ReviewProgress and barriers for the control of diarrhoeal disease
Introduction
Diarrhoea causes 1·3 million deaths in children younger than 5 years every year.1 Some countries in south Asia and Africa have especially high diarrhoea mortality rates (figure 1).1 Reduction of this mortality burden is crucial to achieve the UN's Millennium Development Goal 4 to decrease the child mortality rate by two-thirds between 1990 and 2015.
The cause of infectious diarrhoea varies worldwide. In low-income and middle-income countries, where pathogen transmission occurs mainly through contaminated food or drinking water, bacterial and viral pathogens are responsible for most disease.2 Children younger than 5 years in developing countries have a median of three episodes of diarrhoea every year.3 Fluid loss and dehydration is the cause of death in nearly all patients with diarrhoea.
Over 3 decades ago, the discovery of intestinal sodium-glucose transport, which was the basis for the development of oral rehydration solution, was hailed as the most important medical advance of the 20th century.4 Although use of rehydration solution does not lessen diarrhoea incidence, more than 90% of dehydration from diarrhoea can be remedied with its use—leading WHO to make it the mainstay of diarrhoea treatment.5 Antibiotic therapy in addition to oral rehydration solution is indicated only for cases of bloody diarrhoea or cholera.5, 6 Evidence that zinc therapy reduces the duration and severity of diarrhoeal episodes and recurrence of such illness led WHO and UNICEF to recommend that zinc be provided with oral rehydration solution for all episodes of childhood diarrhoea.7
Oral rehydration solution was initially assessed for cholera treatment, and then shown to be effective irrespective of cause of diarrhoea or age of the patient. The WHO programme for the control of diarrhoeal disease began in 1978, and placed the main emphasis on management of clinical diarrhoeal illness with this solution (table) or home mixtures of sugar and salt, with continued feeding to prevent a diarrhoea–malnutrition cycle.9 International funding for diarrhoea control expanded greatly during the subsequent decade, with tens of millions of dollars going to research and diarrhoea-control programmes every year.9 By 1988, more than 100 countries had established national programmes for control of diarrhoeal disease on the basis of WHO recommendations.10
Activities in diarrhoea-control programmes varied widely,9 and included changes to medical-school curricula, training of partly skilled health workers, participation of religious leaders, educational campaigns in schools, and modifications to use of oral rehydration formulations to fit local traditions and beliefs. Mass media campaigns were set up around the world, and many political leaders and celebrities endorsed the use of oral rehydration solution. Outpatient oral rehydration centres—where mothers were taught to treat their children with the solution and continue feeding—replaced hospital wards where children with diarrhoea from all causes had been treated with intravenous fluids. Production of powder for reconstitution increased from 51 million packets in 1979 to 800 million in 1992—most of which were produced in developing countries.11 Because of the benefits of oral formulation, its use spread to developed countries; a rare example of a health intervention pioneered in developing countries being transferred to developed ones.12
Diarrhoea-control programmes have proved highly effective.13 Investigators for Egypt's national control of diarrhoeal diseases project showed a substantial increase in awareness and use of oral rehydration in the country between 1981 and 1990, and a fall in the infant diarrhoeal death rate from 35·7 to 9·3 per 1000 livebirths—a 74% reduction with no concomitant decrease in diarrhoea incidence. Non-diarrhoeal mortality also fell in this decade, but only by 28%.14 Similarly, results from a large diarrhoea-control programme15 in Brazil showed a 67% reduction in the proportion of registered deaths due to diarrhoea in infants from 1980 to 1989, whereas non-diarrhoeal mortality dropped by only 32%.
By 1988, an estimated 60% of children in developing countries younger than 5 years lived in areas with access to oral rehydration solution, compared with 5% in 1982.5 The percentage of cases of diarrhoea treated with this solution or appropriate home fluids increased from 12% in 1984 to 37% in 1992.11 Results from 15 hospitals in 11 countries showed that hospital admissions for diarrhoea were reduced by a median of 61% after the introduction of oral rehydration programmes.16 Worldwide distribution of oral solution helped to reduce the estimated number of child deaths due to diarrhoea from more than 4·6 million in 1980 to 3·3 million in 1990, to 1·8 million in 2004, and to 1·3 million in 2008.1, 2, 3
Section snippets
Updated oral rehydration solution recommendations
Concerns that the sodium concentration in original WHO oral rehydration solution could lead to hypernatraemia—especially in patients with non-cholera diarrhoea in which salt loss is reduced—led to new formulations being developed that contained reduced glucose and sodium concentrations (table). A meta-analysis17 showed that there was a reduction in stool output, vomiting, and unscheduled intravenous treatment in patients who received low osmolarity solution compared with those given original
Zinc recommendations for diarrhoea
Zinc decreases the duration and severity of diarrhoeal episodes when given with oral rehydration solution (panel). Another meta-analysis18 showed that treatment with zinc noticeably decreased the duration of acute and persistent diarrhoea. Furthermore, a 10–14 day course of zinc during and after diarrhoea decreases the recurrence of diarrhoea in the next 2–3 months.19
Introduction of zinc to community programmes resulted in increased use of oral rehydration solution, decreased use of unnecessary
Barriers to effective policy implementation
Since 1995, use of oral rehydration solution has stagnated in most countries (figure 2). Funding for diarrhoea-control programmes lessened in the 1990s and treatment was incorporated into the integrated management of childhood illness approach promoted by WHO and UNICEF. This incorporation led to an immediate reduction in diarrhoea-control activities from full country programmes to implementation in small areas. The approach was initially undertaken in only a few districts (and in many
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