Compliance with DOTS diagnosis and treatment recommendations by private practitioners in Kerala, India.

The Indian government has a national tuberculosis (TB) plan based on DOTS recommendations. The private health sector plays an increasing role in health care provision in India, and a public-private mix (PPM) project has been introduced to standardise TB diagnosis and treatment methods in Kerala, India. This study interviewed 45 private practitioners (PPs) to evaluate diagnostic, treatment and reporting practices, of whom 80% diagnose with sputum microscopy and 43% treat all of their patients according to the treatment regimens recommended by the DOTS strategy. This study demonstrates that the current management of TB by private practitioners in Kerala is still in need of improvement.

Vitamin A status of children in Sri Lanka.

A representative country-wide rural nutrition status survey determined the extent and distribution of vitamin A deficiency in Sri Lanka in children 6 through 71 months of age. Trained paramedical personnel recorded the presence or absence of selected ophthalmological signs and symptoms associated with vitamin A deficiency in 13,450 children. The results of the country-wide clinical survey indicate that a vitamin A deficiency problem of public health importance may exist in two of 15 health areas. Serum vitamin A levels were determined on 346 survey children from two of 15 health areas and compared with clinical findings for these areas. The lowest mean serum vitamin A, 26.3 microgram/100 ml, occurred in children with clinical eye findings. A high prevalence of clinical eye findings, 34%, and the low mean serum vitamin A value, 28.2 microgram/100 ml, were found in the group of chronically undernourished children--children who are less than 90% of their expected height for age. The survey results enabled planned redirection of the distribution of vitamin A capsules to preschool children in Sri Lanka to areas shown to have the highest prevalences of ophthalmological signs and symptoms and/or the highest prevalence of chronic undernutrition.

Attempted prevention of diarrheal disease in Apache children with a non-absorbable broad-spectrum antimicrobial.

A double-blind study was conducted to test the prophylactic effect of a non-absorbable broad-spectrum antimicrobial (oral colistin sulfate) against acute diarrhea in Apache children. Children 1 to 6 months old had over twice the morbidity from diarrhea if assigned to the antimicrobial group as compared to placebo, while the toddler group (7-30 months) taking the antimicrobial had somewhat less diarrhea. Enteropathogenic E. coli were significantly more often isolated from the antimicrobial group (but only in well children). No special effect on the children's growth by the antimicrobial was discerned.

History of the development of oral rehydration therapy.

Humans have often used oral fluids to replace perceived losses of water, either instinctively or with a therapeutic orientation in the form of folk remedies. Replacement therapy with intravenous (IV) fluids was formally introduced in the last century for the treatment of patients with cholera. The modern implementation of oral replacement therapy was begun by pediatricians in the 1940s who used electrolyte solutions as maintenance therapy in mildly purging children with diarrhea. However, the scientific development of oral rehydration therapy (ORT) has occurred only in the last 30 years. Basic physiologic research in the 1950s demonstrated the cotransport mechanism of sodium and organic solutes (sugars and amino acids) in the intestinal cells, thereby establishing the scientific basis for ORT. The use of ORT based on scientific observations was first reported in 1964 from the Philippines by Phillips and coworkers. Research laboratories in Dhaka and Calcutta subsequently demonstrated that the mechanism of sodium and glucose cotransport remains intact in cholera patients and that oral solutions can successfully rehydrate and maintain hydration in these patients. Clinical studies carried out in Dhaka and Calcutta confirmed the efficacy of oral rehydration solutions (ORS) and showed that nearly 80% of IV fluid could be saved if patients were hydrated by the oral route. Further studies demonstrated the safety and efficacy of ORT in patients of all ages suffering from acute diarrhea of any cause. The use of ORT has substantially reduced morbidity and mortality from acute diarrhea, particularly after the World Health Organization adopted and promoted ORT on a worldwide scale. Researchers continue to search for better ORS formulations in terms of safety, efficacy, availability, and cost. Food-based ORS are a promising area of research. The use of a sound scientific method, the establishment of a close link between basic and clinical science, and the use of field studies have proved to be major assets in the development of ORT.

Oral or nasogastric maintenance therapy for diarrhoea of unknown aetiology resembling cholera.

PIP: Clinical trials under field hospital conditions were undertaken in India and Pakistan to determine the efficacy of oral maintenance solutions in treatment of noncholera diarrheal patients. Those patients with severe dehydration due to diarrhea were 1st rehydrated with a standard intravenous solution until the blood pressure was normal. They were then administered a warmed maintenance solution by mouth or nasogastric tube. Milder cases were given only an oral solution. The oral treatment was found to maintain fluid balance in all cases. Oral electrolyte solutions containing both glucose and glycine produced lower total stool volumes than the solutions made up only of electrolytes and glucose. The addition of glycine to the solution seems to enhance absorption. This oral therapy is recommended because the solution is cheap and the ingredients are widely available. Both solutions eliminated the need for intravenous fluids in 80% of the cases, thus lowering the number of staff man-hours needed per patient. This treatment can, thus, lower total costs and increase availability of diarrhea treatment in developing countries where severe diarrheal diseases are common.^ieng

The private GP and leprosy: a study.

In urban and rural areas alike, people in India tend to prefer private medical care to the existing government health services. Nevertheless, the large private health care sector has hitherto been virtually alienated from activities of public health importance including priority disease control programmes. This study of 106 private general practitioners (GPs), practising in low socioeconomic areas of Bombay, shows a gross lack of knowledge and awareness among private doctors about leprosy and also about the National Leprosy Control Programme. The possible reasons are discussed. Effective involvement of GPs in the National Leprosy Control Programme should facilitate both integration and better implementation of leprosy control activities. The study also highlights some areas for future interventions at both primary and secondary health care levels and the need for a strategy, based on larger studies, to train and make private doctors participate in controlling diseases of major public health concern like leprosy.

Impediments to global surveillance of infectious diseases: consequences of open reporting in a global economy.

Globalization has led to an increase in the spread of emerging and re-emerging infectious diseases. International efforts are being launched to control their dissemination through global surveillance, a major hindrance to which is the failure of some countries to report outbreaks. Current guidelines and regulations on emerging and re-emerging infectious diseases do not sufficiently take into account the fact that when developing countries report outbreaks they often derive few benefits and suffer disproportionately heavy social and economic consequences. In order to facilitate full participation in global surveillance by developing countries there should be: better and more affordable diagnostic capabilities to allow for timely and accurate information to be delivered in an open and transparent fashion; accurate, less sensationalist news reporting of outbreaks of diseases; adherence by countries to international regulations, including those of the World Trade Organization and the International Health Regulations; financial support for countries that are economically damaged by the diseases in question. The article presents two cases--plague in India and cholera in Peru--that illuminate some of the limitations of current practices. Recommendations are made on measures that could be taken by WHO and the world community to make global surveillance acceptable.

Treatment of diarrhoea in Indonesian children: what it costs and who pays for it.

The annual economic burden of diarrhoea in four subdistricts in Indonesia averaged $2.27 per child aged under 5 years when health centre, hospital, and private expenditures were all considered. The community itself spent $1.03 per child or 46% of the total; 96% of community payments went to the private sector, and 4% were for fees at government health centres and hospitals. The widespread availability of oral rehydration therapy has led to only partial abandonment of ineffective or marginally effective medications; non-rehydration medications amounted to 44% of total treatment expenditures. Most medication costs were for antimicrobial agents, such as tetracycline in the government sector and iodochlorhydroxyquin in the private sector. If the use of tetracycline at health centres could be restricted to 10% of episodes treated instead of the present 88%, their costs could be reduced by 50%.

PIP: The annual economic burden of diarrhea in 4 subdistricts in Indonesia averaged $2.27/child under age 5 when health center, hospital, and private expenditure were all considered. The community itself spent $1.03/child or 46% of the total; 96% of community payments went to the private sector, and 4% were for fees at government health centers and hospitals. The widespread availability of oral rehydration therapy has led to only partial abandonment of ineffective or marginally effective medications; nonrehydration medications amounted to 44% of total treatment expenditures. Most medication costs were for antimicrobial agents, such as tetracycline in the government sector and iodochlorhydroxyquin in the private sector. If the use of tetracycline in health centers could be restricted to 10% of the episodes treated instead of the present 88%, their costs could be reduced by 50%.

Oral (or nasogastric) maintenance therapy for cholera patients in all age-groups.

PIP: 56 children and 50 adults were studied to determine the effectiveness of an oral (or nasogastric) therapy with a glucose-electrolyte solution for treating cholera patients. The development of this inexpensive regimen is described. The therapy has the advantages of being cheap, not requiring sterile conditions, and having wide availability in endemic areas. The oral solution contained the following ions (as milliequivalents per liter of water): Na+, 120 K+, 25; CO2-, 48; CL-, 97; and glucose at 110 mmol/liter. Patients received nothing orally except the solution and a 5-day course of tetracycline (dosed according to body weight). The oral (or nasogastric) therapy was used as a supplement when patients arrived in shock, at which time intravenous infusion was used to begin rehydration; patients with milder cholera cases were given only the oral therapy, with much success. All children were maintained in a positive balance with the oral (or nasogastric) solution after correction of shock by intravenous rehydration, and the mean volume of oral solution required by the 56 children was 6 liters. In field trials, 80% of the patients were in positive net intestinal balance by 6 hours after initiation of oral therapy. Adults studied to determine in the 25 mEq potassium/liter solution was safe showed that after administration adult plasma potassium levels were normal.^ieng

Antibodies to heat-labile Escherichia coli enterotoxin in Apaches in Whiteriver, Arizona.

Antitoxin titers to heat-labile Escherichia coli enterotoxin were measured in Apache children hospitalized with acute diarrhea and in Apaches of different age groups without diarrhea in Whiteriver, Ariz. The study suggests that in this locale, exposure to enterotocigenic E. coli is probably widespread and occurs early in life. Antitoxin titer rises after idarrheal disease associated with enterotocigenic E. coli infection, however, were not regulary found.

Effect of glycine and glucose on sodium and water adsorption in patients with cholera.

Electrolyte solutions containing glucose, glycine, or a combination of the two were absorbed sufficiently well from the intestine to supply maintenance fluid and the electrolytes required by cholera patients. Data on net absorption and duration and volume of diarrhoea show that a solution containing both glucose and glycine provides more effective therapy than solutions containing either glucose or glycine alone.

The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used?

During 1980-1990 BRAC, a Bangladeshi non-governmental organization, taught over 12 million mothers how to prepare oral rehydration therapy (ORT) at home with lobon (common salt) and gur (unrefined brown sugar). This was followed by a strong promotion and distribution of prepackaged ORS by various agencies including the government. In 1993 we assessed knowledge of ORT preparation, its local availability and its use for the management of diarrhoea. Over 9000 households in 90 villages were revisited; 306 government outreach health workers, 296 drug sellers, and 237 village doctors were interviewed; 152 government facilities and 495 pharmacies/shops were visited. ORT prepared by mothers in a sub-sample of the households was analyzed for chloride content and interviewers collected information on use of ORT for diarrhoeal episodes occurring in the preceding two weeks. The data quality was assessed through a resurvey of sample respondents within two weeks of the first interview. Over 70% of the mothers could prepare a chemically 'safe and effective' ORS. A significant proportion of these mothers were very young at the time of the mass campaigns using house to house teaching, implying an intergenerational transfer of the knowledge on ORT. ORT was found to be used in 60% of all diarrhoeal episodes, but the rate varied with the type of diarrhoea, being highest for daeria (severe watery diarrhoea) and lowest for amasha (dysentery). Drug sellers and village doctors now recommend ORT much more frequently than before. Members of the medical profession (qualified and unqualified) still lag behind in prescribing the use of ORT. The availability of pre-packaged ORS in rural pharmacies has improved enormously. There is convincing evidence that the widescale promotion in the past of ORS for dehydration in diarrhoea has led to this marked improvement today. Nevertheless the use of rice-based ORS, culturally appropriate messages and the promotion of ORS with food offer opportunities to further improve the utilization of ORT.

Efficacy of a live oral cholera vaccine in human volunteers.

A live attenuated oral cholera vaccine has been given to volunteers with complete safety. The vaccine strain appeared to multiply significantly in intestinal contents and to result in appreciable vibriocidal antibody response. Subsequent challenge with virulent Inaba vibrios demonstrated substantial protection from clinical illness and from vibrio shedding. The possibility of reversion to toxin production is discussed.

Enterotoxigenic Escherichia-coli-associated diarrheal disease in Apache children.

A search for intestinal enterotoxigenic Escherichia coli was made in 59 Apache children hospitalized with 64 episodes of acute diarrhea. Esch. coli isolates from acute-phase and convalescent-phase specimens of small-bowel fluid and stool were tested in three currently recognized models: the adult-rabbit ileal loop; infant rabbit; and the adrenal-cell assay. Enterotoxigenic strains were isolated from 10 children during acute diarrheal episodes (16 per cent); none were isolated from convalescent-phase specimens. None of 64 "enteropathogenic" serotypes of Esch. coli from 43 children with diarrhea, however, caused fluid production in the ileal-loop model. These results suggest that enterotoxigenic Esch. coli may be the cause of considerable diarrhea in this population and that the term "enteropathogenic" as applied to serotypes of Esch. coli needs to be redefined.