Slow progress in diarrhea case management in low and middle income countries: evidence from cross-sectional national surveys, 1985-2012

Facility capacity and provider knowledge for cholera surveillance and diarrhoea case management in cholera hotspots in the Democratic Republic of Congo - a mixed-methods study

BACKGROUND

Wider healthcare-strengthening interventions are recommended in cholera hotspots and could benefit other types of diarrhoeal diseases which contribute to greater mortality than cholera.

OBJECTIVE

Describe facility capacity and provider knowledge for case management of diarrhoea and cholera surveillance in cholera hotspots in the Democratic Republic of Congo (DRC) among health facilities, drug shops, and traditional health practitioners.

METHODS

We conducted a sequential exploratory mixed-method study, using focus group discussions, facility audits, and provider knowledge questionnaires during September and October 2022 in North Kivu and Tanganyika provinces, Eastern DRC. Content analysis was used for qualitative data. Quantitative data were summarised by facility level and healthcare provider type. Audit and knowledge scores (range 0-100) were generated. Multivariable linear regression estimated association between scores and explanatory factors. Qualitative and quantitative data were triangulated during interpretation.

RESULTS

Overall, 244 facilities and 308 providers were included. The mean audit score for health facilities was 51/100 (SD: 17). Private facilities had an -11.6 (95% CI, -16.7 to -6.6) lower adjusted mean score compared to public. Mean knowledge score was 59/100 (95% CI, 57 to 60) for health facility personnel, 46/100 (95% CI, 43 to 48) for drug shop vendors and 37/100 (95% CI, 34 to 39) for traditional health practitioners. Providers had particularly low knowledge concerning when to check for low blood sugar, use of nasogastric tubes, and dosing schedules. Knowledge about case definitions for cholera was similar between groups (range 41-58%) except for traditional health practitioners for the definition during an outbreak 15/73 (21%).

CONCLUSIONS

Increasing awareness of cholera case definitions in this context could help improve cholera surveillance and control. Increased support and supervision, especially for private providers, could help ensure facilities are equipped to provide safe care. More nuanced aspects of case management should be emphasised in provider training.

Quantifying the Cost of Shigella Diarrhea in the Enterics for Global Health (EFGH) Shigella Surveillance Study

Background

Comparative costs of public health interventions provide valuable data for decision making. However, the availability of comprehensive and context-specific costs is often limited. The Enterics for Global Health (EFGH) Shigella surveillance study-a facility-based diarrhea surveillance study across 7 countries-aims to generate evidence on health system and household costs associated with medically attended Shigella diarrhea in children.

Methods

EFGH working groups comprising representatives from each country (Bangladesh, Kenya, Malawi, Mali, Pakistan, Peru, and The Gambia) developed the study methods. Over a 24-month surveillance period, facility-based surveys will collect data on resource use for the medical treatment of an estimated 9800 children aged 6-35 months with diarrhea. Through these surveys, we will describe and quantify medical resources used in the treatment of diarrhea (eg, medication, supplies, and provider salaries), nonmedical resources (eg, travel costs to the facility), and the amount of caregiver time lost from work to care for their sick child. To assign costs to each identified resource, we will use a combination of caregiver interviews, national medical price lists, and databases from the World Health Organization and the International Labor Organization. Our primary outcome will be the estimated cost per inpatient and outpatient episode of medically attended Shigella diarrhea treatment across countries, levels of care, and illness severity. We will conduct sensitivity and scenario analysis to determine how unit costs vary across scenarios.

Conclusions

Results from this study will contribute to the existing body of literature on diarrhea costing and inform future policy decisions related to investments in preventive strategies for Shigella.

What drives poor quality of care for child diarrhea? Experimental evidence from India

Most health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades. Using randomized experiments in India, we estimated the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider's financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing, whereas stock-outs and financial incentives explain only 6 and 5%, respectively.

Prevalence and predictors of diarrhea among children under five in Ghana

BACKGROUND

Globally, childhood diarrhea is a major public health concern. Despite numerous interventions that have been put in place to reduce its incidence over the years, childhood diarrhea remains a problem and is the fourth leading cause of child mortality in Ghana. This study examined the predictors of diarrhea among children under the age of five in Ghana.

METHODS

Data from the 2014 Ghana Demographic and Health survey, a cross-sectional survey, was used for the purpose of this study. A total of 2,547 children under the age of five were included in this study. Logistic regression analysis was performed to establish the factors associated with childhood diarrhea and ascertain explanatory variables.

RESULTS

The prevalence of diarrhea was 11.7%. Male children (13.4%) and those living in rural areas (12%), particularly in the Brong Ahafo region (17%) recorded the highest prevalence of diarrhea. Children aged 6 to 35 months of age, maternal age and education, sex of children and region of residence were the predictors of diarrhea among children under the age of five years in this study.

CONCLUSION

To lessen the prevalence of diarrhea among children under five in Ghana, existing interventions must be evaluated in the context of the predictors identified. Based on observations deduced from this study, the Ministry of Health, Ghana Health Service and other health regulatory agencies should intensify monitoring and awareness in the various regions, particularly in the transition and savannah zones on the causes, risk factors, and methods of preventing diarrhea in children under five. Various stakeholders including government and non-governmental organizations should take into account the predictors of diarrhea identified in the design of interventions to effectively reduce morbidity and mortality associated with childhood diarrhea.

Management of Diarrhea in Young Children in Sub-Saharan Africa: Adherence to World Health Organization Recommendations During the Global Enteric Multisite Study (2007-2011) and the Vaccine Impact of Diarrhea in Africa (VIDA) Study (2015-2018)

BACKGROUND

Reducing diarrhea-related morbidity and mortality is a global priority, particularly in low-resource settings. We assessed adherence to diarrhea case management indicators in the Global Enteric Multisite Study (GEMS) and Vaccine Impact of Diarrhea in Africa (VIDA) study.

METHODS

GEMS (2007-2010) and VIDA (2015-2018) were age-stratified case-control studies of moderate-to-severe diarrhea (MSD) in children aged <5 years. In this case-only analysis, we included children enrolled in The Gambia, Kenya, and Mali. A case with no dehydration received adherent care at home if they were offered more than usual fluids and at least the same as usual to eat. Children with diarrhea and some dehydration are to receive oral rehydration salts (ORS) in the facility. The recommendation for severe dehydration is to receive ORS and intravenous fluids in the facility. Adherent care in the facility included a zinc prescription independent of dehydration severity.

RESULTS

For home-based management of children with MSD and no signs of dehydration, 16.6% in GEMS and 15.6% in VIDA were adherent to guidelines. Adherence to guidelines in the facility was likewise low during GEMS (some dehydration, 18.5%; severe dehydration, 5.5%). The adherence to facility-based rehydration and zinc guidelines improved during VIDA to 37.9% of those with some dehydration and 8.0% of children with severe dehydration.

CONCLUSIONS

At research sites in The Gambia, Kenya, and Mali, suboptimal adherence to diarrhea case management guidelines for children aged <5 years was observed. Opportunities exist for improvement in case management for children with diarrhea in low-resource settings.

Assessment of Determinants of Paediatric Diarrhoea Case Management Adherence in Pakistan

Worldwide, diarrhoea in children under five years of age is the second leading cause of death. Despite having high morbidity and mortality, diarrhoeal diseases can be averted by simple and cost-effective interventions. The Integrated Management of Childhood Illness (IMCI) has proposed the use of Oral Rehydration Salt (ORS) and zinc together with adequate food and fluid intake for the management of acute non-dysenteric watery diarrhoea in children. In the past, few studies examined the determinants of adherence to diarrhoea case management. Therefore, this study measured the determinants of therapeutic and dietary adherence to diarrhoea case management using the third and fourth wave of Pakistan Demographics and Health Surveys (PDHS) datasets. Data from 4068 children between 0 to 59.9 months with positive history of diarrhoea were included, while data on children with dysentery, severe dehydration, and co-morbid condition was excluded. This study reported therapeutic adherence in less than 10% of children in Pakistan, while dietary adherence was reported in 39.2% of children (37.7% in 2012-2013 and 40.7% in 2017-2018). A significant improvement in therapeutic (0.8% in 2012-2013 and 8.1% in 2017-2018) and dietary adherence (37.7% in 2012-2013 and 40.7% in 2017-2018) was reported in the 2017-2018 survey compared to the 2012-2013 survey. In general, children over the age of one year (compared to children <1 year) and of the richer/richest socioeconomic class (compared to poorest/poorer socioeconomic class) showed higher therapeutic and dietary adherence. Therapeutic and dietary adherence among diarrhoeal children can be improved by increasing the awareness and accessibility of ORS, zinc, and essential foods.

Prevalence and predictors of oral rehydration therapy, zinc, and other treatments for diarrhoea among children under-five in sub-Saharan Africa

Background

Despite the evidence-based effectiveness of diarrhoea treatment in preventing diarrhoea-related child mortality, the accessibility and utilization of diarrhoea treatments remain low in sub-Saharan Africa, even though these treatments are available. Therefore, this study aimed to assess the prevalence and predictors of diarrhoea treatment among under-five children in sub-Saharan Africa.

Methods

This study involved cross-sectional analyses of secondary data from the most recent Demographic and Health Surveys of 30 countries in sub-Saharan Africa. Percentages with their respective 95% confidence intervals (CI) were used to summarise the prevalence of diarrhoea treatment. A multivariable multilevel binary logistic regression analysis was employed to examine the predictors of diarrhoea treatment among children under five years in sub-Saharan Africa. The regression results were presented using adjusted odds ratio with their accompanying 95% confidence intervals. Statistical significance was set at p<0.05. Stata software version 16.0 was used for the analyses.

Results

The overall prevalence of diarrhoea treatment among under-five children in sub-Saharan Africa was 49.07% (95% CI = 44.50–53.64). The prevalence of diarrhoea treatment ranged from 23.93% (95% CI = 20.92–26.94) in Zimbabwe to 66.32% (95% CI = 61.67–70.97) in Liberia. Children aged 1 to 4 years, those whose mothers had at least primary education, those whose mothers had postnatal care visits, those whose mothers believed that permission to go and get medical help for self was a big problem, and those whose mothers’ partners had at least primary education were more likely to undergo diarrhoea treatment as compared to their counterparts. The odds of diarrhoea treatment increased with increasing wealth index with the highest odds among those in the richest quintile. Also, the odds of diarrhoea treatment was higher in the Central, Eastern, and Western geographical subregions compared to those in the Southern geographical subregion. However, children whose mothers were cohabiting, those whose mothers were exposed to watching television, and those living in female-headed households were less likely to undergo diarrhoea treatment.

Conclusion

The study found that the prevalence of diarrhoea treatment among children in sub-Saharan Africa was relatively low and varied across countries. The sub-regional estimates of diarrhoea treatment and identified associated factors can support country-specific needs assessments targeted at improving policy makers’ understanding of within-country disparities in diarrhoea treatment. Planned interventions (e.g., provision of quality and affordable supply of oral rehydration salts and zinc) should seek to scale up diarrhoea treatment uptake among under-five children in sub-Saharan Africa with much focus on the factors identified in this study.

Under-five mortality in the Democratic Republic of the Congo: secondary analyses of survey and conflict data by province

Objective

To compare coverage of key child health policy indicators across provinces and to explore their association with under-five mortality and level of conflict in the Democratic Republic of the Congo.

Methods

We made a secondary analysis of nationally representative data from 1380 health facilities and 20 792 households in 2017-2018. We analysed provincial-level data on coverage of 23 different indicators for improving common causes of childhood mortality, combined into mean scores for: newborn health, pneumonia, diarrhoea, malaria and safe environment. Using negative binomial regression we compared the scores with provincial-level under-five mortality. With binary logistic regression at the individual level we compared indicators (outcome) with living in a conflict-affected province (exposure).

Findings

All grouped coverage scores demonstrated large ranges across the 26 provinces: newborn health: 20% to 61%; pneumonia: 26% to 86%; diarrhoea: 25% to 63%; malaria: 22% to 53%; and safe environment: 4% to 53%. The diarrhoea score demonstrated the strongest association with under-five mortality (adjusted coefficient: -0.026; 95% confidence interval: -0.045 to -0.007). Conflict-affected provinces had both the highest as well as the lowest mortality rates and indicator coverages. The odds of coverage were higher in conflict-affected provinces for 13 out of 23 indicators, whereas in provinces unaffected by conflict only one indicator had higher odds of coverage.

Conclusion

Conflict alone is a poor predictor for child health. Ensuring that children in unaffected provinces are not neglected while addressing the needs of the most vulnerable in conflict settings is important. Prevent, protect and treat strategies for diarrhoeal disease could help improve equity in child survival.

The burden of diarrhea, etiologies, and risk factors in India from 1990 to 2019: evidence from the global burden of disease study

Background

This study aims to measure the burden of diarrhea in India and analyze the trend of mortality associated with it for the past 30 years. We also intend to find the prevailing etiology and risk factors associated with diarrheal mortality in India.

Methods

The study has used the latest round of Global Burden of Disease (GBD) study-2019. GBD data is available across age groups and gender-wise over the period from 1990 to 2019. The study has identified 13 etiologies for the cause of diarrhea deaths and 20 risk factors to analyze the burden of disease.

Results

Our study shows, childhood diarrhea has declined over the years significantly, yet contributes to a larger share of DALYs associated with the disease. Among all the death cases of Diarrhea, in 2019, the most prevalent disease-causing pathogen is found to be Campylobacter. But Adenovirus is the major contributor to childhood diarrheal deaths. Though the burden of diarrhea is declining over the period, still there is a need to progress the interventions to prevent and control diarrhea rapidly to avoid the huge number of deaths and disabilities experienced in India.

Conclusions

Consumption of safe and clean water, proper sanitation facility in every household, required nutrition intake by mother and child, safe breastfeeding and stool disposal practices and careful case management, rotavirus vaccination are some of the effective interventions to be implemented all over the country. Further, evidence-based policies should be made and implemented to sustain diarrhea prevention programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12515-3.

The Cost-Effectiveness of Community Health Workers Delivering Free Diarrhea Treatment: Evidence from Uganda

Community health workers (CHWs) are a vital part of the health infrastructure in Uganda and in many other low- and middle-income countries. While the need for CHWs is clear, it is less clear how they should dispense health products to maximize the health benefits to their community. In this study, we assess the cost-effectiveness of several competing CHW distribution strategies in the context of treatment for child diarrhea. We used data from a 4-armed cluster-randomized controlled trial to assess the cost-effectiveness of 1) free distribution of oral rehydration salts (ORS) via home deliveries prior to diarrhea onset (free delivery arm), 2) free distribution via vouchers where households retrieved the treatment from a central location (voucher arm), 3) a door-to-door sales model (home sales arm), and 4) a control arm where CHWs carried out their activities as normal. We assessed the cost-effectiveness from the implementor's perspective and a societal perspective, in terms of cost per case treated with ORS and cost per disability adjusted life-year (DALY) averted. Free delivery was the most effective strategy and the cheapest from a societal perspective. Although implementor costs were highest in this arm, cost savings comes from households using fewer resources to seek treatment outside the home (transport, doctor fees, and treatment costs). From the implementors' perspective, free delivery costs $2.19 per additional case treated and $56 per DALY averted relative to the control. Free delivery was also extremely cost-effective relative to home sales and vouchers but there was a large degree of uncertainty around the comparison with vouchers. Free distribution of ORS by CHWs prior to diarrhea onset is extremely cost-effective compared to other CHW distribution models. Implementers of CHW programs should consider free home delivery of ORS.

Health-care seeking for childhood diseases by parental age in Western and Central Africa between 1995 and 2017: A descriptive analysis using DHS and MICS from 23 low- and middle-income countries

BACKGROUND

Globally, health care seeking for childhood diseases seems to be on the rise. However, progress is slow and still, many cases of infectious diseases in children remain untreated, leading to preventable child mortality. A better understanding of care seeking behaviour may help to further increase the probability that a sick child is taken to a health facility for care.

METHODS

We investigated whether mother's and father's age at birth of the child is associated with health care seeking behaviour for childhood diseases and how this association changed over time. For this observational study, we used repeated cross-sectional data, namely all available Demographic and Health Surveys as well as Multi-Indicator Cluster Surveys from Western and Central Africa, 1995 to 2017. We analysed care seeking behaviour for diarrhoea, acute respiratory infections (ARI), and treatment of diarrhoea with oral rehydration solution (ORS). We estimated ordinary least squares regressions, controlling for socioeconomic characteristics of the household and adding survey year- and country-fixed effects. Estimated associations are presented for the entire region and for each country separately to highlight heterogeneity.

RESULTS

Overall, the likelihood that care is sought for a child suffering from diarrhoea or ARI is low in Western and Central Africa. Probability of care seeking for diarrhoea ranges between 49% for mothers above 40 years and 53% for mothers between 25 and 29 years. For ARI, the rates are 60% and 62%, respectively. Treatment of diarrhoea with ORS is even lower, ranging between 23% and 26%. The probability that parents seek health care for their child does not seem to be associated with parents' age at birth. Mother's level of education and household's wealth status seem to be more important factors. There is evidence of the relationship between parents' age and care seeking changing over time, suggesting a stronger association in the past.

CONCLUSIONS

Parents' age at child birth does not seem to have a relevant association with care seeking for common childhood diseases. Identifying relevant factors may help in improving health care seeking behaviour of parents in low- and middle-income countries leading to reductions in child morbidity and mortality.

Oral Rehydration Therapy Utilization and Associated Factors Among Children with Diarrhea in Debre Berhan, Ethiopia, 2020

BACKGROUND

Oral rehydration therapy is a critical intervention to save the lives of children during episodes of diarrhea and vomiting. However, millions of children die every year due to failure to replace fluid effectively. Nearly all dehydration-related deaths can be preventable by prompt administration of rehydration therapy. The current study aimed to assess oral rehydration therapy utilization and associated factors among children with diarrhea in Debre Berhan town.

METHODS

Community-based cross-sectional study was conducted from February to March 2020. The study participants were selected by systematic random sampling. The first household was selected randomly by the lottery method. The collected data were checked for completeness and relevance, and then entered into EPI data and transferred to SPSS for analysis. Multivariate logistic regression was used to determine the ORT utilization and predictor variables. A p-value less than 0.05 was considered a cutoff point for statistical significance for all statistical tests.

RESULTS

The study included 233 participants with a 99% response rate. Among them, 73% [95% Cl: 66.8 78.6] of caregivers had given oral rehydration therapy to their children. Previous use of oral rehydration therapy [AOR: 5.3, Cl: 2.1-13.32], health-seeking behavior [AOR: 5.7, Cl: 2.07-15.6], knowledge about oral rehydration therapy [AOR: 4.2, Cl: 1.7-10.46], caregivers' perception of tooth eruption [AOR: 3.13, Cl: 1.08-9], weaning as causes of diarrhea [AOR: 6.7, Cl: 2.49-17.9], and recognize the severity sign of dehydration [AOR: 5.6, Cl: 2.16-14.7] became significant factors of oral rehydration therapy.

CONCLUSION

Nearly two-thirds of the mothers give oral rehydration therapy while their child develops diarrhea. Mothers had previous oral rehydration therapy, good health-seeking behavior, knowledge about oral rehydration therapy, caregivers' perception of tooth eruption, and weaning as causes of diarrhea. Signs to recognize the severity of dehydration were important factors with oral rehydration therapy utilization. It will be better to give mothers special attention to hindering factors from giving oral rehydration therapy for their beloved child during diarrheal disease.

Barriers and facilitators to implementation of oral rehydration therapy in low- and middle-income countries: A systematic review

BACKGROUND

Oral rehydration therapy (ORT) is an effective and cheap treatment for diarrheal disease; globally, one of the leading causes of death in children under five. The World Health Organization launched a global campaign to improve ORT coverage in 1978, with activities such as educational campaigns, training health workers and the creation of designate programming. Despite these efforts, ORT coverage remains relatively low. The objective of this systematic review is to identify the barriers and facilitators to the implementation of oral rehydration therapy in low and middle-income countries.

METHODS

A comprehensive search strategy comprised of relevant subject headings and keywords was executed in 5 databases including OVID Medline, OVID Embase, OVID HealthStar, Web of Science and Scopus. Eligible studies underwent quality assessment, and a directed content analysis approach to data extraction was conducted and aligned to the Consolidated Framework for Implementation Research (CFIR) to facilitate narrative synthesis.

RESULTS

The search identified 1570 citations and following removal of duplicates as well as screening according to our inclusion/exclusion criteria, 55 articles were eligible for inclusion in the review. Twenty-three countries were represented in this review, with India, Bangladesh, Egypt, Nigeria, and South Africa having the most representation of available studies. Study dates ranged from 1981 to 2020. Overarching thematic areas spanning the barriers and facilitators that were identified included: availability and accessibility, knowledge, partnership engagement, and design and acceptability.

CONCLUSION

A systematic review of studies on implementation of ORT in low- and middle-income countries (LMICs) highlights key activities that facilitate the development of successful implementation that include: (1) availability and accessibility of ORT, (2) awareness and education among communities, (3) strong partnership engagement strategies, and (4) adaptable design to enhance acceptability. The barriers and facilitators identified under the CIFR domains can be used to build knowledge on how to adapt ORT to national and local settings and contribute to a better understanding on the implementation and use of ORT in LMICs. The prospects for scaling and sustaining ORT (after years of low use) will increase if implementation research informs local applications, and implementers engage appropriate stakeholders and test assumptions around localized theories of change from interventions to expected outcomes.

REGISTRATION

A protocol for this systematic review was developed and uploaded onto the PROSPERO international prospective register of systematic reviews database (Registration number: CRD420201695).

Comparison of 1-week and 2-week recall periods for caregiver-reported diarrhoeal illness in children, using nationally representative household surveys

BACKGROUND

Diarrhoeal outcomes in children are often ascertained using caregiver-reported symptoms, which are subject to a variety of biases and methodological challenges. One source of bias is the time window used for reporting diarrhoeal illness and the ability of caregivers to accurately recall episodes in children.

METHODS

Diarrhoea period prevalence in children under five was determined using two similarly administered, nationally representative household surveys: Performance Monitoring and Accountability 2020 (PMA2020) (1-week recall, N = 14 603) and Demographic and Health Surveys (DHS) (2-week recall, N = 66 717). Countries included in the analysis were the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya and Uganda. Diarrhoea period prevalence estimates were compared and water, sanitation and hygiene risk factors were analysed.

RESULTS

Childhood diarrhoea prevalence using 1-week recall (PMA2020) pooled across countries was 21.4% [95% confidence interval (CI): 19.9%, 22.9%] versus 16.0% using 2-week recall (DHS) (95% CI: 15.4%, 16.5%). In stratified analyses for all five countries, the number of diarrhoea cases detected was consistently higher using 1-week recall versus 2-week recall. The key risk factors identified in the PMA2020 data that were not associated with diarrhoeal episodes or were attenuated in the DHS data included: the main sanitation classifications for households, disposal method used for child faeces, number of household members and wealth quintiles.

CONCLUSIONS

For nationally representative household surveys assessing childhood diarrhoea period prevalence, a 2-week recall period may underestimate diarrhoea prevalence compared with a 1-week period. The household sanitation facility and practices remain key risk factors for diarrhoeal disease in children under five.

A Half Century of Oral Rehydration Therapy in Childhood Gastroenteritis: Toward Increasing Uptake and Improving Coverage

Termed by the Lancet, as "potentially the most important medical advance of the twentieth century," therapy with oral rehydration solutions (ORSs) has been essential to reducing mortality in children less than 5 years (under five) with infectious gastroenteritis and diarrhea. The target of the diarrhea-control programs in the 1990s was to achieve ORS use in 80% of diarrhea cases by the year 2000. Nevertheless, nearly 20 years later, global uptake remains limited to only a third of the cases. Our analysis shows that from 1990 to 2017, mean ORS coverage in Countdown countries [the 81 Countdown-to-2030 priority countries, which together account for 95% of maternal deaths and 90% of under-five deaths] increased from ~ 30% to nearly 40%. Flawed government policies, inadequate supplies, and lack of awareness among health workers and communities all contributed to this shortfall in coverage. Moreover, imperfect measurement methodology is implicated in questionable coverage data. A multipronged approach focusing on the manufacture, supply, training, and behavioral change is essential to ensure that ORS is used in all epidemic diarrhea cases globally, especially in the under-five population.

Principles and Practice of Oral Rehydration

PURPOSE OF REVIEW

An understanding of fluid and electrolyte losses from diarrhea and mechanisms of solute cotransport led to development of oral rehydration solution (ORS), representing a watershed in efforts to reduce diarrheal disease morbidity and mortality. This report reviews the scientific rationale and modifications of ORS and barriers to universal application.

RECENT FINDINGS

Solutions with osmolality and electrolyte composition different from original ORS for routine and unique pathophysiology such as in malnutrition have met with varying success. Following the conceptual rationale of sodium-glucose cotransportation to facilitate water absorption, other cotransporters and formulations have been explored with the aim to improve ORS efficacy and acceptance. ORS remains the anchor of acute watery diarrhea and dehydration management worldwide. Despite development of different formulations, the current standard solution is the mainstay of treatment for nearly all situations. Efforts to improve oral hydration solution and to increase acceptance and usage are ongoing.

Quality of care for children with severe disease in the Democratic Republic of the Congo

BACKGROUND

Despite the almost universal adoption of Integrated Management of Childhood Illness (IMCI) guidelines for the diagnosis and treatment of sick children under the age of five in low- and middle-income countries, child mortality remains high in many settings. One possible explanation of the continued high mortality burden is lack of compliance with diagnostic and treatment protocols. We test this hypothesis in a sample of children with severe illness in the Democratic Republic of the Congo (DRC).

METHODS

One thousand one hundred eighty under-five clinical visits were observed across a regionally representative sample of 321 facilities in the DRC. Based on a detailed list of disease symptoms observed, patients with severe febrile disease (including malaria), severe pneumonia, and severe dehydration were identified. For all three disease categories, treatments were then compared to recommended case management following IMCI guidelines.

RESULTS

Out of 1180 under-five consultations observed, 332 patients (28%) had signs of severe febrile disease, 189 patients (16%) had signs of severe pneumonia, and 19 patients (2%) had signs of severe dehydration. Overall, providers gave the IMCI-recommended treatment in 42% of cases of these three severe diseases. Less than 15% of children with severe disease were recommended to receive in-patient care either in the facility they visited or in a higher-level facility.

CONCLUSIONS

These results suggest that adherence to IMCI protocols for severe disease remains remarkably low in the DRC. There is a critical need to identify and implement effective approaches for improving the quality of care for severely ill children in settings with high child mortality.

Prevalence of oral rehydration therapy use and associated factors among under-five children with diarrhea in Dangure, Benishangul Gumuz Region, Ethiopia/2018

OBJECTIVES

This study aims to assess the prevalence of oral rehydration therapy use and associated factors among under-five children with diarrhoea in Dangure district, Benishangul Gumuz Region, Ethiopia/2018.

RESULT

A total of 615 under-five children who suffered from diarrhoea 2 weeks before the study were included and the response rate was 610 (99%). Among the total children participated in this study 189 (31%) were between 12 and 23 months with mean 23.5 and SD ± 6.9. Five hundred seventeen (84.8%) of mothers had access to oral rehydration therapy and 85% of mother's home had taken less than 1 h distance from the health facility. The prevalence of oral rehydration therapy is 51%. Two hundred sixty-seven (43.8%) mothers mentioned correctly about the importance of oral rehydration therapy which is to replace fluid while other 243 (39.8%) mothers stated that oral rehydration therapy uses to decrease diarrhoea. Mother's educational status, monthly income, knowledge of oral rehydration therapy, previous experience and seeking advice for treatment from health facilities were factors associated with oral rehydration therapy use.

The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda

BACKGROUND

Over half a million children die each year of diarrheal illness, although nearly all deaths could be prevented with oral rehydration salts (ORS). The literature on ORS documents both impressive health benefits and persistent underuse. At the same time, little is known about why ORS is underused and what can be done to increase use. We hypothesized that price and inconvenience are important barriers to ORS use and tested whether eliminating financial and access constraints increases ORS coverage.

METHODS AND FINDINGS

In July of 2016, we recruited 118 community health workers (CHWs; representing 10,384 households) in Central and Eastern Uganda to participate in the study. Study villages were predominantly peri-urban, and most caretakers had no more than primary school education. In March of 2017, we randomized CHWs to one of four methods of ORS distribution: (1) free delivery of ORS prior to illness (free and convenient); (2) home sales of ORS prior to illness (convenient only); (3) free ORS upon retrieval using voucher (free only); and (4) status quo CHW distribution, where ORS is sold and not delivered (control). CHWs offered zinc supplements in addition to ORS in all treatment arms (free in groups 1 and 3 and for sale in group 2), following international treatment guidelines. We used household surveys to measure ORS (primary outcome) and ORS + zinc use 4 weeks after the interventions began (between April and May 2017). We assessed impact using an intention-to-treat (ITT) framework. During follow-up, we identified 2,363 child cases of diarrhea within 4 weeks of the survey (584 in free and convenient [25.6% of households], 527 in convenient only [26.1% of households], 648 in free only [26.8% of households], and 597 in control [28.5% of households]). The share of cases treated with ORS was 77% (448/584) in the free and convenient group, 64% (340/527) in the convenient only group, 74% (447/648) in the free only group, and 56% (335/597) in the control group. After adjusting for potential confounders, instructing CHWs to provide free and convenient distribution increased ORS coverage by 19 percentage points relative to the control group (95% CI 13-26; P < 0.001), 12 percentage points relative to convenient only (95% CI 6-18; P < 0.001), and 2 percentage points (not significant) relative to free only (95% CI -4 to 8; P = 0.38). Effect sizes were similar, but more pronounced, for the use of both ORS and zinc. Limitations include short follow-up period, self-reported outcomes, and limited generalizability.

CONCLUSIONS

Most caretakers of children with diarrhea in low-income countries seek care in the private sector where they are required to pay for ORS. However, our results suggest that price is an important barrier to ORS use and that switching to free distribution by CHWs substantially increases ORS coverage. Switching to free distribution is low-cost, easily scalable, and could substantially reduce child mortality. Convenience was not important in this context.

TRIAL REGISTRATION

Trial registry number AEARCTR-0001288.

Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 provides an up-to-date analysis of the burden of diarrhoea in 195 countries. This study assesses cases, deaths, and aetiologies in 1990-2016 and assesses how the burden of diarrhoea has changed in people of all ages.

METHODS

We modelled diarrhoea mortality with a Bayesian hierarchical modelling platform that evaluates a wide range of covariates and model types on the basis of vital registration and verbal autopsy data. We modelled diarrhoea incidence with a compartmental meta-regression tool that enforces an association between incidence and prevalence, and relies on scientific literature, population representative surveys, and health-care data. Diarrhoea deaths and episodes were attributed to 13 pathogens by use of a counterfactual population attributable fraction approach. Diarrhoea risk factors are also based on counterfactual estimates of risk exposure and the association between the risk and diarrhoea. Each modelled estimate accounted for uncertainty.

FINDINGS

In 2016, diarrhoea was the eighth leading cause of death among all ages (1 655 944 deaths, 95% uncertainty interval [UI] 1 244 073-2 366 552) and the fifth leading cause of death among children younger than 5 years (446 000 deaths, 390 894-504 613). Rotavirus was the leading aetiology for diarrhoea mortality among children younger than 5 years (128 515 deaths, 105 138-155 133) and among all ages (228 047 deaths, 183 526-292 737). Childhood wasting (low weight-for-height score), unsafe water, and unsafe sanitation were the leading risk factors for diarrhoea, responsible for 80·4% (95% UI 68·2-85·0), 72·1% (34·0-91·4), and 56·4% (49·3-62·7) of diarrhoea deaths in children younger than 5 years, respectively. Prevention of wasting in 1762 children (95% UI 1521-2170) could avert one death from diarrhoea.

INTERPRETATION

Substantial progress has been made globally in reducing the burden of diarrhoeal diseases, driven by decreases in several primary risk factors. However, this reduction has not been equal across locations, and burden among adults older than 70 years requires attention.

FUNDING

Bill & Melinda Gates Foundation.

Use of quantitative molecular diagnostic methods to assess the aetiology, burden, and clinical characteristics of diarrhoea in children in low-resource settings: a reanalysis of the MAL-ED cohort study

Background

Optimum management of childhood diarrhoea in low-resource settings has been hampered by insufficient data on aetiology, burden, and associated clinical characteristics. We used quantitative diagnostic methods to reassess and refine estimates of diarrhoea aetiology from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study.

Methods

We re-analysed stool specimens from the multisite MAL-ED cohort study of children aged 0–2 years done at eight locations (Dhaka, Bangladesh; Vellore, India; Bhaktapur, Nepal; Naushero Feroze, Pakistan; Venda, South Africa; Haydom, Tanzania; Fortaleza, Brazil; and Loreto, Peru), which included active surveillance for diarrhoea and routine non-diarrhoeal stool collection. We used quantitative PCR to test for 29 enteropathogens, calculated population-level pathogen-specific attributable burdens, derived stringent quantitative cutoffs to identify aetiology for individual episodes, and created aetiology prediction scores using clinical characteristics.

Findings

We analysed 6625 diarrhoeal and 30 968 non-diarrhoeal surveillance stools from 1715 children. Overall, 64·9% of diarrhoea episodes (95% CI 62·6–71·2) could be attributed to an aetiology by quantitative PCR compared with 32·8% (30·8–38·7) using the original study microbiology. Viral diarrhoea (36·4% of overall incidence, 95% CI 33·6–39·5) was more common than bacterial (25·0%, 23·4–28·4) and parasitic diarrhoea (3·5%, 3·0–5·2). Ten pathogens accounted for 95·7% of attributable diarrhoea: Shigella (26·1 attributable episodes per 100 child-years, 95% CI 23·8–29·9), sapovirus (22·8, 18·9–27·5), rotavirus (20·7, 18·8–23·0), adenovirus 40/41 (19·0, 16·8–23·0), enterotoxigenic Escherichia coli (18·8, 16·5–23·8), norovirus (15·4, 13·5–20·1), astrovirus (15·0, 12·0–19·5), Campylobacter jejuni or C coli (12·1, 8·5–17·2), Cryptosporidium (5·8, 4·3–8·3), and typical enteropathogenic E coli (5·4, 2·8–9·3). 86·2% of the attributable incidence for Shigella was non-dysenteric. A prediction score for shigellosis was more accurate (sensitivity 50·4% [95% CI 46·7–54·1], specificity 84·0% [83·0–84·9]) than current guidelines, which recommend treatment only of bloody diarrhoea to cover Shigella (sensitivity 14·5% [95% CI 12·1–17·3], specificity 96·5% [96·0–97·0]).

Interpretation

Quantitative molecular diagnostics improved estimates of pathogen-specific burdens of childhood diarrhoea in the community setting. Viral causes predominated, including a substantial burden of sapovirus; however, Shigella had the highest overall burden with a high incidence in the second year of life. These data could improve the management of diarrhoea in these low-resource settings.

Funding

Bill & Melinda Gates Foundation.