Causes of infant and early childhood deaths in Sierra Leone

Information about the causes of infant and early childhood (1-4 years) mortality was compiled from the vital registration system for the Western Area, records from the children's Hospital in Freetown and two demographic sample surveys conducted in various chiefdom headquarters towns around the country. The leading causes of infant mortality are tetanus, fevers, measles and diarrhoea. A breakdown of certified deaths in infancy showed that tetanus is quite important in the neonatal period accounting for as much as 68% of neonatal deaths. Measles and diarrhoea were the leading causes of death in the last 6 months of infancy. The leading causes of early childhood deaths were measles, diarrhoea and fevers. Nutritionally related diseases such as measles and diarrhoea were seen to account for up to 40% of all early childhood deaths. The major factors affecting these causes of death were childbirth and childcare practices in the case of tetanus and the nutritional status of the children in the case of measles and diarrhoea. The majority of deliveries were still being performed by Traditional Birth Attendants in very unhygienic surroundings which it was felt contributed significantly to the high incidence of neonatal tetanus. At the other childhood ages the poor nutritional status of the majority of children in Sierra Leone as shown by the results of the 1978 National Nutrition Survey was seen as the significant factor. The effects of the identified major causes of infant and early childhood mortality (tetanus, fevers, measles, and diarrhoea) can be largely diminished by effective intervention programmes such as oral rehydration therapy and the training of Traditional Birth Attendants.

Morbidity and mortality in a diarrhoeal diseases hospital in Bangladesh

Records of all patients who were admitted to or who died in Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) between July 1980 and 30th June 1981 were reviewed to identify epidemiological characters associated with in-hospital diarrhoeal diseases-related deaths. Information on aetiological agents, age, sex, major complications, nutritional status and level of dehydration were analysed. Over the one-year period, 3251 patients were admitted to the medical wards and 400 died. Children under five made up 72% of patients admitted and 77% of those who died. All patients were cultured for enteric vibrios, Salmonella and Shigella; 25% of the patients had at least one of these organisms. Shigella was most common and was isolated from 13% of the patients and 19% of those who died. Case-fatality rates in patients with Shigella and Vibrio cholerae non-OI (NAG) were significantly higher than other enteric pathogens (V. cholerae OI, Salmonella typhi and mixed). Case fatality for Vibrio cholerae non-OI was higher than Shigella (25.8% and 17.2%) but the difference was not statistically significant. Among those who died 21% were severely dehydrated and 50% had various complications. Patients with V. cholerae OI were significantly more dehydrated than other groups (P less than 0.05 by chi 2 test). The patients who died with Shigella were significantly more malnourished and had more frequent associated complications than other non-Shigella diarrhoea patients (P less than 0.01 by chi 2 test). Overall our observations indicate that Shigella and Vibrio cholerae non-OI are associated with unusually high case fatality.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute respiratory infections in children under five years. Control project in Bagamoyo District, Tanzania

Control of acute respiratory infections (ARI) in children under five years of age has been implemented as an integrated part of Primary Health Care in rural Bagamoyo District in Tanzania. Community supported Village Health Workers visited each family at their homes every six to eight weeks, giving health education on recognition and prevention of ARI, treating children with pneumonia on the spot with oral Cotrimoxazole or referring them to the next higher level of care. Within a two-year period the total under five mortality has been reduced by 27.2% from 40.1 to 29.2/1000 children aged under five per year. The disease-specific mortality rate for pneumonia has been reduced by 30.1% from 14.3 to 10.0/1000 under-five per year, contributing 40% to the overall mortality reduction. It is concluded that an active health service outreach programme, within Primary Health Care, can efficiently reduce high child mortality rates from ARI and other diseases. A similar approach will be used to tackle other problems such as diarrhoeal diseases, malnutrition, malaria and child spacing.

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.

Declining fertility in England and Wales as a major cause of the twentieth century decline in mortality. The role of changing family size and age structure in infectious disease mortality in infancy

The decline in infectious disease mortality in England and Wales beginning about 1880 has been attributed to improved nutrition, hygiene, and sanitation. Such an explanation does not adequately explain the lack of improvement in infant and diarrheal disease mortality before 1900 nor the abrupt subsequent decline. A hypothesis was proposed that the decline in fertility rate was a major cause of the decline in infant mortality by raising the median age at infection. The hypothesis could only be tested indirectly. A review of morbidity data demonstrates the importance of family characteristics on the median age at infection for measles, pertussis, and common respiratory illness. The association of parity with infectious disease mortality supports the hypothesis. A method was developed for estimating the change in birth order distribution resulting from declining fertility. Using 1949-1950 data, it was shown that declining fertility could account for at least a 24% decline in postneonatal mortality due to bronchitis and pneumonia. Age-specific measles mortality rates are consistent, with an increase in age at infection. Declining fertility appears to have played a major role in the decline in infectious disease mortality in England and Wales by increasing the median age at infection.

Control of diarrhoeal disease in Tonga 1978-83

Tonga, like many developing countries, suffers from a shortage of medical staff and a high morbidity and mortality from paediatric diarrhoeal disease. In 1980 a programme was started to train medical assistants and village administrators in the correct use of oral rehydration salt solution for rehydration. The effect on morbidity, mortality, and admission to hospital over the six years 1978-83 was assessed. After the introduction of the scheme the number of deaths due to diarrhoea fell considerably and the state of hydration in children admitted to hospital with diarrhoea greatly improved. It is recommended that similar programmes be adopted where clinical problems of diarrhoea with dehydration persist. Instruction in the use of oral rehydration fluid was most effectively given by non-medical staff to groups of mothers, rather than by paediatricians in their inevitably brief, although important, explanation given in hospital.

Correlates of infant death from infectious diarrhea in the southeastern United States

Infectious diarrhea (ID) caused 242 infant deaths in South Carolina between 1970 and 1978, and is still a significant cause of death in the southeastern United States. Therefore, using South Carolina death certificates from 1970 to 1978 and the state's linked birth/death certificate file, we sought prenatal and postnatal characteristics that might predict death from gastroenteritis in the first year of life. Accuracy of diagnoses was verified from the original death certificates and in a sample of hospital charts. Most deaths caused by ID occurred after the first 28 days of life and were significantly concentrated in the winter. Low birth weight (odds ratio 7.09), nonwhite race (7.00), inadequate prenatal care (4.35), small size of hospital (0.31), and illegitimate birth (2.35) were all significantly associated with postneonatal death. Infants with all of the three strongest predictor characteristics were 14 times as likely to die of ID, but the "predictive value" of this combination for ID death was only 0.54%. Although mothers of these high-risk infants should be given special education about prevention of dehydration, and the families would be logical candidates for a rotavirus vaccine trial, more expensive interventions should not be instituted without a cost-benefit analysis.

Diarrhea in nonhuman primates: a survey of primate colonies for incidence rates and clinical opinion

Veterinary clinicians associated with 18 colonies of nonhuman primates were surveyed for their experience with diarrhea disease in colony animals for calendar year 1981. The 1981 diarrhea incidence rate, diarrhea-specific mortality rate and diarrhea case fatality rate for 13,385 monkeys were 10.6%, 1.2% and 11.1%, respectively. It was not possible to incriminate age or type of housing as risk factors for diarrhea, but some species seemed at greater risk than others. Erythrocebus patas monkeys had relatively high diarrhea incidence rates (18.8%) and the highest case fatality rate (48.4%) of all species surveyed. Squirrel monkeys (Saimiri sciureus) and baboons (Papio sp.) had low diarrhea incidence rates (2.1% and 3.2%, respectively). This opinion survey indicated a lack of uniformity among primate clinicians with respect to approaches to diagnosis and therapy of monkey diarrhea. The survey also suggested that many of the agents associated were perceived differently among primate clinicians, and that the roles of some agents are still poorly understood.

Malumfashi Endemic Diseases Research Project, XXI. Pointers to causes of death in the Malumfashi area, northern Nigeria

For 228 of 425 deaths (54%) occurring among 26 100 people of known age in the Malumfashi area of northern Nigeria, data were collected on symptoms present prior to death. Information was obtained on monthly registration visits, as part of demographic investigations, and data for the period November 1977-October 1978 have been analysed. Enumerators used a carefully prepared list of 25 symptoms to elicit information from relatives of the deceased. Pyrexia, diarrhoea and measles accounted for 77% of all deaths. Epidemiological determinants were responsible for all cases of meningococcal infections in the dry season and most cases of diarrhoea in the wet season. Most deaths attributed to measles occurred in the late dry season and early wet season. Epidemics of measles seemed to be localized at any one time in certain villages and the micro-epidemiology of this feature is considered. Malaria does not appear to be responsible for all deaths from pyrexia in the nought to four age group.

Clinical illnesses and causes of death in a Burmese refugee camp in Bangladesh

In 1978 almost 200 000 Burmese refugees entered Bangladesh. Thirteen camps were set up for refugees. Data for the camp at Leda is presented here. There were four medical clinics; including a diarrhoea clinic operated by the International Centre for Diarrhoeal Disease Research, Bangladesh. The four clinics recorded a total of 174 201 visits by the refugees, of which 28% were for watery diarrhoea, 32% for dysentery and 40% for other illnesses. Of 2321 diarrhoea stools cultured, 29.2% yielded pathogens of which 22% were Shigellae alone. Coliform count of water was extremely high. The death rate (89/1000/year) was higher than the birth rate (28/1000/year). Most of the deaths were among infants (640), children (357) and old people (131). Main causes of death were clinical diarrhoea (11.8%), fever (23%) and poor nutrition (52%). Prompt arrangements for food, identifying the vulnerable groups, and proper sanitation perhaps could have reduced the number of deaths considerably.

Excess mortality among children discharged from hospital after treatment for diarrhoea in rural Bangladesh

Five hundred and fifty one children aged between 3 months and 3 years were followed up at home for 12 months after treatment of diarrhoea in a rural treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh. During follow up the children were found to have a significantly higher mortality than generally observed in the community. The first three months after discharge appeared to be crucial, some 70% of the deaths occurring in that period. Severely malnourished children (nutritional state below 56% of the American National Center for Health Statistics (NCHS) standard of weight for age ratio) had a risk of death 14 times that of their well nourished counterparts (nutritional state 66% or more of the NCHS standard). The highest mortality occurred in 2 year olds, one in three of the severely malnourished children dying compared with one in 10 of the moderately malnourished. This pattern was not seen in children aged under 2 years. Immediate priority should be given to providing nutritional rehabilitation for malnourished children who contract diarrhoea.

Naturally occurring Tyzzer's disease in a clean mouse colony: high mortality with coincidental cardiac lesions

Light and electron microscopic examinations were performed on tissues from 12 young mice which were affected by naturally-occurring Tyzzer's disease. Eight of the 12 mice had cardiac lesions which have not previously been reported in mice and which caused a high mortality. The cardiac lesions were detected in mice which had severe and advanced intestinal lesions which penetrated the deeper mucosa and muscular layer with active regeneration of the mucosal epithelium. Periodical serological tests to monitor the bacterial and viral status of this colony showed that it was free of other agents of murine disease such as mouse hepatitis virus, Corynebacterium kutscheri and Salmonella spp. until the onset of Tyzzer's disease and that no mixed infection occurred at the onset. It is considered that an advanced intestinal lesion is essential for the formation of cardiac lesions in Tyzzer's disease in mice.

A diarrhea clinic in rural Bangladesh: influence of distance, age, and sex on attendance and diarrheal mortality

Attendance rates at a diarrhea clinic were monitored in a defined population in rural Bangladesh. Weekly home visits were also carried out to determine diarrheal attacks in communities within six miles of the clinic. Within the first one mile radius, 90 per cent of diarrheal cases came to the clinic for treatment. At two miles the attendance fell to 70 per cent for males and 40 per cent for females. On an average, the greater the distance to the clinic, the more severe was the degree of dehydration on presentation, requiring more frequent use of intravenous fluid. Mortality secondary to diarrhea was significantly reduced only within a two-mile radius of the clinic.

Morbidity and mortality study on diarrhoeal diseases in North Jakarta - an urban area

Diarrhoea including its interaction with undernutrition is one of the most important health problems and a major cause of death in young children in developing countries including Indonesia. To quantify the problems and to have comparison with results of other diarrhoeal surveys in Indonesia as well as in other developing countries, a survey was done in urban community comprising a population of 5,115 living in a relatively good area which was not a slum, nor wealthy area. The incidence of diarrhoea in this area was 149 per 1000 population a year and mortality rate of 0.2 per 1000 population, and 1.8% of diarrhoeal cases in the community became dehydrated needing hospitalization. The incidence of diarrhoeal disease was lower than in the survey done in semiurban area Ujung Pandang 8 years ago. This may be due to the improvement of environmental health, socio-economic status and better education. 47% of the diarrhoeal cases had occurred in children under age five. The peak incidence was in the 6 to 12 months age group. Young-age combined with low-nutritional status and early weaning may be factors leading to high incidence and death rates of diarrhoeal diseases. Incidence increased in the middle of the rainy season. 30% of the episodes were caused by enteropathogenic bacteria, 15.4% by rotavirus while for 50% of episodes the causative agent could not be determined.

Diarrhoeal problems in Southeast Asia

Diarrhoea up till now is still a major problem in Southeast Asia with high morbidity and mortality, particularly among children under 5 years of age, with the peak in children between 6 - 24 months. In Indonesia, in 1981, it was estimated that there are 60 million episodes with 300,000 - 500,000 deaths. In the Philippines, diarrhoea ranks as a second cause of morbidity (600 per 100,000 in 1974) and second cause of infant mortality (5 per 1,000 in 1974). In Thailand, in 1980, the morbidity rate was 524 per 100,000 and the mortality rate 14 per 100,000. In Malaysia, in 1976, diarrhoea was still ranking number 5 (3.1%) as a cause of total admission and number 9 (2.2%) as a cause of total deaths. In Singapore, diarrhoea still ranks number 3 as a cause of deaths (4% of total deaths). In Bangladesh, the overall attack rates imply a prevalence of 2.0% for the entire population, with the highest for under 5 groups i.e. 4.1%. The diarrhoea episode in rural population is 85.4%, 39% of them are children under 5. The most common enteropathogens found in all countries are rotavirus followed by Enterotoxigenic E. coli, Vibrio spp., Salmonella spp., Shigella spp. and Campylobacter. Malnutrition and decline of giving breast-feeding play an important role in causing high morbidity, besides socio-economic, socio-cultural and poor environmental sanitation.

Experimental Escherichia coli and rotavirus infection in lambs

Colostrum-deprived lambs were infected with either enteropathogenic Escherichia coli(O9:K30:K99) or rotavirus or a mixture of the E coli and rotavirus. E coli doses of 10(6) and above consistently produced diarrhoea, as did experimental rotavirus infection. When both of the agents were administered, the mortality rate was higher, although the duration of diarrhoea was no greater than that observed when either of the two agents was administered alone.

Diarrhoeal disease in Bangladesh: epidemiology, mortality averted and costs at a rural treatment centre

The basic epidemiology of acute diarrhoeal disease seen at a rural Bangladesh hospital in 1975 is reviewed. V. cholerae 01 was isolated from 28% of 1 964 patients. Significant differences in hospitalisation rates were observed between males and females in several age groups. Overall hospital case fatality was 9/1000 cases. We estimate that approximately a quarter to half of the hospitalised patients would have died had no rehydration therapy been available. The region's total mortality was reduced by approximately 7%-15%, at a cost of United States $0.14 per capita. Mortality from acute diarrhoeal diseases was greatly reduced for all age groups, and total mortality and mortality from all diarrhoeal diseases were particularly reduced for young children and young adults. Rehydration therapy used in a field hospital was apparently highly effective in reducing general mortality and mortality from acute diarrhoeal diseases.

[Acute diarrheal diseases in Cuba]

A brief description is made of how acute diarrheal diseases, known as gastroenterites, were the cause of diseases and death since the beginning of the Republic. Different results of works carried out by different authors on the mortality due to such diseases is reported. Statistical data show the situation in Latina America according to the criteria of several authors and synthesis is made of the general picture of diarrheal diseases in Cuba, beginning on the decade of 1960. The different causes of these acute diarrheal diseases in our country are analyzed and all the plans and control programs that have been developed up to the presented with the idea of eradicating these diseases are pointed out.

The treatment of acute diarrhea in children. An historical and physiological perspective

This review examines the historical, physiological, clinical, and epidemiological evidence to support a method of therapy for children's diarrhea that may be recommended for general acceptance. The understanding and use of fluid and nutritional therapy of acute diarrhea in childhood have progressed over the years to a point where acute mortality can be reduced to nearly zero. At the same time, the ill effects on electrolyte balance and nutrition may be reduced to a minimum. Through use of an oral glucose electrolyte solution with a carefully designed composition, physiologically correct treatment may now be so simplified and inexpensive as to be readily available to the remote, under-served areas of the world where most of the morbidity exists; and be useful as well to more sophisticated settings. The method of therapy recommended in this paper has several important departures from traditional teaching. It advocates rapid restoration of extracellular fluid with a polyelectrolyte solution containing sodium, base and potassium; use of an oral glucose electrolyte solution for repletion of those not in shock and for maintenance; use of a single oral glucose electrolyte solution for all age groups, regardless of diagnosis, and quite early feeding with tolerated foods. Sodium loads given are generally higher than advocated by standard pediatric teaching. The origins of that teaching and support for the newer approach come from a detailed analysis of current knowledge in the epidemiological, clinical, and physiological aspects of diarrheal illness.

Epidemiology and causes of death among children in a rural area of Bangladesh

From a longitudinal surveillance programme among a rural Bangladesh population of 260,000, the epidemiology and causes of child death (under age 5) over 3 years (1975-1977) were analyzed. The most significant causes of death were diarrhoea (watery and dysentery), tetanus, measles, fever, respiratory disease, drowning, skin disease, and other causes. Of an infant mortality rate of 142.6/1000 live births, neonatal tetanus (37.4/1000), diarrhoea (19.6/1000), and respiratory disease (10.4/1000) were the most significant identifiable causes. Many infant deaths (62.2/1000) were unidentified, taking place during the neonatal (1-28 days) period. The 1-4 year mortality averaged 34.3/1 000. Diarrhoea (15.1/1 000), measles (4.5/1 000), fever (2.9/1 000) and respiratory disease (1.6/1 000) accounted for most 1-4 year deaths. Mortality trends over the past 10 years showed sharp temporary fluctuations in response to 2 disasters but no definitive long-term trend. Most causes of death displayed seasonal fluctuation, and sex differentials were marked with female deaths exceeding male deaths for all ages after the neonatal period. Malnourished children from low socioeconomic status families had higher mortality rates than their better nourished and wealthier counterparts. Overall, the data suggest that the delivery of a few basic health measures (oral hydration and immunization) could result in substantial reduction of under 5 mortality.

Diarrhoeal mortality in two Bangladeshi villages with and without community-based oral rehydration therapy

To combat dehydration from diarrhoea in Shamlapur, a village of 7021 people, multiple community-based points were set up by trained volunteers for the distribution of glucose-electrolyte oral rehydration salt (ORS) packets. The comparable adjoining village, Bordil, with a population of 3888, obtained its supply of ORS from Shamlapur. Surveilance for 2 years showed that although diarrhoeal attack-rates were equal, consumption of ORS after diarrhoea was 80% in Shamlapur and 38% in Bordil. There were 8 deaths in Shamlapur caused by diarrhoea and 23 in Bordil, showing an overall case fatality-rate of 0.5% and 2.4%, respectively, and a diarrhoeal mortality-rate per 1000 population of 0.6 and 2.9, respectively. The observation indicated that although it may not be possible to reduce diarrhoeal attack-rates, easy availability of rehydration solution and its early use after village-based training may save many lives, particularly those of children.

Identification of some infants at immediate risk of dying unexpectedly and justifying intensive study

Children who die unexpectedly in infancy often have symptoms of illness before death. Survey data are used to evaluate risks associated with symptoms. There is a 1 in 50 chance of unexpected infant death occurring in the next 9 days when two or more symptoms occur in infants defined to be at high risk by a discriminant score. The score is based on data collected on all infants at birth and by health visitors at 1 month. This system would identify 50% of cot deaths and provides a basis for prospective physiological studies.

The problem of diarrhoeal disease in children

In Western Austnalia, diarrheal disease in Aboriginal children found inhalf cases of malnutrition, sugar intolerance in 25% of patients and approximately 50% showed high rates of infection and infestation. The most commonly isolated are Giardia lamblia, Enteropathogenic E. Coli, Salmonellaea and Shigellae.The mortality rate of diarrhoeal disease is maro than 5%, which is severaltimes than white children. The cause of death are hypokalemia, hypoglycaemia, delayed rehydration treatment, the high incidence of malnutrition and sugar intolerance.To improve and solving the problem the prime aim should be preventionby upgrading many factors including maternal nutrition, promotion of breast feeding, standard of living, nutritional and hygiene education and related socioeconomic condition, the availability of skilled medical and nursing facilities.