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CLOSE THIS BOOKOral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)
Module Two: Diarrhea, dehydration and rehydration
VIEW THE DOCUMENT(introduction...)
Session 3 - Prevention and control of diarrheal diseases
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTHandout 3A: Sanitation, water quality and the spread of disease
VIEW THE DOCUMENTHandout 3B: Common causes of diarrhea
VIEW THE DOCUMENTHandout 3C: Methods of controlling enteric diseases
VIEW THE DOCUMENTHandout 3D: Water, excrete, behaviour and diarrhoea
VIEW THE DOCUMENTHandout 3E: Primary health care
VIEW THE DOCUMENTTrainer Attachment 3A: The global impact of diarrhea
VIEW THE DOCUMENTTrainer Attachment 3B: A story about diarrhea
VIEW THE DOCUMENTTrainer Attachment 3C: Suggestions for using the picture story
Session 4 - Dehydration assessment
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTTrainer Attachment 4A: Pictures of children with signs of dehydration
VIEW THE DOCUMENTTrainer Attachment 4B: Guidelines for presentation of the who diarrhea treatment chart
VIEW THE DOCUMENTTrainer Attachment 4C: Answers for exercises
VIEW THE DOCUMENTTrainer Attachment 4D: Creating a case study
VIEW THE DOCUMENTTrainer Attachment 4E: Adaptation of the treatment chart
Session 5 - Rehydration therapy
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTHandout 5A: ORT preparation worksheet
VIEW THE DOCUMENTTrainer Attachment 5A: Materials and equipment needed for ORT stations
VIEW THE DOCUMENTTrainer Attachment 5B: Using models to show why rehydration is important
VIEW THE DOCUMENTTrainer Attachment 5C: Suggestions for a lecturette on the hows and whys of ORS
VIEW THE DOCUMENTTrainer Attachment 5D: Oral rehydration therapy: the scientific and technical basis
VIEW THE DOCUMENTTrainer Attachment 5E: Storing and maintaing supplies of oral rehydration salts (ORS)
VIEW THE DOCUMENTTrainer Attachment 5F: Oral rehydration with dirty water?
VIEW THE DOCUMENTTrainer Attachment 5G: A pinch of salt' a handful of molasses...
VIEW THE DOCUMENTTrainer Attachment 5H: Cautious prescription
Session 6 - Practicing ort in the village
VIEW THE DOCUMENT(introduction...)
VIEW THE DOCUMENTTrainer Attachment 6A: Problem situations - ORT in the home

Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)

Module Two: Diarrhea, dehydration and rehydration

OVERVIEW

This module includes the basic technical core of oral rehydration therapy knowledge and skills. Session Three provides an overview of the prevention control of diarrhea. Sessions 4 and 5 include demonstration and practice in basic skills in dehydration assessment and preparing and using oral rehydration therapy. Session 6 discusses problems encountered in using ORT in the home.

OBJECTIVES

· To describe at least three mayor points on the route of transmission of diarrheal diseases.

· To list at least four ways that sanitation and good hygiene can control and prevent the spread of diarrhea.

· To correctly assess three stages of dehydration using the WHO Treatment Chart and case studies,

· To determine appropriate treatment for the three stages of oral rehydration according to the WHO criteria stated in the Treatment of Diarrhea,

· To correctly prepare sugar-salt solution and mix ORS packets according to the WHO recommendations stated in the Treatment of Diarrhea,

· To list the four basic ingredients in ORS packets and explain the purpose that each serves as stated in Session 5.

· To accurately describe four problems commonly encountered in using ORT in the home and describe one culturally appropriate, feasible way to resolve each problem.

Cross reference with the Technical Health Training Manual:

Session 5 Primary Health Care
Session 42 Improving Health Through Safe Water and a Clean Community

Session 3 - Prevention and control of diarrheal diseases

TOTAL TIME

3 hours

OVERVIEW

In less technically developed countries diarrhea is one of the most common illnesses, and dehydration from diarrhea is one of the five leading causes of death in children under five. In addition, frequent bouts of diarrhea aggravate malnutrition. Most of these deaths could be prevented through oral rehydration therapy in the short term and through sanitation and hygiene efforts in the long term. In this session participants lock at the causes of diarrhea, how it is transmitted, and types of interventions that. can be used to prevent and control diarrhea as a part of primary health care efforts in the host country, Optional, mini-sessions on prevention techniques give participants a chance to improve skills in: latrine building and care; purifying and protecting water; and proper disposal of refuse.

OBJECTIVES

· To identify environmental; social and cultural factors that affect the occurrence of diarrheal diseases in the host country.
(Step 1, 2)

· To explain how diarrheal diseases are transmitted.
(Step 3)

· To identify ways to prevent and control diarrheal diseases in local communities.
(Step 4)

MATERIALS

Markers, newsprint, visual aids on prevention and control of diarrhea.

RESOURCES

Control of Communicable Diseases in Man. pp.: 78-82; 109-114; 147-151.

Water Treatment and Sanitation: Simple Methods of Treatment for Rural Areas

Technical Health Training Manual. Sessions: 5 (Primary Health Care); 8 (Factors Affecting Health); 42 (Improving Health Through Safe Water and a Cleaner Community).

Where There is ND Doctor. Chapter 12, pp. 131-145.

Community Culture and Care. pp. 206-210.

UNICEF Slides on the Global Impact of Diarrhea, Oral rehydration Therapy (ORT) for Childhood Diarrhea, (ORT Resource Packet)

Handouts:

- 3A Sanitation, Water Quality and the Spread of Disease
- 3B Common Causes of Diarrhea,
- 3C Methods of Controlling Enteric Diseases
- 3D Water Excreta Behavior and Diarrhea,
- 3E Primary Health Care Trainer Attachments:
- 3A The Global Impact of Diarrhea,
- 3B A Story About Diarrhea
- 3C Suggestions for Using The Picture Story

PROCEDURE

Trainer Note

This session builds upon the knowledge that participants acquired in basic training and their experience in the field, particularly the topics and skills covered in the Technical Health Training Manual, Sessions: 3 (Primary Health Care); 5 (Factors Affecting Health); and 42 (Improving Health Through Safe Water and a Cleaner Community). If participants lack this background, supplement this session with some of the activities or resource materials from those sessions.

In preparation for this session, adapt Trainer Attachment 3B (A Story About Diarrhea, to fit local conditions and characters. If time allows also adapt the pictures, using the tracing technique described in Session 18 (Adapting and Pretesting Health Education Materials).

Also prepare a lecturette on the global impact of diarrhea using Trainer Attachment 3A (The Global Impact of Diarrhea, and, if possible, slides or other visual aids, include information on the extent to which diarrhea is a problem in the host country. You may want to refer to the decrease in deaths associated with diarrhea in the U.S. after public health and sanitation measures were introduced, but prior to the introduction of antibiotics, These data make a strong case for the importance of preventive measures and home treatment to reduce deaths associated with diarrhea.

Locate and display visual aids on the prevention and control of diarrhea, particularly those aimed at teaching community people about oral rehydration therapy.

Step 1 (20 min.)

Introduction: the Global Impact of Diarrhea

Introduce the session by briefly reviewing the objectives and using the lecturette that you prepared on the global impact of diarrhea.

Trainer Note

The lecturette is a means to briefly give the participants a sense of where their work in ORT fits into similar work worldwide by Peace Corps programs as well as programs in other organizations. Some main points to include and discuss are:

- number of cases of illness and death resulting from diarrhea, and the resulting dehydration, worldwide and in the host country.

- emphasize the fact that most of these deaths are preventable through oral rehydration therapy in the short term, and sanitation and hygiene in the long term.

- the prevention and control of diarrhea is part of primary health care.

Step 2 (30 min)

A Story About Diarrhea,

Tell the story that you adapted from Trainer Attachment 3B (A Story About Diarrhea, using the pictures, and following the suggest tons in Trainer Attachment 3C (Suggestions for Using the Picture Story).

Ask participants to discuses Why did Musu Die? and list the causes that they suggest.

Then ask: Could Musu's death have been presented? How? and list the interventions that they suggest.

Point to the circle of pictures that you made when you told the diarrhea story and ask participants to identify where in the circle they can intervene in their work in the community. As they offer suggestions, post the appropriate intervention pictures beside the pictures in the circle. (See Trainer Attachment 3C for an illustration of how to do this.)

Trainer Note

See the end of the Procedure Section for an alternative to this step. During the discussion make sure that participants give cultural, economic and social factors affecting the death of Musu as well as the environmental (sanitation) and biological (disease agents) factors. Be sure that participants also discuss which interventions they can actually do in their work in the community.

Step 3 (20 min.)

Discussing How Diarrhea is Transmitted

Make certain that participants understand how diarrhea is transmitted by asking them to use the diarrhea story to explain diarrhea transmission in simple terms that they could use in the community. Ask someone to use the pictures from the diarrhea story to explain how diarrhea is transmitted from one person to another through contaminated food, water and hands.

Distribute Handouts 3A (Sanitation Water Quality and the Spread of Diseases) and 3B (Common Causes of Diarrhea, as supplementary reading.

Trainer Note

Be sure to cover the following points in the discussion:
- During diarrhea, stools are more frequent and contain more water than normal. In most societies this is three or more watery stools a day. There are changes in color and odor of the stool as well.
- A number of different disease agents cause diarrhea (such as cholera, giardia). Handout 3B (Common Causes of Diarrhea) summarizes some mayor causes, also Control of Communicable Diseases in Man.

An example of one simple way to illustrate the spread of disease carried by feces is shown below:


Figure

Step 4 (30 min)

Preventing Diarrhea

Follow up the discussion of how diarrhea is transmitted with a discussion of how to prevent its transmission. Refer back to the interventions suggested in Step 1. Clarify the meaning of prevention and control. Discuss prevention in reference to actual conditions in communities where participants work. Some questions for discussion are:

- What and where are the primary sources of water in your community?

- Could these sources contribute to diarrhea in your community?

- What do community people think is the cause of diarrhea?

- Whose job is it to fetch water? What implications does this have for its use? Could this contribute to the water's contamination?

- What happens during the dry season? Is there more diarrhea then?

- What demands are put on the water source? Is it good quality water? Are the people satisfied with the water quality?

- What latrine facilities are available now in your community?

- What are people's attitudes toward latrines?

- Who uses them? Why? Who doesn't use them? Why?

- How do people teach their children about personal hygiene, defecation, urination and hand washing? Is this different for male and female children?

Trainer Note

Be sure to discuss "control" and "prevention" as similar ideas; both are interventions that occur at different points in the cycle of the disease. Also make sure the following ideas are discussed:

- Prevention is important because once diarrhea occurs, the body is weakened and susceptible to malnutrition and future bouts of diarrhea.

- Sanitation, disposal of excrete and good hygiene are primary preventive measures; that is, they stop the spread of diarrheal diseases at their sources of contamination. Make the point that in preventive work we want to get as close to eliminating the source of disease as we possibly can.

Step 5 (20 min)

Discussing Different Types of Interventions

Ask participants to look at the interventions that they suggested and divide them into the following categories:

- Interrupting the transmission of the disease (for example clean water; use of latrines).
- Strengthening the body's defenses (such as providing good nutrition).
- Therapy 'such as oral rehydration

Discuss the advantages and disadvantages of these different interventions particularly the short term and long term results that they offer.

Also discuss how these interventions are a part of primary health care, using the information on Handout 3E (Primary Health Care).

Discuss which interventions are most realistic for Volunteers and Counterparts, given the conditions in which they work.

Conclude the session by referring back to the objectives and training schedule to see where the participants will be developing skills in these areas.

Trainer Note

Tell the participants the following book is a good reference on the Prevention of Diarrheal Diseases. It is available through ICE.

Water Treatment and Sanitation: Simple Methods for Treatment for Rural Areas

The Water and Sanitation: for Health Project (WASH) is also a good source of materials.

Alternative Step 2 (30 min)

An alternative to using the picture story is to tell the story and lead a discussion of why Musu died. As people state reasons, list them on separate pieces of paper. Ask one person to take each reason. Have them pin the paper with the reason on it to the back of their shirt and form a circle, holding hands.

Ask each person to read their factor saying "I helped cause the death of Musu by (read the factor)." Ask the rest of the group what can be done to break this vicious cycle that killed Musu. Write each suggested intervention on another sheet of paper. Have one person (for each intervention) pin one paper to their shirt and break into the circle where their intervention is supposed to break the cycle. Lead a discussion following the suggestions in the Trainer Note at the end of Step 2.

Optional Step 4 (60 min)

Mini-sessions on Prevention Measures

Use Steps 2 and 3 from Session 42 (Improving Health Through Safe Water and a Cleaner Community) from the Technical Health Training Manual to plan prevention projects. If possible during the training course give participants an opportunity for practical experience such as building and cleaning a latrine and teaching community members to do so.

Trainer Note

The actual implementation of these control measures requires more time than allocated for the mini-sessions For example, latrine building requires several hours, depending on the soil and the number of diggers.

Handout 3A: Sanitation, water quality and the spread of disease


Figure 1. Spread of disease

Waterborne Diseases (Water Quality Related)

In the waterborne diseases, the microorganisms which cause the disease are swallowed with contaminated water. All but one, Guinea worm, are caused by organisms round in human excrete, the source of the contamination. The infective stage Or Guinea worm is not from fecal contamination, but is from a tiny larva that develops in a water-flea after the larva is discharged into the water. The larva comes from a blister on the skin of a person infected with the meter-long adult worm.

Cholera and typhoid fever are the waterborne diseases which are most feared because, when untreated, they have high death rates. However, the diarrheas and dysenteries are more important because Or the infant deaths and huge numbers Or illnesses they cause. In the developing countries, the diarrheas and dysenteries cause hundreds Or millions Or illnesses and millions Or infant deaths each year.

The basic transmission Or waterborne disease is person to person. The microorganisms for infected people contaminate water which is consumed by other people. Figure 1 shows a common way that water becomes contaminated. The contamination of water supplies occurs:

1. Where latrines and privies are located uphill from or very close to a water source such as a spring, stream, pond or well. Liquids carrying the organisms seep from the latrines into the water supply.

2. Where privy pits, soakage pits, or sewage absorption systems penetrate 'he water table of an aquifer located near the surface and shallow wells and springs whose water comes from the aquifer are contaminated.

3. Where wells and springs are unprotected so that surface run-off renters these water sources. The runoff after rainfall carries disease-causing organisms into the water source.

4. Where sanitation is poor. If people defecate on the ground or in bodies of water rather than in safe latrines or privies, disease-causing organisms can get into water supplies.

5. Where Guinea worm occurs, water 19 contaminated when the skin of an infected person with a blister caused by the worm is immersed in water and great numbers of larvae are released into the water. Some Or the larvae are eaten by tiny water fleas (Cyclops). The larvae in the water fleas grow, shed their skins, and become infective. hen a water flea containing an ineffective larva is drunk with water from the contaminated source, the little worm is transmitted to a new person where it grows to maturity under the skin.

Water-Washed Diseases (Water Quantity and Accessibility Related)

Water-Washed diseases are diseases whose transmission results from a lack of sufficient clean water for frequent bathing, hand washing before meals and after going to the toilet, and for washing clothes and household utensils. Several common diseases fall into this category. Shilgellosis (bacillary dysentery), salmonellosis (food poisoning), trachoma, and scabies are all diseases that can be passed by direct contact between people or by the direct contamination of food by dirty hands or flies. Figure 2 shows one way water-washed diseases are spread. The diseases in this group are transmitted:


Figure 2. Transmission of Water-Washed Diseases

1. When a water supply produces insufficient quantities to meet peoples' needs or when the water supply is located at a distance from the users. The availability of only small amounts of water makes the practice of good personal and household hygiene difficult, or even impossible.

2. When feces are not disposed Or in a sanitary way. Uncovered or unprotected latrines or stools passed on the ground are breeding places for flies and sources Or bacteria. Bacteria and viruses are passed from feces to people by flies, contaminated fingers and food. Food contamination with salmonella quickly grows great numbers of the bacteria. When eaten, the food causes food-poisoning diarrhea with life-threatening consequences, especially for small children.

3. When people are ignorant of the need for personal hygiene and, for whatever set Or reasons, either do not bathe frequently or use the same water and towels to wash more than one person, then trachoma and conjunctivitis are passed around within a family or other groups living together and scables get passed from the skin of one person to the skin of another.

Handout 3B: Common causes of diarrhea

This table gives the information that will help to identify, on clinical grounds along the most common agents of diarrhoea. It is greatly simplified. For example some agents produce a variety of clinical foods. Only agents of major importance world-wide have been included. In certain areas, at certain times, the picture may be quite different.

Try and find out what the important causes of diarrhoea are in your area.

Caution: There are a number of other conditions associated with diarrhoea such as infections outside the gut (e.g. measles and malaria), malnutrition, food intolerance etc. Remember to look for these and give specific treatment where appropriate.

If readers find this table useful, we may present other information in the same way in future issues of Diarrhoea Dialogue.

Please send us your comments on this clinician's guide.


Table

Handout 3C: Methods of controlling enteric diseases


Technical Note No. DIS. 2.M.4

Enteric diseases are those that affect the gastrointestinal tract of humans, They are caused by bacteria, parasites or viruses. The disease organisms are passed from infected people in their feces or urine. Others become infected when they take in the disease causing agents by eating soiled food or by drinking water contaminated with fecal matter. Enteric diseases are common throughout the world and, in most areas, some part of the population is always infected.

This technical note discusses measures which can be instituted to control the spread of enteric diseases. Special emphasis is given to basic preventive measures that should be taken to provide hygienic conditions in individual households and in the entire community.

Useful Definitions

DEHYDRATION - A condition in which the body loses more liquid than it takes in.

FECES - The waste from the body, moved out through the bowels.

PARASITE - Worms, insects or mites which live in or on animals or people.

STOOL - Human excrement, or a single bowel movement.

VIRUS - Germs smaller than bacteria which cause some infectious (easily spread) diseases.

Disease Transmission

The transmission of enteric diseases is by the fecal-oral route. The bacteria, parasites or viruses (germs) pass from the body of an infected person in excrete. The germs later enter the body of an uninfected person through the mouth. There are two main ways that germs can enter an uninfected person or re-enter the same person

· Through the water that people drink. In many situations, water supplies are contaminated by enteric disease germs. If a person drinks fecally contaminated water, he is likely to surfer from an enteric disease.

· Through the consumption of food. Food can be contaminated by dirty hands or raw infected water, or by being exposed to fecally contaminated organic fertilizer or garden soil. Vegetables thus contaminated would only be safe to eat after befog cooked or sterilized. Flies can carry germs to food. Flies that light on and taste food can inoculate food with germs that are consumed with the food.

Table 1 lists the principal enteric diseases and their routes of transmission. Diarrhea is a mayor symptom of all enteric disease. Many types of germs can grow on food if it is not refrigerated. Cholera and typhoid fever are dangerous to people of all ages. Cholera is an especially dangerous enteric disease. Among children, enteric diseases are a mayor cause Or high mortality. Diarrhea is the leading killer of small children in most developing countries. It kills by dehydration.


Table 1. Principle Enteric Diseases and Their Common Transmission Routes

Controlling Enteric Diseases

The control of enteric diseases involves three important interrelated activities: a health education program, a safe water and sanitation program, and home treatment of patients. These three activities should be implemented simultaneously and continuously.

Health Education

Most enteric diseases result from poor sanitation and a lack of safe (good quality) water in the community. Effective health education is necessary to help people understand the connection between improved hygiene and improved health. Health education aimed at eliminating the enteric disease should include the following:

· Formation of a community sanitation committee to coordinate the various activities and work needed to attack the problem.

· Participation of community groups. Teachers should be trained in the basics of disease transmission and prevention so that they can teach their students. Community groups, 4-H clubs, women's groups, other clubs, and the like should be active in health education.

· Development of audio-visual materials. Films, puppets, slides, songs, flashcards, and other methods can be used to make the problem and its solution clear to the members of the community. Students and clubs should be taught how to prepare their own audio-visual materials for demonstration.

· Implementation of specific education programs in clinics and hospitals.

Health education should start people thinking about the problem and create a desire to change their behavior to solve the problem. When people recognize the need to use a latrine and wash their hands, and understand the ways in which water is contaminated and the role of flies and other vectors in the spread of disease, they will be more willing to do something to change the situation.

Preventive Measures

Several measures can be taken to either remove sources of disease transmission or to prevent the sources from ever existing.

Latrines

· Build latrines at least 15m from any water supply or household. Be sure to site latrines so that they are downhill from any water source. Do not excavate pits into the water table. See Figure 1.


Figure 1. Proper Location of Privy

· Make sure that all latrines are sanitary. Ideally, the latrine should have a concrete floor. When not in use, the hole through the floor should be covered. Uncovered latrines permit the breeding of files which can carry disease agents from feces to food. See Figure 2.


Figure 2. Cover Latrine Openings Tightly

· Accustom people to use latrines. One of the biggest problems is getting young children to use a latrine. Parents may use it but allow their children to defecate on the ground. Latrine openings should be sized so that children do not fear falling in. For more information on latrine design and construction, read the appropriate technical notes on sanitation. See "How to Use Technical Notes," HR.G, for a full list of technical notes. If latrines are not used, water sources can easily be contaminated by surface run-off.


Figure 3. Proper Protection of Water Supplies

Water Supply

· Provide for a safe supply of water for the community. Read the appropriate technical notes on rural water supply. Protect all wells from the entrance of surface run-off. A wellhead and a pump should be installed in order to prevent contamination from entering the wells.

· Cap springs to prevent their contamination from surface run-off. See Figure 3.

· Where wells and springs are not protected or where surface water sources are used, water should be treated. Individual or community treatment should be used depending on the situation. Boiling and chlorination are the most common methods. For information on water treatment methods, see "Methods of Water Treatment,''
RWS.3.M.

Hygiene

Personal and household cleanliness is important for preserving health. The following practices are essential for controlling the spread of enteric diseases. Figure 4 shows some of these practices.

· Always wash hands with soap and water before eating and after using the latrine.


Figure 4. Individual Preventive Measures

· Wash fruits and vegetables before eating them. Be sure to scrub those vegetables which grow in ground that may be infected.

· Do not allow animals to enter the house.

· Store food in screened areas or in refrigerators and cover food with netting. These measures will keep flies away from food and help prevent she spread of disease.

· Keep the house clean by sweeping it daily.

· Require that food handlers are trained in personal hygiene and are Aware of the need to store and cook food correctly.

· Dispose of all garbage properly. Make sure that garbage does not accumulate in such a way that flies can breed in it,

· Eat well. Diseases such as dysentery are more dangerous to people suffering from malnutrition

Treatment Measures

At the same time that health education and preventive measures are being implemented, measures to treat patients with enteric diseases should be adopted. When diarrhea is present, liquid and salt are rapidly lost and must be restored to the body. Many children die from diarrhea or dysentery when they do not have enough water in their bodies. Persistently and frequently give liquids to a person with diarrhea. In severe cases in children, rehydration liquid should be given. Preparation of a rehydration drink: to a liter Or boiled water, add two tablespoons Or sugar, one-quarter teaspoon of salt, and one-quarter teaspoon of taking soda. Give the dehydrated person sips Or this drink every five minutes, day and night, until he begins to urinate normally. An adult needs at least 3 liters Or water each day while a child needs 1 liter. Table 2 lists foods that should and should not be eaten by a person with diarrhea.


Table 2. Foods for a Person with Diarrhea

Where diarrhea is very severe and looks like it will not stop, keep giving liquids to the patient and seek medical help immediately. Seek medical help when:

· Diarrhea lasts more than four days and is not getting better or more than one day in a small child with severe diarrhea.

· A person is dehydrated and getting worse.

· A child vomits everything it drinks. .

· The child begins to have fits or its feet and face swell.

· The person was sick or malnourished before the diarrhea began.

· There is blood in the stool.

Under these conditions, a more serious enteric disease may be present in the system and some type of drug treatment will be necessary.

Handout 3D: Water, excrete, behaviour and diarrhoea

Improving only water quality or only latrines will have lime or no effect on the incidence of diarrhoeal disease. Richard Feachem discusses how only an integrated control pro" gramme can be effective in the long term.

Oral rehydration and other curative approaches to diarrhoea may have a great effect upon mortality, but they cannot significantly reduce transmission or the incidence of infection and disease. Most children may be kept alive by a comprehensive curative programme which makes simple therapy readily available in the village, but they will continue to be regularly reinfected. The main goal of diarrhoea programmes must therefore be control.

How is control to be achieved?

There are three basic approaches:

· interrupting transmission by the improvement of water supply, excrete disposal and hygiene

· improving the general health of children by improved nutrition and reducing the incidence of other infections

· immunization.

In the long run control will be achieved by a combination of each of these approaches but it is significant that, in developed countries, and in wealthy communities in developing countries, control has been achieved by a combination of the first two alone.

Transmission

The classical view of diarrhoeal disease transmission, derived from studies of mayor urban common-source outbreaks, was that it is primarily associated with faecally contaminated drinking water - in other words it is water-borne. This view has been progressively modified as more and more information has come to light on the non-water-borne transmission of diarrhoeal diseases in both endemic and epidemic situations.

It now seems very probable that, among poor people in developing countries, most of the spread of organisms which cause diarrhoea is by faecal-oral routes that do not involve drinking contaminated water. All the main diarrhoea-causing pathogens are transmitted from anus to mouth and there are many opportunities for such transmission in a poor and crowded community.

Water-borne transmission is but one special case of faecal-oral transmission and most authorities would agree that a great deal of the transmission of rota-viruses, shigellae, enterotoxigenic E. coli and Entamoeba histolytica is by non-water-borne routes. There is less agreement on the transmission of cholera. Some suggest that cholera is largely waterborne everywhere; others that it is mainly water-borne in Bangladesh but not necessarily elsewhere. However, a third group maintain that it is not primarily water-borne anywhere.

Water quality

Water-borne transmission is reduced by improving water quality. Many people drink heavily contaminated water (containing up to 10² E. roll per 100 milliliters) from open wells, ponds or streams. Replacing these sources by piped water or protected wells will dramatically improve water quality and will therefore reduce water-borne transmission. However, some studies in Bangladesh, Guatemala, Lesotho, the United States of America and elsewhere hare found that such improvements failed to have a marked effect on diarrhoeal disease incidence. One possible explanation for these findings is that diarrhoeal diseases in the communities studied were mainly non-water-borne.

Water availability and water use if diarrhoea-causing pathogens are being transmitted by non-water-borne routes (es instance on hands, clothes and food) it is important to improve personal and domestic cleanliness. This is difficult, if not impossible, when the nearest water source is far from the house and the water must be laboriously carried in small containers. It is also difficult when there is a tap near the house which provides only an intermittent supply. Improved personal and domestic cleanliness depend upon an abundant supply of water (about 30- 40 litres per person daily) located near the house and available 24 hours a day for 365 days of the year. Improved cleanliness also depends on the correct use of the water once it is available, and this behavioural factor is discussed below and on page three.

Excreta disposal

The main diarrhoea-causing pathogens are shed in the faeces and therefore the hygienic disposal of human faeces is of the utmost importance. Each family must have access to a latrine which ail members use and keep clean. The latrine must be acceptable and attractive to the users. Some studies have shown that the construction of latrines does not necessarily reduce the incidence of diarrhoeal diseases. This is probably because the latrines were not used, not kept clean, or not used by the most important section of the community - the children.

Behaviour

The provision of good water supplies and latrines will achieve little unless people understand these new facilities, like them, maintain them and use them. Therefore ail water and excreta disposal projects must be accompanied by vigorous programmes of community education and must be planned and implemented in cooperation with the community The promotion of frequent hand washing may be especially effective

Focus on children

Children are not only the main sufferers from diarrhoea, they are also the main source of infection. Symptomatic and asymptomatic infection rates are highest in children and is their faeces which are most likely to spread infection to the rest of the family and neighbouring households. The defaecation and hygienic behaviour of children is the vital but neglected component of diarrhoeal disease control programmes.

For children under about four years the educational programmes must be directed at the parents, especially the mothers. For older children, education of both children and parents is important. The design of educational programmes to change child hygiene will vary enormously from community to community. However, in many cultures (including my own in England) parents often believe that the faeces of small children are fairly harmless. It would be relatively simple to design a programme to convey the message the stools of small children are dangerous.

An integrated approach

There is abundant evidence that improving only water quality or only latrines will has e little or no effect on the incidence of diarrhoeal disease. We must hope, and evidence exists to support this hope, that a combination of improved water qualify' increased water availability, hygienic and acceptable latrines, and vigorous and sustained educational programmes will be effective. The impact of such an integrated approach will clearly be different on different types of diarrhoea. For instance, cholera, typhoid and shigellosis may be substantially reduced whereas rotavirus diarrhoea is likely to be unresponsive.

Nevertheless the goal must be to design affordable and effective integrated programmes which will reduce overall diarrhoeal disease morbidity and mortality even before there has been any dramatic reduction in poverty. The most cost-effective mixes of water, sanitation and education arc yet to be defined and arc a major priority of the applied research component of the WHO Diarrhoeal Diseases Control Programme to be described in the next issue of Diarrhoea Dialogue.

Handout 3E: Primary health care

"Primary health care is essential health care based on practically, scientifically sound and socially acceptable methods and technology made university accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which is the central function and main focusa, and of the overall social and economic development of the community. It is the first level of contact of the individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process."

- from the Declaration of Alma-Ata

A 1975 recommendation by the UNICEF - World Health Organization (WHO) Joint Committee on Health Policy was the first major official recognition of the primary health care concept, which has been steadily gaining momentu in recent years. Primary health care was elevated to an even higher level of importance at the International Conference on Primary Health-Care, held in Alma-Ata, USSR, in September 1978, jointly sponsored by WHO and UNICEF. There, delegates from 140 nations and a variety of Non-Governmental Organizations unanimously approved the Declaration of Alma-Ata, calling for urgent and effective international and national action to develop and implement primary health care throughout the world, particularly in developing countries, aiming toward "an acceptable level of health for all the people of the world by the year 2000."

Community, Communication, and the Health Practitioner
by Cecile De Sweemer

Like other development efforts, primary health care in developing countries depends heavily on communication, a dependence that is intensified both by primary care's special and by the importance of helth to other development efforts. Primary health care seeksto deliver promotive, preventive, and curative care for the most common diseases through the most cost-effective means. It aims directly at the reduction of morbidity and mortality, and, where the appropriate motivation exists, can be used to make related services such as family planning wide available. It thus contributes significantly to the aspect of development termed the "quality of life" and can have a strong impact on people's perception of their achievements in development.

Maurice King, in Medical Care in Developing Countries (Nairobi: Oxford University Press, 1966) suggests a number of principles on which primary health care should be based. These statements are as valid today as when they were formulated:

· Patients should be treated as close to their homes as possible in the smallest, cheapest, most humbly staffed, and most simply equiped unit that is capable of looking after them adequately...

· Some form of medical care should be supplied to all people the same time.

· In respect of most of the common conditions there is little relationship between the cost and the size of a medical unit and its therapeutic efficiency.

· Medical care can be effective without being comprehensive...

· Medical services should be organized from the bottom up and not from the top down.

· The health needs of a community must be related to their wants.

The constant effort, in fact, is to get "the maximum return in human welfare from the limited money and skill available."

Primary health care projects around the world have found that the implementation of primary helath care hinges on the quality and quantity of communication. "Extension", "health education", and "community orientation" have all tried to capture the essence of the communication process. They are incomplete terms, as they seem to imply unilateral communication from the health services institutions to the people. The successful examples have gone far beyond this pattern, stimulating feedback from communities and recognizing in program design the importance of face-toface communication between community members.

Primary health care in developing countries consists only partially of the services to be performed for people in the curative and preventive realms. It also constitutes a major effort to reorient the helth-related behavior of the people by giving them new knowledge and new skills. Preventive and curative services derive part of their utility from their role in support of communication efforts to change health behavior.

For example, in most developing countries diarrhea is a major killer, particularly of small children. At least one-third of all early childhood deaths in Latin America are attributable to diarrhea. Diarrhea kills through dehydration and shock. If oral rehydration is started when the first abnormal bowel movement takes place, the chances of the diarrhea's becoming fatal are greatly reduced.

Curative services for diarrhea should thus be accompanied by a major educational effort to teach the mother of the sick child the procedures for preparing and administering simple water-salt-sugar solutions for oral rehydration. If these are taught to a mother when her child has a diarrheal problem, she has an enhanced eagerness to learn, and she gets immediate feedback on the practicability and utility of the new behavior. This not only encourages the learning process but also sets a precedent to encourage the mother to help teach the new health behavior. This not only encourages the learning process but also sets a precedent to encourage the mother to communicate the new information in turn. Such lateral communication is likely to cover more of the population more quickly and with a deeper impact than would ever be possible merely through the health practitioners themselves.

Trainer Attachment 3A: The global impact of diarrhea

Oral rehydration therapy

As the half-way point in the first year of life approaches, one of two evils begins to undermine the normal growth and weight-gain of tens of millions of the world's infants. The first is that the mother will not begin to give her baby other food in addition to breastmilk. The second is that she will.

From the age of five or six months, breastmilk alone is no longer sufficient to meet the needs of a growing child. If supplementary feeding is not now introduced, then growth slows down, weight-gain falters, and resistance falls. Not beginning to add supplementary foods at this time therefore pushes the child towards the edge of the vortex of malnutrition and infection. Yet in many countries, including India and Bangladesh, more than a third of all infants are still being exclusively breastfed even at the age of one year or more. At that point, malnutrition is the certain result.

If, on the other hand, supplementary foods are introduced at the age of five or six months, then the risk of infection and malnutrition is almost as great. For as a child is weaned from the breast on to other food and drink, so it is weaned into increasing contact with an outside environment which may well include unsafe water, contaminated foodstuffs, unhygienic sanitation and uncontrolled infection. Weaned or unweaned therefore, it is at this point - mid-way through that first year - that so many millions of young children slip into the downward spiral.

To keep a child growing normally, there is no question that the introduction of supplementary foods must begin at this time. So help for the mother - help in weaning her child safely - is the next obvious fulcrum against which leverage for improvements in child health and growth can be exerted.

For most infants in most pans of the developing world, the greatest danger of the weaning period is the danger of dehydration induced by diarrhoeal infections. A study in the villages of Guatemala, for example, has shown that the incidence of diarrhoea increased sharply in the second six months of life and rose to become twice as likely in the second year as in the first.

To protect the child from diarrhoeal infection is a task which no mother can accomplish alone. For it involves an armoury of deterrents - health and nutrition education, more and better weaning mixes, more hygienic preparation and storage of food, more water and safer sanitation, improved domestic and personal hygiene, and immunizations against diarrhoea-inducing infections like measles.

Action on all of these fronts is obviously necessary - and not just for the prevention of diarrhoea. But in the meantime, dehydration continues to claim the lives - and strike at the growth - of millions of children in almost all communities of the developing world. Mothers therefore need help now if they are to protect the health and growth of their children through the vulnerable years. Thanks to one of the simplest but most important breakthroughs in the history of science, that help may now be at hand.

Diarrhoea itself is so common in the developing world - with an estimated 500 million children suffering the infection three or four times a year - that most parents regard it as just a normal part of growing up (see Figure 1.11). Normally, the infection cures itself in a matter of days, but in about 10% of all cases, something starts to go seriously wrong.

Perhaps feeding stops - the natural reaction of most mothers when a child has diarrhoea. Perhaps the child just won't eat - the appetite depressed by infection. Or perhaps the child's powers of recovery are already at a low ebb. Whatever the cause, the infection persists and the fluids continue to drain from the body. soon, 5% of the child's bodyweight is lost. Even now, most children will recover- though their growth will have received another serious setback. But for some, the diarrhoea continues.

In a matter of hours now, the child's skin begins to lose its resilience and the thirst becomes unbearable? though the child may not have the energy to express it Without urgent treatment, 10% of body-weight is soon lost. Now shock sets in, and stupor. Blood pressure begins to drop. The pulse quickens. Within minutes the kidneys begin to malfunction. Acids build up m the body. Peripheral blood cells begin to collapse.

One our of every 20 children born into the developing world dies like this before reaching the age of five.

Until recently, the only effective treatment recommended for dehydration was the intravenous feeding of solutions administered by qualified personnel in medical institutions which were beyond the physical or financial reach of most mothers. Now, the great majority of those 5 million dehydration deaths could be prevented by another breakthrough in the child health revolution- the use of oral rehydration therapy (ORT).

Attempts had often been made to rehydrate patients by mouth - usually by making them drink solutions of salt and water. But diarrhoeal infections not only increase the loss of fluids and salts from the body, they also inhibit the absorption of salts and water through the intestinal wall. Nonetheless it was the addition of sugar to such a salt and water solution, in an attempt to make it more drinkable, which led to the accidental discovery of oral rehydration therapy. For it was shown that the absorption of sucrose was not affected by the infection. And the sucrose carries salt and water through with it.

So by using glucose as a Trojan Horse to smuggle salt and water through the intestinal wall, oral rehydration was suddenly made possible. Mixed in the right proportions, the sugar can increase the body's absorption of the salt and water by twenty-five times. And by administering enough of the solution to replace fluids lost to body during diarrhoea, dehydration can be prevented or corrected in almost all cases. In the remote Teknaf region of Bangladesh, for example, a three-year study of over 30,000 cases of diarrhoeal infection has shown that 95% could be successgully treated by ORT.

Oral rehydration salts can be made up locally in health centres (see panel p. 3). Or with the right kind of community education programme, an almost equally effective mix can be made by mothers using ordinary domestic sugar and salt - supplying potassium in the form of bananas, plantains or papaya. Alterantively, the right proportions of salt and sugar, with small quantities of potassium and bicarbonate (to correct metabolic acidosis), can be made up and pre-packed in factories at a cost of less than 10 cents.

Whatever kind of oral rehydration method is used, the two vital messages for parents are:

· Continue feeding even when your child has diarrhoea and...
· Begin replacing fluid losses by oral rehydration treatment as soon as the diarrhoea begins.

By this technology and these messages, most dehydration deaths can be prevented and growth can be maintained. Studies in the Philippines, for example, have shown that children treated with oral rehydration therapy during attacks of diarrhoea maintained monthly weight gain whereas children who did not have ORT available had lost weight as a result of diarrhoeal infections.

So much for the theory. Does ORT work in practice?

· In Guatemala, child deaths have been reduced by half among a population of 64,000 people in the eastern region of the country after 'health promoters' began teaching mothers how to use locally-made packets of oral rehydration salts (see panel p. 3).

· In Egypt, child deaths in the Nile village of Berket Ghatas have been reduced by 50% whithin a year of a community-backed oral rehydration campaign (see panel p.11).

· In India, a population of 18,000 people in thirteen villages of the Punjab has seen its infant mortality rates from diarrhoeal infections halved by ORT in less than two years.

· In Costa Rica, child deaths from dehydration have dropped by more than 80% in hospitals since ORT was introduced and the hospital services have saved an estimated $3 million in the first year.

· In Egypt, thousands of mothers have reduced the overall pre-school death rate from Diarrhoeal diseases by 50% - using home-made salt and sugar solutions.

· In Bangladesh, community-based distribution of oral rehydration salts in the village of Shamlapur (population 7,000) resulted in 80% of diarrhoea cases being treated with ORT and a fall in the death rate to 0.5% of all cases as opposed to 2.4% in comparable villages.

· In India, death rates from diarrhoea in six village' fell to levels 80% lower than in nearby villages after health workers and community organizations began promoting locally-manufactured oral rehydration salts.

· In Honduras, the number of diarrhoea deaths among children under the age of two has been almost halved by the use of ORT. One year after the beginning of an education campaign-backed by intensive radio coverage - 95% of mothers knew how to make and administer the salts (see panel No. ).

· In Trinidad and Tobago, child deaths from diarrhoeal infection dropped by 60% in the General Hospital, Port of Spain, in the five years after ORT replaced intravenous feeding as the main treatment for dehydration.

· In Haiti, the diarrhoea death rate among children brought into the State University Hospital, Port-au-Prince, fell from 40% to 1% after ORT was introduced in 1980. Because the mothers themselves were taught ORT, each child benefited from intensive care' and earlier rehydration.

· In Bangladesh, 900 field-workers have taught 2.5 million women how to make ORT solutions from the salt and molasses available in every household. Follow-up surveys have shown that more than 90% of the mothers can prepare an effective mix and a significant number are now using it (see panel p. 29).

· In Nicaragua, 80,000 young literacy workers have carried the ORT message into thousands of households and 334 ORT units have been set up across the nation. From being the leading cause of child death in 1980, Diarrhoeal infection had dropped to fifth place by 1982. (see panel p. 21).

· In Jordan, 1,720 out of 1,732 cases of diarrhoea were successfully treated by ORT in the General Hospital of Amman.

· In one area of Turkey, the number of cases of Diarrhoeal inaction which had to be referred to fully qualified doctors has fallen from 34% to 4% since Assistant Nurse Midwives began taking oral rehydration salts into village homes and teaching their use.

Such examples demonstrate the potential of ORT. Both in preventing infant deaths and in preventing frequent setbacks to normal healthy growth, the technique could play a major part in a child health revolution And there are now signs that things are starting to move. Countries as diverse as Nicaragua, Haiti and Honduras have now launched ORT campaigns designed to put this breakthrough at the disposal of every family. In total, over 30 nations are now beginning ORT programmes and at least 20 are gearing up for large-scale factory production of oral dehydration "Its (see Figure 1.12). UNICEF itself is producing over 20 million sachets a year (or 87 nations and, together with the World Health Organization, we are assisting more than 20 countries to begin local manufacture. Brazil alone it preparing to produce 20 million sachets a year and Pakistan has stepped up its distribution of salts from one million sachets in 1982 to five million in 1983. In total, present annual production of oral rehydration gaits is running at around 80 million sachets a year as against the billion or more which would be needed if the sachets were to be made available to all children at risk.


Fig. 1.11 Child deaths from diarrhoeal infections

But shortage of the salts themselves need not prevent the rapid spread of ORT. For if parents have the knowledge and the confidence to mix sugar and salt and water in the right proportions, then an almost equally effective oral rehydration solution can be administered in the child's own home. Although not quite as good as the pre-packaged salts made according to the UNICEF and WHO recommended formula, this slight disadvantage is more than made up for if home preparation means that oral rehydration therapy can begin earlier. If the parents also know that they should keep on feeding the child throughout the illness and that the solution should be used to replace body losses as soon as the diarrhoea begins, then most of those 5 million child deaths per year could be prevented.

In all of this, the central challenge will remain the creation of support (or ORT among the health professionals, understanding within the community and confidence among mothers) (see panel p. 11). Several times, ORT campaigns have foundered because mothers who knew how to make an effective oral rehydrationmixture did not have the confidence to use it when the time came (see panel p.9). But once created, a parent's confidence in his or her own ability to bring about improvements in family health will probably not stop at ORT.


Fig. 1.12 Developing countries producing oral rehydration salts

The campaign to promote the knowledge and use of oral rehydration therapy was given a major boost in June of 1983 when experts and practitioners from all over the world convened at the International Conference on ORT in Washington D.C. to share recent experiences and plan future strategies. The Conference (sponsored by US AID, WHO, UNICEF, and the International Centre for Diarrhoeal Disease Research, Bangladesh) reached a consensus on all the fundamental points - that diarrhoea is a major killer and debilitator of children; that ORT is a safe, affordable and effective therapy; that the right basic chemical composition of the salts is generally agreed upon; and that the challenge now is how to put the new technology at the disposal of all who need it. 'Much progress has been made,' said Dr. Lincoln Chen in his summing up of the Conference's proceedings, 'much more needs to be done, and done soon. Oral rehydration therapy is increasingly capturing the imagination of the policy makers, the scientists, and the public.'

Meanwhile, further advances in the therapy itself are still being made. In the last two years, the International Centre for Diarrhoeal Research in Bangladesh (a pioneering institute which has been given substantial support by the United States Agency for International Development and by the United Nations Development Programme) has run successful field-trials with an oral rehydration solution based on ground-rice boiled into a thin soup with only a three-finger 'pinch' of salt added. Other creals - all of which contain the necessary glucose - could be used in the same way. Even cheaper and more available than sucrose or sugar-based solutions, these cereal-based salts have even less risk of side effects and shorten the duration of diarrhoeal infection. And even without the chicken or vegetables which can be added, they can help in the vital task of maintaining nutrition and protecting growth even through bouts of diarrhoeal infection.

Research is now needed to prove the viability of cereal-based salts and to find and test the combinations of locally available ingredients from which effective oral rehydration solutions can be made. But the more difficult challenge is to put what is already known at the disposal of millions of farmers who need it. And just as glucose and salt are two vital ingredients of the 'technological brekthrough', so support of the national community through all avilable means of communication and the rise of new kinds of local community through all available means of communication and the rise of new kinds of local community development workers are the two vital ingredients in the 'social breakthrough', so support of the national community through all avilable means of communication and the rise of new kinds of local community development workers are the two vital ingredients in the 'social breakthrough' which is as necessary as the salts themselves if ORT is to play its part in a child health revolution.

Nicaragua and Honduras: ORT cuds deaths

· Because child diarrhoea and the malnutrition that goes hand in hand with it were such deadly scourges in Nicaragua UNICEF's emergency assistance at the end of (he civil war in July 1979 was concentrated on oral rehydration Twenty-three oral rehydration units were established with trained staff distributing oral rehydration salts tree of charge and leaching mothers how to mix them at home The units soon showed their effectiveness. and the emergency effort rapidly turned into a priority national programme

The government used every available means to inform the public about oral rehydration All the mass media were co-opted. The campaign was splashed across billboards and leaflets comic books and posters were distributed nation-wide The 80 000 young workers of the mass literacy campaign carried the message to every part of the country along with the advice to continue feeding children during diarrhoea. Monthly reports from the oral rehydration units were widely circulated so as to dispel any doubts the medical profession might have

By 1982 there were 334 units in operation with a steady stream of child patients- more than 300 000 so far. And diarrhoea has taken from first to fifth place as a killer of Nicaragua's children

· In Honduras likewise diarrhoea has traditionally been the foremost cause of infant and child mortality and an intensive public information campaign has been mounted to combat it.

Radio was the principal channel for the Honduran campaign One 60-second radio spot - a song extolling the benefits of breastfeeding - quickly became a national hit; it was always followed by an announcement urging the use of Litrosol, a locally-packaged brand of oral rehydration salts. Other radio spots some of them humorous covered related topics such as the importance of hygiene in preparing a child's food.

Distributed simultaneously with the radio campaign was a large poster of a mother breastfeeding her child complete with rose laurel and the campaign emblem of a red heart Other eye catching posters gave instructions on why and how to use Litrosol

Mayors midwives and health workers were given stocks of Litrosol packers and they raised flags outside their homes displaying the red heart to identity them as dispensers of the salts

A year after the launching of the campaign the proportion of diarrhoea cases being treated with Litrosol rose from zero to 50%. Moreover 95% of women surveyed after a year knew about Litrosol and how to use it in the most heartening finding of all the death rate from diarrhoea in children under two fell by 40% within a year and a half.

Trainer Attachment 3B: A story about diarrhea


Picture One

This is the story of Thabo. Here is young Thabo when he was a happy, healthy child


Picture Two

One day Thabo's sister was helping her mother bring home drinking water from the river where others do the wash and bring animals to drink. She beg m feeling pains in her stomach.


Picture Three

She had diarrhea by the river in the tall grasses where other people did the same. Then she went back home and poured the water in the clay pot in the kitchen where it was stored uncovered for drinking, cooking, and washing dishes.


Picture Four

She poured out some of the water into a baby bottle to feed to her little brother Thabo. She did not wash her hands or the baby bottle before she gave it to Thabo.


Picture Five

The next day Thabo cried all day long and had diarrhea. Mother told Fatu, "babies always get diarrhea. Don't worry."


Picture Six

The next day Thabo still had diarrhea. His mother began to worry and decided that the only way to make him better was to stop giving him food.


Picture Seven

Thabo was very thirsty and cried for water but his mother did not give him water. She believed that water would make the diarrhea worse.


Picture Eight

Thabo became very weak and dry end still had diarrhea. His mother was very worried and she did not know what to do. When Thabo's father came home, he decided that the mother and baby should go to the clinic 10 kilometers away. He asked the local truck driver for a ride but the man demanded 100 francs and Thabo's father had only 50.


Picture Nine

Thabo's father tried to borrow money from his neighbor but the man had spent all his money on drink. He went to his boss Mr. Kola to ask for a loan. Mr. Kola refused, saying "you already owe 1000 francs from the last loan for Thabo's christening." Mr. Kola advised him " tell your wife to feed the family better so you and your children aren't so weak and thin.


Picture Ten

Five days later Thabo died. What caused Thabo's death! Could his death have been prevented?

Intervention Pictures


Figure


Figure


Figure


Figure


Figure


Figure

Trainer Attachment 3C: Suggestions for using the picture story

As you tell the story, hold up the appropriate picture. Then ask one of the participants to place it on the wall so that all the pictures form a circle going clockwise as shown below.


Figure

After the discussion of causes and interventions for diarrhea, ask participants to put the intervention pictures beside the pictures in the circle that the interventions affect, as shown below. Leave these pictures on the wall for reference in the next few sessions.


Figure

Session 4 - Dehydration assessment

TOTAL TIME

3 hours

OVERVIEW

Specific checklists and charts that summarize "what to look for" will help participants more accurately identify potential dehydration resulting from diarrhea. In this session participants identify the visual signs and symptoms of dehydration resulting from diarrhea. Using the WHO Diarrhea Treatment Chart, they assess the signs of dehydration presented in case studies and determine the appropriate treatment plan to follow for severity and degree of dehydration. There is an optional discussion of how to adapt the treatment chart for use with community health workers.

OBJECTIVES

· To identify the physical signs and symptoms of dehydration.
(Steps 1 and 2)

· To use the WHO Diarrhea Treatment Chart to assess signs of dehydration and determine appropriate treatment plans.
(Steps 4-6)

RESOURCES

- Treatment of Diarrhoea (ORT Resource Packet)
- Helping Health Workers Learn, Chapter 24, pp. 18-19.

Trainer Attachments:

- 4A Pictures of children with Signs of Dehydration.
- 4B Guidelines for Presentation of the WHO Treatment chart.
- 4C Answers for Exercises
- 4D Creating a Case Study
- 4E Adaptation of the WHO Treatment Chart

MATERIALS

Slide projector, (WHO or UNICEF) slides and/or pictures of children with physical signs of dehydration; poster-size version of the WHO Diarrhea Treatment Chart; newsprint and markers, plastic bag, water, gourd or plastic baby, thermometer, weighing scales.

PROCEDURE

Trainer Note

Prior to this session, obtain photos such as those shown in Trainer Attachment 4A (Pictures of Children With Signs of Dehydration) or slides (UNICEF or WHO) of children who exhibit some of the following signs of dehydration:

- dry cracked lips
- slightly sunken eyes
- inelastic skin (pinched skin does not respond after two seconds)
- weight loss
- sunken fontenelle
- sad listless appearance

Post these pictures in the room prior to Step 1. Obtain a copy of the WHO poster-size Diarrhea Treatment Chart (available from either the WHO country coordinator or local UNICEF representative) or make one using the small version in Treatment of Diarrhoea Try to get copies of these materials in the local language. You may want to simplify the chart based on conditions in rural communities. For example, it may not be possible to take the temperature because thermometers may not be available.

Also make a vocabulary list of terms related to dehydration in the local language.

One or two days before this session, ask a participant with some health background, to help you prepare the presentation of the WHO Chart for Step 3. The information they should include in their presentation is found in The Treatment of Diarrhoea Suggested guidelines for this presentation are found in Trainer Attachment 4B.

Ask two participants to prepare a role play for Step 4 on assessing dehydration using the WHO chart. Have them read pages 8-10 of Treatment of Diarrhoea and use those in Exercise B as a bests for the role play. Work with them to make sure that they ask all the questions and do all the measures listed in the left column of the WHO chart. Provide props such as a doll, a thermometer, scales for weighing, chart for the health worker, local dress for the mother.

Ask two participants to prepare a role play for Step 7 on Selecting the Proper Treatment plan using the WHO chart. Have them review the case on pages 20-22 in Treatment of Diarrhoea and use it as the basis for their role play.

The WHO Supervisory Skills Module for CDD, entitled Treatment of Diarrhoea, included in the CRT resource packet, is the primary handout for this session.

Step 1 (10 min)

Dehydration Picture Gallery

Introduce the session by reviewing the objectives, and explaining that they will be doing a "picture gallery" activity. Point to the posted pictures, or show similar slides or photos. Ask the participants to examine the pictures or slides and to individually record the physical symptoms they observe without discussing their observations with others. Have participants describe how each child appears to feel (e.g., lethargic, inactive).

Step 2 (20 min.)

Discussion of Observations in Pictures

Hold up or show the pictures or slides of dehydrated children one at a time and ask the participants to share their recorded observations. Write their response on newsprint and post the appropriate picture next to it. Discuss the limitations of observations. Emphasize the need to ask questions, feel the child and take certain measurements.

Using the captions on the back of the pictures, review the signs and symptoms of dehydration.

Trainer Note

In reviewing the signs and symptoms of dehydration, also use a drawing such as the one below as a summary of all the key points. See the Treatment of Diarrhoea, pages 8-13 for a list of signs and symptoms.


Figure

Some of the participants observations may relate more to malnutrition, vitamin deficiencies and/or certain infectious diseases than to dehydration. While the children in the photos may indeed be suffering from these conditions, the purpose here is to concentrate on and discuss only the symptoms of dehydration. Sessions in Module 3 (Nutrition and Diarrhea) discuss the interrelationship between diarrhea and malnutrition.

Step 3 (15 min.)

Introducing the WHO Chart

Ask the preassigned person to assist you in introducing the chart. Post the large version of the WHO Chart. Refer to the photos from Step 1, during this presentation.

Step 4 (20 min.)

Using the WHO Chart to Assess Dehydration

Ask the two participants to perform the role play they prepared to demonstrate the use of the WHO chart to assess a "case".

Ask one of the participants to describe, step-by-step, what was done in the diagnosis of the dehydration case and questions the "health worker" asked the mother. Ask the rest of the group to add comments and corrections.

Ask participants to look at the chart in their copy of the Treatment of Diarrhoea and decide and discuss:
- Were the questions on the chart asked during the demonstration?
- What signs and symptoms were mentioned (point to these on the chart)? What was the assessments Has it correct?

Step 5 (20 min)

Practice Assessment of Diarrhea and Dehydration

Ask the participants to turn to page 28 of the manual Treatment of Diarrhoea. Have the participants form small groups and work through the exercises on pages 28-31 and write their answers on a sheet of paper. Suggest that they review the pictures of children with signs of dehydration to help them complete the assessment exercise more easily. Tell them to answer only the questions related to assessment and hold the questions on treatment until later in the session.

Step 6 (20 min.)

Comparison and Discussion of Assessments

Reconvene the group. Ask one small group to report and initiate discussion on each exercise, The reports should include explanations of how each group arrived at an assessment. Allow time for questions and discuss any differences of opinion or conflicting answers. Also discuss any difficulties encountered in using The WHO chart. Encourage participants to help each other solve these problems.

Trainer Note

Use Trainer Attachment 4C (Answers for Exercises) as a reference for the discussion of answers here and in Step B.

Steps 5 and 6 take considerably longer if translation into the local language is necessary or if Counterparts have difficulty reading. In these situations, assign only one case to each group.

If time is limited, you can go through the case assessments in a larger group discussion. Another option is to use the cases in the Treatment of Diarrhoea bock for self instruction. Have participants work individually and check their own answers as "home work". Provide an opportunity for questions and answers if you use this test option.

Step 7 (25 min)

Determining Proper Treatment for Diarrhea and Dehydration

Uncover and point to the treatment plan portion of the large WHO chart. Note that Treatment Plan A is used when there are no signs of dehydration; Plan B is used with mild dehydration and Plan C is used in the clinic for severe dehydration.

Ask the second pair of role players to do their performance by selecting a treatment plan and advising the mother how to care for the child.

Discuss the role play and ask a participant to summarize Treatment Plan A.

Describe one of the case examples and answers from Treatment of Diarrhoea (pages 2324) to illustrate and summarize Treatment Plan B.

TRAINER NOTE

For the case using Treatment Plan A, the following rules for home treatment should be stressed:

- Increase fluids

- Continue feeding (food should be offered five to seven times a day).

- Lock for signs of dehydration.

- Give the sugar-salt or ORS solution (If available) every time the child has a loose stool and if the child vomits wait ten 10 minutes and then continue to give solution in small amounts.

- The mother should go to a clinic if diarrhea persists for longer than two days or at the first signs of dehydration.

Emphasize that Treatment Plan A is extremely important and that if begun at the first sign of diarrhea and mixed correctly this treatment may prevent dehydration.

The main points in Treatment Plan B are:

- The amount of ORS to give depends on the child's weight or age.
- The child's status should be reassessed after four to six hours of treatment.
- This plan should be followed if the child shows two or more signs of dehydration.

In both cases the participants should understand that the solutions should not be kept more than 12 hours. ´Also, that their role for the most part will be in explaining to mothers how to make and when to give sugar-salt solution and when children should be referred to health centers for treatment with ORS packets.

Emphasize that treatment Plan C is for health clinic use. Any cases with symptoms in column C should be referred to a clinic immediately.

Step 8 (20 min.)

Case Studies

Ask the participants to go back to the case studies from Steps 4 and 5 and work individually to answer the questions which refer to treatment using the WHO treatment charts and what they've learned from the previous step.

Give them 15 minutes then ask for volunteers to read their answers. Discuss any differences or difficulties the group encountered in using the chart.

Step 9 (10 min.)

Review of the Session

Ask a participant to summarize the main points they learned in this session.

Trainer Note

This summary should include the main things to "lock for" in assessing dehydration and when to refer children to health centers.

If possible, the participants should be taken IV a health center where they can observe health workers assessing children for diarrhea and dehydration and treating them. If possible; arrange for opportunities for- participants to practice assessing dehydration under the supervision of a qualified health worker. Practice with case studies and pictures is not adequate to master dehydration assessment.

In previous training courses it has been useful to provide additional case studies for practice in dehydration assessment. Trainer Attachment 4D (Creating Case Studies) can be used to develop other case studies similar to those in Treatment of Diarrhoea. You can present cases at the beginning of each day or turn them into role plays like the one used in Steps 4 and 7.

Optional Step (60 min)

Adapting The Chart For Local Use

As a final application of the material from this session, discuss the advantages and disadvantages of the WHO treatment chart as a teaching tool for community health workers and how to modify it for local use.

The discussion should include some of the following questions:

- What modifications are needed for use in training literate community health workers?
- What basic information is needed for dehydration assessment in this country?
- Can the chart be adapted for training non-literate community health workers? How?

Trainer Note

Explain that the WHO Treatment Chart was developed as a basic model for adaptation to specific country conditions. Stress the importance of retaining the most essential instructions when such adaptations are made. These are summarized in Trainer Attachment 4E (Adaptation of the WHO Treatment Chart).

Session 18 (Adapting and Pretesting Health Education Materials) has information on adapting materials for use with different target groups. There is also an activity on adapting the WHO chart.

Trainer Attachment 4A: Pictures of children with signs of dehydration

Sunken eyes, dry mouth (dry, cracked lips) sleepy

AGE: 18 MONTHS

Skin does not go back when pinched. No tears though baby is crying

AGE: 3 MONTHS

Sunken fontanelle

AGE: 18 MONTHS

Sunken Eyes, dry mouth and tongue

AGE: 2 YEARS

Floppy, severe undernutrition. Very sunken eyes.

Trainer Attachment 4B: Guidelines for presentation of the who diarrhea treatment chart

Explain the purpose of the Chart

- To show how to assess patients for signs of diarrhea and dehydration
- To serve as a reference for medical personnel.

Briefly review the kind of information included on the chart and the layout of the chart pointing to the parts of the chart as you mention them.

- What to ask about, look at, feel and measure are listed in the left column.

- Across the top of the chart are three columns, A,B and C.

- Listed under A are symptoms indicating no dehydration.

- Listed under column B are symptoms indicating mild dehydration.

- Listed under column C are symptoms showing severe dehydration and other danger signs that require treatment at a clinic.

- Columns A, B. and C refer to treatment plans that you will discuss later in the training session.

Explain how the information on the chart relates to the earlier discussion of the signs and symptoms of dehydration. Briefly review and illustrate the following definitions of diarrhea and dehydration.

Diarrhea is a disease characterized by frequent passage of abnormally loose or watery stools.

Dehydration is loss of a large amount of water and salt from the body.

Use visual aids such as those shown below to illustrate these definitions.


For example. They can pick 2 flowers, put one in water, and keep the other without water. They will see that one lives while the other wilts and dies. Ask them why this happens.


Or the children can put a fruit like a plum or guava in the hot sun to see what happens to it.

Ask the children what they think happens to a baby when he dries out. Right! He loses weight and can become wrinkled.

Distinguish between chronic and acute diarrhea.

Acute Diarrhea is characterized by three or more abnormally loose or watery stools per day for three weeks or less and is caused by an infection of the bowel.

Chronic Diarrhea is characterized by diarrhea lasting more than three weeks and is caused by an infection of the bowel, undernutrition or by worms and other parasites.

- Explain that all children who show signs listed under Column D alone or in conjunction with signs from Columns A, B or C need to visit a health center for treatment with specific drugs as well as with oral rehydration solution.

- If watches are available with second hands, have participants practice taking a pulse and timing respiration rates. Ask them to take their temperature under the arm and in the mouth and compare their readings, if thermometers are available in the community health center.

Close the step by mentioning the five things a person should do in his or her continued assessment of the child's condition.

- Ask the mother about the child's condition
- Look for signs indicating the child's condition
- Feel the child for skin elasticity, pulse rate and sunken fontanelle
- Weigh the child
- Take the child's temperature.

Trainer Attachment 4C: Answers for exercises

TREATMENT OF DIARRHOEA
Possible Answers to Exercise E

Case 1

a. Yes. Sione has the following signs of dehydration:

8 watery stools
some vomiting
a skin pinch which goes back slowly
a sunken fontanelle
eyes that are a little sunken

b. No. Sione is not severely dehydrated.

c. The health worker should select and follow Plan B - Treat Dehydration with ORS solution.

d. The child should be given 200 to 400 ml of ORS solution in the first 4 hours.

e. If the child vomits, wait 10 minutes. Then, give more ORS solution slowly in small amounts.

f. The child should be reassessed after 4 - 6 hours.

g. Since some of the signs of dehydration are still present, Treatment Plan B will still be followed. Sione should be given 200 to 400 ml of ORS solution for another 4 - 6 hours. He should be breastfed between the times he is receiving ORS solution. This procedure should be repeated until the signs of dehydration have gone.

h. Plan A should be selected because there are no longer signs of dehydration, and the health worker wants to ensure that further dehydration is prevented.

Case 2

a. Ana has only one sign of dehydration. She is thirstier than normal.

b. The health worker should select and follow Plan A to prevent dehydration.

c. The child should be given 100 - 200 ml (or 1/2 - 1 cup) of ORS solution after each diarrhoea stool.

d. Give increased amounts of locally available fluids such as
_____________________________________________________
Feed the child as much as she wants 5 to 7 times a day, especially foods that are easily digested such as
_____________________________________________________
and those containing potassium such as
_____________________________________________________

e. Keep feeding the child and giving fluids. Also, watch for the signs of dehydration and bring the child to a health worker if they appear, or if the diarrhoea lasts another 2 days.

Case 3

a. Dano has the following signs of dehydrations

· more than 10 liquid stools a day
· quiet and floppy
· no urine for 6 hours
· dry eyes
· very sunken eyes
· very sunken fontanelle
· very fast pulse

b. There is severe dehydration.

c. Dano has a high fever of 40°C.

d. The health worker should prepare ORS solution for his mother to begin giving while taking Dano to the health centre (400 - 600 ml). m e solution should be given frequently in small amounts, such as by spoon.

e. The child should be given 150 ml (30 x 5) of IV fluid the first hour.

f. The child should be given 200 ml (40 x 5) of ORS during the next 3 hours.

g. Plan B should be selected and followed.

Trainer Attachment 4D: Creating a case study

Introduced by Joseph Naimoli and Elizabeth M. Edmands

Notes to the Trainer:

One way of teaching family health is through a case study. Case studies can focus on common situations that occur during the family life cycle. Case studies can also be used to teach students about factors to consider in uncommon situations. As a trainer, you can use the depth and richness of your experience to create your own case studies, which you can design for the specific group of health workers that you train, and which embrace the local customs, beliefs and practices in your setting. Creating a case study takes time, practice and skill, but you will find considerable satisfaction in what you can accomplish.

The general guidelines that follow provide a framework for you to create your own family health case study.

Guideline 1: determine specific objectives.

To begin, you must decide what you want the students to learn from the case study. It is assumed in family health case studies that the objectives extend beyond the teaching of clinical content to the broader concepts of concern and care.

Guideline 2: outline the content to be covered.

Collect information or recall the facts about cases you have known. Record this information. Decide what is missing. Determine whether to create some hypothetical "facts," or to purposely omit some information, such as the real names of a person or family.

Your outline should cover the broad categories to be included, but it need not be complete or detailed. Other content may suggest itself as you develop your case.

It is helpful to the reader to put in topical headings at appropriate points in the study. These headings also help to organize one's thoughts.

Guideline 3: develop the case study.

1. Focus on a family member in a community. The individual should have a problem and be identified by a title within the family (e.g., mother, son, grandfather).

Provide information about social, physical and personal history; age; appearance and personality; present signs and symptoms; and give beliefs and attitudes regarding current illness. Where appropriate, add occupation (current or previous).

A description of other family members is imperative - their relationship to the primary individual and their acute or chronic problems.

A description of the home and community is helpful: income, type of housing, sanitary facilities, food, resources, transportation and health personnel and facilities available. You may wish to have the students investigate some of these areas as part of the management of the case.

2. In writing up the case study, make a point of telling a story.

· Visualize potential settings based on your own practice and experience.

· Explore the parts about which you are less certain. . Reflect the humor and the pathos gently, but recognize that it is there.

· Recognize also the relationship between anxiety and illness.

· Keep in mind the logic of the situation. For example, don't create a situation involving a 52 year-old mother with a 6-month-old child or a man with three years of school working as a teacher.

Write as vividly as you can. Use descriptive adjectives to help the reader envision a person or a situation. Strive to awaken the students' interest without losing sight of the seriousness or complexity of family problems.

3. Select a format that is suitable for your purposes. If you use the case study format presented in this Journal, then formulating questions will be one of the most thought-provoking tasks that you will face. For example: what are the critical thoughts on assessment? What ideas do you have to stimulate the students to think about nursing or midwifery management? Have you raised questions that promote problem-solving techniques?

4. Read the first draft of the case study carefully. Examine it for logic, relationships of people, facts, and sequence. Usually, some inconsistencies emerge. Correct them

5. It is important at this stage to obtain the reaction and critique of more than one colleague. Because reviewers will tend to visualize your case study a little differently, be sure they understand the objectives and points described in the preceding sections.

Guideline 4: test and revise the case study.

In writing their first case studies, most trainers prefer to test them on a small group of students. This is understandable ant has considerable merit. Always expect that there will be questions. Some things that seem perfectly clear to you will have no point of reference for the student. You may have used terminology that needs to be clarified; perhaps you have focused on complex issues that the student doe. not understand.

However, you have to be the final judge of what revisions are indicated. Change for the sake of change is seldom worth the effort. At the same time, be aware that the student is your best critic. If the case study is rejected as being too simple, too complex, not based on reality, or raising irrelevant questions, probably no learning will take place.

Remember also that case studies need to be re-evaluated after use on a larger scale: are the objectives being met, are students gaining anything from this method of teaching, how do they like this method of teaching?

Other reasons for re-evaluating and revising a given case study might include: new information about etiology, prevention, diagnoses and treatment and nursing care of a specific disease.

Other considerations:

· Some of the best case studies have been developed by a team whose members have specific expertise. Examples of some team compositions are: nurses from obstetrics/gynecology, pediatrics, psychiatry, and public health; nutritionists; social workers; and representatives from the fields of sociology and education.

· Maintain a balance between information that is included and information that is omitted. There should be enough information to stimulate the students' thinking and to give them something to work with. At the same time, it is important to omit certain data so that students can identify that it is missing and needed.

· Observe all the principles of professional writing - clarity, accuracy, simplicity, and cohesiveness.

In addition to the above guidelines on how to write a case study, we present a new family health case study, "Stillbirth, " by Elizabeth M. Edmands, which we hope you will find appropriate and useful.

The preceding Braining tool is taken from A Manual of Case Studies in Family Health written during the African Health Training Institutions Project (AHTIP): University of North Carolina, Chapel Hill, N.C., USA.

Trainer Attachment 4E: Adaptation of the treatment chart

The following information is basic and should be included in even the simplest version of the chart.

1. Ask about: All information

2. Look at: Condition - well alert, sleepy, has fits.

3. Feel skin - pinch

4. Fever - burning

Treatment Plan A

1. Give homemade sugar salts solution after each loose stool 1/2 to 1 glass depending on age.

2. If child vomits wait 10 minutes and give a very small amount of liquid again.

3. Give other liquids (tea, breastmilk etc.) and other foods (multimix, carrot, soup, etc) 5 to 7 times a day.

4. Check for signs of dehydration, look, touch.

Treatment Plan B

1. Give solution made with ORS packets -

For children 6 months, give 1 to 4 glasses of pre mixed solution in 4 to 6 hours.
For children 6 to 12 months give 4 to 6 glasses
For children aged 18 months to 3 years give 6 to 8 glasses

2. Check for puffy eyelids. Stop giving until eyelids return to normal.

3. After 4 to 6 hour-e check dehydration status (skin, urine quantity, area of mouth is watery).

4. Give breastmilk or other liquid in between ORS.

5. If child vomits wait 10 minutes to give again.

6. After 12 hours make new solution.

Treatment Plan C

1. Send to health Center immediately.

Session 5 - Rehydration therapy

TOTAL TIME

4 hours

OVERVIEW

Effective treatment of dehydration requires the replenishment of salts, fluids, and nutrients to the body. Rehydration is necessary for all types of diarrhea. In Session 4 participants learned the signs and symptoms of diarrhea and dehydration that indicate the use of WHO Treatment Plan A (sugar and salt) to prevent dehydration, Plan B (ORS) to treat dehydration, and Plan C (IV or nasogastric tube) for severe dehydration and rapid Rehydration needs. In this session they develop a further understanding of the biological need for rehydration and the reasons for the effectiveness of ORS. Through hands on experience preparing solutions, participants explore the differences in ORT solutions. They also discuss the problems in preparing and giving ORT in the village.

OBJECTIVES

· To explain why oral rehydration is necessary for the prevention and/or treatment of moderate dehydration.
(Step 1)

· To accurately 01x two kinds of oral rehydration solutions.
(Steps 2, 3)

· To describe the components of two kinds of oral rehydration solutions and the appropriate use of each solution.
(Steps 1, 4)

· To describe problems in preparing and giving ORT in the village.
(Steps 5, 6)

RESOURCES

"Oral rehydration Therapy for Childhood Diarrhea, "Population Reports, The Treatment of Diarrhea (WHO Supervisory Skills).

Handout:

- 5A ORT Preparation Worksheet

Trainer Attachments:

- 5A Materials and Equipment Needed for ORT Stations
- 5B Using Models to Show Why rehydration is important
- 5C Suggestions for a Lecturette on the Hows and Whys of ORS
- 5D Oral rehydration Therapy: The Scientific and Technical Basis
- 5E Storing and Maintaining Supplies of Oral rehydration Salts
- 5F Oral rehydration With Dirty Water?
- 5G A Pinch of Salt, A Handful of Molasses
- 5H Cautious Prescription

MATERIALS

Newsprint, markers, Read Trainer Attachment 5A for list of materials and equipment needed for practice stations. Read Trainer Attachment 5B for materials needed for using models.

PROCEDURE

Trainer Note

In strict adherence to WHO guidelines, Peace Corps advocates the use of only two types of ORS solutions-prepackaged and sugar-salt solutions- in Peace Corps projects and in this training program. As discussed in Session 4 and reviewed in this session, WHO Treatment Plans A and B outline the appropriate and effective use of these two solutions in ORT. Before this session, find out what recipes for oral rehydration solutions the government and bother agencies are busing. In some areas more than one agency may be encouraging the use of ORT with different recipes. Be prepared to discuss these differences and their potential for confusing the public.

Please note that research is currently being conducted on "rice powder" ORS. Ricepowder ORS substitutes rice powder (i.e., ground rice) for glucose, an essential component of the standard OR formula (Rice-powder ORS should not be confused with rice water. Rice water is the fluid drained from the rice after cooking. Since it generally contains very little salt and variable amounts of rice starch, rice water is considered unsuitable for active rehydration. It is not an oral rehydration solution.) Possible advantages & disadvantages of rice powder ORS are being studied but no conclusions can be drawn until further research is done.

Trainers should only emphasize rice powder ORS in countries where a definite policy and guidelines on this subject have been developed and operationalized by the MOH. Only in countries where definite policies exist should rice powder ORS be incorporated as an ORT approach. In such cases, the trainer has the responsibility of becoming familiar with exact MOH guidelines and explaining those to the participants through discussion and a handout.

The main purpose of this session is to provide actual experience in correctly preparing the two kinds of solutions. Be sure to allow ample time for practice.

This session requires considerable preparation. Recruit the help of several participants to set up the work stations (with the materials, equipment and task descriptions explained in Trainer Attachment 5A), prepare for the demonstration, and clean up afterwards.

Identify individuals in the group or training center who have had experience preparing and using ORT to act as resource persons during Step 3.

If possible invite a local health worker to participate and assist in this activity. He or she may be able to help you arrange to give the solutions mixed during the session to children in the community or clinic during Step 7.

Ask participants to bring commonly used utenslis from their community work site. Each solution must be mixed as accurately as possible. Predetermine the quantities and weights measured by locally available utensils so recipe mixing may be done precisely under local conditions. Use these utensils in your demonstrations. (See Oral rehydration Therapies for Childhood Diarrhea in the ORT resource packet.)

Ask a participant to help you prepare the demonstration described in Trainer Attachment 5B (Using Models to Explain Why rehydration is important) and the lecturette described in Trainer Attachment 5C (Suggestions for a Lecturette on the Hows and Whys of ORS.

If available, get copies of the WHO Treatment Chart in the local language. hive prepare a list of ORT terms in the local language with the assistance of Peace Corps language trainers.

Step 1 (20 min)

Demonstration and Discussion of Why Rehydration la important

Introduce this Session using the plastic bag, the gourd baby and the watered and wilted flowers to illustrate the need to rehydrate a child with diarrhea (as suggested in Trainer Attachment 5B).

Ask participants to describe Treatment Plan A on the WHO chart, which they discussed in Session 4 (Dehydration Assessment) and explain what this demonstration tells then about Plan A.

Briefly discuss the fluids available in village hoses that are already used or could be used during diarrhea to prevent dehydration (Including sugar salt solution). Also discuss any cultural beliefs that night help or hinder teaching mothers to give children liquids during diarrhea.

Trainer Note

The main point of this activity is to illustrate why rehydration is necessary during diarrhea in a clear simple way that can be used by participants with mothers in the village.

It also provides a way to reinforce and use their learning about Treatment Plan A in the WHO Chart. They should recognize that the plastic bog and other models provide an explanation of why plan

Is very important. Emphasize prevention of dehydration as a major goal for their health education efforts in ORT. Refer back to the circle of pictures that you made for the diarrhea story in Session 3 (Prevention and Control of Diarrhea Note that oral rehydration is one important intervention in the circle.

Step 2 (15 min)

Lecturette on the Hows and Whys of ORS

Point to the pictures showing the signs of dehydration that were introduced in Session 4. Ask someone to quickly summarize the signs of dehydration. Explain that these physical signs are caused by the loss of sodium, potassium and nutrients during diarrhea, in addition to the loss of water.

Present the lecturette that you prepared using Trainer Attachment SC (Suggestions for a Lecturette on the Hows and Whys of ORS). If possible use a simple diagram to illustrate the way that the body chemistry balance is affected by diarrhea.

Ask someone to describe Treatment Plan B on the HO chart. Discuss the ingredients in ORS and how they help the body regain its chemical balance. Ask someone to explain in their own words when they would give ORS to a child with diarrhea and what the ORS does for the child in comparison to sugar salt solution.

Briefly discuss how people in the village have responded to ORS packets (or are likely to respond it they have not been introduced to them). Build on the discussion of cultural beliefs regarding the acceptability of liquids (from Step 1).

Close this step by telling the participants that they will be spending the rest of the session preparing two different oral rehydration solutions' the kind that should be used at the first sign of diarrhea to prevent dehydration (sugar-salt) and the type used to treat mild dehydration (ORS).

Trainer Note

Prepare two sheets of newsprint with the recipes for ORS and for sugar-salt solution as stated in The Treatment of Diarrhea, pages 17 and 42.

During the group's discussion of these two recipes, make sure that the following points are covered:

- Potassium is an essential element in the body and is lost during diarrhea. A minimum level of potassium is needed for the body to function.

- The amount of salt listed in the recipe 16 sufficient to replace sodium and water loss.

- Glucose is preferred to sucrose (table sugar) because it helps the body absorb liquid more quickly.

- Sodium bicarbonate helps prevent acidosis, a condition which decreases a dehydrated child's appetite.

- Mention that, as of 1985, the new WHO formula will replace bicarbonate of soda with trisodium citrate which has a longer shelf life and also appears to reduce stool volume.

- Home-made sugar-salt solution, made properly and used correctly along with other nutrients, can prevent dehydration but is not adequate treatment for dehydration because it lacks potassium in sufficient amounts to replenish body losses.

- OHS packets which are pre-measured and contain the added ingredients of potassium and bicarbonate of soda or trisodium citrate are important to use when treating mild cases of dehydration and can prevent the need for implementing Treatment Plan C, (IV or Nasogastric Therapy).

- None of these solutions should be kept longer than 24 hours. A fresh quantity should be mode daily.

For more technical background see Trainer Attachment 5D (Oral Rehydration Therapy: The Scientific and Technical Basis).

Step 3 (20 min.)

Preparing to Mix Oral Rehydration Solutions

Demonstrate how to mix the two kinds of oral rehydration solution. Have one or two people do return demonstrations and have the group critique their demonstration. Pass the solution around so that everyone has a chance to taste it.

Explain that everyone will be working in small groups at oral rehydration stations for the next hour. Each group will carry out the following tasks at each station:

- Read the instructions for preparing the solution at the station and take turns in mixing and tasting that particular solution.

- Discuss and complete Handout 5A (The ORT Preparation Worksheet) prior to moving to the next station.

- Clean up the station before moving on to the next one.

Trainer Note

In doing the demonstration, make sure that you'

- Emphasize washing hands before you begin mixing the solutions.

- Show all the utensils needed, using locally available items.

- Clearly state the ingredients and proportions, stressing the importance of being as accurate as possible.

- Emphasize that too much salt is dangerous to the child: too much aster makes the solution ineffective.

- Cover the solution when it is mixed.

- Explain how to store ORS packets. You can refer to Trainer Attachment 5E (Storing end Maintaining Supplies of Oral rehydration Salts) and page 19 in The Treatment of Diarrhoea.

An alternative approach is to do a correct demonstration then tell participants that you will be doing an incorrect demonstration and you want thee to tell you what you did wrong. This repetition helps them learn and remember the steps in mixing the solutions.

Step 4 (60 min)

Preparing Oral rehydration Solutions

Ask the group to fore small groups, move to the first station and begin preparing the solutions.

Trainer Note

During this step you should:

- Have resource persons who have mixed these solutions observe, correct and assist the participants with any problems or questions they nay have. Also tints person should make sure everyone uses proper hygienic techniques when mixing the solutions (e.g. washing their hands and all utensils before and after making the solution).

- Make sure each station has adequate supplies and ingredients available for each new group.

- Assign each group the task of reporting on one solution. These reports should include information contained in Handout 5A (ORT Preparation Worksheet) and Incorporate Information from the WHO Diarrhea Treatment Chart as to how much solution should be given, when it should be given and what other fluids and foods should be given when the child is belay treated with their assigned solution.

Step 5 (30 min.)

Discussing The Use of Oral Rehydration Solutions in The Village

Reconvene the group and ask each small group to report on their experience at one of the stations. Have someone from each group record the answers on newsprint, using the format from Handout 5A (ORT Preparation Worksheet). Allow about 5 minutes for each work station report. Encourage comments and discussion after each presentation.

Ask participants to think about what they have learned and answer the following questions:

- Which treatment should be used when a child has diarrhea? Some signs of dehydration? severe dehydration? Why?

- What problems do you foresee in preparation and use of ORS in the village? What about sugar salt solution?

- What can you do to overcome some of the problems encountered in teaching and encouraging people to prepare and use these solutions?

Trainer Note

Be sure to discuss the following kinds of problems:

- Lack of understanding in the village about the importance of accurate measuring.
- Lack of uniform measures.
- The use of too such salt or sugar.
- The cost or lack of availability of the ingredients.
- No ORS packets available at the local health post.
- Limited water supply and/or dirty water.

Make sure that everyone understands the difference between preventing and treating dehydration sad recognizes the need for the potassium and sodium bicarbonate or trisodium citrate (In the ORS packets) for treating dehydration.

Emphasize the importance of adapting the sugar-salt solution recipe to use locally available ingredients and to amounts appropriate for the utensils available for measuring.

Trainer Attachments 5F (Oral rehydration with Dirty Water?) and 5G (A Pinch of Salt, a Handful of Molasses) discuss some of these problems and describe ways to deal with thee.

Following this step you may want to use the optional step (Discussing Drugs Used to Treat Diarrhea).

Step 6 (45 min.)

Practice in ORT

Demonstrate how to give oral rehydration solution to an infant, Including what to do if the infant spits up the solution or is reluctant to take it. Have one of the participants do a return demonstration.

If possible, give all the participants an opportunity to give the solution to an infant or child during or after this session.

After they finish practicing, discuss problems encountered and ways To overcome them.

Step 7 (15 min.)

Session Summary

Ask the participants to summarize the key points that should be taught about rehydration solution preparation and administration in the communities and how they would do this.

Trainer Note

Information that they should include on how to educate community and family members about home treatment of diarrhea can be found in The WHO Supervisory Skills Module, "Treatment of Diarrhoea" pages 4-6.

Optional Step (15 min)

Discussing Drugs Used to Treat Diarrhea

Depending on the health background and task assignments of the participants, you nay want to use Trainer Attachment 5H (Cautious Prescription) and page 55 of Treatment of Diarrhoea to discuss the types of diarrheal diseases that do require drugs in addition to oral rehydration.

- What kinds of drugs are commonly used to treat diarrhea in this country?
- Why is this use of drugs dangerous?
- How can we overcome the idea that drugs are the best cure for any kind of diarrhea?
- What do people in your communities think about the power and/or danger of medicines?
- Who should decide whether a drug is needed to treat a case of diarrhea?

Trainer Note

Emphasize that drugs should be "cautious prescriptions.. They should be given cautiously and only when there is a clear indication (such as bloody stools and high fever) that the cause of the diarrhea is a disease that requires drug treatment. They should be prescribed by a qualified health worker. Drugs should never be given as a routine practice for treating diarrhea. A drug that is not needed can be harmful to the body in a variety of ways; giving the drug is likely to divert the mother's attention from oral rehydration, widespread use of drugs promotes the development of drug-resistant strains of diseases; and antibiotics are expensive.

You nay want to assign two people to visit a local pharmacy or store to ask about and get samples of drugs commonly used to treat diarrhea in the host country. You can ask them to report their findings at the beginning of this step.

Handout 5A: ORT preparation worksheet


Worksheet

Trainer Attachment 5A: Materials and equipment needed for ORT stations

Introduction

The set-up for Stations. 1 and 2 is' intended to permit participants to learn how to prepare two kinds of oral rehydration solutions under organized, clean conditions, wing local utensils and measures. Modify these preparations to fit government standards for ORT preparation.

If the training is conducted at a regional site near a community, you may want to arrange opportunities for participants to mix ORT solutions in local homes, under the supervision of someone skilled in mixing ORT.

Both Stations should have:

- soap and water for handwashing,
- clean water for mixing the solution,
- ladle or means of drawing water,
- hand towels,
- spoons or utensils for stirring,
- drinking glasses or cups for tasting solution.
- large (over 1 liter) container to use in stirring the solution

Station 1: Pre-packaged Solutions

- Proper size containers (usually over one liter but marked to give volume corresponding to exactly 1 liter) for mixing packets and water

- Local containers that approximate 1 liter

- Enough Packets for all participants to mix the solution

Instructions

- Mix the solution in the marked container and pour it into the local container.

- Note hoc closely the local container matches the volume of the marked container and what problems this could cause.

- Complete the ORT Preparation Worksheet (column one) this station.

Station 2: Homemade Solutions: Sugar and Salt

- Proper size local container and marked container for mixing.

- Measuring spoons

- Plenty of salt and sugar (If baking soda is available and is part of the government standards for mixing ORT solutions, include it)

- Knife for leveling measurements

- Weighed, labeled correct amounts of ingredients fusing the WHO recommendations).

It the government standard measurements are the handful and the pinch, have participants compare the weighed amounts of ingredients with their own "handful" and "pinch." This reduces variation in measurement resulting from differences in hand size and perceptions of what constitutes a handful or a pinch. Be sure to include the weighed ingredients in your demonstration. Stress the importance of accurate measurement.

If locally available salt is very coarse, provide a means to grind it for more accurate measurement.

Instructions:

- Measure and mix the solution.

- Compare your measured amounts with the samples of ingredients that were weighed exactly.

- Complete the ORT Preparation Worksheet (Column two). Give particular attention to " problems in solution preparation. and how they could affect the success of mixing ORT solutions in the home.

Trainer Attachment 5B: Using models to show why rehydration is important

Below are two examples of simple ways to present the idea of rehydration. See Helping Health Workers Learn, Chapter 24, pages 17-22 for additional ideas.

Plastic Beg Model

Take a clear plastic hag with no tear or bole in it. With a felt-tip pea (the kind with waterproof ink) draw a picture of a baby on it. Fill the bag with water; the picture of the baby will be full and well-rounded, like a healthy child. Now make a small hole la the lower part of tee bag with a pin. As water flows out, the bag and the picture will become wrinkled. This shows what happens to a child who has diarrhoea and becomes dehydrated.

Ask a trainee to pour water into the bag faster than it is flowing out of the hole. This shows what happens with oral rehydration; the picture of the baby will become normal again. Now seal the hole with a piece of tape or sticking plaster so that the water stops flowing out. This shows that the diarrhoea has stopped and no more rehydration is needed.


PLASTIC BAG MODEL TO DEMONSTRATE DEHYDRATION

Gourd Baby

To leam about dehydration. the children can conduct their own experiment by making a gourd baby' like this one:


Figure

How can dehydration from diarrhea be prevented?


Figure

Trainer Attachment 5C: Suggestions for a lecturette on the hows and whys of ORS

RESOURCES

- Oral Rehydration Therapy (ORT) For ChIIdhood Diarrhea (ORT Resource Packet. pp. 43-44.
- Trainer Attachment 5 (The Scientific Basis for Oral Rehydration Therapy)

IMPORTANT INFORMATION:

1. Diarrhea upsets the body's chemical balance and its' ability to process and absorb eater and nutrients.

When the child is healthy, the lining of his or her intestines transforms food into a tore that can be absorbed and transported by the blood stream to all parts of the body. These nutrients provide energy and enable growth. The blood stream is also the source of the minerals and water needed by the intestine to transform the food into a useable form. The intestine "borrows" and returns water and minerals as it processes food. This chemical balance is upset during diarrhea.

Diarrheal diseases affect the functions of the intestines. During diarrhea, the small intestine loses its ability to absorb water and essential minerals called electrolytes (sodium chloride, potassium, and bicarbonate). Minerals and water needed to process food leave the body in the child's stools, depleting the body's store of these vital elements and the nutrients they help process.

2. Water and electrolye loss cause the physical signs and symptoms recorded on the WHO Treatment Chart.

Fluid and mineral loss of greater than five percent, but less than ten percent of body weight generally causes a weak rapid pulse, loss of skin elasticity, low blood pressure, severe thirst, and other signs noted in Column B of the WHO Diarrhea Treatment Chart.

A loss of more than ten percent of the body weight results in shock, stupor, disrupted kidney function, acids build up in the blood (acidosis), peripheral blood vessels collapse, and death follows (see Treatment Plan C on the WHO chart.

3. Infants and small children are nor- susceptible to dehydration from diarrhea .

Infants and young children are particularly susceptable to dehydration from diarrhea, because of their small body weight For example, it a child who weighs ten kilograms loses one kilogram of water, ho or she has lost ten percent of the body weight and is severely dehydrated.

4. Oral Rehydration Salts (ORS) restore the body's chemical balance, and replaces the water lost.

Oral Rehydration with ORS (Oral Rehydration Salts) replaces the blood's electrolytes nearly as quickly as they are lost in the stool. This is due in large measure to the special ability of glucose to increase the absorption rate of sodium through the intestinal lining.

ORS includes all the essential electrolytes. Sugar and salt solution only has one of the three. This is why it is necessary to give ORS to a mildly dehydrated child.

Summarized below is the formula for the new trisodium citrate ORS. The ingredients for the other solutions are stated in The Treatment of Diarrhoea, p.17 and 42.


ORAL REHYDRATION SALTS (ORS) FORMULATION CONTAINING TRISODIUM CITRATE

SUMMARIZE by stating that Oral Rehydration Therapy is used to:

· Replace fluids
· Restore the chemical balance of the body.

ANALOGIES THAT HELP LEARNERS UNDERSTAND THESE CONCEPTS'

To give participants a more concrete sense of what it means to lose chemical balance, ask someone to stand on one foot and hold objects of equal weight in each hand. Then ask them to remain on one foot but hold both objects in one hand. Ask thee to tell the others hoe that feels to go from a balanced to an unbalanced situation. How well can they function in this states This can provide the basis for discussion.

To convey the idea that children are particularly vulnerable to dehydration from diarrhea, put the sane amount of water in a large cup and in a small cup. Ask participants to compare the cups. Use this as a basis for discussion.

Trainer Attachment 5D: Oral rehydration therapy: the scientific and technical basis

DR. NORBERT HIRSCHHORN
John Snow Public Health Group Inc.
Boston, Massachusetts
Resident Technician
National Control of Diarrheal Diseases Program
Egypt

When a child has diarrhea it loses body fluids - mainly essential minerals and water - and becomes dehydrated. So mix up some salts and sugar in water, and feed the solution to the child, as much as he/she will take until the child is no longer dehydrated, and diarrhea has slowed down or stopped. Make sure the child continues to take food or breast milk.

This is oral rehydration therapy, and it seems so simple (compared, say, to manipulation of genes or artificial hearts) that one may wonder what science has had to do with ORT, or why we need continue scientific studies on ORT. Many older physicians, nurses, or mothers have protested, "This is nothing new, we have been practicing ORT for years" Some of the great clinicians wrote about ORT thirty to forty years ago - Darrow, Harrison, Chatterjee. But this is precisely the point: they wrote about using ORT, but did not know how ORT works (nor to be fair, could they have them and so there was no further development or spread of their anecdotal experience until some decades later. Even today, when we fail to understand and use the scientific approach, we continue erroneous or wasteful methods of therapy; actually, this is the case in all fields of medicine and public health. Not everyone who practices ORT must be a scientist, but the spirit of inquiry and joy of discovery which suffuses science may be shared by all. The spirit of inquiry is present in five stages:

1. Observation - using all one's senses to capture events and think about them: it was noticed that children with dehydration drank the oral rehydration solution vigorously and greedily and, when nearly hydrated, slowed down and often went to sleep.

2. Measurement - taking one's observations and gauging some values on scales of time, length, amount, and degree: children who drank oral rehydration solution at will tended to drink close to what their initial deficit was, as measured by intake, output, and change in body weight.

3. Creative hypotheses - thinking through the implications of a measured observation and asking interesting questions: who can choose more closely the correct amount of fluid for rehydration, the dehydrated child or the physician?

4. Testing experimenting - within the ethical boundaries of conduct, designing, with proper statistical force and safeguards against bias, a test of the hypothesis: in certain situations, children freely drinking oral rehydration solution became hydrated faster and reached better fluid and mineral balance than those on intravenous solutions controlled by physicians.

5. Application - using the results of scientific testing for the widest possible benefit. It is as Jon Rohde and Robert Northrup have written, "taking science where the diarrhea is" Human information must be shared across all political and other boundaries.

The data and information I will present in this paper have gone through several of these five stages of scientific inquiry.

ORT developed from two streams of inquiry, if I may use a liquid metaphor. The first established what dehydration actually meant, how it related to the clinical picture of the dying child, and what was needed to reverse the situation. Believe it or not, this line of inquiry has taken nearly eighty years to come to satisfactory resolution. The second line, still ongoing, is the discovery of how the intestinal tract handles the movement of salts, nutrients, and water between the body and the outside world.

The picture of the dying child is hauntingly familiar. The baby has lost about 10% of its weight in fluid. This amounts to one liter of fluid in a ten-kilogram child, or about a quart in a twenty-two pound baby. Now the child has hollow, sunken eyes; its pulse is feeble or absent; its breathing is deep and rapid; the skin, when pinched, tends to remain dented and inelastic; the abdomen many be distended; urine has ceased to flow; the mouth is parched; the eyelids do not quite shut properly; there are no tears. Dry as the child may be, vomiting and watery diarrhea persist nearly to the end, and this stage may be reached in as little as ten to twenty hours after onset of illness.

Virtually all these signs are due to loss of salt, water, potassium, and sodium bicarbonate, all essential ingredients for life. Most of the loss is in the watery stool, and some, especially in the case of potassium, is from the urine. Regardless of the cause of diarrhea (rotavirus, cholera, E. coli, etc.) or whether in Baltimore or in Bengal, once the child reaches these clinical signs the amount of loss of water and minerals is roughly the same (Table 1) This is fortunate in a way, because the replacement therapy may be uniform and does not require us to know which specific microbe is doing the mischief. Incidentally, while the loss of potassium is of the same magnitude as that of sodium, the body stores of potassium are several times larger. So replacement of sodium is more urgent and also helps conserve potassium.

Although the extreme case I have portrayed is present in 1% to 2% of all bouts of diarrhea, it is sobering realize that with very few visible signs of dehydration beyond thirst, the child may have already lost 5% of body weight, halfway to death, in as little as five to ten hours. By the time parents become alarmed, there may be only a few hours left in which to find competent help. The majority of children who die, however, do linger for two to three days: they have received some fluid, probably of dubious value, by mouth or intravenously; the diarrhea may have slowed a little if various medicines are tried. But by this time the parents may have exhausted their money or the skills and resources of the local practitioner, and the nearest hospital is miles away. The child needs fluid therapy: effective, affordable, trustworthy, nearby.

But we learned about ORT only after we knew how to apply intravenous therapy. Beginning in the mid-1940s, diarrhea research centers in Dhaka, Calcutta, Manila, Cairo, Baltimore, and Taipei proved that intravenous solutions containing sodium chloride, potassium chloride, sodium bicarbonate (or lactate or acetate) in a well-determined combination could be given rapidly so that severely dehydrated children could, Lazarus-like, be resuscitated within two to four hours. Lives are saved by the use of a polyvalent solution, administered quickly with the correct proportion of ingredients. ORT is successful foremost because of this principle, first discovered for intravenous therapy. And we must still rely on intravenous fluids if the child is so severely dehydrated that it cannot drink at all. With this principal exception, what then makes ORT preferable to the intravenous route?

- It can be given by persons with little formal education, even in the home.
- It needs no sterile equipment.
- It is inexpensive (a boon, incidentally, even to well-equipped hospitals)
- It is safer and, under most circumstances, more effective.
- In a pinch, a less-effective formula can be prepared at home from table salt and table sugar (sucrose)
- It allows parents to participate in the care of their children.
- It is comforting to the child and to the parents.

Let us now consider the second stream of inquiry that led to the development of ORT: how the intestine handles salts and water

"What a piece of work is man," given form by skeleton, powered by muscles, coordinated and programmed by a chemical-electric skein of nerves and brain, nourished and defended by a red liquid distantly related to the primordial sea.

The intestine is but a hollow tube connected to the outside world at both ends, the core around which the rest of the body is wrapped. The intestine does many things, but its prime job is to take food, break it into basic molecules that are usable by the body's cells, and transport these molecules across the one-cell-thick lining that separates inside from out. To digest food, it seems necessary to increase the surface area of the tube by multiple folds on the surface of the tube and by fingerlike projections from these folds, called "villa," which carry multiple digestive enzymes at or near their surface. If the surface area is much reduced, as occurs in the disease called "spree," key nutrients and vitamins are not absorbed. It also seems necessary to suspend the particles in liquid and let digestive enzymes do their chemical work. The ultimate source of the digestive liquid is the blood stream, from which the intestine abstracts and secretes salty water free of blood or serum. Secretion of salts and water seems largely to be the function of the youngest cells in the lining, called the "crypt cells" end is controlled by a marvelously organized sequence of enzymes, minerals, and small chemical messengers which ´'know" just when to turn the flow on and off. Infectious agents which cause diarrhea are able to turn the cell mechanisms for secretion to a fixed "on" state until new cells replace the infected ones, usually in two to four days, or until the microbes and toxins are cleared out by the defense mechanisms of the body.

It has been estimated that the intestine of a healthy adult secretes one hundred liters - 264 U.S. gallons - or more of fluid each day; amazing, of course, but, given the total surface area of two million square centimeters (the size of a ballroom carpet seventy by thirty feet), one hundred liters represents but one drop per square centimeter per day Since the well nourished adult body contains only forty-five liters of fluid altogether and the adult would die if just seven to ten liters were permanently lost, there must be a rapid, certain mechanism to put the digestive fluid back into the bloodstream nearly as quickly as it is secreted. In what is surely one of the neater bits of engineering, the very molecules produced by the liquidy digestion are the ones that help transport the salts and water back across the intestinal cell, from there to return to the inner pools of body fluid. The molecules that work this way are principally glucose, the simple sugar derived from starch or table sugar; galactose, a component of milk-sugar; and amino acids and peptides, the products of protein digestion. Each of these molecules combines with sodium, probably in close to a one-to-one ratio, and these dyads cross the cell membrane, per haps by linking in a menage-a-trots to carrier protein molecules anchored in the membrane. Water is pulled along by osmosis, and other minerals (potassium, bicarbonate, more sodium) follow along, caught up in the stream, as it were. Most of this absorption appears to take place in the upper, more exposed regions of the villi, so that if there is extensive damage to villi from, say, viral diarrhea, oral rehydration may fail: failure occurs in about 5% to 10% of seriously ill children.

What is rather elegant about this system is that glucose, amino acids, and peptides seem to enter the cell linked to sodium, but each class of molecules joins with different carrier molecules or finds separate entrances specific to each. One predicts that if one adds an amino acid - glycine, say - to glucose in an oral rehydration solution, more fluid will be absorbed than if glucose or glycine are used alone. This is just what happens, and, as you shall hear shortly, this phenomenon promises a major advance in oral rehydration therapy. But for the moment, let us leave the alimentary canal and return to the child.

The formula for the oral rehydration solution was originally devised to combat epidemic outbreaks of cholera in which both adults and children are affected and where lifesaving intravenous fluids are scarce. The salts are packed in flat aluminum foil packets, paid for and stockpiled by UNICEF ready for shipment to any country on demand. The formula, often referred to as the "WHO formula,' was originally devised as a compromise between what adults needed and children could tolerate. The composition, however, is more inspired than that suggests (Table 2). The amount of salt is sufficient to replace sodium and water losses in severe de: hydration (Table 1), although adults may need to drink extra amounts. Glucose at 2% is optimal, as many studies suggest that water is best absorbed when glucose and sodium are in the ratio of one-to-one, and glucose does not exceed a concentration of 2 1/2%. Potassium deficit is only partially met by this formula because it is unsafe to completely replace losses so fast, but initial replacement must be started quickly (some suggest increasing the replacement rater Acidosis is corrected much faster with bicarbonate than without This formula has proved surprisingly versatile in the treatment of hundreds of thousands of children and adults, with documented success in #5% to 95% of cases, under the following range of situations:

- in persons who are able to drink;

- in malnourished children and the well nourished;

- in bacterial and viral causes of dehydrating diarrhea;

- with serum sodium levels as low as 110 milliequivalents per liter to as high as 165 extremes immediately threatening to life;

- with severe derangement of the blood alkaline-acid balance to the acid side (a condition called acidosis);

- in tropical climates and Baltimore winless;

- with no visible dehydration up to loss of body fluid equivalent to 10% of body weight.

- with voluminous, continuing loss of diarrhea, up to 10 milliliters per kilogram body weight per hour.

Even vomiting does not bar success except in a few instances; in fact, vomiting decreases in direct proportion to the degree of rehydration with ORT what makes ORT so versatile, in addition to its balanced formula, is that most children drink as much oral rehydration solution as is offered up to nearly the amount of which they are deficient. When they are hydrated, or nearly so, they seem to lose their taste for the fluid, then they either fall asleep, or cry for food.

Crying for food: we must think of ORT as more than simply rehydration with a solution of salts and sugar. ORT also means restoration, quickly, of a normal diet. It is now well established that a principal cause of malnutrition in children of the Third World is repeated episodes of diarrhea. The reasons are several and interactive:

- children lose their appetite for food because of salt and water loss and acidosis;

- children are often made to fast when they have diarrhea, sometimes for several days, because it is feared that food makes diarrhea worse;

- potassium loss may make muscle tone too weak for eating and digestion;

- when a child is ill, anxiety and restlessness burn up calories from the child's own stores of fat and protein (which may be already seriously depleted;

- diarrhea and fasting independently damage digestive enzymes in the intestinal tract, leading to malabsorption and loss of food that is eaten.

- with each serious bout of diarrhea, a child loses weight and may never catch up to its potential for growth and good nutrition.

In well-designed studies in the Philippines, Iran, Turkey, India and Panama, ORT appeared to protect against acute weight loss with an episode of diarrhea when the parent was also encouraged to continue to feed the child despite the diarrhea. Breast milk, soft foods and porridges, even fish and fruit and breads were advised. ORT restores a child's appetite u within a few hours, so suddenly this advice made sense to parents. The protective effect was most apparent in those already undernourished, and in those with repeated episodes of diarrhea and protection seemed to last several months. But of course no food, no protection.

We do not know, exactly how ORT works to protect nutrition, but we observe regularly that rapid restoration of fluid and mineral balance restores appetite. Potassium may play a key role here; there is also an intriguing possibility, based on studies of adults who go without food, that the glucose in ORT may help restore or protect intestinal digestive enzymes. The parent certainly finds (ceding the child more acceptable, and the child becomes more settled.

Oral rehydration therapy is, thus, two therapies: rehydration and continued feeding. ORT has already been proved to reduce mortality from diarrhea. It would be an amazing achievement if ORT could also reduce the prevalence of malnutrition.

This hope leads me to consider an impending development in ORT. Often, parents" and physicians' prime concern is to stop the diarrhea, and until they see otherwise, they do not believe that rehydration is the first order of business. ORT does not stop diarrhea, which generally runs its own course of a few days; we spend a lot of effort getting that point across. Perhaps we soon will have the means to slow stool loss even while rehydrating the child.

You will recall, back in the alimentary canal, that the different breakdown products, or metabolites, of digestion (sugars, peptides, amino acids) linked up to sodium and promoted salt and water absorption through different gates in the intestinal cell membrane. There is now sufficient evidence that if we combine these metabolites in a single oral solution, we not only rehydrate but can actually decrease the total loss of stool. Peptides and amino acids are particularly necessary in the combination because they act on absorption all along the small intestine, whereas the action of glucose is more confined to the upper portion. Absorption of peptides and amino acids are also far less susceptible than glucose to damage by diarrhea. So the next step is to develop an enriched ORT, one that combines salt, potassium, bicarbonate, glucose or a simple starch, and peptides or a simple protein. Here are some expected advantages of such a formula.

- Diarrhea is lessened.

- With less diarrhea, there will be less waste of nutrients in regular food, and possible more protection of intestinal enzymes.

- Common local foods, already familiar to parents, may be adapted to form an enriched ORT.

Early studies with such a formula are encouraging. We look forward now to a burst of research to define its optimal composition, the range of severity of illness it can be used for, its advantages over the WHO solution and food given separately, its cost and distribution. We will need to consider, also, how we can enlist parents to prepare and use an enriched ORT at home.

Where does all this take us? From a global public health view, it is possible that ORT is nothing more than a palliative until research produces effective antidiarrheal vaccines. Now. sadly, for many children, ORT merely postpones death. Optimists among us hope ORT programs will enable people to trust other health services, such as family planning, to encourage better nutrition and hygienic practices, to improve the health worker's morale, and to help achieve "Health for All".

We hope these hopes prove true; they need testing. But little can be advanced, I believe, as long as nations fail to make human welfare the first priority.

This brings me full circle to the beginning of this paper.

The international agencies sponsoring this conference have done a lot for our children. They support research; they supply services and technicians; through a generous network of information they link scientists from Boston to community health workers in Bangladesh; but most of all they demonstrate that the global village exists: in helping our neighbor's child survive we establish our common humanity.

Table 1

AVERAGE WATER AND SALT LOSSES IN SEVERE DIARRHEA OF A 10-KILOGRAM CHILD BEFORE TREATMENT (milliequivalents)

Water

Sodium

Potassium

Chloride

Infant diarrhea

1.1 L

90

100

80

Baltimore





Child cholera

1.0L

120

70

100

(Calcutta)





Table 2

COMPOSITION OF THE "WHO FORMULA" FOR ORAL REHYDRATION SOLUTION

Grams per Liter Solution

Sodium Chloride

3.5

Sodium Bicarbonate

2.5

Potassium Chloride

1.5

Glucose

20

Chemical Concentration in Millimoles per Liter Solution

Sodium

90

Chloride

80

bicarbonate

30

Potassium

20

Glucose

111

Trainer Attachment 5E: Storing and maintaing supplies of oral rehydration salts (ORS)

Whether a country is producing ORS locally or using UNICEF sachets, the product must be properly stored so that it remains effective from the time it is delivered to the central store to the moment it is used. Sodium bicarbonate causes decomposition of glucose in oral rehydration salt mixtures. High temperatures and humidity may accelerate this process and manufacturers must consoider these factors when preparing and packing ORS.

Storage

· Temperatures in buildings where ORS is stored should not exceed 30°C. Above this temperature the ORS may melt or turn brown. If this happens, it may be very difficult to dissolve and should not be used. If, however, it has only turned yellow, as long as it can be properly dissolved, it is still safe to use and effective.

· Supplies of ORS should not be stored in buildings with galvanized roofs directly exposed to the sun whithout adequate ventilation. These rooms get very hot.

· Humidity in stores should not exceed 80 per cent. In higher humidity the ORS is likely to cake or turn solid. Increase ventilation and avoid standing water in or near storage rooms.

· As far as possible, stoorage areas should be cleared of insects and rodents.

· Packets should be packed so they are protected from puncturing by sharp objects.

· UNICEF recommend storing their ORS sachets in stacks of cartons approximately 1 to 1 1/2 metres high.

· A rotating system should be introduced so that the oldest ORS (identified by date and batch number) is used first. When in a hurry, avoid distributing the packets which are at the front of the top unless you are sure they are the oldest in the store.

· Regional storage areas should be located in places that will be convenient for subsequent distribution.

Regular inspection of packets

· Laminated foil ORS packets have an estimated shelf life of at least three years. Note the production date on the label. Packets of ORS must be checked regularly (every three months) to see if the quality is still acceptable. Open at least one packet in each batch to see if ORS is usable. Locally produced packets of ORS is usable. Locally produced packets of ORS are often packaged in plastic and will probably have shorter shelf life. It is especially important to check them regularly.

· Check ORS packets in any boxes that appear to be damaged. Open at least one packet from the top, middle and bottom of the box to see if the ORS is still usable.

Keeping records at each point where ORS is received and delivered

· Records should show:

- the quantity, batch number or letter, and date received.
- the quantity and date issued (i.e. sent from one point in the distribution system to another).
- the amount currently in stock.
- stock level at which a new supply should be requested.

· Records should also indicate any problems (such as spoilage due to a leaking warehouse).

· Supplies should be counted every three months and results compared with quantities shown in the recors.

· The evaluation of stock is an important factor in determining future quantities of ORS required.

If you are interested in further information on local production of ORS and quantity control, the following publications are available from the Programme Manager, CDD Programme, World Health Organization, 1211 Geneva 27, Switzerland.

· Guidelines for the production of oral rehydration salts.
· Good practices for the manufacture and quality control of drugs.

Trainer Attachment 5F: Oral rehydration with dirty water?

Many of you have asked about the use of dirty water in making up oral rehydration solution when clean water is unavailable. Richard Feachem suggests that the benefits of early replacement of water and electrolytes in acute diarrhoea far outweigh the possible risk of using contaminated water.

Mothers are encouraged so prepare oral rehydration fluid using only clean water. However, most people in rural areas of developing countries have no access to clean water and in some communities the only available water is heavily contaminated with faecal material. In these circumstances it is recommended that the water be boiled and allowed to cool before preparing the oral rehydration fluid. This is often impracticable - involving use of expensive fuel and delaying the start of treatment. If oral rehydration therapy becomes common place in villages it is certain that the ore's rehydration fluid will often be made up with water containing pathogens of faecal origin. Does this matter? The answer is we don't yet know but it probably doesn't.

The main questions

The dirty water used to make up the fluid may contain faecal viruses, bacteria and intestinal parasites. Of these only tile bacteria may multiply if conditions are right. Oral rehydration fluid is normally used for about 24 hours after it is prepared and therefore the two central questions are:

· can certain bacterial pathogens that ma' be present in water multiply in oral rehydration fluid stored in the home at 20-30°C

· if they can, what is the effect of ingesting a large dose of bacterial pathogens on an intestine already colonized by the same pathogen or by another viral, bacterial or protozoal pathogen

Only multiplication (rather than enhanced survival) of a pathogenic bacterium in oral rehydration fluid is important, since only if multiplication takes place might the child receive a greater dose of the bacterium in the oral rehydration fluid than in plain water.

Laboratory experiments

The results of laboratory experiments are conflicting. Some have found a steady decline in the numbers of pathogens introduced into oral rehydration fluid. On the basis of these findings a WHO Scientific Working Group, concluded that "Escherichia coli, Vibrio cholerae, Salmonella and Shigella do not multiply in oral rehydration fluid and survive in declining numbers for up to 48 hours".

This is unlikely to be true in all circumstances and one recent study has shown that V. cholerae and entero-pathogenic and enterotoxigenic strains of E. cold increased in concentration by between 1 and 5 log10 units after 24 hours in oral rehydration fluid. However, all these experiments used oral rehydration fluid made up with distilled water, or with sterilized surface water and therefore failed to duplicate actual field conditions.

Gambian study

A more relevant study on the behaviour of wilds E. cold in oral rehydration fluid made up with well water has recently been reported from The Gambia.

The concentration of E. cold in well water alone fell slightly during 24 hours storage (2330° C). However, in well water plus oral rehydration salts the concentration increased by over 2 log10 units. The same study compared the response of children (three months to four years) receiving oral rehydration fluid made up with well water with those whose fluid was made up with sterile water. There was no difference in the incidence and duration of acute diarrhoeal attacks, or in the growth rates, between the two groups it was estimated that the E. cold ingested in stored oral rehydration fluid were at most 5 per cent of the E. cold regularly ingested in food eaten by these children in The Gambia.

A sound strategy

In conclusion, some bacteria may multiply in stored oral rehydration fluid. 'There is no evidence, however, that using contaminated fluid increases the incidence severity or duration of diarrhoea, and there is one study indicating that it does not.

A sound strategy, pending more field research, is to advise mothers to use the cleanest water available, to boil it where possible and not to keep the oral rehydration fluid more than 24 hours. To those who express concern at this approach it must be stressed that the proven benefits of water and electrolyte replacement early in acute diarrhoea far outweigh the possible risk of using contaminated water.

Trainer Attachment 5G: A pinch of salt' a handful of molasses...

Bangladesh

In remote Sulla, a deprived area of Sylhet district in Bangladesh, an epidemic of diarrhoea among young children prompted an emergency do-it-yourself solution. That "solution" - salt, water, molasses - has proved a saviour of children's lives. By MEHR KAMAL

Sulla, a low-lying tract in Bangladesh's Sylhet district, is one of the poorest areas in the world. Here, farmers wrest one rice crop a year out of tiny plots of land. Most people, however, are landless and find only seasonal employment as farm hands or as fishermen when the rain-swollen rivers spill over, converting the marshy area into a vast monsoon lake.

So remote and neglected is Sulla that few Bangladeshis have heard of it. In 19 72, when a local non-governmental organization, the Bangladesh Rural Advancement Commitee (BRAC), began rehabilitating destitute refugees returning home after the creation of Bangladesh, it chose Sulla as a base of operations because of its extreme deprivation.

But BRAC workers arriving there were immediately faced with another more urgent problem as a diarrhoea epidemic broke out and hundreds of children began to die of dehydration and malnutrition. With no health services or pharmacies to rely on for support. in dealing with the problem) they prepared oral rehydration solutions for the children with salt, molasses and water, all of which were available even in the poorest homes.

This simple treatment - approved by the International Centre for Diarrhoeal Disease Research in Bangladesh (ICDDRB), the world's leading institution for research on diarrhoeal diseases-and BRAC'S method of teaching mothers how to use it, are now generally recognized as the best hope for an early reduction in infant deaths in Bangladesh.

Of every 1,000 children born alive in the country, some 140 die before reaching their first birthday, approximately half of them from complications such as dehydration and severe malnutrition connected with diarrhoea. While not a serious problem in itself, since the body purges itself of most diarrhoeal infections without any medication, diarrhoea can be devasting to a small child because essential fluids, minerals and nutrients are sometimes expelled from the body in a day. In Bangladesh, most of the 17,000 children who lose their eye-sight every year do so because diarrhoea drains away their already meagre reserves of vitamin A.

The treatment for diarrhoea is simple. A solution of salt, glucose and electrolytes mixed with water and taken orally can help to reverse dehydration. In Bangladesh, the Government is packaging oral rehydration salts (ORS) at four national centres assisted by UNICEF. These are then distributed free through the health services, and commercially-produced ORS packets are sold in dispensaries.

The total national production of ORS is not enough to meet the need. But stepping up production would address only a small part of the problem of getting mothers to use ORS when they should. In one of the world's least developed countries, health services reach only 21 per cent of the people and the nine out of ten people who live in rural areas have no access to pharmacies because these exist only in urban or semi-urban areas.

In addition, only 14 per cent of Bangladeshi women are literate and thus able to read the instructions for mixing the solution. At prices ranging from a few cents to over one dollar a packet, the cost may also be prohibitive, since the annual GNP per capita is only US$110, and four out of every five people live below the official poverty line.

Overcoming the hurdles

In Sulla, BRAC devised a programme which overcame ail of these hurdles. Since the accurate measurement of ingredients is crucial to the success of the therapy, it chose the method that most rural South Asian women use in measuring ingredients for cooking: their fingers.

The only spoon available in many homes is a wooden ladle used for stirring and serving, and women judge the proportion of spices required by pinches and heaps. BRAC therefore suggested a three-finger pinch of salt and a handful! of molasses mixed with an appropriate quantity of water.

Next, BRAC concentrated on one of the most difficult aspects of the problem: a change in attitudes and ingrained habits. Many Bangladeshi women believe that diarrhoea is either an air-borne affliction or is caused by evil spirits. So they hide the problem until it becomes severe. Doctors at the ICDDRB say that, at this stage, death can be only hours away, particularly for under-nourished children. Dehydration is accelerated by the fact that most mothers deny their children food and water during diarrhoea in the hope that this will stop the runny stool.

BRAC devised a simple flip chart which explained the connection between diarrhoea and dehydration by likening a child suffering from diarrhoea to a pitcher of water with a hole in the bottom. Armed with these, a ream of seven girls, who received five days training in diarrhoea management, went from house to house in Sulla, stressing the importance of rehydration from the moment the first loose motion begins.

With ingredients provided by the mother, they demonstrated the proper way to prepare a solution in a utensil available in the home. At the end of the session, the inside of the container was scratched to mark the appropriate water level, and a discussion ensued on the prevention of diarrhoea.

Each team was preceded by male workers who talked to the men about diarrhoea, and the "doctor" who will come to teach mothers how to treat it. Such persuasion was crucial to gaining the confidence of the community and giving the female workers access to all families.

One of the workers, 23-year-old Rooma, says that while mothers almost always accept the treatment, persuading them to take appropriate steps to prevent diarrhoea is hard. She cites the case of Mumtaz Begum whom she has just visited.

Mumtaz is one of the very few rural Bangladeshis lucky enough to have access to both a tubewell and a latrine. Yet, ignorant of the connection between clean water and sanitation and her children's frequent diarrhoea, she uses neither. The tubewell water is rejected because its high mineral content gives it a "peculiar" taste and the latrine her brother constructed when he came home for a visit from Dubai is regarded as a quaint city facility.

When pressed to wash her hands frequently with soap, Mumtaz said that her husband who sells vegetables in the village earns only Taka 30, U.S. $1.20, a day. This, supplemented with occasional remittances from Dubai, is barely enough to buy food. At 20 cents a bar, soap is a luxury they cannot afford on a daily basis.

In Bangladesh, diarrhoea will continue to be a major health hazard as its prevention requires the installation of millions of new tubewells and latrines, as well as a massive health education effort designed to motivate people to use them. The BRAC method of oral rehydration therapy with its home-made solution and house-to-house instruction is therefore winning widespread support. The experiment begun in Sulla, was extended in 1980 to cover five districts. In October 1983, it will enter its second phase, covering another seven of the country's 20 districts by June 1986.

It will take time to wipe out the agony of diarrhoea in Bangladesh, a land where medical historians believe cholera was reported for lee first time ever in the seventeenth century. But random surveys of its own programme carried out by BRAC have shown very positive results. Three months after receiving initial instructions, some 90 per cent of mothers have been able to answer all questions about diarrhoea correctly, and approximately 82 per cent have been able to prepare accurate oral rehydration solutions. Mizanur Rehman Chaudhry, BRAC'S area manager in Sylhet, claims that, at the cost of Taka 7 (U.S. 29 cents) per mother trained, this could be the most cost effective health programme anywhere.

Trainer Attachment 5H: Cautious prescription

Professor Harold explains the clinical situations which justify the use of drugs in addition to oral rehydration therapy.

Two main groups of drugs are commonly prescribed in the treatment of diarrhoeal diseases:

· Antimicrobial drugs - which kill the responsible organism and so lessen the illness.
· Antidiarrhoeal drugs - which diminish the amount of fluid loss by various pharmacological mechanisms.

These two types of drugs are often combined and many preparations are marketed containing both antibiotics and antidiarrhoeal drugs. These combination drugs should never be used.

Only single drugs should be given and only where appropriate.

Antibiotics in bowel infections

For certain specific infections of the gut an appropriate antimicrobial drug is an important part of the treatment.

Shigella infection: in mild, transient diarrhoea caused by shigella, antibiotic treatment may be unnecessary as, for example, in mild Sonne or flexneri dysentery. Antibiotics are, however, an essential part of the treatment of severe bacillary dysentery especially in infants with persistent high fever. Choice is difficult because transferable drug resistance has become very common in these organisms and local knowledge of their drug susceptibility has to be taken into account. Ampicillin or co-trimoxazole are usually suitable (ampicilin 100 mg/kg/day in four divided doses for five days, or trimethoprim 10 mg and sulfamethoxazole 50 mg/kg/day in two divided doses for five days). Single dose treatment in adults with tetrad cycling (2.5g) is also very effective if the bacilli are known to be susceptible to this drug.

Campylobacter infection: Campylobacter jejuni may invade the bowel wall causing abdominal pain and mildly dysenteric stools. Most cases recover well without chemotherapy. Severe cases may be treated with erythromycin (40 mg/kg/day in three divided doses for five days) but its efficacy is unproved. A recent controlled trial showed no clinical benefit from erythromycin but treatment was not started until an average of six days from the onset of illness.

Cholera: Several antibiotics, particularly tetracycline, have been shown to shorten the duration of the disease and are therefore useful in the management of cholera patients. Tetracycline is given as 50 mg/kg/day in four divided doses for three days. Drug resistance is now being seen in areas where mass chemoprophylaxis has been carried out. Alternative drugs include furazolidine and chloramphenicol.

Enterotoxigenic and enteropathogenic E. coli: Relatively few clinical trials have been done on the effect of antibiotics in this group of bowel infections. Enterotoxigenic E. cold generally cause acute episodes of relatively brief duration, making antibiotics unnecessary. Because of the difficulty in identifying these organisms, there seems to be little justification at the moment for treating them with antibiotics. Similarly, for enteropathogenic E. coli, there is no clear evidence that antibiotics are beneficial

Salmonella infections: For the vast majority of acute diarrhoeal illnesses caused by nontyphoid Salmonella strains. antibiotics do not change the course of illness and may actually prolong the period during which stool cultures remain positive. Salmonella septicaemia. which may present in childhood as a combination of diarrhoea with systemic illness and fever requires antibiotic treatment. Ampicillin, chloromycetin, or co-trimoxazole may be used, depending on the sensitivity of the organism.

Amoebiasis and Giardiasis: Both these parasitic infections respond to several antimicrobial agents. Metronidazole is the first choice for either.

Antibiotics in bowel infections of unknown cause

The cause of many bowel infections is never identified, or the organism may be found after the acute illness is over. Antibiotics have no role in the treatment of the large group of viral diarrhoeas. It has sometimes been suggested that antibiotics should routinely be prescribed in case the illness turns out to be due to an infection for which antibiotic treatment is indicated.

This practice is to be avoided for several reasons:

· The giving of antibiotics may divert the attention of mother and nurse from the essential task of replacing water and electrolytes.

· The widespread use of antimicrobials promotes the selection of antibiotic resistant strains and thus lessens the likelihood that the drugs will later be effective for those few patients who need them.

· Antibiotics are expensive.

The balance of factors therefore clearly lies against the blind use of antibiotics in diarrhoeal disease of unknown origin.

Other drugs in gastroenteritis

The most commonly used agents are kaolin and pectin in one or other of many available preparations, despite clinical trials proving lack of efficacy. Most children improve so quickly with fluid and electrolyte replacement that the use of 'constipating agents is unnecessary in acute diarrhoea.

Drugs such as opiates, diphenoxylate and loperamide which reduce bowel motility. although widely used, should never be given to children. By slowing peristalsis they make the situation worse - this has been seen in a number of children and in volunteers with shigellosis. These drugs also depress respiration and are an important cause of accidental poisoning in childhood

Research

Several research projects arc underway aiming to find drugs which will reduce the abnormal transport of fluid across the small bowel mucosa. For example, anti-inflammatory drugs (aspiring and indomethacin) may decrease the action of cholera and other toxins acting on the trowel. Bismuth subsalicylate, in large doses, has been beneficial in adults with travellers' diarrhoea.

Other substances have also been tried; for example, chlorpromazine, which probably inhibits adenylate cyclase, was shown to reduce diarrhoeal losses in cholera. However, since it may cause drowsiness in children and hence a decrease in fluid in lake. it is unsuitable for widespread use Attempts have also been made to prevent cholera toxin binding to the bowel wall, but these studies have not shown the method to be useful in practice.

None of these experimental drugs have reached a stage where they can be recommended for general use in patients with diarrhoea. If drugs which reduce intestinal secretion become better defined, and can be shown to be effective in field conditions against diarrhoea caused by 8 broad range of aetiologic agents, they will be useful adjuncts to therapy.

Conclusion

Oral rehydration therapy- remains the essential treatment and antibiotics arc useful only in the few clinical situations described.

Professor H.P. Lambert, Communicable Diseases Unit, St. George's Hospital-London UK.

Session 6 - Practicing ort in the village

TOTAL TIME

2 hours

OVERVIEW

In Session 13 (The Impact of Culture on Diarrhea) participants gathered and analyzed information on the local beliefs and practices regarding diarrhea. In so doing they indirectly began to realize some of the problems associated with implementing ORT in the village. In this session, participants consider the advantages and disadvantages of using ORT in the village. They explore ways to overcome some of the problems they may face in preparing the different types of rehydration solutions in village conditions, including inappropriate utensils, dirty water, unavailability of key solution ingredients, and so forth. The participants also practice teaching mothers to prepare and give ORT solution to their children.

OBJECTIVES

· To identify problems in mixing pre-packaged salts (ORS), Sugar-Salt Solution, and other home-available ingredients in village settings.
(Steps 1-3)

· To demonstrate and teach technically correct and culturally appropriate methods of rehydration solution preparation and administration in the village.
(Step 3)

· To list potential advantages and disadvantages of using ORT in the village.
(Step 4)

RESOURCES

Helping Health Workers Learn. Chap, 1, pp. 17 -25, and Chap. 27, pp. 1-34.
"Oral Rehydration Therapy (ORT) for Children (ORT Resource Packet).

Trainer Attachment:

-6A Problem Situations: Ort in the Home

MATERIALS

Markers, newsprint.

PROCEDURE

Trainer Note

Use this session after participants have completed the activities in Session 13 (The Impact of Culture on Diarrhea), completed Session 5 (Rehydration Therapy) and Session 16 (Selecting and Using Nonformal Education Techniques).

Adapt the problem situations in Trainer Attachment 6A (Problem Situations: ORT in the Village) to fit the local situation.

If possible, arrange opportunities for participants to teach mothers to mix ORT solutions in homes or the local clinic, under the supervision of someone skilled in mixing them.

Step 1 (30 min.)

Sharing Problems and Discussing Solutions

Begin the session by explaining to the group that they will apply what they've learned to a village setting and deal with a number of problems often encountered in ORT programs at the village level.

Lead a large group discussion of problem situations encountered using ORT in communities in the host country. Adapt and use the problem situations found in Trainer Attachment 6A (Problem Situations: ORT in the Home).

For each problem situation: read it to the group, discuss the more specific questions stated at the end of each problem situation as well as some of the following questions:

- Are adequate containers for measuring and mixing available?
- Are necessary ingredients or alternates available?
- Is there an adequate water source?
- What is the mother's or caretaker's likely perception of the situation?
- What is your perception of the situation?
- Are there any health education opportunities regarding prevention of diarrhea or teaching about ORT?
- What is the most important health education message to communicate?
- What could your role be in the follow-up of this situation?

Finally, ask the group to determine:

- Which problems seem to be most common?

- Which problems can be solved or reduced most immediately?

- How can they be solved?

- Which problems are inherent to the type of ORT used and which are specific to conditions in the country?

- Were the problems presented here realistic? If not, what other problems might be encountered?

Trainer Note

Be sure to discuss the following:

- Availability of substitutes for sugar and other ingredients.

- Water quality, lack of fuel for boiling water, mothers' motivation to boll water.

- Hygiene including hand cleanliness and "kitchen" sanitation for preparing rehydration solutions.

- Inaccurate measures with which to prepare rehydration solutions, and implications of inaccurate measuring for the child.

Examples of some of the basic information the group should include in their answers to each problem situation is given at the end of the problem.

Step 2 (30 min)

Preparing Skits for Teaching Sessions on ORT in The Village

Divide into three groups. Assign one of the problem situations to each group. Tell them that they have 25 minutes to use the problem situation as the basis for planning a ten minute "skit" on how they would teach a mother and her family in that situation.

Trainer Note

For information on what to include when educating family members about home treatment of diarrhea, ask the group to read pages 4-6 in the WHO Supervisory Skills Module "Treatment of Diarrhea".

Step 3 (30 min)

Performing Skits on Teaching ORT in the Village

Ask each group to perform their skit After each skit discuss some of the following questions:

- What was the most important message that needed to be conveyed?
- Was that message conveyed?
- Was all the necessary information provided?
- Was the information accurate?
- Was it presented clearly?
- Was the mother or caretaker actively involved in the session?
- What was good about the teaching session and what could be improved?

After participants have reviewed the teaching sessions, ask someone to summarize the key points that should be taught about solution preparation and administration in the village, and the most effective ways to teach them.

Trainer Note

The main point of this critique and discussion of the teaching sessions is to ensure that participants recognize and can use the most effective techniques for teaching mothers important points about preparation and administration of ORT in the village.

Emphasize the importance of teaching mothers individually and following up to make sure that they have mastered the skills and know when to use them. They can read about the importance of this in "Oral Rehydration Therapy (ORT) for Children" in their ORT resource packet.

Some specific points about effective teaching in the village include:

- Learning by practice (rather than lecture)
- Making certain that the learner understands (by paraphrasing, demonstrating her understanding, etc.)
- Showing respect for the knowledge and skill of the learner
- Drawing on the experiences of the mother or caretaker during the learning session
- Presenting new skills and information in terms that make sense to the mother or caretaker.

Step 4 (15 min)

Discussion of Pros and Cons of Preparing ORT in the Home

Summarize and close the session by ask, participants to discuss the advantages and disadvantages of preparing ORT in the home, based on the teaching activities during this session, their findings in Session 13 (The Impact of Culture on Diarrhea) and their own experiences in the communities where they work. Have someone list these on newsprint.

Trainer Note

Some of the Advantages and disadvantages likely to come out of the discussion are:

Advantages

- Self reliance in health
- Lower cost health care
- Immediate initiation of treatment.

Disadvantages

- Danger of incorrect measurement and lethal or ineffective ORT.
- Requires careful instruction of Mothers to mix and use correctly
- Conflicting messages about using ORT can cause problems.

Trainer Attachment 6A: Problem situations - ORT in the home

The following problem situations are exaggerations of ones that Volunteers may encounter when trying to prepare Oral Rehydration Solutions in their villages. Each situation should be adapted to be culturally appropriate and then read to the participants. Based on their knowledge and experience to date, the group should describe how they would handle each situation given the ingredients available and their ingenuity. Each situation contains ingredients either for:

- preparing homemade sugar-salts solutions,
- using ORS packets
- providing simple nutritious foods and/or
- replenishing the liquids and nutrients lost during diarrhea but not correcting the electrolyte imbalance.

Problem Situation Number 1:

Situation Description: The child who is one year old had four to six loose stools yesterday. The mother had only one packet of ORS and mixed half of it on the first day of her child's diarrhea. She gave the ORS solution from a cup but the baby coughed and choked, and refused to drink. The mother is trying to wean the child from the breast and so is nursing only once a day. The child only wants to sleep and when awake is always reaching for the mother's breast.

Problem: What would you do if in the household you only found the following:

- a fresh but half empty packet of ORS
- water from a clean source
- rice powder
- a dirty one liter container
- salt
- large bulk tea

Answer: Follow treatment Plan B of the WHO Treatment Chart and the information for mixing ORS. If the child continues to have diarrhea after finishing the half liter solution of ORS and if it is used in the local culture give the child the rice powder solution. If the diarrhea persists for longer than two days and or the child shows more signs of dehydration, take him or her to the health center.

Problem Situation Number 2:

Situation Description: The older daughter (ago 7) has told you that both her younger brother and sister have had a runny tummy several times today. The mother is at the market selling bread. The children have diarrhea and cry a lot but appear to be fine. When you check their pulse you find it to be normal. Their skin goes back immediately after you pinch it and they are constantly asking to drink.

Problem: What would you do if in this household you found the following foods and materials:

- potatoes
- salt and molasses (or appropriate country specific sugar substitute)
- large mixing spoon
- water
- large gourd

Answers Follow treatment under Treatment Plan A of the WHO chart and include relevant information from the sessions on nutrition and how to mix sugar-salts solutions.

Problem Situation Number 3:

Situation Description: it is the rainy season and there is little food available. The roads to the health center are washed out. The mother is in the fields most of the time. When you pass by her house you find the woman at home worried because her two year old son has had diarrhea since yesterday. She asks you for some Western medicine to treat her son. You have been told never to give out the medicine from your Peace Corps kit.

Problem: What would you do and say to this mother if, in this household, you look around and find the following:

- sugar cubes
- dirty water in a bucket
- several small tea cups
- carrots and other vegetables and tubers
- small mortar and pestle.

Answer: This scenario should lead to a discussion of the pros and cons of treating children with medicine that is not readily available in that culture or village. If the child is not in danger of dehydration all the materials are there for preparing the sugar-salt solution and providing some nutritious food in between drinking the solution. Review Session 5 for the discussion of the pros and cons of using dirty water to prepare the solution, and Session 9 for information on preventing malnutrition.

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