W O R L D H E A L T H dhi
#I91
ORCANISATIONMONDIALE
ORGANIZATION DE LA S A N T ~
REGIONAL OFFICE FOR THE ,
B U R W REOIONAL
DB LA
EASTERN MEDITBRRANBAN MBDXTERRAPJEB ORIRNTALE
FiEGIONAL COMMITTEE FQR
THE
EASTERN MEDIERRANEANFourteenth Session
~ M / R ~ l 4 / ~ e c h . ~ i s c
./
25 August 1964
Agenda i t e m 12
!lECNNXCAL DISCUSSIQNS
I W A N T I i X DIAlWlOEA
IN THE:
EASTEBNMEDITERRANEAN
REGIONI
Introduction I1 Definition 111 ClassificationfV The Extent of the Problem
V ~pid6miological Factors Influencing the Morbldfty and Mortality
VT
Environmental Sanitary Factors in Relation to Diarrhoea1 Diseases V l I Socio-Econo4lic EnvironmentM Summal?y and Conclusions
References
Annex: Tables 1 to
XITI
Diarrhoea, a very important problem in paediatrics, has been with us sirice antiquity 1 , Even today, in many parts of the world, a large percentage of a l l deaths in infants and children is due to diarrhoea.
Infantile diamhoea has been and atill I s a major problem in almost all countries and remains a leading hazard to the l i f e and health of i n f a n t s and children,
In
the majority of t h e coyntries in this Region, infantile diarrhoea constitutes a big medical and public health problem of prime importance among i n f a n t s and children and is given first priority due to the high morbidity a d mortality.In
many parts of this Region, infantile diarrhoea, and especially gastro-enteritis, accounts for more than 60 to75$
of t h e cases seen or admitted in health centres andb d -
patientsf departments and for more than
50$
of all the fatalities among infants and children under two years o f age. Therefore, infantile d i m - rhoea is considered t o be "the worst killer of c h i l d l i f e " .Though mortality and morbidity have decreased* in some countries
unfortunately the recognition of Infantile diwrhoea,and d;larrhoeal ,dise,aq.es
in
general as a major health problem, has been ~nadequate, leading t o neglect- ing its proper prevention and control.II
DEFINITION
It
is lmown that any factor t h a t I m p a i r s absorption o f fluids from the intestinal tract or increases inteatinal motility may give rise to diarrhoea1 stools, Therefore, diamhoea is an increase in the number and/or a change In the appearance of stools, The number and appearance of stools normally vary from one individual to another and, particularlyin
the infants, depend on the type of feeding, So the changed character of stools may r e s u l t from an increased water content and/or the presence of pus, mucus or blood. An- other abnormal finding is . the presence of f a t or other indigested mterial.A kY0 study group on diarrhoea1 diseases met in November
1958
to study this problem and to consider how this disease could be actively approached and how past experience and present knowledge could be used for advances in t h i s f i e l d . In order t o make results comparable in d i f f e r e n t countries and render t h e d e f i n i t i o n more precise, the group felt that t h e term of% l i p p o c r a t e s defined, this condition suoclnctly as "abnormal frequency and- llguidity of faecal discharges".
"diarrhoea" should be defined as, follows t
Diarrhoea should be held to be ppesent in ohildren up t o two yeaxl$
of age if %hey pass three o r more a o f t or l i q u i d s t o o l s wfthin twelve hours, .or a single soft o r l i q u i d s t o o l containing blood, pua or mucus;
and in chlldren~of three yews or over if they pass t w o . o r more sof%
or
l i q u i d s t o o l s within twelve h o u r s o r a single s o f t or l i q u i d stool containing blood, pus o r wous.
The
changes of t h e stools should be verified &qualified persons.
111
CLASSIFICATION
As technically known, the term "infanttt a p p l i e s to the first year of life,
Le.
rxlom birth up t o twelve months o f age, and the t e r m '"1efantl.le~farrhoea" should apply to this disease among infants only, . However, in their cbntrlbution in the light of the questionnaire issued. by W e WHO Regional Office for the Eastern Mediterranean f o r t h e preparation of t h i s Technical Discussion on fnf'antile Diarrhoea, most countries have included under this term diarrhoeal diseases in children of the pre-school age. More-
over, a few countrfes whiah Wve been emba~rwssed by the specification of the Ixtternational Classification of Diseases have found it advisable to cover in their reply and under t h e same term, t h e diarrhoeal diseases i n children of more than one year of age, as e p ~ e m l o l o g i c a l and environmental sanitary con- d$tions influencing these diseases are associated and ,similar. Therefore, f o r the reasons mentioned above and due . . to lack of background i n f o m a t i o n and to the inadequacy of statistioal data, diarrhoeal diseases in children up to s i x of age have been included in this paper under the
term
ofTo obviate controversy, the WHO study group on diarrhoeal diseases
(1958)
thought t h a t all diseaaes .-.
in which diarrhoeais
a loading symptom, e , g, cholera, typhoid fever, intestinal parasitism, e n t e r i c virus, infections, and m l n u t r l t i o n with diarrhoea, should be classifled as diarrhoea1 . . diseases, One of the main difficulties I s the classifioatlon of diarrhoeal diseases, clinically and etiologically, SlmilaP or even . . identical entities have d i f f e r e n t names i m d l f f e r e n t l o c a l i t i e s , and deaths are c l a s s i f l c d under different oategories, The International Statistical Classification of Diseases, Injury and Causes of Death does not h e l p to clarif'y t h e position, because, while it classifies acute diarrhoeal diseases of specific e t i o l o m under t h e relevant headings, regardless of age ( e.
g.
0 4 ~ . 6 & 1 ; r r t ~ n ~ s e ~ . - . o r 045 bacf llary d y s e n t e ~ ) . , it ola$sifdes ."diarrhoea", "gast~o-mteriti st'and
"
co~itis" without mention of etiolom in separate categories according to age-
~;zder four weeks in diseases of early Srdancy (764 d i m h o e a of t h e new-born) and four weeks up t o two years('571
gastro-enteritis and c o l i t i ~ ) . It also includes "diarkhoea of t w o years and. over"in
t h e section dealing with symptoms, senility, and ill-defined conditions(785.6
diarrhoea age two yearsand over), This clasm~ficatlon under s s v e ~ a l headings cannot be said to simplify t h e collection of data on t h e incidence of diarrhoea1 diseases. The study group f e l t that, at their next reviseon of the classification, an attempt should b~ made: first to bring the t e r m s used in diagnosis 2n accordance wlW1 the term used in the classification, i.e. to combine into one item the present numbers
571, 764
and 785.6; second, t o integrate t h i s item ppk'bhthat coverf ng the accepted i n f e c t i o u s diarrhoea1 diseases, namely 042 salmonella infections, 045 bacillary dysentery, etc, Terms like dyspepsia, ehteritis, colitis, gastro-enteritis, dysentery, and t o x i a o s i s mean different things in different countries, and until they acquire meanings that are understood internationally, they must inevitably cause c~nfuaion,
rV THE
E:mNTOF
THE P510mTo assess the magnitude of this problem, we have t o rely upon statistical data. The accuracy of data on moxgtality due t o gastro-enteritis in Infants and children in many developing countrfes in t h i s Region, as well as in other Regions, is questionable because the lliagnasis of diarrhoea1 disease is chiefly a clznical one, D a t a on the mortality of infants md'children'wlth diarrhoea1 dineases,as cause of d e a t h are not complete because of under-reporting and under-registration.
In
most of t h e developing countries, statistical data a r c available only If there are statistical semlces. Although statistics on diarrhoea1 diseases a r e far f r o m being complete and although mortality is probably higher&I
We countries which have12%
reliable statistlos, the existing data me sufficient to &ow that dlarrhogal df seases are the leading cause of death in a number of countries, and particularly attack children under five years of age, They cause illness and they a r e the reason f o r considerable losses of lives and even for economic losses.It
is estimated that not more thanone
eighth of.all infants and young ohildren in t h e world are f'ree from the appreciable rlsk of lethal diarrhoea.In
Dakar, Senegal, out of the 2272 c h i l e e n admitted inl E 7
to hospitalsby t h e paediatric service,
331
were admitted for diarrhoea. Mortality sta-, t r a t i c s from the same service ' f o r the period 3uly/0otober1958,
fahaw that out of the 977 adrnissiol~s 4 2 . s were far diarrhoea, of whiah42.N
died.In
areview (Pan--American Sanitary Bureau,
1958)
of ten countries of the Americas, including t h e United S t a t e s and Canada, Verhoestraete and Puffer. found diamhoeal dlseases listed among t h e first five causes of infant mortality i n a l l of them. The low r a t e s i n Canada and in the USA contrasted with a minimum o f 700 deaths per 100 000 l i v e - b i r t h s in t h e e i g h t o t h e r countries of 'the study. Infant death from diarrhoea1 diseases in Brazil was reported at approximately 5500 per 100 000 livs- b i r t h s ( A . J.M.
S. W c hl963),
in Venezuela at about 2500, Among children of the 1-4 age group, diarrhoea1 disease is the first cause of deathin
Mexico,Guatemala, Colombia, Venezuela, B r a z i l and Uruguay, The highest r a t e s w e r e recorded inGuatemala
.
and Mexico w i t h about 660 and61CO
deaths, respectively, p e r 100 000 population.A survey of Asia ,and Af r l o a gives very much the same ' f i n d i n g s . Even in Europe and North America, where the r a t e s are among t h e lowest, current differences between countries as l i s t e d in Table
I,
are often extreme,cornparin@; for example, t h e rates of Portugal wi4h those of the Netherlands, or the rates of Mexico w i t h those of the USA. As shown in Table I (sea
Annex) of the Annual Epidemiological and V i t a l Statistics, WHO,
1960,
infant dea%h from infantile diarrhoea is still high in many countries of the world.The most critical p e r i o d seems to be between t h e ages of six and twenty-four months.
As to thZs Region, r e p o r t s show t h a t in3ant mortality due .to infantile diarrhoea is still very high i n some countries. .In the United Arab Republic it ranged between 53.3%
(1956)
to 53.0$(1960) In
t h e first year of life and 7% in the second year of life (Dr, Abbassy,), The rate in the United Arab Republic (TableIT)
shows no decline and even some increase of morta-Lity during the five-year period 19561960, This increase may be due to pro- gressive improvement in the reporting and registration of infant s'
death6and causee of deaths by incr~saZng the number o f health o f f i c e s , than a real increase of diarrhoea1,diseasea. This has also been reported by Dr. G. Abd-El-Messik (united Arab Republic,
1964) ,
as shown In TablesIIX
and
IV,
Other reported figures on infant m o r t a l i t y ,and infantile diarrhoeaI I
deaths in localities In the United Arab Republic with a health bureau
show that death *om a l l causes under one year of age was 171 per 1000 live- bifihs
(1950)
and 141.1 per 1000 in1960,
As f o r deatks f'rom diar~hoea under one ye'ar of age, it'was 92.5 o/oo i n 1 B O and75.4 o/oo i n1960.
The t o t a l number of deaihs hsn t h e age group under one month was 7.8% in1950
with deathr _ "
from diarrhoea 1; the eimd
iie
soup, 2.6% 'againat 7.'is anh 5,
respectively,for
1960. A
comparative study of the most common causes of infant m o ~ t a l i t y during the first five years of b$$q&n,the United Arab Republic (Tab1e.V) and in Pakistana able
VT) showa that, gastro-enteritis 1s the main disease aausfne;children's deaths.
During ~ u l y / ~ c tober
1961,
aWHO
Diarrhoea1 Diseases Advi~loxy Team studied m e problem of diarrhoea1 dlseaaes in the United Arab Republic at t h e invitation of the, Miniatry b f Real th. The survey included the villages of Shubramant, 8400 inhabitants, situated in a rural area at some20 km from Cairo; Nashlet EX-Astap, a v i l l a g e with 3000 inhabitants, at a
d i s t a n c e of 3 km Prom Shubramant; the t h i H area was Embaba, one of the suburban working class quarters of Cairo. The team reported that the average m o r t a l i t y f r o m all J diseases in t h e age group under s i x years of age
in Nashlet El-Astar, Shubramant and Embaba, was 56$, and 27% respective- ly. f n Shubramant, 66$,
'in
h b a b a (the best area) 8&, died from gastro- enteritis. In Embaba, the highest' relatlve mortality rate had' shifted to the youngest age group.A statistical study of cases attending the out-patient department and being adrni tted to the wards of the children ' s hospital of ' the Unf versity of Alexandrba, shows the importance: of -the problem,: During the f i v e years
1956-
1960, %$
of a l l patients attending the Out-Patients'
Department came for moderate to severe gaetro-enteritis, while 2358 of a l l admissions to the wards' 1 1
wepe cases of severe and/or complicated forms of this disease: A' oomp4ratlve study made. by WHO In Karachi, ( ~akistan)
,
Addis Ababa ( ~ t h i o ~ i a ) and Aman( ~ o r d a n ) confirmed the prevalence of the disease, as shown in Table VIIa' and b (see Annex),
In t h e Sudan, the WHO Diarrhoea1 Disease Advisory
Team,
which viaited the country in March-June1961
upon the invitation of the Ministry of Health,I "
surveyed two areas: B a n a t with a population of 16 000, a d i s t r i c t on the south-west outskirts of Omdumnan, and Fetahab, with approximately 8 000 inhabitants, a small v i l l a ~ e which has recently become p a r t of the city of
. P
Omdurman, Thc team r e p o r t e d that the percentage o f p a t i e n t s under six years
, . . , . .
treated f o r diarrhoea in the health centre during 1960-1961 was:
Banat >3$:
Fetahab, 25%. Approximately 30% of children under s i x years a m t t e d in the
4 .
Church Missionary Society Hospital, Omdurman, came f o r treatment of diamnoea.
The case fatality rate monst the admitted cases is high.
In
Ethiopia,1962,
30% of s i c k chlldren seen in the out-patients'De-
partment of the Ethio-Swedish Paediatric Clinio had gastro-enteritis. Most o f the cascs seen or admitted in the children's ward were gastro-enterl-1s casescommonly associated with respiratory diseases and malnutrition. 15$ of the gastro-enteritis cases admitted were
under
s i x months of age and 85% less than a year old. While the overall m o ~ t a l i t y was 3O$,arnong those under three months it was 49$,In
Jordan, infantile diarrhoea * comprised at 1eAs.t:50% of the cases seen in the Out-Patients
'
Department and in the admissions in the Children's Hospital, but no mortality rate was given,In Qatar, t h e disease
is
responsible for' t h e 60$ of t h e 'admisstoxis 'to the children's ward for those'under two years of age. The mortality rate is 8$, however 80% died within 24 hours.In
Israel, it has been reported that the percentage of infantile diarrhoea among hospitalized infants is35$
and among those between one to four years of age, 1 8 . Infant mortality from diarrhoea was 11.4% in 1962, and amowst c h i l d r e n aged one to f~ur'~ears, 5.5% f o r the same year.Tunisia reported t h a t gastro-enteri t l s constitutes 28.66s of cases seen at the Maternal and Child Health P i l o t Centre in Tunis and
14.95$
of aases a d m i t t e d in the Paediatric Ward of Habib Tameur Hospital.In Pakistan,
Dr
, S,M ,K.
Wasty, m o r e , reported that about45%
of infants and children d i e d before reaching 10 years of age, The Incidence of,diarrhoea in the Out-Patients'
Department in 1962 was 24 -3% and 18.%
in the ohildren's ward in1963,
The Incidence of death due to diarrhoea f o r the same year was7 +35$. Dr.
H.A. Khan, Karachi, reported t h a t the incidenae of diarrhoea among children admitted to the department was 17.6% in1959
and 17.12% in 1963.V
EPIDEMIOLOGICAL FACTORS 1NFI;UENCfNG THE MORBIDI7YA N D
MORTALITYSince t h e incidence of and the mortality from infantile diarrhoea are still very high in' many countries and may vary from one country o r region to another, it is, therefore, of great importance t o study carefully the many
t*-
f a c t o r s that may influence t h e d f sease
. AG
f u r t h e r planning for the pre-, ,
vention and t h e control of diarrhoea1 diseases should be based on the results of such studies.
; Statistics show that the highest incidence of the diarrhoea1 diseases is t o be found Sn t h e lower age groups and is more common between six and eighteen months o f age and among infanta artificially fed, as well as in the weaning perlod, This explains the benefit of &east-feeding with less exposare
to
cross-f nfac t i o n s ' and contaminations,
In
259 cases below' one year of age reported by Abul Dahab (Egypt, 19571, the incidence of gastro-enteritis Posein t h e third month of life, (see Table
VIIX)
when shortage of breast-fiilk supply, occurs in poorly nourished mothers and when supplementary artificial feeding is given t o the infants. After the sixth mohth, the incid&ced::ops and w i l l rise again a f t e ~ t h e f $ ~ s t year, The- dlsease f a l l s heavi-1~
on infants of lower age, particularly when assooiated with respiratory diseases and malnutrition ( E t h i o p i a ) , The Incidenoe of gastro-enteritis among breast
-
fed infants is 21 .l$ while among those living on mixed
f
eedlng it is 70.7$, and on artificial feeding, 9.8% (Tunisia).Dr.
Wwsty(1964)
reported fromPakistan that under two years of age, diarrhoea proves fatal to many children and mch so, undes s i x months of age. 6@ of children with diarrhoea admitted t o hospitals a r e under two years of age ( @ t a r ) , and 75% of the diarrhoea]
cases are artificially-fed infants, The high number of artificiallyhfed i n f a n t s in many countries is due not only to short breast-milk s u p p l y in poor17 nourished mothers, but also to t h e belief that breast-feeding prevents f u r t h e r pregnancies.
Sex: Reports show that t h e incidence of the disease is more prevalent amongsit
-
males t h ~ n femalGsv
(UAR,
Iraq), the r a t i o being 61% males to females int h e age group 1 to 30 months (Abbassy,
19%)
and 57.6% to 42.4$, respectively, in those below one year of age (Abul Dahab,1957)
, However, in I%O, f . the live-births in the United Arab Republic were 51.4$ males and 48.6% females, and the rates for infantile diarrhoea deaths were69
for mles and 82 f o rfemales ( ~ r , G , Abdel-MessSh,
1964).
This excess in the number of femalesdoes not appear in diarrhoea1 deaths under one month of age, the rates being 2.4 for mles and 2.0 f o r females. Cyprus reported similar percentages,
59
.%
males and 40 -6% females. In Qatar, the ratio between males and females was1.6
to 1.0. In Pakistan, figures given byDr,
Khan on the incfdence of the disease amongst the patients admitted to the paediatrfc gepartment show a slight increase in females.Season: Infantile diarrhoea is more common in summer with
a
peak frorrr'harch to May (Ethiopia), June to October (%nisi&), May to October(Israel).
115the United Arab Republic, -as reported by 'h. Abbassy and Dr. Nanhfi, ' 1950, 76% of the severe cases occurred during May, June and July, '
In
t h e e Sudan, t h e higher incidence.sf diarrhoea is during t h e rainy season ( ~ u l y to ~c%ober), . ...
In
the form of gast~o-enteritis, enteritis and uolitfs. The WHO Diarrhoea$Diseases Advisory Team r e p o r t d that the monthly attendance of diarrhoelc children irnder six years o$ ,.
we
.. during t h a t period was800
to 1200, Data0
given on temperatures throygh April-October was 40
- s a c
and throughNovember-March, 35'
-
~ O C . The relative humidity maximum driring J u l y toSeptember was 42 to 88%. In t h e Syrian Arab Republic, infantile diarrhoea occurs
aa
epidemics in limited areas influenced b$ seasonal factors, In Teheran, Iran, about one-fifth of a11 p a t i e n t s admitted to t h e paediatSlc wards during t h e last year had diarrhoeal diseases, Half of all diarrhoeal .cases were admitted during the summer season ( ~ r , Gharib, 1964).
Diarrhoeais endemlc in,the large towns of Somalia. The disorders rise t o epidemic proportions a t the time of drbught, drying-up of rivers, locust invasi&ns, floods and loss of harvest, Diarrhoea is commoneat when humidity is high and when the temperature variations between day and night are the most mwked.
In
Qatar, the number of diarrhoeal cases seen and admttted to children ' s wards are t h e same throughout t h e year, but it increases in ~ u n e ' only when the average temperature rises over 105%. No effect of the degree of humidq.ty was found.In
Pakistan, there are two peaks of diarrhoeas, one occurring in.~pqil/$lay and the other, a slightly less prominent curve, in ~eptember/October (Dr. W.asty,
1964). In
Cyprus, climate and seasoh seem to be of l i t t l e importance, .if any, on the incidenoe of infantile diarrhoea.It
h M
to be mentioned that hot weather is charac-berlzed by more dust and flies in most countries. The similarity of the c u w e s of fly index and infant mortality from diarrhoea is epidemiologically significant. Rise of temperature and humidity are favourable f o r the increase of fly population, influencing slightly the rate of spread of the disease and its mortality rates.Severe diarkhoea is one of the consequ6nces of heat e f f e c t s ,
VI ENVIRONMENTAL SANITARY FACTORS IN RELATION TO DIARRHOEAL DISEASES
The e f f e c t o f environmental sanitary factors will ref l e c c to some extent on the infantile diarrhoea death rates in the same manner as it ~eflects on
t h e i n f a n t mortality. The d e c l i n e in moxlhidity and mortality rate in diarrhoeal
dlsrsases in t h e better developed areas in t h e world has been largely attributed t o imp~overnents 9n environmental $anitation. Sanitary f a o t o r s govern more t h e incidence of the disease.
Waters
is
one of the main factors facilitating the transmission of enteric-
i n f ectiorrs, and is a source of danger when contaminated with infected faecal excreta.
In
areas lacking a proper supply 'iystem, water which is n o t kept and handled p r o p e r l y will be contaminated and a t b r e a k s will result. House- holds in rural areas with no piped water available, usually keep their drink- ing water in jars or similar utensils, wfth the result %hat it is oftencontaminated in the course of carrying, filling, handling t h e water and cleanin@; the Jars. Sampling of such water done in a shorter or l o n g e ~ period after cleaning and filling, shows a high colony count per 1 ml &d a high most probable number (M.P.N.) of coliforrn organisms p e r 100 m l . The confirmed t e s t f o r
B.
Colf (faecal o r i g i n ) was p o s l . t i v e i n e v e r y oase.Sypewision of all public water supplies is essential b u t is very dlfficult in mral areas, which should be provided with filtration plants, The advar)tage of a centr8-1 watey-supply is b e l l noticed, but it should a l s o be r e a l i ~ e d that the effectiveness of such systems depends on t h e education of t h e population (health education, personal hygtene, etc. ), and to the same extent, on proper operation and maintenance and control of p o l l u t i o n of t h e supplies.
Sewage disposals Presence of insanitary latrines and privies, badly con- structed and maintained, favours the spread of enterlc Infections from hwnan excreta, which are t h e b e s t f l y breeding medium. Prevention of faecal pollu- tion of ground water and water supplies should not beb overlooked.
Refuse d i s p o s a l : Garbage being the commonesL breeding place for flies and
o t h e r insects, necessitates improved sanitary methods of c o l l s c t i o n and d i s p o s a l , economically feasible.
In
analyzing t h e i n f a n t moriidity rates in relation to sanitary improve- ment, Weir states: 11 t h e only service whZch appears to have had an effect on t h e i n f a n t mortality rate was f l y control".Milk: HygArra3icwlly Improved methods of collection and distribution of milk
Icc..13
are irldfspensable. A s an important f a c t o r for transmission of enteric in- fections, milk must be sterilized by boiling o r pasteurized.
In
h o t areas where no proper storage facilities exist, provision of dry milk ie therefore suggested, provided i t s cost makes it' available t o those with low income.Mothers should be taught how to p r e p a r e formulae and feed their infants.
Therefore, s a n i t a ~ control of processing, storage and consumption of m i l k and other food-stuff w t l 1 . decrease the incidence of diawhoeal dlaeases.
It
has been observed that the presence of many slums, domestic animals, stables and cow-sheds in the l i v i n g environment favour the incidence of t h e diarrhoea1 disease ( s e e TableIX) . In
Somalia, a higher incidence of t h edisease occursr a t the time of epidemic outbreaks amo'hgst cattle, A t these
times, it is'the nomad and the shepherd who are severely affected, (Table
n).
EM/kcl4/~e&h
. ~ i e c ./2 page 10V I I SOCIO-ECONOMIC
ENVIRONMENT
Undoubtedly the tsocio-economic environment has an important bearlng on t h e incidence o f diarrhoea. Family size, poverty, ignorance, bad habits, false t r a d i t i o n s , superstitious b e l i e f s , are causes of low socio-eoonomic status. Most of the diarrhoea1 cases are usually seen in low socio-economic groups,
In
a study of ' socio-economic e n v i r o h e n t of 500 f amiliea'in
Phkistan(Dr. Wasty,
1960),
figures show' the influence* of the disease in larger families of lower income and with a higher room occup&tion patio.It
also shows that t h e congestion t o which t h e children are exposed, favours bacterial exohangeand m o t e i n deficiency.
Malnutrition is another factor that plays an important role and increases the mortality rate among children with diarrhoea1 disease. The additional food given t o infants I s mostly in the form of' stwcheb l a c k i ~ vitainins and proteins. The+efore, the nutritional status at birth was poor'in the majority o f cases.
Most diarrhoea1 diseases a r e of unknown etiology, and, since etlologi.ea1 factors are diverse, a symptomatic and clinicaS. classificwtlon has been made, The classical fom found almost in every text-book of paediatrlos, is the
f ollowingr
1. Dietetic dlarrhoeas 2, 3nfective diarrhoeas 3. Parenteral diarrhoeas 4. Reflex diarrhoeas
Other authors have classified diarrhoeas according to their clinical observations whioh result in f i v e groups:
I . Entoxications and alimentary disorders 2. Diarrhoeas due to vitamin deficiencies 3. Parasltio dlarrhoeas
4. Bacillary diarrhoeas 5 .
virus
diarihoeasHowever, there is a third clinical classification which considers two major and a third minor t y p e of diarrhoea1 diseases, (DP, Abbassy, 1964).
.
?I., Acut,e diarrhoeas which occur in healthy well-nourished infapts or children.
, . - . - , ,
These are mostly due to i n f e c t i o n and are of short duration, and unless they a r e accompanied with systemic manifestations, such as marked dehydmtf on,
~~/hc14flech , ~ f sc ./2 page 11
nervous symptoms and/or toxicity, they end
In
complete recovery Imr-at2'ew days.2. Recurrent o r persistent diarrhoea, whlon OCCUPS
in
malnourished bables, Infeation is also frequent and other faotors exist and aggravate the disease, suoh as reducd tolerance to food, impaired absorptfon and lowered resistance t o infections, e t c .In
malnutrition, diarrhoea occurs frequently and a vicious c f r c l e of gastro-intestinal disturbances ernd malnutrition is establiahedtmalnutrition leading to diarrhoea whloh aggravate6 malnutrlt ion.
Diar~hoeic patients are usually classified according to their nutritional status, aa follows: well-nourished, underAnourlshed, marasmic, and with
Kwwshio~kor. As to the relations of mortality to severity, diarrhaatc cases
are classified: mild without dehydpation, mild with dehyd~ation, moderate and severe. Percentage of deaths occurring in these conditions were
5$,
8%17.9
and 30.7$, respectivkly.(Dr.
Khan,1960).
Drs. Abbassy andMarl,
1950, reported m o r t a l i t y rates of 9.5$, 1@ .and
75%
in' cases of diarrhoea 'with. . "
mild, moderate, and severe wasting, respectively.
3. Diarrhoea of the new-born is the third clinical entity and I s due to infection by bacteria o r viruses, It is of great importance in nurseries.
Other conditions which cause diarrhoea ape parasitid infestation, food poisoning, quantitative dietetic, unsuitable baby's formula or food according t o his age, e t o
.
Foods, by themselves and through the specific nutrients they contain, may induoe acute diarrhoea other than through infection.Various salts, such as sodium f l u o r i d e , compounds of zinc and cadmium, and even sodium chloride aot as poisons if taken in great quantities.
Certain nutritional deficiencfes more commonly cause diarrhoea. This is a characterJs$ic of pellagra apd of bert-beri. Protein deficiency $? the outstanding causal factor in the diarrhoea of Kwashtorkor, and "~wasnzorkor without ~iarrhoea" is likely not to be Kwashiorkor (Gordon, ~ h i t k s r a and Whyon).
It
is unusual to i d e n t i * speciflo diarrhoea of infections originin
Kwashiorkor: 1 t ordinarily prscedes Cather than accompanies the condi-Numeraus foods high in roughage produce diarrhoea through mechanical action, Highly splced foods, p a r t i c u l a r l y the potent pepper6
of
,$ropioal regions, will cause diarrhoeas as w i l l excessive consumption of frpits W i t h .large nwnbes of seeds. Some foods are themselves poisonous and induce a severe diarrhoea; f o r example mushrooms, raw spzlouted potatoes, rhubarb leaves and a number of species of fish.
m / R ~ 1 4 / ~ e o h . ~ i s c ./2 page 12
Etiological Agents: Most of the acute diarrhoeas are of infectious origin.
Although some are speciffc Infectious diseases, the greater proportion is not identified as such, Causative agents are numerous and diverse, From
. ' . '1-l:
the bacteriological point of view, infectious diarrhoea may be classified or divided into the-following oategorfes:
2. Salmonellosis
L
3
.
&teropathogenic E. Coli 4, Viral infections5. Doutbhl pathogens,
Shigellosis or bacillary dysentery is ehe most common specific
..
enteric : I . infection mdng diarrhoeas af children. In countries with good nutrition, . .comprehensive studies as thoee of Hardy and Watt have shown that this infec- tion accounts f o r two-thirds or more of all cases, although fifteen years I n t e r , in t h e same area, Goodwin
-
et al, found only 40$.In
Guatemala, shigella accounted for13
of 100 endemic cases(13%)
and y e t the carrier rate i n the general c h i l d population was essentially the same, i . e m7.5%
asin areas where s h k e l l a accounted f o r t h e greater proportion of cases.
Although shigella is isolated from house animals, the source o f infection
.. .
in infants and children is almost exclusively man himself. Floyd
(1954),
studying a representative group of chfldren in 75 Egyptian villages found that virtually every child
(97.B)
acquired one t y p e o r another of s h i g e l l a i n - f e c t i o n , w i t h o r without symptoms. He isolated 259 strains of shigella . . of which shigella group A accounted for 10.2$, groupB
f o r 70.8$, group C for' . . ,, , , , , , -
3.4%
and group D for 15.6%. Also ~ L b y d-
et al(1956) have s h o w n i n Eg).ptian children that shlgellosis is absent during the neo-natal period, rare in i n f a n t s below six months and i s more prevalent i n the1-3
yeaF dge group*Bacteriological findings reported by the WHO Diarrhoea1 Disease Advisory Team durfng t h e survey i n t h e United Arab Republic, 1961, show that the
,,
percentage of positive cultures of children under s i x years of age with
. .
..
-4 . . .a c t i v e diarrhoea w a s
23.8
f o r the' r u r a l area and 16.1% far the urban area:skigella proved t o be the most frequent organism followed by pathogenic Eschericiiia cofi and salmonella (See Table XI). Practically all types'. of
shigella were found, most of them being of tbe Flexner group, i . e , 67,8$
in
rural area and9%
in urban area. Sensitivity tests showed that alipmxirnateljr70%
of shigella atrains were sulf onamf de-resistant ,Bacteriological ffndings in the Sudan, reported by the same WHO Team (1961), showed that cultures (all causes) were p o s l t l v e i n 19.6%.
The'general class of entero-viruses includes types of polivirus, Coxsackie groups A and
B
and Echo. m p e A andB
groups of Coxsaokie virus have an uncertain r e l a t i o n t o diarrhoea1 disease.Adenovimses, type
3
and type7
have been implicated in outbreaks of diarrhoea1 disease among young children in Great Britain.Reoviruses were first i s o l a t e d from h e a l t b children, and subsequently from ohimpanzees wlth spontaneous rhinitis *om children wit31 diarrhoea,
In this region, very few virological studies have been undertaken due to l a c k of laboratory facilities and of well-trained and experienced workers i n this new f i e l d ,
NAMRU-3
revealed(1959)
that enteric vlmses wereisolated from of
56
children with gastro-enteritis and a fairly high percentage was also isoiated from controls.D o u b t f u l Pathogens: These include pseudomonas, fungi, staphyloaoooi,
proteus bacilli, paracolon and others, and are oonsidered t o produce diarrhoea on first contaot
,
especf ally in t h e malnourished children or. under c e r t a i n conditions a f t e r being promoted to pathogenic powers,Parasitologic agents: Diarrhoea is well h o r n t o occur with some parasitic infestations and is not necessarily caused by them, .Of those which a r e found i n t h e s t o o l s are ~ i a r d i a
b m b l i 4
and Entmoeba histolytica. I n general, protozoa and helminths are wide-spread i n most countries of this Region, especially in the m a 1 areas. Some reported figures show that ~ntamoeba histolytica cysts are widely found inm,
Entamoeba Coli in 5@, ~ a m b ~ i a ' in 22$, Chilomastix and Trichomoms hominis up to about5%.
-There are two straina of Entamoeba histolytica(E.
hartmami), one small strain which is the most frequently met and is said to be non-pa-kogenic, and %he l a r g e , strain which is pathogenic,Helrninths appear w i t h a percentage of
g$
f o r asoaris and hymenolepis nana with 17%.Both bacteriolom and parasitology show t h a t the faecal contaat due t o existing habits -and 3% ving conditTons 5s ,extremely- bi&; which shows t&qt
this group of diseases is a ~ o c i o ~ e c o n o m i c problem rather than anything else.
Complications observed: The f o l l o w i n g complications a r e met in diarrhoea1 diseases :
Dehydration
-
Aoidosis-
Protein Calorie Malnutrition-
Marasmus iChest complications
-
Infections-
Oedema-
Anaemia-
Kwashiorkor vit&ninsJ?Dl/R~14/Teoh.~isc ./2 page
16
deficiencies
-
Convulsions-
DlstedSion of abdomen-
Haemomhages-
Oligy~iaand Anuria
-
Rickets-
Xerophthalmin,The most important is dehydration which calls urgently for replacement
o f f l u i d l o s s e s and correction of electrolytes imbalance.
General p r i n c i p l e s of management in acute dAarrhoea, as it has been suggested, a r e as f o l l o w s :
1. The &mediate treatment of shock If present
2. R e s t o r a t i o n of pre-existing d e f i c i t of water and electrolyte 3. Provision of sufficfent water and electrolyte t o meet daily loss
4.
Re-establishment of an adequate caloric intake as soon as p o s s i b l e 5 , Destruction of infecting agents and treatment of complications.The main eymptoms that r e q u i r e r e l i e f are f r e q u e n t vomiting, dehydration and toxaemia.
Replacement o f fluids and electrolytes by rehydration is the mas%
important and life-saving measure. The l o s s of sodium and retention of acid metabolites may give r i s e t o metabolic acidosis. When vomiting predominates, metabolic alkalosfs may occur, Therapy has t o be planned according to changes in water and electrolyte imbalance,
In
hospitalized caies, it. is' advisablet o g e t an estimation of s e m e l e c t r o l y t e s if p o s s i b l e before rehydration therapy.
The quantfty of f l u i d lost can be judged clinically aocording to t h e
weight loss,
In mild cases, fluids are given by mouth in t h e fom of glucose electrolyte solution.
In
moderate and severe dehydrat-tan, t h e quantity of f l u i d s required is 100 cc and 150 cc per kg body weigh* per day, respectively. Usually - t h efluids available f o r use a r e : 5s Dextrose in water; normal saline;
5s
Dextrose in normal saline ; ~axlrow' s solution; M/6 Sodium Lactate solution.Quantities of these f l u i d s Lo be given depend upon the severity of the diarrhoea w f t h o r without signs of shock or impeding shock, e t c .
Measures taken f o r prevent;ton and control of diarrhoea1 diseases:
The measures taken by most Governments in the r e g i o n f o r the prevention and c o n t r o l of these diseases can be summarized as follows:
1. Increase in number and spread of medical care u n i t s such as MCH centres, paediatric departme~ts 'in h o s p i t a l s ;
2. Health education;
3. 1mprov.ement of environmental sanitation and especially control of flies, sewage disposal, refuse disposal, milk and food oontrol, improvementu of water
' 7 "
t
supplies in rural. areas. Control o f infectious diseases;
4. Community development efforts;
5. ~mirovement of nursing techniqbe;
6 . Raising standards of .housing and livingj 7. Encouragement of breast-feeding;
8, Distrf bution of powder milk through MCH oentres to needy children, free of charge;
9.
Expansion of laboratory services;10. Training of health personnel of various categories.
IX
SUMMARY A N D CONCLUSTONSThe ,incidence.of infantile diarrhoea is sti.11 vewy.-high in the Eastern Mediterranean Region as well as In many countries of the world. Infantile diarrhoea, and especially gastro-enteritis, constitutes a great mediowl and public health p~oblem'of prime importance among infants' diseases
In
thisRegion, as lt accounts f o r more than 60 t o 7% of the cases seen o r admitted in matern 11 and child h e a l t h centres, h e a l t h centres, out-patients
'
departmentsand hospitals
'
wards.Although statistics of diarrhoea1 diseases are far from being complete in many countries, because of under-reporting and under-registration, the existing data are sufficient t o ahow t h a t infant mortality by diarrhoeal.
diseases, and especially i n f a n t i l e diamhoea, i s still very high in some countries and accounts f o r more t h a n
50$
in the f i r s t two years of l i f e ,t
Infantile diarrhoea a t l l l has a high mortality r a t e .
Reports and surveys show that diarrhoeal diseases are more prevalent i n areas Gith low 8ucio-economic 'level as w e l l as with deficient eduoation and environmental sanitation.
Statistics show that the highest morbidity and mortality caused by diamhoeal diseases are t o be found in t h e lower age group and are mare
common between six and eighteen months of age, and among infantp . i * I .
.
artificially . I 'fed or malnourished children as well . . as those s t i l l in the weaning period.
A l s o the incidence of t h e dfseaaen 1s slightly more nrevalent-amnng males
. .
than females and is more common in summer +d hot weather with high incidenoe of dust and' f l i e s . High temperatures and high humidity are favourable t o
m c r .c
t h e inorease of t h e f l y population.
In
areas lacking a proper water supply. . ,
.
. .system, drinking water is one of the main factors fncflltating transmission o f
enteric infections, if it is not collected, stored and handled kb'perl~.
Insanitary latrines and privies favour the spread of enteric infeotlons and increases t h e numier of diarrhoea cases considerably.
M i l k is an important medium f o r t h e transmission of enterfc infections and diarrhoeal diseases if no hygienic methds of collection, storage, distribution and consumption are being used.
Family size, poverty, ignorance, bad habits, false traditions, supersti- tious beliefs aa well as the living in slums and a higher room ocoupation ratio, domestic animals, stables and cow-sheds in the living envl~onment, are all
important factors favouring the Incidence of diarrhoeal diseases.
Malnutrition and nutritional deficiencies are other factors that play an important role by causing diarrhoeas and increasing the morteblfty rate among children with diarrhoeal diseases.
Most of the acute diarrhoeas a r e of Infectious origin. Causative agents are numerous and diverse, and from t h e bacteriological point of view, these agents are: shigella, salmonella, enteropatkogenic Escherichia coli, viruses and doubtf'ul pathogens, '~iam;hoea is well lmdwn to occur with some parasitic infestations such as Giardia, lamblla, Entamaeba histolytica, Entamoeba coli, Chilomastix rnesn5li and Trichomonaa horninis. Also helminths such as Ascaris and Hymenolepis nana are-frequently found in s t o o l s .
Both bacteriology and parasitology show that the faecal contact due t o existing habits and living conditiohs is extremely high f m m which it appears that ahis group of disease is a socio-economic problem rather than anything else,
Facilities for bacteriological studies are lacking in the r n ~ J o r i t y of the countries in this Reglon, especially for virological studies and researoh.
The most important complications obsewlved in diarrhoeal diseases
.
, is dehydration which c a l l s for replacement of fluid losses and correction ofelectrolytes imbalance, Rehydration is the most impoptant and life-saving measure. Simple routine rehydration w i t h fiulds glven orally
t b
diarrhoeicchildren brought tS maternal and child health centres and health centres proved t o be successful if there is no vomiting. Early recognition of
diarrhoea by the papents themselves and administration of a sugar-electrolyte mixture, distributed in packets for disolving in water have been applied
successfully in maternal
and
child health centres and health centres in some countries ' in Latin America. I n severe dehydration, intra+enous yehydration therapy and hospital care a r e essential.Diarrhoea1 disease i s manageable by treatment and p~evention, ?l%ough improvement of the socio-economic and envfronmen-bal sanitary conditions t h a t influence the.hie;h rate of diarrhoea1 diseases is a very l o n g t e r m project and would not give immediate results, however some countries have brought down the incidence. by improving and extending
MCH
services including health education and health services as a whole to redune the incidence of diarrhoea1 diseases and the number of preventable deaths f'rom t h e s ediseases through measures designed to prevent, recognize and treat t h e disease and t h e dehydration which u s u a l l y occurs,
The main recommendations made by most countries in this region can be s u m r i z e d a s follows :
The Ereat need for the establishment of efficient maternal and child h e a l t h services:
As infantile diarrhoea constitutes a- btg.-.md9caI.~and. pub3.l~-.health.
problem in t h e majority of the countries, prime importance should be given to the maintenance and skrengthening of prevention thl.ou&h t h e establishment and extension of mate~nal and c h i l d health services, These services should be provided properly and sufficiently to maintain and promote i n f a n t s and children' s health, through medical examinations, Immunization, home visiting, health educational programmes to mothers in baby's hygiene, repeated in- structlons and demonstrations in the rudiments of personal hygiene, home sanitation and the choice, storage and preparation of food; preparation of formula and well balanced meals; feeding methods and encouragement of breast- feeding; causes, prevention and c o n t r o l of diseases in infancy and early childhood and instructions i n the e a r l y recognition of Illness, including diarrhoeal diseases and d e w d r a t i o n j simple and practical means and methods for the care of s f c k . b a b i e s , . , Preventive measures in the control of diarrhoea1 diseases should include the management of contacts and c a r r i e r s .
Ma-tiernal and c h i l d health should a t least have as high a p r i o r i t y as in the ,more ,developed countries.
Tho necessity f o r o b t a i n i n f ~ proper h e a l t h and 'cbtal statistics:
The accuracy o f data on infants' and children's morbidity and mortality due t o infantile diarrhoea and other diseases, is s t i l l questionable