Control of Diarrheal Diseases
Authors: C E Taylor, W B Greenough
Journal: Annual Review of Public Health (1989)

The tremendous advances made in the control of diarrheal diseases in the past few years indicate what more can be achieved. Even though the lives of an estimated three quarters of a million children are being saved each year, over three million children are still dying from readily preventable diarrheal disease. The challenge is to build on the successes thus far, to learn from experience, to promote changes in health habits that will prevent diarrhea, and to make all of these activities sustainable. From this analysis, we have three specific recommendations for CDD programs in the next decade. 1. ORT programs should move strongly toward promoting home treatment, building on local traditions of giving food-based preparations, with ORS available from health workers and health facilities for those who need it. Local assessment of people's beliefs and practices in caring for diarrhea should lead to simple methods of adapting ORT preparations that are culturally acceptable. Most of these traditional preparations have adequate amounts of the proteins and starches that are now being shown to produce better clinical results than the glucose in the standard ORS formula. Usually, the main change needed is more precision in the quantity of sodium added. Education of parents can then focus simply on how to make these adapted preparations, on starting rehydration early, and on replacing fluid volume as it is lost. The use of ORS packets in health facilities should continue, but the main indicator of progress in CDD should be ORT use including home solutions. Every packet of ORS should have printed on it the locally recommended formula for home ORT. 2. Nutritional support is just as important as rehydration. Diarrhea precipitates and accelerates the progression of malnutrition, which lowers resistance and increases the duration of diarrhea. Nutritional support through continued breast feeding and improved weaning practices using high density, easily digestible, local foods is especially important during and after episodes of diarrhea. 3. For long-term prevention, breaking the transmission cycles of the many common pathogens that cause diarrhea will be necessary. The most immediate preventive impact can be achieved by promoting hand washing with soap. Priority should also continue to be given to improving water supply, sanitation, and excreta control, especially of childrens' stools. Even with the great progress of recent years, the Child Survival and Development Revolution has just begun.Globally 4.5 million small children died because of infections in 1982. Diarrheal diseases, respiratory infections, and malnutrition are predisposing factors to infections. Diarrhea can be watery and dysenteric causing loss of body water. Oral rehydration therapy (ORT) prevented 700,000 deaths in 1986 period. Improved case management can prevent deaths: nutrition both during and after an episode of diarrhea, appropriate use of medications, antimicrobial agents in cholera, and factors that protect against enteric infections (gastric acid). Antibiotic use during an epidemic of verotoxin-producing strain of E. coli increased that risk of death. 330 million packets of oral rehydration salt (ORS) were produced around the work in 1987. Continuation of breast feeding and nutrient rich, food-based oral rehydration therapy (ORT) is vital. ORT benefit illnesses caused by Shigella, Salmonella, or campylobacter. Hand washing with soap and water reduces the incidence of dysentery. Chemotherapy can control chronic diarrhea, while malnutrition prolongs diarrhea. Among antidiarrhea drugs berberine and bismuth subsalicylate are effective. Typhoid vaccine TY 21a, a killed oral cholera vaccine with rotavirus, protects against Shigellae. Social mobilization efforts relying on mass media include the Child Survival and Development Revolution (CSDR) of UNICEF, Expanded Program for Immunization (EPI), and Control of Diarrheal Diseases (CDD). Promotion of breast feeding reduced 8-20% of diarrhea-related morbidity and 24-27% of mortality up to 6 months of age. Improved weaning practices by education cut mortality by 2-12% for under fives. A rotavirus immunization program could slash the 6% incidence of diarrhea and 20% of deaths in children under 5. Cholera immunization with efficacy of 70% could eliminate the .4% of diarrhea episodes and 8% of diarrhea deaths caused by cholera. Measles immunization coverage of 60% would reduce diarrhea morbidity by 1.8% and mortality by 13% in children under 5. Improved water supply and sanitation lowered morbidity by 22%, hand washing with soap and water cut diarrhea by 14-48%, secondary Shigella Cases by 35%, and all diarrhea episodes by 37%. Sustainability suffers from inadequate planning. The integration of CDD with primary health care is shown by the example of Thailand where the rural health network was expanded. The World Health Organization has developed a framework for local problem solving. Advances have been made in the past few years, but 3 million children are still dying from preventable diarrheal disease.