From Knowledge to action Child Survival: From Knowledge to action Venice, 26 to 28 January 2003 Session 2: Diarrhoeal Diseases Dr Hans Troedsson, Director, Department of Child and Adolescent Health and Development (CAH) CAH

Time trends in diarrhoea mortality 1975-2000 Time trends in mortality Since the creation of CDD in 1978,with ORS as a primary tool to fight dehydration, mortality for children suffering from diarrhoea has fallen from about 4.5million a year to 1.5million deaths annually in 2003. One of the greatest public health success of the 20th century. Source: Boschi-Pinto C et al. Deaths from diarrhoeal diseases among children under five years of age in the developing world. A review. Submitted for publication CAH

Major causes of death among children under five years of age - World 2002 Proportional mortality However, in spite of this impressive achievement acute diarrhoea remains a leading cause of childhood death in developing countries. Source: WHR, 2003 CAH

number of episodes/person/year Age specific incidence for diarrhoea episode per child per year from 2 reviews of prospective studies in developing areas,1955-2000 number of episodes/person/year Incidence of diarrhoea Overall, this impressive decrease in mortality was not associated with a parallel decrease in morbidity due to diarrhoea. The incidence of diarrhoea per age group did not vary much in the last 50 years,especially in the last 20 years. In 1985 3.5 episodes per child per year In 2000 3.2 episodes per child per year Source: Kosek et al. Bulletin of the WHO 2003; 81:197-204 CAH

Case Management of Diarrhoea in the Home prevent dehydration through early administration of appropriate fluids available in the home, and if available ORS solution; continue feeding or increased breastfeeding during, and increased feeding after the diarrhoeal episode know signs of dehydration indicating the need to take a child to a health care provider for treatment with either ORS or intravenous electrolyte solution, and other indications for medical treatment (such as bloody diarrhoea); The decrease in mortality was due essentially to the improved case management strategy promoted by CDD Programme, which included….. CAH

Case Management of Diarrhoea in Health Facilities Educate mothers to begin appropriate home fluids as soon as the child has diarrhoea; treat dehydration with ORS solution (or with an intravenous electrolyte solution in case of severe dehydration); recommend continued feeding or increased breastfeeding during,and increased all feeding after the diarrhoeal episode; use antibiotics only when appropriate (in case of bloody diarrhoea or shigellosis, and cholera) and discourage use of anti-diarrhoeal drugs; advise caretakers on the need to increase fluids and continued feeding during future episodes. CAH

number of episodes/person/year Evolution of Oral Rehydration Therapy use rates in three regions from 2001 to 2004 number of episodes/person/year However, disturbingly there are some contradictory evidences concerning the evolution of ORT use rates. If DHS surveys show a steady increase in ORT use rates,especially in Sub Sahara Africa, the statistics provided every year by UNICEF show a very constant decrease of these ORT use rates. Diarrhoea is still a leading cause of death and some evidence show that the gains made in the last 20 years could be reversed iif the trend in ORT use rates published by UNICEF are true and not addressed with the greatest energy. The DHS are porting much higher ORT use rates and improved use rates over the last few years: In AFRO: 2001 68% 2003 75% Source: The State of the World Children 2001 and 2004, UNICEF (Statistical Tables- Health) CAH

Recent Developments in the Management of Diarrhoea Two new vaccines against rotavirus are being licensed for Phase II trials; A new improved ORS solution that significantly reduces severity of diarrhoea is now being available through UNICEF; Zinc supplements given during an episode of diarrhoea andfor14 days after reduces the severity of the episode and the incidence of diarrhoea for the following 4 to 6 months. May be now is the perfect time to re-activate or to increase our efforts against diarrhoea as new developments in the case management of diarrhoea are providing even better tools to fight diarrhoea: new vaccines against rotavirus are ready for licensure new low osmolarity ORS that significantly reduces duration and severity of diarrhoea as well as the need for unscheduled IV therapy is now available through UNICEF Zinc supplements given at the time o f a diarrhoea episode and for 14 days after has been shown to reduce severity and duration but also to reduce the incidence of diarrhoea for the following 4 to 6 months. A tool to reduce diarrhoea morbidity finally. CAH

Reduced Osmolarity ORS Solution in children with acute non-cholera diarrhoea stool output reduced by 20%, vomiting reduced by 30%, and need for unscheduled IV reduced by 35%. A slight increased risk of biochemical hyponatremia was observed in some studies. To further investigate this studies are underway in Bangladesh and soon to start in India to evaluate the risk of hyponatremia with this new ORS. The data collected in Bangladesh so far are rather encouraging (personal communication). CAH