Impact of fly control on childhood diarrhoea in Pakistan: community-randomised trial

BACKGROUND

Several million children are killed each year by diarrhoeal diseases; preventive strategies appropriate for developing countries are vital. Despite strong circumstantial evidence that flies are vectors of diarrhoeal diseases, no convincing studies of the impact of fly control on diarrhoea incidence in developing countries have been reported. We undertook a randomised study of the effect of insecticide spraying on diarrhoea incidence.

METHODS

Six study villages were randomly assigned to two groups. Flies were controlled through insecticide application in group A in 1995 and in group B in 1996. In 1997 the effectiveness of baited fly traps was tested in group A villages. Diarrhoea episodes were monitored in children under 5 years through mothers' reports during weekly visits by a health visitor. Fly density was monitored by use of sticky fly-papers hung in sentinel compounds.

FINDINGS

During the fly seasons (March-June) of both 1995 and 1996, insecticide application practically eliminated the fly population in the treated villages. The incidence of diarrhoea was lower in the sprayed villages than in the unsprayed villages in both 1995 (mean episodes per child-year 6.3 vs 7.1) and 1996 (4.4 vs 6.5); the reduction in incidence was 23% (95% CI 11-33, p=0.007). At times other than the fly season there was no evidence of a difference, in diarrhoea morbidity between sprayed and unsprayed villages. Fly density data for 1997 indicate the ineffectiveness of baited traps in this setting.

INTERPRETATION

Fly control can have an impact on diarrhoea incidence similar to, or greater than, that of the interventions currently recommended by WHO for inclusion in diarrhoeal disease control programmes in developing countries. This important finding needs confirmation in other settings in developing countries. Technologies and practices that interrupt disease transmission by flies need to be developed and promoted.

Risk factors for development of dehydration in children aged under five who have acute watery diarrhoea: a case-control study

OBJECTIVE

To identify factors for development of dehydration in under five year olds with acute watery diarrhoea.

DESIGN

Hospital based unmatched case-control study.

SETTING

Diarrhoea Treatment Unit, Government Medical College Hospital, Nagpur, India.

PARTICIPANTS

The study included 387 cases of diarrhoea having severe or moderate dehydration and 387 controls suffering from diarrhea with mild or no dehydration.

RISK FACTORS

The study included infancy, female sex, religion, residing in urban slums or rural area, under nutrition, cessation of breast feeding during diarrhoeal episode, fluid intake decrease/stopped during diarrhoea, ORS not received, home available funds (HAF) not received, both ORS and HAF not received, non-washing of hands by mother before preparation of food, after defaecation, after disposal of faeces, history of measles in the previous six months, frequency of stools > 8/d, frequency of vomiting more than twice per day and temperature more than 99 degrees F, as risk factors for development of dehydration.

STATISTICAL ANALYSIS

Univariate analysis included OR, 95% CI for OR and Chi-square test. Multivariate analysis was carried out by unconditional multiple logistic regression (MLR).

RESULTS

This study identified the significance of infancy, religion, severe undernutrition, non-washing of hands by mother before preparation of food, frequency of stool > 8/d, frequency of vomiting > 2/d, history of measles in previous six months, withdrawal of breast feeding during diarrhoea, withdrawal of fluids during diarrhoea and not giving ORS, HAF or both during diarrhoea, in the outcome of development of moderate or severe dehydration.

CONCLUSIONS

Timely intervention in the preventable risk factors included in this study may prevent the development of moderate or severe dehydration in the children suffering form acute watery diarrhoea.

Infant feeding practices and child health in Bolivia

The effects of breast-feeding and supplementation practices on recent diarrhoea occurrence and stunted growth are modelled using logistic regression techniques. Data from the Demographic and Health Survey of Bolivia, 1989, show that, among children aged 3-36 months at the date of interview, the benefits of breast-feeding to child health were most pronounced among children living in rural poverty. Reduced breast-feeding among these children increased the likelihood of diarrhoea and stunted growth. In addition, the introduction of solid foods to currently lactating infants negatively influenced child health.

Rotavirus vaccines against diarrhoeal disease

Rotaviruses are responsible for more diarrhoeal disease-associated mortality than any other single agent. Vaccination may therefore hold the key to combating diarrhoeal disease worldwide. Natural immunity to rotavirus infection indicates that rather than protection from reinfection such immunity gives rise to less severe and less frequent attacks of diarrhoea. Early attempts to design a rotavirus vaccine with bovine rotavirus failed because of poor efficacy in some developing countries. Research into rhesus rotavirus, particularly the high-titre rhesus rotavirus tetravalent (RRV-TV) vaccine, has given slightly better results. A stumbling block to truly effective oral vaccines seems to be immunogenicity in developing countries. If efficacy can be ensured by trials in the developing countries, money spent on rotavirus vaccines will be well spent.

Gastroenteritis, diarrhoea and breast feeding

In this paper we review the literature in regard to possible relationships between breast feeding and diarrhoea or gastroenteritis. We show that in the developed as well as the developing world, there is consistent evidence of a protective effect of exclusive breast feeding in the first 4-6 months of life. The odds ratios were generally in excess of 3.0 for non-breast milk feeds. The relationship was not consistent for rotavirus infections but was consistently strong for non-viral pathogens. There are a number of indicators that suggest biological plausibility, in both the developing and developed world. The triple indicators of consistency and strength of the epidemiological associations, together with biological plausibility are major arguments for believing that there is a causal sequence involved.

Breast-feeding promotion in a diarrhoea programme in rural communities

Breast-feeding promotion is an important intervention for the control of infant diarrhoea. This study assesses the impact of a breast-feeding counselling programme on the prevalence of exclusive breast feeding in rural communities in Nigeria. Mothers attending primary care facilities because their infants had acute diarrhoea were randomised into two groups. The study group (n = 82) received individual, focused breast-feeding counselling, while the controls (n = 79) had routine advice for diarrhoea. Both groups were monitored and followed with home visits to determine infant-feeding practices. The results showed marked increases in exclusive breast-feeding prevalence for the intervention group at day 7 (49% vs. 6% control; p < 0.0001) and day 21 (46% vs. 8%; p < 0.0001). Moreover, diarrhoea re-occurrence at day 21 was less in the intervention group (12%) than controls (18%). It is concluded that focused breast-feeding counselling can increase exclusive breast feeding and reduce the prevalence of diarrhoea in rural communities.

Evidence of malnutrition having a threshold effect on the risk of childhood diarrhoea in Zimbabwe

OBJECTIVE

Diarrhoeal disease is a major cause of childhood morbidity and mortality in Zimbabwe. This paper examines the relationship between diarrhoea and malnutrition to determine whether there is a threshold effect in operation.

DESIGN

Multivariate analysis of a retrospective survey.

SETTING/SUBJECTS

Using a nationally representative sample, the Zimbabwe Demographic and Health Survey, 1994, collected diarrhoeal, anthropometric and socio-economic data for 2,073 children aged 0 to 35 months.

RESULTS

Age of the child, residence, and severe stunting and wasting were found to be significant predictors of childhood diarrhoea. However, moderate stunting and wasting failed to show any relationship.

CONCLUSIONS

Moderate malnutrition is the main nutritional complaint in Zimbabwe. Thus malnutrition may have a relatively small role in determining the prevalence of childhood diarrhoea. Instead, factors related to exposure--namely sanitation, water supply, population density and hygiene--may be more important. Consequently supplementary feeding programmes should work in tandem with initiatives to reduce exposure if the morbidity burden of children is to be reduced.

Dietary management of acute diarrhoea in children: effect of fermented and amylase-digested weaning foods on intestinal permeability

BACKGROUND

There is a strong relationship between diarrhoea, malnutrition, and intestinal integrity. To investigate the effect of different dietary-treatment on intestinal permeability during acute diarrhoea, 87 Tanzanian children aged 6-25 months were recruited to this study when admitted to hospital.

METHODS

Children with acute diarrhoea were rehydrated and then randomly assigned to one of three dietary treatment groups: a conventional low-energy density porridge, a high-energy density amylase digested porridge (AMD), or a high-energy density amylase digested and then fermented porridge (FAD). Lactulose/mannitol permeability tests were performed on admission, at 3 days, and at follow-up 2 and 4 weeks after discharge. The lactulose/mannitol (L/M) ratios were compared between dietary treatment groups and to a group of age-matched, healthy control subjects.

RESULTS

Children with diarrhoea had higher L/M ratios (geometric mean 0.85, 95% CI 0.68-1.05) compared with control subjects (0.14, 0.12-0.17) on admission. There was a significant difference in the change in L/M ratio between admission and 3 days between dietary treatment groups in favour of the FAD group (p < 0.05).

CONCLUSIONS

Dietary treatment and intestinal damage at admission explain 13.5% of the variation in L/M ratio, but when age at admission and age at weaning are included as covariants, 21.9% is explained. FAD porridge seems to be more effective in the treatment of intestinal permeability than AMD or conventional porridge. Urinary lactose concentrations in spot urine samples taken prior to the permeability test were also measured. There was a significant correlation with the L/M ratio (correlation coefficient = 0.62, p < 0.001).

The influence of breast feeding on the occurrence of dysentery, persistent diarrhoea and malnutrition among Nigerian children with diarrhoea

A case-control study of children attending a diarrhoea treatment unit (DTU) in Calabar, Nigeria was undertaken to evaluate the association between failure to breastfeed on one hand, and dysentery, persistent diarrhoea and malnutrition on the other. The prevalence of dysentery, persistent diarrhoea and underweight were 6.3%, 1.2% and 36.4% respectively among a total of 1133 children with diarrhoea. The proportion of the children with persistent diarrhoea or underweight was significantly lower among currently breastfeeding children than the age-matched, non-breastfeeding counterparts (p < 0.05). Dysentery was also less frequent among breastfeeding children (5.8%) than the non-breastfeeding ones (7.4%), but this did not reach statistical significance. The findings lend support to the enormous benefit of breastfeeding as a child survival strategy. Global efforts geared towards the support of breastfeeding should be intensified especially the less developed countries where diarrhoea-related morbidity and mortality constitute a major public health problem.

Efficacy of standard glucose-based and reduced-osmolarity maltodextrin-based oral rehydration solutions: effect of sugar malabsorption

Previously we reported that standard oral rehydration salts (ORS) solution is not as effective as a reduced-osmolarity glucose-based ORS for the treatment of children with acute noncholera diarrhoea: with standard ORS the diarrhoea lasts longer, stool output is greater, serum sodium is higher, and there is more need for supplemental intravenous infusion. We studied a reduced-osmolarity maltodextrin (MD)-based ORS to determine whether it had similar benefits, and also the effect of sugar malabsorption on the efficacy of standard and MD-based ORS. A total of 90 boys aged 3-24 months with acute noncholera diarrhoea and moderate dehydration were randomly assigned to either standard ORS (glucose 20 g/l, osmolarity 311 mmol/l) or MD-ORS (MD 50 g/l, osmolarity 227 mmol/l). There were no differences in treatment results. Some 46% of subjects had a high total stool output (> 300 g/kg), which was unrelated to the type of ORS given. High stool output was significantly associated with a longer duration of diarrhoea (33 vs. 15 hours; P < 0.001), a persistently elevated serum sodium (149 vs. 144 mmol/l at 24 h; P < 0.02), the need for intravenous infusion (11/41 vs. 0/48; P < 0.002), and an increase in faecal reducing substances (10.8 vs. 3.4 g/l at 24 h; P < 0.001). We conclude that some children given standard ORS develop osmotic diarrhoea owing to the combined effect of transient sugar malabsorption and slight hypertonicity of the ORS. Earlier studies show that this adverse outcome can largely be avoided when extra water is given in reduced-osmolarity glucose-based ORS. Reduced osmolarity has no benefit, however, when glucose is replaced by maltodextrin, probably because the sugars released by hydrolysis of MD, when malabsorbed, raise the intraluminal osmolarity to equal or exceed that of standard ORS. Thus, reduced-osmolarity glucose-based ORS is superior to both standard ORS and reduced-osmolarity solutions based on maltodextrin and probably other complex carbohydrates. Studies are in progress to define the optimal formulation of reduced-osmolarity glucose-based ORS.

Community-based hygiene education to reduce diarrhoeal disease in rural Zaire: impact of the intervention on diarrhoeal morbidity

BACKGROUND

Diarrhoeal disease is a leading cause of morbidity in young children in rural Zaire. Few diarrhoea prevention programmes have been implemented in Bandundu Province, where available data suggest an annual prevalence rate of 10%. The urgent need to reduce diarrhoeal morbidity in Zaire, together with the potential effectiveness and feasibility of hygiene education as a diarrhoea prevention strategy, led to the development of the present research project.

METHODS

A randomized, controlled trial of an education intervention to reduce diarrhoea through improved personal and domestic hygiene behaviours was conducted in 18 geographically separate village clusters (sites) in rural Zaire. For 12 weeks baseline information on the diarrhoeal morbidity of 2082 children aged 3-35 months was collected at weekly home visits, and structured observations of hygiene practices related to diarrhoea were made on a subset of 300 families. Intervention messages addressed disposal of animal faeces from the yard, handwashing after defecation and before meal preparation and eating, and disposal of children's faeces. Three months after the start of the intervention and exactly 1 year after the baseline studies, a second diarrhoeal morbidity study and a second observational study were conducted in order to evaluate the intervention.

RESULTS

Children in intervention communities experienced an 11% reduction in the risk of reporting diarrhoea during the peak diarrhoeal season, compared to controls (P < 0.025). The largest differences were seen among children aged 24-35 months, with those from intervention communities reporting significantly fewer episodes, shorter mean durations and hence fewer days of diarrhoea. There was some evidence that greater reductions in diarrhoea occurred in sites where the quality of the intervention, a scored measure of volunteer efficacy and community participation, was highest.

CONCLUSIONS

The results of this study suggest that hygiene education may be an effective approach to reduce the incidence and duration of diarrhoeal episodes in rural Zaire. Children aged 2 years appear to benefit the most. A Hawthorne effect of the education may contribute to diarrhoeal reductions.

Cooperative studies on diarrheal diseases

Enteric infection still causes the highest global morbidity and mortality in children under 5 years old. While there have been impressive developments in the early treatment of diarrhea, adequate diagnostic techniques are not yet available. An international collaboration was conducted with the National Institute of Cholera and Enteric Diseases, Calcutta on the rapid diagnosis and prevention of diarrheal diseases. Forty to fifty per cent of the 780-bed Infectious Diseases Hospital is occupied by cases of diarrhea. Vibrio cholerae O1 continues to occupy a prominent position, and the prevalence in children up to 2 years is 30.9%. Accordingly, immuno-enzymatic detection of cholera toxin in stool was achieved. Bead enzyme-linked immunosorbent assay (ELISA) could successfully detect 40 pg/mL toxin within 4 h, but the detection rate of culture, bead ELISA and polymerase chain reaction (PCR) method was 72.2, 71.1 and 95.9%, respectively, indicating that PCR provides the most sensitive and specific assay for diagnosis of cholera directly from the stool of patients. Heat-stable enterotoxin (STa) is another virulence factor of gastroenteritis. Various monoclonal antibodies were established against it, and developed a competitive ELISA for the detection of STa producing strains. A DNA probe was also prepared, and genus vibrio was monitored. V. mimicus were found to be the reservoirs of STa among clinical vibrios. Various monoclonal antibodies against STa were also useful for the epitope mapping, providing information on the topology of toxin-host interaction.

A community-based randomized trial of home-made oral rehydration therapies

A field trial of the relative efficacy of three oral rehydration therapies (ORT) in the treatment of acute childhood diarrhoea in children < 5 years old was carried out in a rural Ethiopian district. The three ORT were 1) pre-packaged glucose and salt solution (GORS; n = 153), 2) home-made cereal added to pre-packaged salt solution (CBORS; n = 154), and 3) entirely home-made cereal-based and salt therapy (CBORT; n = 156). Out of 127 eligible peasant associations, 18 were randomly selected, and groups of six were then randomly assigned to receive one of the three treatment options. In infants aged 0-12 months, after adjusting for baseline weight and diarrhoea frequency, CBORT was found to be superior (P < 0.01) to GORS and CBORS in terms of weight gain at 24, 48, and 96 hours. There were no significant between-group differences in weight gain in children > 12 months old. Over the 96-hour duration of follow-up, mothers' compliance was significantly better among those giving CBORT when compared to CBORS (P < 0.001) or GORS (P < 0.013). The results of this field trial indicate that CBORT is an efficacious alternative to GORS or CBORS in the treatment of acute childhood diarrhoea in rural community settings. Larger scale, effectiveness studies are recommended.

Structured observations of hygiene behaviours in Burkina Faso: validity, variability, and utility

The use of observation techniques has been promoted for the study of hygiene practices; however, questions still remain about the validity and repeatability of such techniques. In this article we compare data on hygiene behaviours obtained from questionnaires with data obtained using a structured observation approach and examine the repeatability of structured observations of behaviours and spot observations of environmental conditions. Poor agreement between questionnaire responses and observations was found for child defecation and stool disposal practices (kappa statistic: 0.25 and 0.28, respectively). There was evidence of over-reporting of "good" behaviours (P < 0.0001). Repeated observations of child defecation and stool disposal behaviours showed better agreement (kappa statistic: 0.76 and 0.62, respectively) based on small sample sizes. These findings suggest that our questionnaire data are less valid than data obtained by direct observation. However, different approaches to questioning may be less prone to over-reporting of "good" behaviours than our approach. Further research into the validity of different forms of question is warranted. Behaviours and conditions related to hygiene vary. Observations may be useful in determining the frequency of different behaviours/conditions in the community. However, individual practices may be too variable to assign individuals to exposed and non-exposed groups for the purpose of identifying links with health outcomes. Further studies on the variability of behaviours and the repeatability of observations are therefore needed.

The use of diarrhoeal management counselling cards for community health volunteer training in Indonesia: the HealthCom Project

The Indonesian Ministry of Health relies on a network of over a million kader (community health volunteers) to bring primary health care to the village level. In West Java, the Department of Health's Control of Diarrhoeal Disease (CDD) Program recently carried out an extensive research and development effort to produce effective job aids for the kader in CDD and a training programme to teach their use. A set of counselling cards was produced to provide kader with a tool to diagnose and treat diarrhoea and teach the proper use of ORS. Researchers conducted a controlled evaluation in which they measured the cards' effectiveness through observations of kader performance and interviews with mothers they had counselled. In the intervention group, 15 kader underwent two days training in the use of the cards when diagnosing and advising treatment for cases of diarrhoea in their villages. The 16 control kader received comparable CDD training without the cards. Each group provided lists of local mothers they pledged to counsel during the coming weeks. Follow-up interviews were held with these mothers to test their level of knowledge on CDD and to observe their ability to mix ORS properly. Significant performance differences between the intervention kader and mothers, and the control kader and mothers, were demonstrated. The intervention kader were consistently more accurate in their diagnoses and recommendations for treatment with a mean of 83% accuracy vs 68% for the control kader. Mothers counselled by the intervention kader also prepared ORS significantly better than the mothers counselled by the control kader, with 97 vs 74% accuracy.

Household behaviors in the management of diarrhea and their relevance for persistant diarrhea

There has been a great deal of research in recent years on household behaviors related to diarrhea management. Most of the available data on household diarrhea management, however, pertains to acute diarrheal episodes. There is a death of knowledge concerning household and caretaker behaviors when the diarrhea is of longer duration. This paper briefly reviews some of what has been learned about household behaviors in the management of acute diarrhea and discusses its relevance for persistent diarrhea. Based upon what has been learned from anthropological studies of acute diarrhea and the little that is known about caretaker behavior during persistent diarrhea, a hypothetical model of the interactions among household behavior and characteristics of diarrheal episodes is presented. The model argues that maternal (or caretaker) concern increases with diarrheal duration, and that changes in behavior, both adaptive and maladaptive, are more likely to occur during an episode of persistent diarrhea, compared to acute. In some cases, these actions may directly influence the outcome of the episode. There is a need to better understand household case management behaviors through the continuum of diarrheal duration and the effect of these behavioral factors on episode outcome. This information is necessary in order to communicate effective message to caretakers about what they should know and what they should do when persistent diarrhea occurs.

Hypernatraemia surveillance during a national diarrhoeal diseases control project in Egypt

The nationwide introduction of oral rehydration therapy to Egypt has led to improvement in diarrhoea case management and a fall in infant and child mortality. With the wider use of oral rehydration solution (ORS) prepared from packets, the incidence of hypernatraemia (serum sodium greater than 150 mmol/l) in inpatients with dehydration seen at Abu El-Reeche Hospital, Cairo, increased between 1980 and 1984. Systematic surveillance of hypernatraemia in the outpatient rehydration unit began in late 1984, and we report trends in hypernatraemia and analyses of key variables affecting its incidence in dehydrated children. In 1980, 17 of 100 children sampled had hypernatraemia and 2 had severe hypernatraemia (ie, serum sodium greater than 165 mmol/l). The frequency in inpatients peaked at 49% of 222 children in 1984 (19% with severe hypernatraemia). Between 1986 and 1989, at least 1000 dehydrated outpatients were surveyed each year; by 1989 the incidence of hypernatraemia had fallen to around 10% (2% severe hypernatraemia). The rise and decline coincided with increasing use of ORS and then increasing ability of mothers to mix the solution correctly. Hypernatraemia was positively related to the quantity of ORS taken, severity of dehydration, nutritional status, and the cooler season, and negatively related to age and duration of diarrhoea. Explanations for our findings include improved use of ORS and better case-management. Good practice promoted through the mass media has facilitated these changes; if the standard of ORS use is not maintained, there may be a case for reducing the sodium content of ORS.

A comparative study of specific gene probes and standard bioassays to identify diarrhoeagenic Escherichia coli in paediatric patients with diarrhoea in Bangladesh

We compared the usefulness of gene probes with standard bioassays to identify diarrhoeagenic Escherichia coli amongst isolates from Bangladeshi children under 1 year of age with diarrhoea. E. coli isolates were analysed with specific gene probes for localised adhesiveness (LA), diffuse adhesiveness (DA), heat-labile toxin (LT), heat-stable toxin (ST), Shiga-like toxins (SLT I and SLT II), and enteroinvasiveness, and in bioassays for production of enterotoxins and cytotoxins, and for cell adherence. With 1136 isolates from 387 patients, there was general agreement between the two assay methods. When there was disparity, gene-probe-positive isolates gave negative results in the corresponding bioassay. In the HeLa cell adherence assay, 94% of the LA probe-positive isolates and 91.6% of the DA probe-positive isolates gave positive bioassay results for LA and DA respectively. Thirty-six of 39 LT probe-positive isolates and 73 of 86 ST probe-positive isolates gave positive results in the bioassays. Of 28 isolates that gave negative results in the suckling mouse assay but were initially positive with the probe for ST, 15 were later found to hybridize with the cloning vector for the ST probe. Addition of denatured vector DNA at a concentration of 10 micrograms/ml in the hybridisation solution eliminated these false positive results. None of the other probe-positive isolates hybridised with any of the cloning vectors used. The DNA hybridisation assay appeared to be a convenient alternative to bioassays for screening large numbers of isolates in epidemiological investigation.

The role of breast milk in protecting urban Peruvian children against cryptosporidiosis

To test the hypothesis that breast milk of nursing mothers may afford children protection against cryptosporidiosis, a prospective cohort study was carried out in the young peoples' community of San Juan de Miraflores near Lima, Peru. Mothers and newborn children were sorted into cohort groups based on the mothers' breast milk antibody response to Cryptosporidium sporozoites using an antibody-capture enzyme-linked immunosorbent assay to detect parasite-specific immunoglobulin A. Children were monitored for Cryptosporidium infection using an indirect immunofluorescence assay. Of 211 mothers enrolled in the study, 39 (18.5%) had high breast milk antibody titers, 107 (50.7%) had medium titers, and 65 (30.8%) had low titers. Sixty-one episodes of Cryptosporidium infection were detected in 50 children of these mothers. Eleven (22%) had mothers in the high antibody titer group, 20 (40%) had mothers in the medium titer group, and 19 (38%) had mothers in the low titer group. The prevalence of infection within children of each group was 0.17, 0.19 and 0.38 respectively. There was no significant difference in the prevalence or duration of infection among children of the different groups. The data does not support the notion that there is protection from Cryptosporidium infection afforded children whose mothers have demonstrable breast milk antibodies against the parasite.

Health education through interactive radio: a child-to-child project in Bolivia

In developing countries it is common for older children to assume much of the responsibility for care of their younger siblings. Based on this observation, the "child-to-child" approach to health education targets these older children as a means of improving child health. As the initial phase in the development of a radio health curriculum in Bolivia, a module on diarrheal disease was developed and field-tested among fourth- and fifth-grade students in Cochabamba. The module consists of 10 interactive radio lessons in which the students respond orally to drill and practice, sing songs, or write key concepts in their notebooks. Following the 25-minute radio broadcast, the teacher conducts a 20-minute session that focuses on application and practice of the new behaviors. The module includes lessons on personal hygiene, water and oral rehydration, home sanitation, and nutrition. The field evaluation revealed the need for modifications in the teachers' role and greater attention to teacher training. Students responded enthusiastically and achieved significant knowledge gains as a result of the program. Plans are underway to expand the radio health program.

Oral rehydration therapy: a community trial comparing the acceptability of homemade sucrose and cereal-based solutions

Sugar-based oral rehydration therapy (ORT) for diarrhoea is promoted in many countries of the world. One programme in Bangladesh has instructed more than 13 million mothers in the preparation of a sugar-salt solution in the home; despite very high rates of correct mixing and knowledge, subsequent application was found in only some 20% of all diarrhoea episodes. Since rice is far more available in rural homes (95%) than any type of sugar (30%) and rice gruel is a widely accepted food during illness, a field trial was conducted in three areas (total population, 68,345) to compare the acceptability and use of rice-based ORT with that of sugar-based ORT. Although the mothers unanimously agreed that the rice-based solutions "stopped" the diarrhoea more quickly, they used the sugar-based solutions twice as often (in 40% of severe watery episodes) as the rice-based solutions (in 18%), because the rice-ORT was much more time-consuming and difficult to prepare. The observed reduced utilization of home-made rice-ORT makes it a poor substitute for sugar-ORT at the community level in rural Bangladesh.

Bacterial indicators of risk of diarrhoeal disease from drinking-water in the Philippines

Inadequate measures of water quality have been used in many studies of the health effects associated with water supplies in developing countries. The present 1-year epidemiological-microbiological study evaluated four bacterial indicators of tropical drinking-water quality (faecal coliforms, Escherichia coli, enterococci and faecal streptococci) and their relationship to the prevalence of diarrhoeal disease in a population of 690 under-2-year-olds in Cebu, Philippines. E. coli and enterococci were better predictors than faecal coliforms of the risk of waterborne diarrhoeal disease. Methods to enumerate E. coli and enterococci were less subject to interference from the thermotolerant, non-faecal organisms that are indigenous to tropical waters. Little difference was observed between the illness rates of children drinking good quality water (less than 1 E. coli per 100 ml) and those drinking moderately contaminated water (2-100 E. coli per 100 ml). Children drinking water with greater than 1000 E. coli per 100 ml had significantly higher rates of diarrhoeal disease than those drinking less contaminated water. This threshold effect suggests that in developing countries where the quality of drinking-water is good or moderate other transmission routes of diarrhoeal disease may be more important; however, grossly contaminated water is a major source of exposure to faecal contamination and diarrhoeal pathogens.

Role of breast-feeding in the prevention and treatment of diarrhoea

Recent studies have again shown the beneficial effects of breast-feeding in preventing morbidity and mortality from diarrhoea in infants. A case-control study in Brazil has shown that young infants who are not breast-fed have a 25-time greater risk of dying of diarrhoea than those who are exclusively breast-fed. A longitudinal study in the urban slums of Lima, Peru found that exclusively breast-fed infants have a reduced risk of diarrhoeal morbidity when compared with infants receiving only water in addition to breast-milk. Both these studies, along with numerous others in developing countries, point to the need to extend the duration of exclusive breast-feeding to at least 4-6 months. A review of concerned studies throughout the world shows that even in malnourished women, breast-milk output is sufficient to maintain growth of infants up to this age. The addition of early food supplements to infants fed under prevailing environmental conditions in developing countries leads to their increased diarrhoeal attacks and associated reduced food intake. This results in worsened nutritional status of the affected infants. Breast-feeding helps maintain hydration status during diarrhoeal episodes. Studies in Peru, India, and Nigeria have shown that breast-feeding can be continued during diarrhoea when the infants often refuse other foods, specially non-human milk. Thus, breast-feeding is important in providing necessary calories and protein during a time when a loss of appetite for other foods is common. Diarrhoeal disease control programmes need to modify service delivery to ensure that breast-feeding mothers are not separated from their infants while being treated with oral rehydration therapy (ORT) as inpatients or outpatients. Oral rehydration solution (ORS) should be given to infants with cup and spoon rather than bottles, in order not to interfere with suckling. When in a health system bottles are used for treatment, an implicit credibility is given to their role in modern treatment. Programmes also need to include breast-feeding promotion as a part of their activities. This should comprise hospital practices supporting and ensuring breast-feeding immediately after delivery of the infants and subsequently while they are treated in the hospital: immediate breast-feeding after delivery; Mothers and infants rooming together; On demand breast-feeding; No bottle feedings of water or infant formula; No pre-lacteal feeds. In addition, health professionals need to understand the skills for the management of breast-feeding, so that mothers are given appropriate advice on how to breast-feed and counteract breast-feeding problems.

Field trial of oral cholera vaccines in Bangladesh: results from three-year follow-up

The protective efficacy (PE) of B subunit killed whole-cell (BS-WC) and killed whole-cell-only (WC) oral cholera vaccines was assessed in a randomised double-blind field trial among children aged 2-15 years and women over 15 years in rural Bangladesh. Among the 62 285 subjects who received three doses of BS-WC, WC, or Escherichia coli K12 strain placebo, cumulative PE at 3 years of follow-up was 50% for BS-WC and 52% for WC. PE was similar against severe and non-severe cholera, but was significantly lower in children who were vaccinated at 2-5 years (26% for BS-WC; 23% for WC) than in older persons (63% for BS-WC; 68% for WC). Among persons vaccinated at 2-5 years, protection at 4-6 months of follow-up was similar to that for older persons, but rapidly waned thereafter and was not evident during the third year of follow-up. In contrast, persons vaccinated at older ages were protected even in the third year of follow-up (PE 40% for BS-WC; 62% for WC). PE was substantially higher against classical cholera (58% for BS-WC; 60% for WC) than against El Tor cholera (39% and 40%).

Health beliefs related to diarrhea in Haitian children: building transcultural nursing knowledge

Regardless of where they live or under what circumstances, mothers throughout the world seem to have a compelling desire to provide the best possible health care for their children (Huston, 1979). Haitian mothers living in the Dominican Republic were no exception. The health beliefs and practices of these mothers related primarily to diarrhea among their children which demonstrated a concern and resourcefulness that is commendable. The results of this study clearly indicate the importance of transcultural nurses conducting culturally relevant research as a basis to develop sound health programs in developing countries. Diarrhea was identified as the single most important threat to a child's health in these communities. That mothers did not know about the correct ingredients and/or proportions for oral rehydration solutions (Western views) was of interest. Although the Dominican government makes some commercial packets of ORS, most of the women interviewed did not have ready access to this product. This finding reflected the need for transcultural nurses to offer to teach mothers how to make ORS using the sugar, salt, and water they had available. Since the mothers' perception that diarrhea was a dangerous threat to their children's health, was verified by childhood mortality statistics in the bateys, it would seem that ORS could make a significant impact on the health status of the children. Breastfeeding also was a major health belief factor associated with the treatment of diarrhea. Even though the majority of mothers believed breast feeding should be continued if a child had diarrhea, a number believed it should be discontinued. Nurses working with CHWs will need to emphasize the importance of breastfeeding and help them to develop creative ways of communicating this information to the mothers. The second most dangerous threat to the child identified by the mothers was respiratory ailments. This suggests a new area of concentration for future research and training of CHWs. A host of new questions related to respiratory problems such as health beliefs, causative factors, course of disease, traditional treatments, mortality rate, etc. need to be investigated. When transcultural nurses plan health care programs for women and children in other cultures, it is important to recognize the concerns mothers have for their children, and their intense desire to nature and care for them. In this study, mothers willingly participated and demonstrated active interest in learning to use methods to improve the health and well being of their children. It is well documented (Lieban, 1977) that established health beliefs are not automatically discarded when new knowledge is made available, but that exploration and incorporation of new information when presented in a culturally relevant framework does occur. An understanding of local beliefs surrounding health is fundamental to the development of appropriate transcultural nursing interventions.

Value of a chicken-based formula for refeeding of children with protracted diarrhea and malnutrition in a developing country

Two hospital-made, lactose-free, hypoosmolar formulas were compared for therapy for 61 children aged 10-28 months who had severe malnutrition and protracted diarrhea. The formulas were isocaloric and contained dextrin-maltose, carrots, sunflower oil, minerals, and vitamins. One had chicken meat as the protein source and the other had hydrolyzed lactalbumin (LAD). Initially the formulas were given as a continuous enteral feeding by nasogastric tube and pump. Six patients died from metabolic and infectious complications: four failed to equilibrate and changed diet. The remaining 51 were divided into two groups; group A, chicken formula (n = 26), and group B, LAD formula (n = 25). The mean duration of diarrhea was similar in both groups; number of days with liquid stools = 6.0 +/- 4.1 in group A, 5.5 +/- 2.8 in group B; number of days with greater than 4 stools/day = 3.5 +/- 3.4 in group A, 4.1 +/- 2.1 in group B. The time until beginning nutritional recovery was 13.2 +/- 12.0 days in group A and 13.3 +/- 7.8 days in group B. Intercurrent infections were significantly more frequent in patients receiving chicken formula (12 of 30 patients) than in those receiving LAD formula (4 of 27 patients) (p less than 0.05). We conclude that chicken formula is an efficient substitute to expensive semielemental formulas for continuous enteral feeding of protracted diarrhea in severely malnourished children.

[Control of diarrheal diseases in Mexico and Latin America]

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

Mothers' personal and domestic hygiene and diarrhoea incidence in young children in rural Bangladesh

This study examines the effect of maternal personal and domestic hygiene on the incidence of diarrhoea in children aged 6-23 months from rural areas around Teknaf, Bangladesh. The intervention area received augmented water supply through handpumps and health education while the control area received no project inputs. From July 1980 to June 1983, diarrhoea incidence was recorded weekly while mothers' personal and domestic hygiene was observed yearly. Annual incidence of diarrhoea in 314 children from the intervention area and 309 children from the control area was analysed in relation to maternal personal and domestic hygiene, controlling for education and occupation of household head and household size. Results show that, in both areas, use of handpump water for drinking and washing, removal of child's faeces from the yard, and maternal handwashing before handling food and after defaecation of self and child, observed together, decreased yearly diarrhoea incidence in children by more than 40% compared to children living in households where none or only one of these practices was observed.

Infant feeding and risk of severe diarrhoea in Basrah city, Iraq: a case-control study

A case-control study of the relationship between feeding mode and risk of hospitalized diarrhoea in infants (aged 2-11 months) in Basrah city was conducted between September 1983 and May 1984. A total of 597 cases were recruited from among infants admitted with diarrhoea to the major paediatric hospital in the city, while 723 controls were recruited from among healthy infants attending any of the seven maternal and child health clinics in Basrah. A variety of potentially confounding variables were controlled in the analysis. For infants aged 2-5 months, breast-feeding alone or breast-feeding plus food were the least risky feeding modes. Bottle-feeding was dangerous and bottle-feeding alone was associated with a risk of 55 among infants aged 2-3 months, and 37 among infants aged 4-5 months, relative to exclusive breast-feeding. For older infants (6-11 months), the risks of hospitalized diarrhoea were not significantly different among different partial breast-feeding modes, but non-breastfeeding was dangerous, especially exclusive bottle-feeding. Food intake was associated with a reduced risk of severe diarrhoea among bottle-fed infants but not with an increased risk among breast-fed infants. Among bottle-fed infants, no association was found between risk of severe diarrhoea and method of bottle-cleaning. Previous breast-feeding conferred no current protection.

Turning off the diarrhea: the role of food and ORS

Ninety-three boys aged 5 years or less who had diarrhea due to Vibrio cholerae were randomly assigned to treatment with glucose oral rehydration salt (ORS) or rice-based ORS. For the first 24 h, ORS only was given to all the patients. During the next 24 h, ORS and normal food were given. The efficacy of the two types of ORS was compared in terms of ORS intake, stool output, change in hematocrit reading, serum specific gravity, and increase in body weight. At the end of the first 24 h of treatment, a 50% reduction in ORS intake and stool output was observed in the 47 patients randomly assigned to receive rice ORS as compared with the 46 patients who received glucose ORS. During the second 24 h of treatment, a significant reduction in the stool output was noticed in the glucose ORS group, making the efficacy of glucose ORS equal to that of rice ORS. The study suggests that normal food can impart some of the superiority of "super" ORS to standard glucose ORS with regard to reduction of stool volume.

Comparison of efficacy of a glucose/glycine/glycylglycine electrolyte solution versus the standard WHO/ORS in diarrheic dehydrated children

It was hypothesized that a mixture of glucose and amino acids enhances sodium and water absorption and therefore diminishes the volume of oral rehydration solution, stool output, and duration of diarrhea. To investigate this hypothesis, the efficacies of two oral rehydration solutions (ORS) were compared, one containing (mmol/L): Na+ 90, K+ 20, Cl- 80, citrate 10, glucose 67, glycine 53, and glycylglycine 30, yielding an osmolality of 350 mosmol/kg H2O, and the other, the standard ORS recommended by the World Health Organization, containing the same electrolyte concentrations and only glucose 110 mmol/L, yielding 310 mosmol/kg H2O. The study group comprised 31 infants and small children for group A (receiving solution A, the glucose/glycine/glycylglycine-based ORS) and 31 patients for group B (receiving solution B, the standard WHO/ORS). There were no significant differences between the groups in age, fluid loss, or dehydration, or between the groups with respect to clinical outcome, mean time to achieve rehydration, mean percent body weight gain, and serum electrolyte composition. The only statistically significant difference was the mean time between admission and the last diarrheic stool. The glycylglycine/glycine/glucose electrolyte solution was found to be suitable for rehydration, but not to have an advantage over the standard WHO/ORS.

Perceived causes and traditional treatment of diarrhoea by mothers in Eastern Sudan

Mothers of Eastern Sudan seek or practice traditional treatment for diarrhoeal disease in their children based on their perception of causation. Fifty-six mother groups from 39 villages and 17 urban centres were surveyed in this study. The collected data were grouped by definition of diarrhoea, its perceived causes and practiced treatment thought to be appropriate. Differences were shown between the urban and rural groups. A longer list of perceived causes was obtained from rural mothers. Fumigation and use of rice water and custard were the preferred managements of urban mothers, while cautery, use of mihaya and goat's milk prevailed in rural areas. The importance of having the definition of diarrhoea cited in future studies is discussed and recommended.

Breast milk anti-Escherichia coli heat-labile toxin IgA antibodies protect against toxin-induced infantile diarrhea

A prospective study to assess whether milk IgA antibodies against Escherichia coli heat labile-toxin protect breast-fed children against labile toxin-induced gastroenteritis was carried out among infants of a marginal urban area in Guatemala. One hundred and thirty children were kept under surveillance for diarrhea by periodic home visits. Stool specimens were collected from each child routinely every 2-3 weeks and during diarrheal episodes, to study the excretion of labile toxin-producing Escherichia coli. Milk samples from the children's mothers were obtained concomitantly with the fecal specimens of the infants to be analyzed for anti-labile toxin antibodies. Twenty infections by heat-labile toxin-producing Escherichia coli as a sole agent were documented among breast-fed infants. Nine of these infections resulted in gastroenteritis, while the remaining 11 were asymptomatic. At the time of infection children who became sick were ingesting breast milk with significantly (p = 0.028) lower titers of antilabile toxin IgA than those who remained healthy. Only one of the 8 infected children receiving breast milk with high titers (greater than or equal to 256) of anti labile toxin IgA developed diarrhea, compared to 8 of the 12 subjects being fed milk with low titers (less than or equal to 64) (p = 0.025). This is the first report documenting protection by IgA antibodies in milk against labile toxin-induced gastroenteritis in infected breast-fed infants.