• Aucun résultat trouvé

DB LA

N/A
N/A
Protected

Academic year: 2022

Partager "DB LA "

Copied!
39
0
0

Texte intégral

(1)

W O R L D H E A L T H dhi

#I

91

ORCANISATION

MONDIALE

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 MEDIERRANEAN

Fourteenth 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:

EASTEBN

MEDITERRANEAN

REGION

(2)

I

Introduction I1 Definition 111 Classification

fV 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 Environment

M Summal?y and Conclusions

References

Annex: Tables 1 to

XITI

(3)

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 to

75$

of t h e cases seen or admitted in health centres and

b 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, particularly

in

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".

(4)

"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

of

To obviate controversy, the WHO study group on diarrhoeal diseases

(1958)

thought t h a t all diseaaes .

-.

in which diarrhoea

is

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'

(5)

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 years

and 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'bh

that 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:mNT

OF

THE P510m

To 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 have

12%

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 than

one

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 in

l E 7

to hospitals

by 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/0otober

1958,

fahaw that out of the 977 adrnissiol~s 4 2 . s were far diarrhoea, of whiah

42.N

died.

In

a

(6)

review (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 h

l963),

in Venezuela at about 2500, Among children of the 1-4 age group, diarrhoea1 disease is the first cause of death

in

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 and

61CO

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 (Table

IT)

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

'

death6

and 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 Tables

IIX

and

IV,

Other reported figures on infant m o r t a l i t y ,and infantile diarrhoea

I 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 in

1960,

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 n

1960.

The t o t a l number of deaihs hsn t h e age group under one month was 7.8% in

1950

with death

r _ "

from diarrhoea 1; the eimd

iie

soup, 2.6% 'againat 7

.'is anh 5,

respectively,

(7)

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 Pakistan

a able

VT) showa that, gastro-enteritis 1s the main disease aausfne;

children's deaths.

During ~ u l y / ~ c tober

1961,

a

WHO

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 some

20 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-June

1961

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 cases

(8)

commonly 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 is

35$

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 about

45%

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 in

1963,

The Incidence of death due to diarrhoea f o r the same year was

7 +35$. Dr.

H.A. Khan, Karachi, reported t h a t the incidenae of diarrhoea among children admitted to the department was 17.6% in

1959

and 17.12% in 1963.

V

EPIDEMIOLOGICAL FACTORS 1NFI;UENCfNG THE MORBIDI7Y

A N D

MORTALITY

Since 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 Pose

(9)

in 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&ce

d::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 from

Pakistan 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 in

t 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 were

69

for mles and 82 f o r

females ( ~ r , G , Abdel-MessSh,

1964).

This excess in the number of females

does 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 was

1.6

to 1.0. In Pakistan, figures given by

Dr,

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).

115

the 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 was

800

to 1200, Data

0

given on temperatures throygh April-October was 40

- s a c

and through

(10)

November-March, 35'

-

~ O C . The relative humidity maximum driring J u l y to

September 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)

.

Diarrhoea

is 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 often

(11)

contaminated 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 Table

IX) . In

Somalia, a higher incidence of t h e

disease 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).

(12)

EM/kcl4/~e&h

. ~ i e c ./2 page 10

V 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 exohange

and 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

diarihoeas

However, 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,

(13)

~~/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 establiahedt

malnutrition 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 and

Marl,

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 origin

in

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.

(14)

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 infections

5. 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 for

13

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 m

7.5%

as

in 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$, group

B

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 the

1-3

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 and

9%

in urban area. Sensitivity tests showed that alipmxirnateljr

70%

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%.

(15)
(16)
(17)

The'general class of entero-viruses includes types of polivirus, Coxsackie groups A and

B

and Echo. m p e A and

B

groups of Coxsaokie virus have an uncertain r e l a t i o n t o diarrhoea1 disease.

Adenovimses, type

3

and type

7

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 were

isolated 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 in

m,

Entamoeba Coli in 5@, ~ a m b ~ i a ' in 22$, Chilomastix and Trichomoms hominis up to about

5%.

-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 i

Chest complications

-

Infections

-

Oedema

-

Anaemia

-

Kwashiorkor vit&nins

(18)

J?Dl/R~14/Teoh.~isc ./2 page

16

deficiencies

-

Convulsions

-

DlstedSion of abdomen

-

Haemomhages

-

Oligy~ia

and 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' advisable

t 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 e

fluids 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;

(19)

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 CONCLUSTONS

The ,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

this

Region, 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

'

departments

and 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

(20)

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 of

electrolytes imbalance, Rehydration is the most impoptant and life-saving measure. Simple routine rehydration w i t h fiulds glven orally

t b

diarrhoeic

children 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.

(21)

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 e

diseases 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

in

many developing c o u n t r i e s in Lhis Region as well as i n other Regions. Daxa are not complete due to lack of available statistical services and of undexl-repor t i n g and under-~egistration

.

Theref ore e s t a b l f shment a n a r

Références

Documents relatifs

Effect of incorrect proportioning of the resin and hardener components on the tensile strength development of a typical waterproofing membrane. Both ER and EH retard the development

The two targeted nutritional risks were declined into the perceived characteristics defined by Slovic & al (1980; 1985), Sparks & Shepherd (1994), Fife-Shaw & Rowe

Explanatory variables were anemia (binary categorization in anemic and nonanemic), parasitic infection (binary presence/absence of all tested intestinal parasites), age (in months

Effectiveness of nutritional supplementation (ready-to-use therapeutic food and multi micronutrient) in preventing malnutrition in children 6-59 months with infection (malaria,

The addition of ephemeral keys would require the ground entity to also archive its public/private ephemerals (consistent with message retention policy) associated with each

According to a first account, gender congruency effects are restricted to the definite (and possibly the indefinite) French determiners because the time course of determiner

Schools provide an efficient and effective way to reach large numbers of people: In 2013, over 90% of children of primary school age and over 80% of children of lower secondary

Taking advantage of the availability of other data sets of relevance to the parameter under concern, though different, a method is proposed for the synthesis of the initial