shall have to bear availability of space in
mind when considering letters for publication, every effort will be made to include as
much as possible. Teaching and training
Do you know of any developing countries where teaching and training materials about oral
rehydration therapy are available in the local languages? If so, please tell us - and if
possible, send us samples. Safe keeping
We suggest that as soon as you and your colleagues have read your copy of Diarrhoea
Dialogue that you punch the spine and file it. In this way, the information it
contains will always be easily accessible. The next issue
- is planned for July/August 1980
- will contain a main feature by Dr Jon Rohde on different ways of measuring and
delivering ORS ingredients (recipes and methods)
- will (we know!) have plenty of news, ideas and comments which you have sent us.
|In each issue of Diarrhoea
Dialogue we plan to highlight one major area in the fight against diarrhoeal disease.
Probable future topics will include water, feeding, health education, drugs and therapy,
immunisation, sanitation, nutrition and chronic diarrhoea. Both within these main features
and throughout the rest of the newsletter, we shall try to explore as many questions
related to diarrhoeal disease control as possible. We list below some that have already
occurred to us but look forward to receiving many more suggestions from you
- what treatment can be given if the special packets of oral rehydration mixture are not
- why is glucose and salt in water better than plain water for severe diarrhoea?
- is it important to have boiled, purified or clean water for rehydration?
- if glucose and sugar mixed with salts are good, what about other sugars like honey?
- what is the role of other food items, for example starches used with salt solutions?
- is there a case for using different mixtures in different circumstances?
- how can the risks associated with contaminated water be reduced?
- which cases should be referred to health facilities - i e. what are the dangerous signs
- what are the local beliefs about the causes and treatment of diarrhoea? These are very
important as regards acceptability of a technique like oral rehydration.
- are there any traditional remedies that have been shown to be effective?
- when diarrhoea is related to other diseases such as measles, malaria and middle ear
infection, should it be treated differently?
- which drugs are really of proven value against diarrhoea?
- how much or how little food should be given to children with diarrhoea?
- breast milk (fed directly) cannot be easily contaminated. Is this the only, or most
significant reason why breastfed babies have less diarrhoea?
- "rest the bowel" is a traditional treatment for diarrhoea. Is this necessary?
- which aspects of hygiene are most important in preventing diarrhoea?
The Appropriate Health Resources and Technologies Action Group (AHRTAG) came into being
in London in 1977 as a sister organization to the Intermediate Technology Development
Group (ITDG). AHRTAG is a WHO Collaborating Centre for Appropriate Technology for Health,
and the many and varied aspects of diarrhoeal disease control call for development of much
appropriate 'hardware' and 'liveware' to assist in diminishing the problem. We hope that
the pages of Diarrhoea Dialogue will reflect AHRTAG's role as a meeting place for
the ways and means to better health. AHRTAG serves as an information centre and clearing-house for materials relating to
primary health care and health-related technologies. AHRTAG is interested in both health
care people and health care tools. The Group works with other international organizations,
shares in overseas projects, produces information sheets, bibliographies and other
publications, and helps to identify unmet needs and possible answers to such needs. AHRTAG is one of the recognized fixed points in an informal world network which links
individuals and institutions interested in the exchange of ideas about health care at
neighbourhood or village level. If you would like to learn more about AHRTAG you can
indicate this on the Diarrhoea Dialogue mailing list form inside.
Scientific editors Dr Katherine Elliott and Dr William Cutting
Executive editor Denise Ayres
Designer Celia Stothard Proposed editorial advisory group
Dr I Dogramaci (Turkey)
Professor Richard Feachem (UK)
Dr Michael Gracey (Australia)
Dr Norbert Hirschhorn (USA)
Dr D Mahalanabis (India)
Professor Leonardo Mata (Costa Rica)
Dr Mujibur Rahaman (Bangladesh)
Dr Jon Rohde (USA)
Ms E O Sullesta (Philippines)
Dr M K Were (Kenya)
Dr Michel Manciaux (France) With support from WHO and UNDP
Issue no. 1 - May 1980
This edition of Dialogue on Diarrhoea Online is produced by Rehydration Project. Dialogue on Diarrhoea was published four times a year in English, Chinese, French, Portuguese, Spanish, Tamil,
English/Urdu and Vietnamese and reached more than a quarter of a million readers worldwide. The English edition of Dialogue on Diarrhoea was produced and distributed by Healthlink Worldwide. Healthlink Worldwide is committed to strengthening primary health care and
community-based rehabilitation in the South by maximising the use and impact
of information, providing training and resources, and actively supporting
the capacity building of partner organisations. - ISSN 0950-0235 Reproducing articles
Healthlink Worldwide encourages the reproduction of
articles in this newsletter for non-profit making and educational uses. Please
clearly credit Healthlink Worldwide as the source and, if possible, send us a copy of any uses made of the material.
updated: 4 March, 2016