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.

Cost of childhood diarrhoea in rural South Africa: exploring cost-effectiveness of universal zinc supplementation

OBJECTIVE

To describe the cost of diarrhoeal illness in children aged 6-24 months in a rural South African community and to determine the threshold prevalence of stunting at which universal Zn plus vitamin A supplementation (VAZ) would be more cost-effective than vitamin A alone (VA) in preventing diarrhoea.

DESIGN

We conducted a cost analysis using primary and secondary data sources. Using simulations we examined incremental costs of VAZ relative to VA while varying stunting prevalence.

SETTING

Data on efficacy and societal costs were largely from a South African trial. Secondary data were from local and international published sources.

SUBJECTS

The trial included children aged 6-24 months. The secondary data sources were a South African health economics survey and the WHO-CHOICE (CHOosing Interventions that are Cost Effective) database.

RESULTS

In the trial, stunted children supplemented with VAZ had 2·04 episodes (95 % CI 1·37, 3·05) of diarrhoea per child-year compared with 3·92 episodes (95 % CI 3·02, 5·09) in the VA arm. Average cost of illness was $Int 7·80 per episode (10th, 90th centile: $Int 0·28, $Int 15·63), assuming a minimum standard of care (oral rehydration and 14 d of therapeutic Zn). In simulation scenarios universal VAZ had low incremental costs or became cost-saving relative to VA when the prevalence of stunting was close to 20 %. Incremental cost-effectiveness ratios were sensitive to the cost of intervention and coverage levels.

CONCLUSIONS

This simulation suggests that universal VAZ would be cost-effective at current levels of stunting in parts of South Africa. This requires further validation under actual programmatic conditions.

Health care seeking for childhood diarrhea in developing countries: evidence from seven sites in Africa and Asia

We performed serial Health Care Utilization and Attitudes Surveys (HUASs) among caretakers of children ages 0–59 months randomly selected from demographically defined populations participating in the Global Enteric Multicenter Study (GEMS), a case-control study of moderate-to-severe diarrhea (MSD) in seven developing countries. The surveys aimed to estimate the proportion of children with MSD who would present to sentinel health centers (SHCs) where GEMS case recruitment would occur and provide a basis for adjusting disease incidence rates to include cases not seen at the SHCs. The proportion of children at each site reported to have had an incident episode of MSD during the 7 days preceding the survey ranged from 0.7% to 4.4% for infants (0–11 months of age), from 0.4% to 4.7% for toddlers (12–23 months of age), and from 0.3% to 2.4% for preschoolers (24–59 months of age). The proportion of MSD episodes at each site taken to an SHC within 7 days of diarrhea onset was 15–56%, 17–64%, and 7–33% in the three age strata, respectively. High cost of care and insufficient knowledge about danger signs were associated with lack of any care-seeking outside the home. Most children were not offered recommended fluids and continuing feeds at home. We have shown the utility of serial HUASs as a tool for optimizing operational and methodological issues related to the performance of a large case-control study and deriving population-based incidence rates of MSD. Moreover, the surveys suggest key targets for educational interventions that might improve the outcome of diarrheal diseases in low-resource settings.

Health care-seeking behavior for childhood diarrhea in Mirzapur, rural Bangladesh

We evaluated patterns of health care use for diarrhea among children 0–59 months of age residing in Mirzapur, Bangladesh, using a baseline survey conducted during May–June 2007 to inform the design of a planned diarrheal etiology case/control study. Caretakers of 7.4% of 1,128 children reported a diarrheal illness in the preceding 14 days; among 95 children with diarrhea, 24.2% had blood in the stool, 12.2% received oral rehydration solution, 27.6% received homemade fluids, and none received zinc at home. Caretakers of 87.9% sought care outside the home; 49.9% from a pharmacy, and 22.1% from a hospital or health center. The primary reasons for not seeking care were maternal perception that the illness was not serious enough (74.0%) and the high cost of treatment (21.9%). To improve management of childhood diarrhea in Mirzapur, Bangladesh, it will be important to address knowledge gaps in caretakers' assessment of illness severity, appropriate home management, and when to seek care in the formal sector. In addition, consideration should be given to inclusion of the diverse care-giving settings in clinical training activities for diarrheal disease management.

Health care use patterns for diarrhea in children in low-income periurban communities of Karachi, Pakistan

Diarrhea causes 16% of all child deaths in Pakistan. We assessed patterns of healthcare use among caretakers of a randomly selected sample of 959 children ages 0–59 months in low-income periurban settlements of Karachi through a cross-sectional survey. A diarrheal episode was reported to have occurred in the previous 2 weeks among 298 (31.1%) children. Overall, 280 (80.3%) children sought care. Oral rehydration solution and zinc were used by 40.8% and 2%, respectively; 11% were admitted or received intravenous rehydration, and 29% sought care at health centers identified as sentinel centers for recruiting cases of diarrhea for a planned multicenter diarrheal etiology case-control study. Odds ratios for independent predictors of care-seeking behavior were lethargy, 4.14 (95% confidence interval = 1.45–11.77); fever, 2.67 (1.27–5.59); and stool frequency more than six per day, 2.29 (1.03–5.09). Perception of high cost of care and use of home antibiotics were associated with reduced care seeking: odds ratio = 0.28 (0.1–0.78) and 0.29 (0.11–0.82), respectively. There is a need for standardized, affordable, and accessible treatment of diarrhea as well as community education regarding appropriate care in areas with high diarrheal burden.

Determinants of health care seeking for diarrheal illness in young children in urban slums of Kolkata, India

Maternal practices regarding children's health care have been recognized as an important factor associated with mortality rates among children < 5 years of age. We focused on health care-seeking practices of primary caretakers of children < 5 years of age with diarrheal disease in Kolkata. We interviewed caretakers of 1,058 children in a baseline survey and 6,077 children on six subsequent surveys. The prevalence of diarrhea during the preceding 2 weeks was 7.9% in the baseline survey and 5.7% (lowest 3.5% to highest 7.8%) in subsequent surveys. Multivariate logistic regression showed that formal education of primary caretakers was associated with seeking care outside the home (odds ratio [OR] = 15.5; 95% confidence interval [CI] [2.5-85.7]; P = 0.002). Multinomial logistic regression showed that formal education of the primary caretaker (OR = 21.4; 95% CI [3.2-139.0]; P = 0.002) and presence of dry mouth during diarrhea (OR = 17.3; 95% CI [2.7-110.9]; P = 0.003) were associated with seeking care from licensed providers compared with the children for whom care was not sought outside of the home. This health care utilization and attitudes survey (HUAS) can serve as a tool to identify the factors that influence a better health care-seeking pattern in urban slums of Kolkata.

Setting research priorities to reduce global mortality from childhood diarrhoea by 2015

Olivier Fontaine and colleagues applied a priority-setting methodology to identify research priorities aimed at reducing global diarrhea mortality by 2015.

Resource utilization and costs of treating severe rotavirus diarrhea in young Mexican children from the health care provider perspective

BACKGROUND

Rotavirus is the most common cause of severe diarrhea in infants. The economic costs of treating severe rotavirus can be quite significant and are important to include in any evaluation of prevention programs. The aim of this study was to determine utilization of health care resources and costs incurred due to severe diarrhea associated with rotavirus infection in Mexican children < 5 years of age.

MATERIAL AND METHODS

The costs of rotavirus infection evaluated in this observational study consisted of hospital, emergency room care and out-patient visit expenses at three hospitals of the Mexican Institute of Social Security throughout 1999-2000. Service costs were estimated from costs of care for rotavirus versus non-rotavirus diarrhea obtained through a follow-up study data of 383 children and administrative records.

RESULTS

Diarrhea cases due to rotavirus infection comprised 36% of the sample. Participants with rotavirus diarrhea spent an average of 3.2 days in the hospital, 5.9 hours in the emergency room, and had 1.3 visits to an outpatient physician's office. Some differences in the consumption of health care were found between rotavirus and non-rotavirus diarrhea cases, although the mean costs of rotavirus and nonrotavirus cases were not significantly different. The mean cost per case of severe rotavirus diarrhea was estimated to be US $936. The total cost of treating severe rotavirus diarrhea, including 5,955 rotavirus hospitalizations for 2004, was estimated at US $5.5 million.

CONCLUSION

Health care costs due to treatment for severe rotavirus diarrhea are a significant economic burden to the Mexican Social Security system.

Infantile gastroenteritis in the community: a cost-of-illness study

Rotavirus infections are the main cause of gastroenteritis in infants and children and it is expected that by the age of 5 years, nearly every child will have experienced at least one episode of rotavirus gastroenteritis. While severe cases are hospitalized, milder disease is either treated at home or by the GP, and as such the true prevalence of rotavirus infection in the community, and the burden of disease, is unknown. This paper reports the results of a cost-of-illness study which was conducted alongside a structured community surveillance study. Forty-eight percent of our sample was found to have rotavirus acute gastroenteritis; and the average total cost of a child presenting with rotavirus gastroenteritis ranged between pound sterling 59 and pound sterling 143 per episode, depending on the perspective. Given the prevalence and severity of the disease, the estimated burden of rotavirus gastroenteritis to society is pound sterling 11.5 million per year.

Comportamiento clínico y costos de la gastroenteritis por rotavirus en lactantes: Adquisición comunitaria versus nosocomial

This is a prospective 12 month (July 2003-June 2004) cohort study in one large tertiary hospital of Santiago, Chile aimed to describe clinic features and calculate the direct costs of hospitalization associated to community-acquired (n = 78) and nosocomially-acquired (n = 52) rotavirus infection. A gastroenteritis severity score after Rennels 1996, (0 to 17 points) was applied and costs where calculated based on those assigned by the Chilean National Funds for Health (FONASA). Severe gastroenteritis manifested by a score > 14 occurred in 26.9% and 9.6% of community and nosocomially-acquired cases respectively (p < 0.015). The former had lower bicarbonate levels (p < 0.001), and required more volume expansion compared to the latter (p < 0.023). The average cost was US 277 per case for community acquired rotavirus and US 268 for nosocomial infection. In this hospital the cost of nosocomial rotavirus infection was approximately 13,900 US dollars for a 12 month period. These results should stimulate the implementation of active prevention and control programs.

Cost-effectiveness of zinc as adjunct therapy for acute childhood diarrhoea in developing countries

OBJECTIVE

To analyse the incremental costs, effects and cost-effectiveness of zinc used as adjunct therapy to standard treatment of acute childhood diarrhoea, including dysentery, and to reassess the cost-effectiveness of standard case management with oral rehydration salt (ORS).

METHODS

A decision tree was used to model expected clinical outcomes and expected costs under four alternative treatment strategies. The best available epidemiological, clinical and economic evidence was used in the calculations, and the United Republic of Tanzania was the reference setting. Probabilistic cost-effectiveness analysis was performed using a Monte-Carlo simulation technique and the potential impacts of uncertainty in single parameters were explored in one-way sensitivity analyses.

FINDINGS

ORS was found to be less cost-effective than previously thought. The use of zinc as adjunct therapy significantly improved the cost-effectiveness of standard management of diarrhoea for dysenteric as well as non-dysenteric illness. The results were particularly sensitive to mortality rates in non-dysenteric diarrhoea, but the alternative interventions can be defined as highly cost-effective even in pessimistic scenarios.

CONCLUSION

There is sufficient evidence to recommend the inclusion of zinc into standard case management of both dysenteric and non-dysenteric acute diarrhoea.A direct transfer of our findings from the United Republic of Tanzania to other settings is not justified, but there are no indications of large geographical differences in the efficacy of zinc. It is therefore plausible that our findings are also applicable to other developing countries.

[Hospitalization due of infectious diarrhea in Rio de Janeiro State]

Diarrhea is an important cause of hospitalization among infants. There are many complex factors that influence hospital use: socioeconomic and cultural characteristics, access, medical needs, and supply. The objective was to measure hospitalization rates from diarrhea among infants in Rio de Janeiro in 1996 and the association with demographic, geographical, and clinical data comparing differentials between public/university and private/philanthropic hospital care under the Unified National Health System (SUS). The authors used data from the Hospital Information System. Private/philanthropic hospitals admitted approximately four times more children than public/university hospitals. Analysis shows that variation in age, length of hospital stay, and use of pediatric intensive care may reflect differences in physicians' practice styles. This may in turn influence the respective health care unit's capacity to prevent death associated with diarrhea. The authors conclude that it is necessary to continue the analysis of hospital utilization under the SUS due to implications for the cost and quality of pediatric care.

Implementing an evidence-based acute gastroenteritis guideline at a children's hospital

BACKGROUND

Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children's Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization.

METHODS

Comparisons were made between patients seen during peak gastroenteritis months (December-May) before (fiscal year [FYs] 1994-1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records.

RESULTS

Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (p = 0.002). Mean length of stay decreased 21% for children with minor illness (p = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (p < 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; p < 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly.

DISCUSSION

Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.

The economic impact of breastfeeding

Although breastfeeding is well accepted as the optimal method of infant feeding, the US failed to reach the goals set for the year 2000. Support from employers, health insurers, health providers, and society are required to reach the goals set forth in Healthy People 2010-75% of mothers initiate breastfeeding, 50% of infants still receive breast milk at 6 months, and 25% of infants are still breastfed at 1 year of age. In today's era of cost accountability and economic competition, these groups likely will desire information regarding the financial effects of breastfeeding and breastfeeding promotion from their perspectives. Although much research still is needed in this area, evidence suggests that a significant return on investment is likely with breastfeeding promotion. Also, the finances of health care must be viewed within the concept of value. In health care, value can be thought of as the cost required to achieve a specified outcome. In lay terms, this can be thought of as "how much bang we get for our buck." Breastfeeding clearly improves the health of infants and mothers and seems to result in cost savings for parents, insurers, employers, and society, which means that the medical and economic value of breastfeeding is high. To reap the health and economic benefits associated with breastfeeding, society must support breastfeeding promotion, which most likely will necessitate a coordinated US breastfeeding program. The US government is in a unique position to accomplish this goal as it views the associated costs from the joint perspectives of employer, health insurer, medical provider, and society. Through support of such a program, the US government likely will benefit significantly by improving the health of children and its financial bottom line.

The World Health Organization oral rehydration solution in US pediatric practice: a randomized trial to evaluate parent satisfaction

BACKGROUND

The World Health Organization's effective, inexpensive oral rehydration solution (WHO-ORS) is used worldwide, but rarely by US practitioners because, in part, of concerns about parent satisfaction.

OBJECTIVE

To compare caretaker satisfaction with the WHO-ORS, a packet-based solution requiring preparation, with satisfaction with a commercially prepared oral rehydration solution (C-ORS), (Pedialyte; Ross Nutritionals, Columbus, Ohio).

DESIGN AND METHODS

Randomized controlled trial in an urban pediatric clinic and a suburban family medicine clinic. Children aged 3 to 47 months treated as outpatients for diarrhea were randomized to receive either WHO-ORS or C-ORS. After 48 hours of use, caretakers completed a telephone interview measuring satisfaction with aspects of the solution.

RESULTS

Of 97 families enrolled, 91 (94%) were available for follow-up interviews. The WHO-ORS and C-ORS groups were comparable at baseline in all respects, except that slightly more caretakers in the latter group had used the C-ORS for the current illness before study enrollment (P= .06). Caretakers in the WHO-ORS group had higher overall satisfaction, satisfaction with cost, willingness to purchase in the future, and to recommend use (P<.001 for all). Differences remained significant after controlling for prior use of the C-ORS. There was no difference in satisfaction with ease of administration (P=.90), appearance (P=.20), and effectiveness (P=.80). No adverse effects attributable to either study solution occurred.

CONCLUSIONS

Caretakers who prepared and used the WHO-ORS were more satisfied with their solution than a comparable group who administered C-ORS. Fear of parental dissatisfaction need not be a barrier to use of the WHO-ORS in the United States.

[Rotavirus laboratory network: results after one year of observation]

Rotavirus is the most common cause of severe diarrhea in children and it has been estimated that in Argentina Rotavirus is responsible for 21,000 hospitalizations, 85,000 medical attentions and an annual medical cost of US$ 27 millions. Given that a Rotavirus vaccine is about to be approved, a laboratory network based surveillance system was organized. Herein, we present the results after one year of study. Severe diarrhea was responsible for 9% of pediatric hospitalizations and rotavirus was detected in 42.1% of the diarrhea cases. We estimated that Rotavirus causes 3.8% of pediatric hospitalizations. The number of diarrhea and Rotavirus diarrhea hospitalizations was greater during the first year of life (62% and 71.3%, respectively). The number of diarrhea hospitalizations during the December-May semester was significantly higher than the rest of the year. A Rotavirus diarrhea peak was detected between April and June. These results indicate that Rotavirus is the most important etiological agent of severe diarrhea in Argentine children and show the importance of performing Rotavirus diagnosis in every pediatric hospital. The additional costs will be compensated by many benefits such as better use of antibiotics, improved nosocomial spread control, better handling of hospital beds and of laboratory resources and of the hospitalized patient.

Rotavirus gastroenteritis: impact on young children, their families and the health care system

OBJECTIVE

To assess the impact of rotavirus gastroenteritis on young children attending a paediatric hospital, their families and the health care system.

DESIGN

Cross-sectional descriptive survey.

SETTING

New Children's Hospital (Royal Alexandra Hospital for Children), Sydney, New South Wales, 15 July to 4 October 1996.

PARTICIPANTS

Children aged under three years attending the Emergency Department with acute diarrhoea as the presenting symptom.

OUTCOME MEASURES

Cases of rotavirus infection confirmed by enzyme-linked immunosorbent assay by age; rotavirus serotype; gastroenteritis severity score; estimated costs to parents (lost pay or leave, travel, medication and other expenses) and to the health care system (visits to Emergency Department and other health care workers, hospital admissions).

RESULTS

280 children were recruited (73% of 384 children who met the inclusion criteria and 27% of the 1037 aged under three years with acute gastroenteritis). Rotavirus was detected in 188 of the 280 (67%); most isolates were serotype G1 (86% of the 174 serotyped). Of the 188 children with confirmed rotavirus infection 78% were aged 7-24 months and 82% visited at least one other health care worker, usually a general practitioner. Seventy (37% of the 188) were admitted to hospital; 33 of these (47%) were aged 13-24 months. Estimated mean total cost per episode of rotavirus gastroenteritis was $1744 for children admitted to hospital and $441 for children not admitted. The mean cost to families was $493 for children admitted to hospital and $228 for children not admitted.

CONCLUSIONS

Rotavirus gastroenteritis has a significant impact on young children, their families and the health care system. Prevention of severe disease through routine infant vaccination would be potentially cost-effective.

The cost of not breastfeeding: a commentary

Breastfeeding, a valuable natural resource, promotes health, helps prevent infant and childhood disease, and saves health care costs. Additional annual national health care costs, incurred for treatment of four medical conditions in infant who were not breastfed were estimated. Infant diarrhea in nonbreastfed infants costs $291.3 million; respiratory syncytial virus, $225 million; insulin-dependent diabetes mellitus, from $9.6 to $124.8 million; and otitis media, $660 million. Thus, these four medical diagnoses alone create just over $1 billion of extra health care costs each year. Breastfeeding may also enhance intellectual development of children according to at least one medical research study. The potential societal benefits of more intelligent children is incalculable even though it cannot be directly measured in terms of dollars. Finally, it was calculated that an additional $2,665,715 in federal funds is needed yearly in order for WIC to provide infant formula to nonbreastfeeding mothers. For the average family, the cost of purchasing formula is twice the cost of supplemental food for the breastfeeding mother. Breastfeeding education and support should be an integral part of health care, especially under managed care which rewards the prevention of health problems and reduced use of health services.

Costs associated with office visits for diarrhea in infants and toddlers

We determined costs associated with diarrhea in a < 36-month-old ambulatory population. Children with acute diarrhea were enrolled during the rotavirus season at three centers. Questionnaires to assess costs of both medical and nonmedical factors were administered at the enrollment visit and 1 week later. Office computer records were reviewed to identify all visits by children with diarrhea during 1 year. Fifty-one patients were enrolled. The average cost per episode of diarrhea was $289, which included: $144, missed work; $57, office visits; $23, laboratory tests; $21, medications; $18, changed diet/oral rehydration solutions; $15, travel; $7, extra diapers; and $6, extra child care. During 1 year diarrhea accounted for 4% of all visits and 10% of visits among those < 36 months old. The annual cost at the three centers was $346,000, which extrapolates to $0.6 to $1.0 billion for the United States. Twenty-one percent of this cost was attributable to rotavirus diarrhea. We conclude that outpatient care for pediatric diarrhea is a major health care cost in the United States.

Costs of diarrhoeal diseases and the savings from a control programme in Cebu, Philippines

A control of diarrhoeal diseases programme was set up in Cebu Province, Philippines, in 1986. In order to compare the reduction in treatment costs before and after implementation of the programme, and the potential savings to be made from its continuation, we collected data for 1985 and 1989 in 10 health facilities in Cebu. Since the programme's introduction, household expenditures on drugs for diarrhoea cases have decreased by a total of 1.03 million Philippine pesos (P) (US$ 41,200). At the health centre level, the costs of treating diarrhoea cases were close to optimum, but in the district hospitals treatment of inpatients with diarrhoea changed little between 1985 and 1989. This arose because such hospitals were compensated by the central authorities for inpatients but not for outpatients. Potential savings of around US$ 60,000 could have been made, however, had the district hospitals adopted the practices used in the main referral hospital.

[An evaluation of the 4 years of the Oral Rehydration Service of the Hospital Infantil de Monterrey]

At four years of being founded the Service of Oral Hydration from Hospital Infantil de Monterrey, we carried out this investigation to know its productivity, to determine costs of internments, death rates due to diarrhea and dehydration in the hospital and at a State level. The statistics from the hospital were revised in the previous and subsequent years to the institution of the Service in September of 1986, so as the statistics of death due to diarrhea from the State Health Department. The cases attended were 12,139, from which 9,024 belonged to plan A, 2,983 to plan B and 72 to plan C. Three hundred (300) doctors were trained and nine (9) research studies were accomplished. A decrease was achieved from the hospital rate admission by diarrhea and dehydration, throw the oral dehydration therapy in a 66%, the mortality rate was reduced 72% and an expenditure of $619,243,480.00 pesos in drugs and auxiliary examinations of diagnostic was avoided. At a State level the general death rate due to diarrhea got a cutdown of 13.1 to 5.8, and in infants under a year old decreased from 275 to 122.3. The oral hydration therapy applied in the State seems to be the main reason in that results.

Cost effective strategy for promotion of appropriate case management of diarrheal diseases--establishment of DTUs

Oral rehydration therapy (ORT) is one of the essential components of child survival technologies which are currently being utilised to reduce morbidity and mortality on account of common illnesses. ORT has made it possible to undertake a global effort to reduce deaths from dehydration and diarrhea associated malnutrition. Appropriate case management can also combat deaths from dysentery and persistent diarrhea. During the last decade considerable success has been achieved by incorporating this simple, effective and economic therapeutic intervention in the primary health care package. However, the ultimate objective of improved case management of diarrhea including the use of ORT at all levels of health care system is yet to be achieved. Patients with dysentery need antimicrobial therapy apart from ORT. Clinical experience has shown that with ORT and appropriate dietary therapy, most patients with persistent diarrhea can be managed effectively. Unfortunately, injudicious use of intravenous fluids and irrational prescription of antibiotics and anti-diarrheal agents is quite common even in the hands of pediatricians. The training of mothers visiting health facilities is poor for ORT and feeding. Establishment of diarrhea training and treatment units (DTUs) is aimed to improve current practices in the teaching hospitals and to promote appropriate case management of diarrhea by all health personnel.

[Infantile malnutrition: social cost of respiratory and digestive pathology]

Information from the hospital records of 1,660 children under two years of age admitted to the Hospital Roberto del Río (Northern District of Santiago) during 1979, allowed carrying out an analysis of the effect of malnutrition upon the admission rate and length of stay for diarrhea and respiratory infections. The following indexes were calculated and related to nutritional status: a) Admission rate for the total population of children under two years of age from the Northern District of Santiago; b) frequency of associated and intercurrent pathology, and c) length of stay. The three indexes evidenced a clear relationship with nutritional status (P much less than 0.01), showing a progressive deterioration as the relationship weight/age became impaired. The admission rate for diarrhea was nine times higher, and the length of stay 16.9% higher (P less than 0.001) in children with mild malnutrition as compared with normal patients. For respiratory infections the rates were 2.4 and 24.7% higher (P less than 0.001) in malnourished patients than in normals. The excess of admission rate for diarrhea and respiratory pathology, conditioned by malnutrition in the Northern District of Santiago, was estimated as the cost equivalent to 10,609 extra days of stay, with an annual cost above US$300,000. The investment of such an amount of money in health promotion and protection activities would certainly increase its social cost-effectiveness.