Academic journal article Bulletin of the World Health Organization

Reducing Deaths from Diarrhoea through Oral Rehydration Therapy

Academic journal article Bulletin of the World Health Organization

Reducing Deaths from Diarrhoea through Oral Rehydration Therapy

Article excerpt

Voir page 1253 le resume en francais. En la pagina 1254 figura un resumen en espanol.

Introduction

In 1980, diarrhoea was the leading cause of child mortality, accounting for 4.6 million deaths annually (1). Efforts to control diarrhoea over the past decade have been based on multiple, potentially powerful interventions implemented more or less simultaneously. Oral rehydration therapy (ORT) was introduced in 1979 and rapidly became the cornerstone of programmes for the control of diarrhoeal diseases (CDD) (2, 3). Consisting of the oral administration of sodium, a carbohydrate and water (4), ORT was potentially the most significant medical advance of the 20th century (5). Other important interventions likely to have had an impact on mortality caused by diarrhoea include the promotion of breastfeeding, improved supplemental feeding, female education, and immunization against measles. Improvements in socioeconomic status, safe water supply, safe faeces disposal and the provision of vitamin A may also have played a role. We place special emphasis on the role of ORT but it is important to recognize the combined influence of these developments in reducing deaths associated with diarrhoea.

At the World Summit for Children in 1990, over 150 countries undertook to attain 80% ORT coverage by 1995 with a view to achieving a reduction of 50% in mortality attributable to diarrhoea by 2000.

We review the strategy for controlling diarrhoea through case management, with special reference to ORT, and the relationship between its implementation and reduced mortality. The focus on ORT does not preclude recognition that broader case management interventions, including ORT, are important for reducing the case-fatality rate associated with dysentery and persistent diarrhoea (6).

Evolution of ORT

Scientific progress in the management of diarrhoea, together with considerations of feasibility, have led to a series of changes in recommendations on the use of ORT for early home treatment of diarrhoea. Recommendations on the use of ORT in health facilities have, however, remained essentially unchanged. An understanding of the evolution in thinking about ORT in people's homes is important for interpreting changes in the control of diarrhoea. Table 1 (7-12) summarizes these changes and demonstrates their effect on estimated coverage rates in the light of 76 CDD surveys conducted between 1990 and 1993 (13). The following phases can be identified.

Table 1. Changes in definitions of indicators of diarrhoea management

Years and           Main Indicator: proportion      Global coverage
references           of diarrhoea cases             rates according
                     in children aged under         to indicator(a)
                     5 years who were:

1981 (7)            Treated by oral rehydration           23%

1988 (8, 9)         Treated by oral rehydration           57%
                    therapy: oral rehydration
                    salt solution and/or
                    recommended home fluids

1991 (13)           Treated by oral rehydration           32%
                    therapy (increased fluid
                    intake)

1993 (10, 11, 12)   Treated by oral rehydration           21%
                    therapy (increased fluid
                    intake) and continued feeding

                                    Comments

1981 (7)            Oral rehydration usually interpreted as being
                    limited to oral rehydration salts.

1988 (8, 9)         Separate indicators were also proposed for:
                    oral rehydration salt solution only;
                    increased fluids (oral rehydration salt
                    solution or recommended home fluids);
                    continued feeding.

1991 (13)           Oral rehydration therapy redefined as increased
                    fluid intake.

1993 (10, 11, 12)   Continued feeding included as part of the
                    indicator. … 
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