Control of deaths from diarrheal disease in rural communities: II. Motivating and monitoring the community.

In 1980 the Ministry of Health of Egypt undertook a short term investigation into means and methods to reduce the annually excessive number of preschool child deaths from Diarrheal Disease. This investigation sought to identify ways to overcome constraints related to logistics, supplies, and community participation. The unifying theme of this study was to examine the feasibility of stressing Oral Rehydration Therapy (ORT) instead of the then conventional parenteral treatment and heavy use of antibiotics. Study cells were arranged to test feasibility of placing responsibility for the intervention primarily with rural mothers, secondly with itinerant nurses. Appropriate health education programs, revised supervision and data collection systems were developed and implemented. Results limited to mortality indicators demonstrating that mothers could affect a significant decrease in the diarrhea-specific death rate were reported in an earlier paper. In this paper a more comprehensive presentation of various survey data associated with the investigation are presented. These data show that mothers were indeed able to recognize diarrheal disease and institute early and effective treatment, and that they developed remarkable skills of preparing safe oral rehydration fluids from home supplies of sugar and salt. In addition, the data show that health service staff increasingly gained confidence in ORT as demonstrated by increasing rates of utilization of the method, and as mothers indicated ORT to be the preferred method of treatment of diarrheal disease.

Diarrhoea and mortality in Menoufia, Egypt.

From 1982 the Ministry of Health of Egypt implemented the National Control of Diarrhoeal Diseases Project (NCDDP) which attempted to improve case management of childhood diarrhoea by making oral rehydration salts (ORS) widely available and used, to improve feeding patterns during diarrhoea, and other measures. National data indicate a high level of success in achieving the targets. However, impact evaluation is hampered by weak national baseline information available prior to NCDDP on case management of diarrhoea and causes of infant and childhood mortality. A study in Menoufia Governorate in 1979-80 obtained such information. Consequently, in 1988 the area was revisited to examine subsequent changes. Findings showed marked improvement in case management of diarrhoea and rapid mortality decline, with diarrhoeal mortality apparently declining somewhat faster than mortality from other causes.

PIP: The Ministry of Health (MOH) of Egypt has done much for more than a decade to control diarrheal disease (CDD). Oral rehydration salts (ORS) have been distributed since 1978, and the National Control of Diarrheal Diseases Project (NCDDP) was launched in 1982. Full CDD measures in place since 1984 have expanded the use of ORS to treat diarrhea, and have resulted in lower levels of infant and child mortality across the country. Impact evaluation is, however, hampered by weak national baseline data. At the national level, information on the cause of death in the vital register is not considered reliable. Second, there is little data on the case management of diarrhea before the initiation of the NCDDP. These issues were addressed in some sample villages in Dakahlia Governorate, where increases in knowledge and the use of ORS between 1980 and 1986 were associated with a decrease in diarrheal mortality. A potentially comparable situation existed in Menoufia Governorate, where the effect of a program of home distribution of ORS on mortality was evaluated in 12 villages in 1979-80. This paper reports findings from a return visit to the villages in 1988 to compare the current treatment of diarrheal diseases and mortality patterns against conditions at baseline. The authors report marked improvement in the case management of diarrhea and rapid mortality decline, with diarrheal mortality apparently declining somewhat faster than mortality from other causes.

Effect of diarrhoeal disease control on infant and childhood mortality in Egypt. Report from the National Control of Diarrheal Diseases Project.

The effect of the National Control of Diarrheal Diseases Project, started in 1983, on infant and childhood mortality in Egypt was assessed by means of national civil registration data, nationwide cluster sample surveys of households, and local area studies. Packets of oral rehydration salts are now widely accessible; oral rehydration therapy is used correctly in most episodes of diarrhoea; most mothers continue to feed infants and children during the child's illness; and most physicians prescribe oral rehydration therapy. These changes in the management of acute diarrhoea are associated with a sharp decrease in mortality from diarrhoea, while death from other causes remains nearly constant.

Evaluating tetanus neonatorum as a child survival risk in rural Egypt in the absence of reliable cause-of-death registration.

The principal finding of the investigation is that neonatal tenanus is, indeed an important cause of infant death in rural Egypt even though the normal cause-of-death reporting system had not altered health authorities to the problem. The finding is based on a comparison of registration statistics with (anthropological) reconstruction of pregnancies and child survival using the case-history rather than the epidemiological method. The histories go back ten years and refer to 102 women in two villages of Egypt. An incidental finding is confirmation of the known deficiency of infant death reporting, and associated births, with the extra dividend of showing how serious this may be in the neonatal period. Another incidental finding is the identification of induced abortion as a health problem.

PIP: A short-term study of pregnancy, births, and child mortality was conducted in 2 Egyptian villages to assess the reliability of official statistical records that suggest that neonatal tetanus is rarely a cause of death. Through an anthropologic interview technique based on several visits, reproductive histories were collected from 102 women from 3 age groups: 15-29 years, 30-44 years, and 45 years and over. Respondents from village A, in Upper Egypt, had experienced an average of 8.2 pregnancies, while those from village B, in Lower Egypt, reported 7.3 pregnancies. A total of 114 abortions (14% of all pregnancies) and 14 stillbirths (1.7%) were recorded. Official statistics indicate that 82% of infants in village A and 89% of those in village B survived to age 5 years; however, data from the present study suggest that the 5-year survival rates in these 2 villages were actually 56% and 77%, respectively. Moreover, although vital statistics indicate a rate of neonatal tetanus of 1/6 or less, 75% of the 87 neonatal deaths identified in this study were attributed to tetanus neonatorum/septicemia. Prematurity was the cause of an additional 13% of neonatal deaths in this survey compared with 0.1% of such deaths in official statistics. The results of this study indicate that the underregistration of births and deaths may be a major problem in these 2 villages and probably in other villages in rural Egypt. Neonatal tetanus as a cause of infant mortality was more prevalent in village A (39%) than in village B (9%), presumably because of the higher level of socioeconomic development in the latter region. It is estimated that tetanus immunization of eligible women would have reduced neonatal mortality from 193 to 33/1000 in village A and from 51 to 36/1000 in village B.

Control of deaths from diarrheal disease in rural communities. I. Design of an intervention study and effects on child mortality.

From May through October 1980, the "Strengthening Rural Health Delivery" project (SRHD) under the Rural Health Department of the Ministry of Health of Egypt had conducted an investigation into prevention of child mortality from diarrheal disease through testing various modules of Oral Rehydration Therapy delivery mechanisms. In a six-cell design counting a total of almost 29,000 children, ORT was provided both as hypotonic sucrose/salt solution prepared and administered by mothers and normotonic, balanced electrolyte solution in the hands of both mothers and health care providers and the effects on child mortality during the peak season of diarrheal incidence were measured. In addition, utilization and effects of ORT when made readily available through commercial channels was similarly examined. A cost-benefit analysis was performed on the cost of the services as well as on the outcome for each of five study cells using the sixth, the control, as reference. Results showed that early rehydration with a sucrose/salt solution in the hands of mothers, backed by balanced oral rehydration solution in the hands of health care providers proved the most cost-effective means of reducing diarrhea-specific mortality as well as being as safe as prepackaged commercial preparations.

PIP: A study design consisting of 2 control and 4 treatment cells was used to compare the effectiveness of different compositions of oral rehydration fluids and preventing dehydration and ultimately child deaths from diarrheal disease. Specifically, the extent of reduction in child mortality among 3 groups was compared: 1 group used a combination of oral rehdration therapy (ORT) prepared from the home ingredients of sugar and salt and administered by the mother and ("Oralyte") placed in the hands of the health care providers only; and 1 group used "Oralyte" only administered by both mothers and health care providers. Several data collection processes were employed to collect data on both baseline, intermediate (process), and impact (outcome) variables, including household surveys on demographic composition, sources of (drinking) water, incidence of diarrheal disease, knowledge and practice (KP) of mothers on diarrheal disease (DD) recognition and treatment regimen, availability of utensils and supplies necessary for the preparation of rehydration fluid, sodium concentration of randomly selected samples of home prepared rehydration fluids. In all study villages, the clerk in each health station maintained a regular count of the number of preschool children who had died within the preceding week. Age, sex, house number, and father's name were reported for each death. 2760 children (12.1%) of the total population under care in egypt's "Strengthening Rural Health Delivery" project were seen in the course of outpatient clinics during the 6 months of the program, May through October 1980. Overall, the rate of referral to secondary levels of care was almost 11 times higher in the control than treatment villages. From an initial level of about 22/1000 children per 6 months (May through October) in 1976-77, mortality dropped sigififcantly to a mean of 17.5/1000 in 1978-79 and to a mean of a mean of 10.5 by 1980 in the 3 treatment cells. A most important finding was the demonstration that ordinary household sugar and salt together with potassium containing fruits and vegetables or, intheir absence, tea, may serve as the basic ingredients of an alternative to, and temporary replacement of, the more costly and less readily available prepackaged ORS. This is not to suggest that a simple oral rehydration solution made from sugar and salt is as effective as the balanced "Oralyte", yet this simple solution when backed with adeqate supplies of "Oralyte" in the hands of the health care provider becomes a more cost effective means of reducing high child mortality from diarrheal disease than the "Oralyte" alone.