ARNFRIED A. KIELMANN AND COLIN McCORD
Home Treatment of Childhood Diarrhea in Punjab Villages* by ARNFRIED A. KIELMANN and COLIN McCORD Department of International Health, The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland, U.SA.
Acknowledgements *The advice and assistance of Dr. Carl E. Taylor and Dr. R. D. Singh is gratefully acknowledged. Hannder K. Arora, Raj D. Babbar, Shakti B. Chadha, Swaran Chadha, Raj K. Chib, Sarla Devi, Amarjit K. Gandi, Surinder K. Grewel, Amarjit Kakaria, Amar Kaura, Madalsa H. Khera, Peter Ganda Mai, Bayant K. Mayo, Daljit K. Sachdeva, Rajinder Sharma, Kanchan Sood, Sudershan Trikha, Usha Trivedi, and yeena Verma, lady health vistiors and auxiliary nurse midwives, resident in the thirteen villages carried the main responsibiltiy for child care. Dolores Laliberte, Norah Masih and Senyukta Vohra, public health nurses, and Shushum Bhatia, Susheila B. Takulia, and I. S. Uberoi, project physicians, supervised patient care and played a major role in modifying and implementing the standing orders. Environmental Child Health, August 1977
institution to the home is not simple and that without attention to certain important problems, program failure is likely. Training programs and procedures developed by project staff (including the authors) had emphasized treatment of diarrhea and included instruction in detection and referral of serious cases. Review of these procedures by supervisors and field staff showed that they contained several inappropriate and impractical recommendations and were in conflict with some well established local practices. Ultimately, improved results followed reorganization of management along lines suggested by village level conferences, placing almost all of the treatment in the hands of the auxialiary nurse midwives resident in the villages together with the mothers of the affected children. Methods and Procedures The study was carried out in 13 study villages of the nutrition and population projects at the Narangwal Rural Health Research Center in Punjab, India. Total population of the 13 villages was 18,000 and the population of children aged 0 to 3 years averaged slightly over 1,400. In these villages food supplementation, infectious disease control or a combination of the two were provided to all children below three years of age, and program effects on growth, disease experience and mortality were monitored through repeated surveys at monthly or shorter intervals. Diagnosis, treatment and referral of sick children was the responsibility of auxiliary nurse midwives and lady health visitors resident in each village, following standing orders drawn up by public health nurses and physicians in charge. Several longitudinal surveys were carried out (anthropometry, fertility, dietary history, morbidity and vital statistics), but this report is concerned only with morbidity and vital statistics results. Morbidity data was collected at a weekly visit to every study child during which the mother was asked to recall illness episodes that occurred over the preceding six days according to a roster of 44 clinical signs or symptoms. This recall survey was followed by a physical examination of each child to verify conditions reported and detect unreported illness. Vital statistics (births and deaths) were collected on an ongoing basis by the resident health worker and supplemented by information from two other sources: the village chowkidar — traditional 197
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
Diarrhea with dehydration has long been recognized as a major cause of death among preschool children in developing countries. 12 Our own experience in Punjab, North India, confirmed this observation. Diarrhea! disease was the most common cause of death, producing 42 percent of all deaths among children eight days to three years of age in 13 study villages. The overwhelming majority of cases of childhood diarrhea are due to infections by organisms not affected by available antibiotics3 * and the mainstay of therapy must be fluid replacement to prevent or relieve dehydration. Hospital experience has shown that fluid therapy alone is remarkably effective in preventing death but unfortunately the majority of children in developing countries in need of this therapy have limited access to hospitals. Fortunately the materials necessary for fluid and electrolyte replacement (water, salt, and sugar) are universally available, oral treatment is effective and the principles of treatment are simple and easily taught to paraprofessionals or the mothers of children affected with diarrhea. In view of the numerous reports of successful oral fluid therapy in an institutional setting5 6 7 and the extensive discussion of proper fluid composition and other aspects . of individual patient management*' it is surprising that there are relatively few reports of successful management of this important clinical problem in populations or community groups.10 n Our own experience with a combined nutritional supplement and infectious disease control program for small children in villages of northern India has shown that the transfer of effective fluid treatment from the
ARNFRIED A. KIELMANN AND COLIN McCORD
Table I Cause of 45 Deaths in 1,415 Children 8 days to 3 years of age (1971)
Diarrhea and Dehydration L.R.T. Infection* Marasmus and Nutritional Deficiency Diseases. Tetanus Neonatorum Other Causes Unknown
Number
Percent
Deaths/1,000 Children/Year (0-3 Years of Age)
20 10 3 1 8 3
44 22 7 2 18 7
14.1 7.1 2.1 0.7 5.7 2.1
source of Indian rural vital statistics — and specially appointed vital statistics investigators who toured all villages at fortnightly intervals to collect data from selected village contacts (midwives, village leaders, grocers, faith healers, etc.). From January, 1971 every death in a child of less than five years of age was investigated by a physician who interviewed the family and reviewed the record, usually within two weeks after the event. The collected information from these "verbal autopsies" was subsequently discussed by a group of physicians and a most likely cause of death assigned. By the latter half of 1971 it had become clear that diarrheal disease and lower respiratory tract infection were responsible for most deaths (Table I). This high'death rate from preventable diseases despite an intensive village level program to improve nutrition and treat diarrhea and other infectious diseases led to a series of conferences at which existing standing orders were reviewed and completely revised. Previous treatment guidlines had considered acute diarrhea as one of several important conditions prevalent in the area but had not singled it out as the condition responsible for the majority of child deaths. Oral rehydration with diarrhea mixture and maintenance of adequate caloric intakes — including the advice not to stop either breast milk or supplementary milk — was emphasized in the standing orders for children with diarrhea in the absence of dehydration; who was to do the rehydrating, however, was left to the judgement of the health worker. Children with signs of dehydration were referred to the Narangwal physician for intravenous fluid therapy. Criteria for differentiating between serious and minor diarrheal disease failed to take into account the very large number of insignificant cases, and were therefore impractical. The following simple criteria for categories of management were established: Standing Orders for Diarrheal Disease Finding History .>6 stools/24 hours fever vomiting blood and mucus in stool 198
Grade
Special Characteristics
Physical Examination
103°F weight loss (only on revisit)
+ + + + ++ ++ ++
Subsequent management depended on overall assessment of the child's condition according to the above criteria and was divided into three main groups. I. Diarrhea in the absence of any of the above: Explain need for fluid replacement and preparation of "diarrhea mixture"* to mother. Mother to administer at least one liter of fluid per 24 hours and to continue regular caloric intake. Instruct mother to return to clinic next day if diarrhea persists. Revisit child within one week. II. If any of the "one-plus" criteria is present: Prepare one liter of "home diarrhea mixture",* start giving it to child and show mother how to give it and how to prepare more. Advise continuous fluid intake; two to three liters per 24 hour period. If child is on milk supplement, ask mother to stop milk for 24 hours but continue all other foods. If exclusively breast fed, skip one feeding. Treat fever, blood or mucus in stool if present as per standing orders. Revisit home within 12 hours. III. If any of the "two-plus" criteria is present: Prepare "project diarrhea mixture".** Start giving it to child. Refer to physician for immediate consultation. Remain with child giving fluids until physician arrives. *Six teaspooons of sugar, one level teaspoon of salt per liter of water. "From a centrally (Narangwal pharmacy) prepared "diarrhea mixture" concentrate containing sodium and potassium chloride (no sodium bicarbonate), with sucrose added from household supply. Environmental Child Health, August 1977
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
•Pneumonia, Bronchitis, or Bronchiolitis
ARNFRIED A. KIELMANN AND COLIN McCORD
Results Treatment with" the same standing orders and the same procedures was provided for all children, but the morbidity surveys covered only children from the nutrition project villages (60% of total). Calculations of incidence and mean duration are based on-217,127 child days of observation in 1970; 188,367, 153,850 and 81,483 child days of observation in 1971, 1972, and from January through May 1973 respectively. Prior to 1971 the cause of death was not established by "verbal autopsy". Deaths before that date were not included in the analysis. The study was terminated suddenly and unexpectedly at the end of May 1973, but fortunately the five-month period from January to May included times of both high and low diarrhea incidence — in 1971 and 1972, 34 per cent of deaths from diarrhea and 48 per cent of diarrhea episodes occurred in these five months. Adjustment for seasonal variation of diarrhea incidence was, therefore, not necessary. Incidence of diarrheal disease was highest in the hot, dry season, generally rising to more than 60 episodes per 100 children per month between March and June. This period (March through June) also coincides with both the hottest time of the year, when temperatures average 22.5 C for March-April, 31.5C for May and June14 and the spring (wheat) harvest. During this harvest all able hands are usually out in the fields all day, leaving the care of small children to those unable to work because of age or physical disability. The average incidence of 41 episodes per 100 children per month is approximately three times higher than that reported in an earlier study conducted in the same area.2 In this earlier study, the morbidity survey was carried out once a month and may not have been as sensitive as our own. Our criterion for a diarrhea Environmental Child Health, August 1977
episode was "more than three watery bowel movements per 12 hours for one day or more". Mean duration of diarrhea tended to be longer during the first 5 months of the year than the succeeding 7 months and fell significantly after introduction of the new standing orders (Figure 1 and Table II). Figure 1 Incidence and Mean Duration of Acute Diarrhea in Children under 3 (From January-February 1970 to May 1973
\
-/ r ii
The number of days of diarrhea per child per month was important as a measure of the work load for village level workers (and mothers). This was also quite consistent from year to year, varying from 1 to 1.5 diarrhea days per child per month in the low season to 4.8 days in the hot season. Since there were about 110 children in an average village (population 1,400), this meant that 18 children suffered from diarrhea on any given day during the hot season in one of these villages. Case fatality rates can be calculated in those villages in which morbidity and mortality data was collected simultaneously and averaged 2.1 deaths per 1,000 episodes of diarrhea during the 29 months in which both kinds of data are available on the same children. There was a drop in the case fatality rate after introduction of the revised standing orders, from 3.2 to 1.4, but this difference is not significant since only 63 per cent of deaths occurred among children who were also included in the morbidity survey. Annual death rates from diarrheal disease per 1,000 child years of exposure (0-3 years of age) fell from 14.1 to 7.3 between the initial 12 months period in 1971 and the subsequent 17 months period in 1972 and 1973. This decrease is statistically significant (Table II). New standing orders were introduced in January 1972. Many patients continued to consult local practitioners (faith healers, traditional healers, and others) but most of the population consulted project staff at some point. The number of deaths of patients who had never consulted project staff was essentially unchanged — 7 in 1971 and 8 in 1972/1973. Deaths of patients who had consulted project staff fell from 13 in 1971 to 4 in 1972/1973. Seventy-one per cent of the 35 diarrheal deaths suffered from concomitant malnutrition — arbitrarily defined as below 70 per cent of th« Harvard standard weight-for-age median. Summer 1972 was unusually 199
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
Following the introduction of new standing orders an intensive training program for all health workers resident in study villages was carried out over a threemonth period. At these sessions recognition, management and referral of patients with diarrhea was reviewed with reference to the newly revised standing orders and recent case histories were reviewed with respect to management and outcome. Following this training period a village conference was held in each group of four villages every two weeks at which service and research records were examined for compliance with standing orders and children currently under treatment were visited at home when a visit could serve an educational purpose (e.g., demonstration of signs of dehydration). Deaths among the child population in a given village over the preceding two months were received and analyzed for cause, events leading to death, treatment given and avoidability. Observed problems and results led to further modifications in the standing orders, often because of practical suggestions made by the auxiliary health staff.
ARNFRIED A. KIELMANN AND COLIN McCORD
Time Period
Table II Incidence, Mean Duration and Deaths from Acute Diarrhea in Children Under 3 (January 1971 through May 1973) Deaths from Diarrheal Disease Diarrheal Incidence Disease Per (No. of Episodes Mean Duration Deaths 1,000 Child per 100 Children from Child Years per Month) s.d. Diarrhea of Exposure Years of Exposure days 48.0 34.1
7.4 5.0
4.37 4.91
6 14
590 825
Jan.-Dec. 1971
36.6
5.4++
5.71
20
1,415
Jan.-May 1972 June-Dec. 1972 Jan.-May 1973
47.3 39.3 56.3
5.8 4.9 4.0
6.13 4.89 3.59
5 7 3
611 855 597
Jan. 1972-May 1973
44.1
4.7++
4.75
15
2,063
Jan. 1971-May 1973
41.0
5.0
5.22
35
3,478
10.2 17.0
1.8 4.1
14.1 +
3.2
8.2 8.2 5.0
1.4 1.7 0.7
7.3 +
1.4
10.1
2.1
'Calculated by extending mean incidence of diarrheal disease from sample population to total child population. +X 2 test for significance in proportion of deaths from diarrheal disease between the two time periods = 3.97; P < .05. ++t = 4.68;P< .001.
hot and the mean prevalence of this degree of malnutrition increased slightly from 22% in 1971 to 24% in 1972. No other external factors were identified which might have altered mortality after January 1972. An intensive program to treat pneumonia12 in preschool children was also introduced in 1972 and the number of deaths from this cause fell significantly — mortality from causes other than acute diarrheal disease or lower respiratory tract infection remained unchanged. Discussion Before and after comparisons of mortality rates are less satisfactory measures of improved results than double blind controlled studies, but in this situation the latter did not appear to be applicable. It would have been neither moral nor practical to deny to a part of ihe population any improvement in the application of a treatment which was known to be effective. The efficacy of oral fluid therapy is well established and we were faced with the problem of apparent failure when it was transferred from an institutional to a village setting. There was a significant drop in the death rate from diarrhea despite an increase in the incidence of diarrheal disease and we were convinced that this drop was directly related to wider and more efficient utilization of oral treatment. (Mean temperatures during March through August 1972 were considerably higher than either the 30 year average or those during the same months in 1971. Temperatures in 1973 similarly were higher than the 30 year average and about equal to those in 1971. 1314 ) One" of the best 200
measures of program effectiveness was the observation in 1973 that most mothers had already instituted oral fluid treatment when their child was first seen by a project staff member. The incidence of diarrhea in the child population was so high that a home treatment program automatically became an education program (since all mothers and children were sooner or later included) and appropriate exploitation of a few successful cases did convince these mothers that the treatment was worthwhile. Magical beliefs about diarrhea and dehydration existed here, as elsewhere in India, 1316 but were less important negative influences than practical considerations. . The two major blocks to widespread utilization of treatment were the great mass of cases of diarrhea which were not life threatening and traditional beliefs about restriction of fluids and milk which were founded on the accurate observation by mothers that increased intake of fluid containing carbohydrates often aggravated diarrhea.17 " Our initial standing orders and other procedures were quite inadequate to the task of overcoming these problems. With 18 cases of diarrhea per day in each village at the peak period a village level worker could not possibly have the time to prepare a diarrhea mixture for all these children, educate the mothers in its proper use, administer the fluid herself when the mothers failed to give it properly and make the necessary return visits to be sure that instructions were being properly followed — all this in addition to her other duties. Furthermore, the mothers knew that most of these episodes of diarrhea subsided without vigorous treatment and their belief that administration of fluids and partidularly of milk could aggravate diarrhea was based on fact. It is a rather Environmental Child Health, August 1977
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
Jan.-May 1971 June-Dec. 1971
Case Fatality* (No. of Deaths per 1,000 Episodes)
ARNFRIED A. KIELMANN AND COLIN McCORD
Environmental Child Health, August 1977
for intensive treatment will probably vary from country to country, but it is likely that the basic procedures described in this article will be applicable anywhere. Summary Diarrhea was the main cause of death among preschool children under surveillance in a combined nutrition and infectious disease control program in Punjab, India. Case fatality rates were low (0.7-4.1 deaths per 1,000 cases), but incidence was very high, averaging 41.0 episodes per 100 children per month. Initial efforts at home treatment with oral fluid were not successful but an intensive training program for supervisors, village level workers, and mothers resulted in a significant reduction in mortality from diarrhea, although the incidence was unchanged. Training emphasized classification of cases into treatment categories according to defined criteria and placing responsibility for treatment of all but the most severe cases in the hands of auxiliaries and mothers.
References 1. Editorial; Lancet, 1975,1, 79. 2. Scrimshaw, N. S., Taylor, C. E. and Gordon, J. E. "Interactions of Nutrition and Infection", WHO Monograph No. 57,1968, pp. 216-261. 3. Garcia de Olarte, D., Trujillo, H., Agudelo, N., Nelson, J. D. and Haltalin, K. C. (l914).Amer.J.Dis. Children, 127,379. 4. Ryder, R. W., Sack, D. A., Kapickian, A. Z., McLaughlin, J. C , Chakraborty, J., Misanur Rahman, Merson, M. H. and Wells, J. G. (1976). Lancet, 1,661. 5. Nalin, D. R., Cash, R R. A., Islam, R., Molla, M., Phillips, R. A. (1968). Lancet, 2, 370. 6. Cash, R. A.I Nalin, D. R.I Rochet, R.1 Reller, L. B., Haque, F. A., Rahman, A. S. M. (1970). Amer. J. Trop. Med. Hyg., 19,653. 7. Hirschhorn, N., Cash, R. A., Woodward, W. E. and Spivey, G. H. (1972). Lancet, 2,15. 8. Hirschorn, N. (1975). Lancet (C), 2,1049. 9. Moenginah, P. A.; Suprapto, Soenarto, J.; Bachtin, M.; Sutrisha, D. S.; Sataryo and Rhode, J. E. (1975) Lancet (C), 2,323. 10. Ascoli, W. and Mata. L. J. (1965). Amer. J. Trop. Med. Hyg., 14,1057. 11. Hirschhorn, N., McCarthy, B., Ranney, M. Hirschhorn, S., Woodward, A., Cash, R. A., LaCapa, A. and Woodward, W. (1973). Pediatrics, 83, 562. 12. McCord, C. and Kielmann, A. A. In preparation. 13. Government of Punjab (India). Statistical Abstract of Punjab. Economic and Statistical Organization, 1972, 1973 and 1974. The Economic Advisor to Government, Chandigarh, Punjab. 14. Werustedt, F. L. (1972) World Climatic Data, Climatic Data Press, Penn. State Univ., University Park. 15. Kielmann, N. Personal communication, August 1976. 16. Lozoff, B., Kamath, K. R., Feldman, R. A. (1975). Human Organization, 34,353. 17. Prader, A. and Auricchio, S. (1965). Defect of Intestinal Disaccharide Absorption, Ann. Rev. Med., 16, 345. 18. Morley, D. (1973). Paediatric Priorities in the Developing World, Butterworths and Co., Ltd., London. Pp. 172-174. * 19. Hirschhorn, N. Personal communication, July 1976. 201
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
complicated process to explain to a mother that she should give more fluid to overcome the increase in diarrhea which she is producing by giving fluid. The changes which appear to have broken this vicious cycle were (1) emphasis that diarrhea was the major cause of death; (2) establishing criteria for degrees of severity of diarrhea with actions appropriate to each degree; and (3) establishing in the minds of both the village level workers and the mothers the importance of follow-up and close observation of all children with diarrhea since a mild case may turn into a severe case at any time. With these principles established, it was then possible to conduct an education program based on discussion of actual cases in the home setting and eventually to make every village worker and most mothers competent in the diagnosis and treatment of dehydration resulting from diarrhea. It is probably important that almost all of the children in this series were treated with materials available in the home: table salt, table sugar, and water. Only the most severely dehydrated children received a preparation prepared in the project pharmacy which contained added potassium but no bicarbonate. Only two patients in the 17 months of the 1972-1973 phase, of the project received parenteral solutions. This was not because we were unconvinced of the value of glucose, bicarbonate, potassium, and, on occasion, intravenous fluids, but because we believed that these additional substances were not necessary in the overwhelming majority of cases and we were'trying to develop methods which would be immediately applicable on a wide scale throughout India and which could be used by mothers at home without further supervision after initial training. There is an economic problem also which must be faced by those proposing to distribute packets of electrolyte and sugar solution widely. Most solutions proposed are based on the mixtures developed at the Cholera Laboratory in Dacca, Bangladesh, and contain sodium bicarbonate, potassium, and glucose. Cost of the packaged preparation varies from 13c to 50c.19 Most of the cost is for the packaging which must be water-tight or the preparation is destroyed in a fairly short time by hygroscopic adsorption. Since the average prevalence of diarrhea in our villages was 2.41 diarrhea days per child per month, the cost of providing one packet of diarrhea preparation for each child each day that he had diarrhea would be $3.80$14.50 per child per year or $0.50-$1.90 per head of total population per year, assuming that 13 per cent of the population is children 0 to 3 years old. This, of course, also assumes that diarrhea packets would be used only for children under three, which is unlikely and undesirable. The cost of providing diarrhea packets in this fashion would amount to between 25 and 96 per cent of the total health budget for Punjab State in 1975-1976. Obviously, widespread use of packets of sugar-electrolyte solution will not be practical unless sensitive and specific criteria for their use are developed. The criteria for selection of cases
Home Treatment of Childhood Diarrhea in Punjab Villages* by ARNFRIED A. KIELMANN and COLIN McCORD Department of International Health, The Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland, U.SA.
Acknowledgements *The advice and assistance of Dr. Carl E. Taylor and Dr. R. D. Singh is gratefully acknowledged. Hannder K. Arora, Raj D. Babbar, Shakti B. Chadha, Swaran Chadha, Raj K. Chib, Sarla Devi, Amarjit K. Gandi, Surinder K. Grewel, Amarjit Kakaria, Amar Kaura, Madalsa H. Khera, Peter Ganda Mai, Bayant K. Mayo, Daljit K. Sachdeva, Rajinder Sharma, Kanchan Sood, Sudershan Trikha, Usha Trivedi, and yeena Verma, lady health vistiors and auxiliary nurse midwives, resident in the thirteen villages carried the main responsibiltiy for child care. Dolores Laliberte, Norah Masih and Senyukta Vohra, public health nurses, and Shushum Bhatia, Susheila B. Takulia, and I. S. Uberoi, project physicians, supervised patient care and played a major role in modifying and implementing the standing orders. Environmental Child Health, August 1977
institution to the home is not simple and that without attention to certain important problems, program failure is likely. Training programs and procedures developed by project staff (including the authors) had emphasized treatment of diarrhea and included instruction in detection and referral of serious cases. Review of these procedures by supervisors and field staff showed that they contained several inappropriate and impractical recommendations and were in conflict with some well established local practices. Ultimately, improved results followed reorganization of management along lines suggested by village level conferences, placing almost all of the treatment in the hands of the auxialiary nurse midwives resident in the villages together with the mothers of the affected children. Methods and Procedures The study was carried out in 13 study villages of the nutrition and population projects at the Narangwal Rural Health Research Center in Punjab, India. Total population of the 13 villages was 18,000 and the population of children aged 0 to 3 years averaged slightly over 1,400. In these villages food supplementation, infectious disease control or a combination of the two were provided to all children below three years of age, and program effects on growth, disease experience and mortality were monitored through repeated surveys at monthly or shorter intervals. Diagnosis, treatment and referral of sick children was the responsibility of auxiliary nurse midwives and lady health visitors resident in each village, following standing orders drawn up by public health nurses and physicians in charge. Several longitudinal surveys were carried out (anthropometry, fertility, dietary history, morbidity and vital statistics), but this report is concerned only with morbidity and vital statistics results. Morbidity data was collected at a weekly visit to every study child during which the mother was asked to recall illness episodes that occurred over the preceding six days according to a roster of 44 clinical signs or symptoms. This recall survey was followed by a physical examination of each child to verify conditions reported and detect unreported illness. Vital statistics (births and deaths) were collected on an ongoing basis by the resident health worker and supplemented by information from two other sources: the village chowkidar — traditional 197
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
Diarrhea with dehydration has long been recognized as a major cause of death among preschool children in developing countries. 12 Our own experience in Punjab, North India, confirmed this observation. Diarrhea! disease was the most common cause of death, producing 42 percent of all deaths among children eight days to three years of age in 13 study villages. The overwhelming majority of cases of childhood diarrhea are due to infections by organisms not affected by available antibiotics3 * and the mainstay of therapy must be fluid replacement to prevent or relieve dehydration. Hospital experience has shown that fluid therapy alone is remarkably effective in preventing death but unfortunately the majority of children in developing countries in need of this therapy have limited access to hospitals. Fortunately the materials necessary for fluid and electrolyte replacement (water, salt, and sugar) are universally available, oral treatment is effective and the principles of treatment are simple and easily taught to paraprofessionals or the mothers of children affected with diarrhea. In view of the numerous reports of successful oral fluid therapy in an institutional setting5 6 7 and the extensive discussion of proper fluid composition and other aspects . of individual patient management*' it is surprising that there are relatively few reports of successful management of this important clinical problem in populations or community groups.10 n Our own experience with a combined nutritional supplement and infectious disease control program for small children in villages of northern India has shown that the transfer of effective fluid treatment from the
ARNFRIED A. KIELMANN AND COLIN McCORD
Table I Cause of 45 Deaths in 1,415 Children 8 days to 3 years of age (1971)
Diarrhea and Dehydration L.R.T. Infection* Marasmus and Nutritional Deficiency Diseases. Tetanus Neonatorum Other Causes Unknown
Number
Percent
Deaths/1,000 Children/Year (0-3 Years of Age)
20 10 3 1 8 3
44 22 7 2 18 7
14.1 7.1 2.1 0.7 5.7 2.1
source of Indian rural vital statistics — and specially appointed vital statistics investigators who toured all villages at fortnightly intervals to collect data from selected village contacts (midwives, village leaders, grocers, faith healers, etc.). From January, 1971 every death in a child of less than five years of age was investigated by a physician who interviewed the family and reviewed the record, usually within two weeks after the event. The collected information from these "verbal autopsies" was subsequently discussed by a group of physicians and a most likely cause of death assigned. By the latter half of 1971 it had become clear that diarrheal disease and lower respiratory tract infection were responsible for most deaths (Table I). This high'death rate from preventable diseases despite an intensive village level program to improve nutrition and treat diarrhea and other infectious diseases led to a series of conferences at which existing standing orders were reviewed and completely revised. Previous treatment guidlines had considered acute diarrhea as one of several important conditions prevalent in the area but had not singled it out as the condition responsible for the majority of child deaths. Oral rehydration with diarrhea mixture and maintenance of adequate caloric intakes — including the advice not to stop either breast milk or supplementary milk — was emphasized in the standing orders for children with diarrhea in the absence of dehydration; who was to do the rehydrating, however, was left to the judgement of the health worker. Children with signs of dehydration were referred to the Narangwal physician for intravenous fluid therapy. Criteria for differentiating between serious and minor diarrheal disease failed to take into account the very large number of insignificant cases, and were therefore impractical. The following simple criteria for categories of management were established: Standing Orders for Diarrheal Disease Finding History .>6 stools/24 hours fever vomiting blood and mucus in stool 198
Grade
Special Characteristics
Physical Examination
103°F weight loss (only on revisit)
+ + + + ++ ++ ++
Subsequent management depended on overall assessment of the child's condition according to the above criteria and was divided into three main groups. I. Diarrhea in the absence of any of the above: Explain need for fluid replacement and preparation of "diarrhea mixture"* to mother. Mother to administer at least one liter of fluid per 24 hours and to continue regular caloric intake. Instruct mother to return to clinic next day if diarrhea persists. Revisit child within one week. II. If any of the "one-plus" criteria is present: Prepare one liter of "home diarrhea mixture",* start giving it to child and show mother how to give it and how to prepare more. Advise continuous fluid intake; two to three liters per 24 hour period. If child is on milk supplement, ask mother to stop milk for 24 hours but continue all other foods. If exclusively breast fed, skip one feeding. Treat fever, blood or mucus in stool if present as per standing orders. Revisit home within 12 hours. III. If any of the "two-plus" criteria is present: Prepare "project diarrhea mixture".** Start giving it to child. Refer to physician for immediate consultation. Remain with child giving fluids until physician arrives. *Six teaspooons of sugar, one level teaspoon of salt per liter of water. "From a centrally (Narangwal pharmacy) prepared "diarrhea mixture" concentrate containing sodium and potassium chloride (no sodium bicarbonate), with sucrose added from household supply. Environmental Child Health, August 1977
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
•Pneumonia, Bronchitis, or Bronchiolitis
ARNFRIED A. KIELMANN AND COLIN McCORD
Results Treatment with" the same standing orders and the same procedures was provided for all children, but the morbidity surveys covered only children from the nutrition project villages (60% of total). Calculations of incidence and mean duration are based on-217,127 child days of observation in 1970; 188,367, 153,850 and 81,483 child days of observation in 1971, 1972, and from January through May 1973 respectively. Prior to 1971 the cause of death was not established by "verbal autopsy". Deaths before that date were not included in the analysis. The study was terminated suddenly and unexpectedly at the end of May 1973, but fortunately the five-month period from January to May included times of both high and low diarrhea incidence — in 1971 and 1972, 34 per cent of deaths from diarrhea and 48 per cent of diarrhea episodes occurred in these five months. Adjustment for seasonal variation of diarrhea incidence was, therefore, not necessary. Incidence of diarrheal disease was highest in the hot, dry season, generally rising to more than 60 episodes per 100 children per month between March and June. This period (March through June) also coincides with both the hottest time of the year, when temperatures average 22.5 C for March-April, 31.5C for May and June14 and the spring (wheat) harvest. During this harvest all able hands are usually out in the fields all day, leaving the care of small children to those unable to work because of age or physical disability. The average incidence of 41 episodes per 100 children per month is approximately three times higher than that reported in an earlier study conducted in the same area.2 In this earlier study, the morbidity survey was carried out once a month and may not have been as sensitive as our own. Our criterion for a diarrhea Environmental Child Health, August 1977
episode was "more than three watery bowel movements per 12 hours for one day or more". Mean duration of diarrhea tended to be longer during the first 5 months of the year than the succeeding 7 months and fell significantly after introduction of the new standing orders (Figure 1 and Table II). Figure 1 Incidence and Mean Duration of Acute Diarrhea in Children under 3 (From January-February 1970 to May 1973
\
-/ r ii
The number of days of diarrhea per child per month was important as a measure of the work load for village level workers (and mothers). This was also quite consistent from year to year, varying from 1 to 1.5 diarrhea days per child per month in the low season to 4.8 days in the hot season. Since there were about 110 children in an average village (population 1,400), this meant that 18 children suffered from diarrhea on any given day during the hot season in one of these villages. Case fatality rates can be calculated in those villages in which morbidity and mortality data was collected simultaneously and averaged 2.1 deaths per 1,000 episodes of diarrhea during the 29 months in which both kinds of data are available on the same children. There was a drop in the case fatality rate after introduction of the revised standing orders, from 3.2 to 1.4, but this difference is not significant since only 63 per cent of deaths occurred among children who were also included in the morbidity survey. Annual death rates from diarrheal disease per 1,000 child years of exposure (0-3 years of age) fell from 14.1 to 7.3 between the initial 12 months period in 1971 and the subsequent 17 months period in 1972 and 1973. This decrease is statistically significant (Table II). New standing orders were introduced in January 1972. Many patients continued to consult local practitioners (faith healers, traditional healers, and others) but most of the population consulted project staff at some point. The number of deaths of patients who had never consulted project staff was essentially unchanged — 7 in 1971 and 8 in 1972/1973. Deaths of patients who had consulted project staff fell from 13 in 1971 to 4 in 1972/1973. Seventy-one per cent of the 35 diarrheal deaths suffered from concomitant malnutrition — arbitrarily defined as below 70 per cent of th« Harvard standard weight-for-age median. Summer 1972 was unusually 199
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
Following the introduction of new standing orders an intensive training program for all health workers resident in study villages was carried out over a threemonth period. At these sessions recognition, management and referral of patients with diarrhea was reviewed with reference to the newly revised standing orders and recent case histories were reviewed with respect to management and outcome. Following this training period a village conference was held in each group of four villages every two weeks at which service and research records were examined for compliance with standing orders and children currently under treatment were visited at home when a visit could serve an educational purpose (e.g., demonstration of signs of dehydration). Deaths among the child population in a given village over the preceding two months were received and analyzed for cause, events leading to death, treatment given and avoidability. Observed problems and results led to further modifications in the standing orders, often because of practical suggestions made by the auxiliary health staff.
ARNFRIED A. KIELMANN AND COLIN McCORD
Time Period
Table II Incidence, Mean Duration and Deaths from Acute Diarrhea in Children Under 3 (January 1971 through May 1973) Deaths from Diarrheal Disease Diarrheal Incidence Disease Per (No. of Episodes Mean Duration Deaths 1,000 Child per 100 Children from Child Years per Month) s.d. Diarrhea of Exposure Years of Exposure days 48.0 34.1
7.4 5.0
4.37 4.91
6 14
590 825
Jan.-Dec. 1971
36.6
5.4++
5.71
20
1,415
Jan.-May 1972 June-Dec. 1972 Jan.-May 1973
47.3 39.3 56.3
5.8 4.9 4.0
6.13 4.89 3.59
5 7 3
611 855 597
Jan. 1972-May 1973
44.1
4.7++
4.75
15
2,063
Jan. 1971-May 1973
41.0
5.0
5.22
35
3,478
10.2 17.0
1.8 4.1
14.1 +
3.2
8.2 8.2 5.0
1.4 1.7 0.7
7.3 +
1.4
10.1
2.1
'Calculated by extending mean incidence of diarrheal disease from sample population to total child population. +X 2 test for significance in proportion of deaths from diarrheal disease between the two time periods = 3.97; P < .05. ++t = 4.68;P< .001.
hot and the mean prevalence of this degree of malnutrition increased slightly from 22% in 1971 to 24% in 1972. No other external factors were identified which might have altered mortality after January 1972. An intensive program to treat pneumonia12 in preschool children was also introduced in 1972 and the number of deaths from this cause fell significantly — mortality from causes other than acute diarrheal disease or lower respiratory tract infection remained unchanged. Discussion Before and after comparisons of mortality rates are less satisfactory measures of improved results than double blind controlled studies, but in this situation the latter did not appear to be applicable. It would have been neither moral nor practical to deny to a part of ihe population any improvement in the application of a treatment which was known to be effective. The efficacy of oral fluid therapy is well established and we were faced with the problem of apparent failure when it was transferred from an institutional to a village setting. There was a significant drop in the death rate from diarrhea despite an increase in the incidence of diarrheal disease and we were convinced that this drop was directly related to wider and more efficient utilization of oral treatment. (Mean temperatures during March through August 1972 were considerably higher than either the 30 year average or those during the same months in 1971. Temperatures in 1973 similarly were higher than the 30 year average and about equal to those in 1971. 1314 ) One" of the best 200
measures of program effectiveness was the observation in 1973 that most mothers had already instituted oral fluid treatment when their child was first seen by a project staff member. The incidence of diarrhea in the child population was so high that a home treatment program automatically became an education program (since all mothers and children were sooner or later included) and appropriate exploitation of a few successful cases did convince these mothers that the treatment was worthwhile. Magical beliefs about diarrhea and dehydration existed here, as elsewhere in India, 1316 but were less important negative influences than practical considerations. . The two major blocks to widespread utilization of treatment were the great mass of cases of diarrhea which were not life threatening and traditional beliefs about restriction of fluids and milk which were founded on the accurate observation by mothers that increased intake of fluid containing carbohydrates often aggravated diarrhea.17 " Our initial standing orders and other procedures were quite inadequate to the task of overcoming these problems. With 18 cases of diarrhea per day in each village at the peak period a village level worker could not possibly have the time to prepare a diarrhea mixture for all these children, educate the mothers in its proper use, administer the fluid herself when the mothers failed to give it properly and make the necessary return visits to be sure that instructions were being properly followed — all this in addition to her other duties. Furthermore, the mothers knew that most of these episodes of diarrhea subsided without vigorous treatment and their belief that administration of fluids and partidularly of milk could aggravate diarrhea was based on fact. It is a rather Environmental Child Health, August 1977
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
Jan.-May 1971 June-Dec. 1971
Case Fatality* (No. of Deaths per 1,000 Episodes)
ARNFRIED A. KIELMANN AND COLIN McCORD
Environmental Child Health, August 1977
for intensive treatment will probably vary from country to country, but it is likely that the basic procedures described in this article will be applicable anywhere. Summary Diarrhea was the main cause of death among preschool children under surveillance in a combined nutrition and infectious disease control program in Punjab, India. Case fatality rates were low (0.7-4.1 deaths per 1,000 cases), but incidence was very high, averaging 41.0 episodes per 100 children per month. Initial efforts at home treatment with oral fluid were not successful but an intensive training program for supervisors, village level workers, and mothers resulted in a significant reduction in mortality from diarrhea, although the incidence was unchanged. Training emphasized classification of cases into treatment categories according to defined criteria and placing responsibility for treatment of all but the most severe cases in the hands of auxiliaries and mothers.
References 1. Editorial; Lancet, 1975,1, 79. 2. Scrimshaw, N. S., Taylor, C. E. and Gordon, J. E. "Interactions of Nutrition and Infection", WHO Monograph No. 57,1968, pp. 216-261. 3. Garcia de Olarte, D., Trujillo, H., Agudelo, N., Nelson, J. D. and Haltalin, K. C. (l914).Amer.J.Dis. Children, 127,379. 4. Ryder, R. W., Sack, D. A., Kapickian, A. Z., McLaughlin, J. C , Chakraborty, J., Misanur Rahman, Merson, M. H. and Wells, J. G. (1976). Lancet, 1,661. 5. Nalin, D. R., Cash, R R. A., Islam, R., Molla, M., Phillips, R. A. (1968). Lancet, 2, 370. 6. Cash, R. A.I Nalin, D. R.I Rochet, R.1 Reller, L. B., Haque, F. A., Rahman, A. S. M. (1970). Amer. J. Trop. Med. Hyg., 19,653. 7. Hirschhorn, N., Cash, R. A., Woodward, W. E. and Spivey, G. H. (1972). Lancet, 2,15. 8. Hirschorn, N. (1975). Lancet (C), 2,1049. 9. Moenginah, P. A.; Suprapto, Soenarto, J.; Bachtin, M.; Sutrisha, D. S.; Sataryo and Rhode, J. E. (1975) Lancet (C), 2,323. 10. Ascoli, W. and Mata. L. J. (1965). Amer. J. Trop. Med. Hyg., 14,1057. 11. Hirschhorn, N., McCarthy, B., Ranney, M. Hirschhorn, S., Woodward, A., Cash, R. A., LaCapa, A. and Woodward, W. (1973). Pediatrics, 83, 562. 12. McCord, C. and Kielmann, A. A. In preparation. 13. Government of Punjab (India). Statistical Abstract of Punjab. Economic and Statistical Organization, 1972, 1973 and 1974. The Economic Advisor to Government, Chandigarh, Punjab. 14. Werustedt, F. L. (1972) World Climatic Data, Climatic Data Press, Penn. State Univ., University Park. 15. Kielmann, N. Personal communication, August 1976. 16. Lozoff, B., Kamath, K. R., Feldman, R. A. (1975). Human Organization, 34,353. 17. Prader, A. and Auricchio, S. (1965). Defect of Intestinal Disaccharide Absorption, Ann. Rev. Med., 16, 345. 18. Morley, D. (1973). Paediatric Priorities in the Developing World, Butterworths and Co., Ltd., London. Pp. 172-174. * 19. Hirschhorn, N. Personal communication, July 1976. 201
Downloaded from http://tropej.oxfordjournals.org/ at Ryerson University on June 19, 2015
complicated process to explain to a mother that she should give more fluid to overcome the increase in diarrhea which she is producing by giving fluid. The changes which appear to have broken this vicious cycle were (1) emphasis that diarrhea was the major cause of death; (2) establishing criteria for degrees of severity of diarrhea with actions appropriate to each degree; and (3) establishing in the minds of both the village level workers and the mothers the importance of follow-up and close observation of all children with diarrhea since a mild case may turn into a severe case at any time. With these principles established, it was then possible to conduct an education program based on discussion of actual cases in the home setting and eventually to make every village worker and most mothers competent in the diagnosis and treatment of dehydration resulting from diarrhea. It is probably important that almost all of the children in this series were treated with materials available in the home: table salt, table sugar, and water. Only the most severely dehydrated children received a preparation prepared in the project pharmacy which contained added potassium but no bicarbonate. Only two patients in the 17 months of the 1972-1973 phase, of the project received parenteral solutions. This was not because we were unconvinced of the value of glucose, bicarbonate, potassium, and, on occasion, intravenous fluids, but because we believed that these additional substances were not necessary in the overwhelming majority of cases and we were'trying to develop methods which would be immediately applicable on a wide scale throughout India and which could be used by mothers at home without further supervision after initial training. There is an economic problem also which must be faced by those proposing to distribute packets of electrolyte and sugar solution widely. Most solutions proposed are based on the mixtures developed at the Cholera Laboratory in Dacca, Bangladesh, and contain sodium bicarbonate, potassium, and glucose. Cost of the packaged preparation varies from 13c to 50c.19 Most of the cost is for the packaging which must be water-tight or the preparation is destroyed in a fairly short time by hygroscopic adsorption. Since the average prevalence of diarrhea in our villages was 2.41 diarrhea days per child per month, the cost of providing one packet of diarrhea preparation for each child each day that he had diarrhea would be $3.80$14.50 per child per year or $0.50-$1.90 per head of total population per year, assuming that 13 per cent of the population is children 0 to 3 years old. This, of course, also assumes that diarrhea packets would be used only for children under three, which is unlikely and undesirable. The cost of providing diarrhea packets in this fashion would amount to between 25 and 96 per cent of the total health budget for Punjab State in 1975-1976. Obviously, widespread use of packets of sugar-electrolyte solution will not be practical unless sensitive and specific criteria for their use are developed. The criteria for selection of cases
