Tag: diarrhoea

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Oral Rehydration Salts for Children Underprescribed Despite Effectiveness

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Photo by Ron Lach : https://www.pexels.com/photo/mother-taking-care-of-sick-daughter-9874630/

Health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for diarrhoeal disease, a leading cause of death for children worldwide – yet few prescribe it.

A new study published in Science suggests that closing the knowledge gap between what treatments health care providers think patients want and what treatments patients really want could help save half a million lives a year and reduce unnecessary use of antibiotics.

“Even when children seek care from a health care provider for their diarrhoea, as most do, they often do not receive ORS, which costs only a few cents and has been recommended by the World Health Organization for decades,” said Neeraj Sood, senior author of the study, senior fellow at the USC Schaeffer Center for Health Policy & Economics and a professor at the USC Price School of Public Policy.

“This issue has puzzled experts for decades, and we wanted to get to the bottom of it,” said Sood.

A closer look at childhood illness in India

There are several popular explanations for the underprescription of ORS in India, which accounts for the most cases of child diarrhoea of any country in the world:

  • Physicians assume their patients do not want oral rehydration salts, which come in a small packet and dissolve in water, because they taste bad or they aren’t “real” medicine like antibiotics.
  • The salts are out of stock because they aren’t as profitable as other treatments.
  • Physicians make more money prescribing antibiotics, even though they are ineffective against viral diarrhea.

To test these three hypotheses, Sood and his colleagues enrolled over 2000 health care providers across 253 medium-size towns in the Indian states of Karnataka and Bihar. The researchers selected states with vastly different socioeconomic demographics and varied access to health care to ensure the results were representative of a broad population. Bihar is one of the poorest states in India with below-average ORS use, while Karnataka has above-average per capita income and above-average ORS use.

The researchers then hired staff who were trained to act as patients or caretakers. These “standardized patients” were given scripts to use in unannounced visits to doctors’ offices where they would present a case of viral diarrhea — for which antibiotics are not appropriate — in their 2-year-old child. (For ethical considerations, children did not attend these visits.) The standardized patients made approximately 2,000 visits in total.

Providers were randomly assigned to patient visits where patients expressed a preference for ORS, a preference for antibiotics or no treatment preference. During the visits, patients indicated their preference by showing the health care provider a photo of an ORS packet or antibiotics. The set of patients with no treatment preference simply asked the physician for a recommendation.

To control for profit-motivated prescribing, some of the standardized patients assigned as having no treatment preference informed the provider that they would purchase medicine elsewhere. Additionally, to estimate the effect of stockouts, the researchers randomly assigned all providers in half of the 253 towns to receive a six-week supply of ORS.

Provider misperceptions matter most when it comes to ORS underprescribing

Researchers found that provider perceptions of patient preferences are the biggest barrier to ORS prescribing – not because caretakers do not want ORS, but rather because providers assume most patients do not want the treatment. Health care providers’ perception that patients do not want ORS accounted for roughly 42% of underprescribing, while stockouts and financial incentives explained only 6% and 5%, respectively.

Patients expressing a preference for ORS increased prescribing of the treatment by 27 percentage points — a more effective intervention than eliminating stockouts (which increased ORS prescribing by 7 percentage points) or removing financial incentives (which only increased ORS prescribing at pharmacies).

“Despite decades of widespread knowledge that ORS is a lifesaving intervention that can save lives of children suffering from diarrhea, the rates of ORS use remain stubbornly low in many countries such as India,” said Manoj Mohanan, co-author of the study and professor of public policy, economics, and global health at the Sanford School of Public Policy at Duke University. “Changing provider behavior about ORS prescription remains a huge challenge.”

Study authors said these results can be used to design interventions that encourage patients and caretakers to express an ORS preference when seeking care, as well as efforts to raise awareness among providers about patients’ preferences.

“We need to find ways to change providers’ perceptions of patient preferences to increase ORS use and combat antibiotic resistance, which is a huge problem globally,” said Zachary Wagner, the study’s corresponding author, an economist at RAND Corporation and professor of policy analysis at Pardee RAND Graduate School. “How to reduce overprescribing of antibiotics and address antimicrobial resistance is a major global health question, and our study shows that changing provider perceptions of patient preferences is one way to work toward a solution.”

Source: University of Southern California

Categories : Diseases, Syndromes and Conditions VaccinesTags : Leave a comment

A New Way to Vaccinate Against Diarrhoeal Diseases: ‘Bribe’ the Bacteria

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Scanning electron micrograph image of E. Coli bacteria. Credit: NIH

Scientists have found that pairing specific diets with disease-causing bacteria can create lasting immunity in mice without the costs of developing sickness, revealing a new potential vaccination strategy. Their findings, published in Science Advances, may lead to new vaccines that could promote immunity for those with diarrhoeal diseases and possibly other infections.

The body takes one of two defence strategies against bacterial infections: kill the intruders or impair the intruders but keep them around. If the body chooses to impair the bacteria, then the disease can occur without the diarrhoea, but the infection can still be transmitted – also known as asymptomatic carriage.

“We discovered that immunisation against diarrhoeal infections is possible if we allow the bacteria to retain some of its disease-causing behaviour,” says senior author Professor Janelle Ayres at Salk Institute. “This insight could lead to the development of vaccines that could reduce symptoms and mortality, as well as protect against future infections.”

In 2018, Ayres’ lab looked at how dietary interventions can create an asymptomatic infection, which Ayres calls a cooperative, asymptomatic relationship between bacteria and host. They discovered that an iron-rich diet enabled mice to survive a normally lethal bacterial infection without ever developing signs of sickness or disease. The high-iron diet increased unabsorbed glucose in the mice’s intestines, which the bacteria could feast on. The excess glucose served as a ‘bribe’ for the bacteria, keeping them full and incentivised to not attack the host.

This process produced long-term asymptomatic infection with the bacteria, leading the researchers to believe that the adaptive immune system (which ‘remembers’ infections) may be involved.

“Being able to generate lasting immunity against bacteria like C. rodentium or E. coli has not been possible using established vaccination strategies. We wanted to figure out what mechanism was sustaining this lasting immunity, so we could use that mechanism to create an impactful solution to these diarrheal diseases,” says first author Grischa Chen, a former postdoctoral researcher in Ayres’ lab.

The researchers moved to figure out how the body suppresses infection symptoms, whether infection without symptoms can create long-term immunity, and whether that immunity is reproducible as a vaccination strategy.

The team compared mice with iron-rich and normal diets after C. rodentium infection to find whether the diet impacted symptomless infection. Immediately after infection, mice fed an iron-rich diet had no symptoms whereas mice fed a normal diet did have symptoms. All mice were then put on a normal diet to see whether the asymptomatic infection would last.

Mice without functional adaptive immune systems, regardless of whether they had ever been on an iron-rich diet, could not continue maintaining a cooperative relationship with the bacteria. Although the iron-rich diet suppressed symptoms immediately after infection, the adaptive immune system was required for lasting cooperation. Importantly, the mice with functional adaptive immune systems had the disease without any symptoms, with lasting immunity, as demonstrated by survival upon reinfection after a month.

Ayres and team concluded that an iron-rich diet alone can prevent bacteria from creating deadly symptoms in mice during active infection. But a functional adaptive immune system is required for immunity against future infection in the absence of dietary supplementation.

Some bacterial strains, if mutated enough, don’t cause symptoms. To test whether such bacteria could produce lasting immunity, the team repeated their iron-diet versus normal-diet experiment in mice, but this time using bacteria that could cause disease and bacteria that could not cause disease. They found that only mice that received disease-causing, unmutated bacteria were able to support immunity upon reinfection.

The scientists note that this is only a preliminary study and people shouldn’t consume large amounts of iron after reading it. They also hope their insights will provide a basis for future research in humans and the creation of a vaccination regiment that protects and prevents against diarrhoeal illness.

Source: Salk Institute

Categories : Diseases, Syndromes and Conditions PaediatricsTags : Leave a comment

18th & 19th Century Grannies Protected Their Grandchildren from Infectious Diseases

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While grandmothers today have a popular image of spoiling their grandchildren with treats, in premodern times they also acted as healthcare providers. To find out more, University of Turku researchers looked at historical data on childhood mortality from infectious diseases in the 18th and 19th century in Finland. The study, which is published in the journal Proceedings of the Royal Society B, found that grandmothers decreased all-cause and cause-specific mortality of children.

In historical and in several contemporary societies, children with living grandmothers are more likely to survive into adulthood, but the mechanism behind this effect remains poorly known.

As childhood infections have been a leading cause of death in children under the age of 5 years, the researchers aimed to investigate whether the effect of grandmothers on childhood survival was related to providing knowledge in childcare, particularly during critical times such as epidemics. One way for grandmothers to do so could be by encouraging vaccine uptake or earlier vaccination against childhood infections, as has been observed in some contemporary populations.

Researchers first studied the effects of grandmothers on children’s cause-specific mortality, using historical records of five causes of death: smallpox, measles, pulmonary infections, diarrhoeal deaths, and accidents. The large multigenerational dataset of pre-industrial Finnish families included 9705 individuals from 12 parishes across Finland, where the survival of individuals until the of age 15 years was monitored from 1761 to 1900. In the second part of the study, the researchers determined whether increased survival against the childhood infection smallpox was mediated by vaccination. To this end, they used 1594 vaccination records from two rural parishes and matched them to their individual family histories.

The results show that grandmothers decreased all-cause mortality, an effect which was mediated through improved survival from smallpox, pulmonary and diarrhoeal infections, but not from measles or accidents. However, the researchers found no evidence of increased or earlier vaccination between children with or without grandmothers.

“Our results show that the grandmother’s presence protected against some childhood infections, which could indicate that in historical Finnish society, the assistance provided by grandmothers in childcare was likely an important factor in ensuring the survival of children,” says study lead author, Doctoral Researcher Susanna Ukonaho.

Grandmothers in contemporary societies

Although grandmother care provided health benefits in many historical societies, these benefits may no longer be relevant in contemporary societies. The progress in healthcare during the 20th century especially in high-income countries likely decreased the role of grandmothers. However, some studies indicate that grandmothers improve childhood survival in several contemporary middle- and low-income countries.

“The type of benefits that grandmothers provide may vary depending on cultural contexts and individual circumstances. Even though in many societies grandmothers are no longer essential for childhood survival, their efforts in childcare remain valuable for the well-being of the whole family,” says Ukonaho.

Source: University of Turku

Categories : GastrointestinalTags : Leave a comment

Regular Probiotic Use Could go a Long Way in Preventing Diarrhoea and Illness

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Gut Microbiome. Credit Darryl Leja National Human Genome Research Institute National Institutes Of Health

Diarrhoeal disease outbreaks are on the increase in South Africa owing to unsafe or unhygienic water sources, which is being compounded by the effects of loadshedding.1 Equally, the deadly floods that affected particularly the Eastern Cape and KwaZulu-Natal in April last year damaged an already ailing sewerage and water system, with millions of litres of untreated sewage spilling onto beaches, rivers, harbours and the ocean in and around Durban.2

This has resulted in an increased incidence of gastroenteritis, which is caused by intestinal infection owing to the contamination of food, water or hands.3 Acute-onset vomiting and diarrhoea is second only to respiratory illnesses as a cause of childhood deaths worldwide.3

Diarrhoea accounts for 19% of deaths of under-fives in South Africa and for 46% on the African continent.4 Acute diarrhoea has several risks and complications, and may lead to life-threatening dehydration and electrolyte disturbances.3 When diarrhoea is not halted, there is a risk of disturbed digestion and absorption of nutrients with nutritional deterioration.3

Guidelines published in the South African Medical Journal (SAMJ) state that acute diarrhoea is predominantly a problem of fluids and feeding – both being heavily dependent on the caregiver’s understanding and reactions.3

It is vital that healthcare practitioners and caregivers understand the ‘what’ and the ‘how’ of oral rehydration therapy (ORT) and re-feeding, and that they are given guidance on the need to seek further help in the event of the following:3

• Ongoing vomiting despite small fluid sips, especially if associated with abdominal distension or pain

• Persisting fever after 24 hours of ORT

• Increasing lethargy and failure to feed

• Deteriorating hydration and failure to pass urine

• Presence of blood in the stools

• Diarrhoea persisting for more than 1 week.

Momeena Omarjee, Consumer Healthcare Country Head: Scientific Affairs, at Sanofi South Africa, outlines an ambitious campaign by Sanofi in partnership with non-profit organisation (NPO), Save the Children, to impact over 2 000 000 lives by 2025, through education on hygiene and nutrition and improved access to water.

“Sanofi is committed to ensuring that no child dies of a preventable disease. Since October 2022, Sanofi has donated 15 water tanks and 14 hand-washing stations to Early Childhood Development centres in KwaZulu-Natal communities in need, to ensure access to clean, drinkable water. This will help to curb the prevalence of diarrhoea and diarrhoea-associated deaths in children under five, which are entirely avoidable,” says Omarjee.

“Children living in poverty-stricken environments are approximately 10 times more likely to die from diarrhoea than their more privileged counterparts.5 Providing adequate access to clean, drinkable water and quality early childcare and development will impact the lives and health of so many vulnerable children,” says Omarjee.

Several studies have shown that probiotics shorten the duration of diarrhoea and prevent recurrence of other episodes.6 Furthermore, probiotics can prevent diarrhoea from infection in infants with malnutrition.6

The World Gastroenterology Organisation states that oral administration of probiotics shortens the duration of acute diarrheal illness in children by approximately 1 day.7 There is also evidence of efficacy in adults or children who are receiving antibiotic therapy, for prevention of antibiotic-associated diarrhoea.7

“Healthcare professionals should encourage parents to give children a daily, regular probiotic, which could go a long way in preventing diarrhoea and illness,” concludes Omarjee.

References

  1. Ebrahim, N. Western Cape Municipality asks residents to boil water as load shedding hits treatment plants. News24, 16 January 2023, available from: https://www.news24.com/fin24/economy/municipality-voices-concerns-over-water-quality-and-sewage-spills-amid-load-shedding-20230116, accessed 29 May 2023.
  2. Khan, AJ. Water worries hang over Durban months after heavy flooding. The Guardian, 9 January 2023, available from: https://www.theguardian.com/environment/2023/jan/09/water-quality-worries-hang-over-durban-months-after-deadly-flooding, accessed 29 May 2023
  3. Wittenberg, DF. 2012. Management guidelines for acute infective diarrhoea/gastroenteritis in infants. SAMJ, vol. 102, No. 2.
  4. Awotione, O.F., et al. 2016. Systematic review: Diarrhoea in children under five years of age in South Africa (1997-2014). Tropical Medicine and International Health, 21(9), 1060-1070.
  5. Chola, L., et al. 2015. Reducing diarrhoea deaths in South Africa: costs and effects of scaling up essential interventions to prevent and treat diarrhoea in under five children. BMC Public Health, 15, 394.
  6. Solis, B. et al. 2002. Probiotics as a help in children suffering from malnutrition and diarrhoea. European Journal of Clinical Nutrition, 56, S57-59.
  7. World Gastroenterology Organisation. 2017. Global Guidelines: Probiotics and prebiotics, available from: https://www.worldgastroenterology.org/UserFiles/file/guidelines/probiotics-and-prebiotics-english-2017.pdf, accessed 29 May 2023.
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Diarrhoea in Infants Requires Urgent Attention

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Holding a baby's hand
Photo by William-Fortunato on Pexels

Diarrhoea remains one of the leading causes of death, ill health and disability among children under five years of age in developing countries,1 accounting for 19% of deaths of under-fives in South Africa and for 46% on the African continent.1 Globally, diarrhoea is the second leading infectious cause of death, accounting for 9.2% of deaths in under-fives.1

The high incidence of malnutrition in South Africa2 adds to this toll. The relationship between diarrhoea and malnutrition is bidirectional: diarrhoea may lead to malnutrition, while malnutrition may aggravate the course of diarrhoea.3 Diarrhoea is more common and more severe in children with malnutrition (ie, undernutrition), and malnourished children often have persistent or repeated diarrhoea.4 In addition, malnourished children are more likely to develop severe diarrhoea and die from it.4 Vulnerable groups such as pregnant women and children under five years of age are the most affected by malnutrition, especially in rural areas.5

Identifying children at risk

The Centres for Disease Control advises that caregivers should be trained to recognise signs of illness or treatment failure that necessitate medical intervention.6 Infants with acute diarrhoea are more prone to becoming dehydrated than older children,6 and healthcare workers or parents of infants with diarrhoea should promptly seek medical evaluation as soon as the child appears to be in distress. Reports of changing mental status in the child are of particular concern.6

When the child’s condition is in doubt, immediate evaluation by a healthcare professional is recommended.6 Clinical examination of the child provides an opportunity for physical assessment, including vital signs, degree of dehydration, and a more detailed history, and for providing better instructions to the caregivers.6

Treatment

The treatment emphasis for acute diarrhoea in children is the prevention and management of dehydration, electrolyte abnormalities and comorbid conditions.3 The objectives of diarrhoeal disease management are to prevent weight loss, encourage catch-up growth during recovery, shorten the duration and decrease the impact of the diarrhoea on the child’s health.3

A number of studies have shown that probiotics shorten the duration of diarrhoea and prevent recurrence of other episodes.7 Furthermore, probiotics can prevent diarrhoea from infection in infants with malnutrition.7

Momeena Omarjee, Consumer Healthcare Country Head: Scientific Affairs, at Sanofi South Africa says: “Good gut health is crucial for one’s wellbeing – and healthcare professionals should encourage parents to give children a daily, regular probiotic which could go a long way in preventing diarrhoea and illness.”

How can the risk of diarrhoea be reduced?

Breastfeeding, a clean safe water supply, appropriate hand-washing and good sanitation will prevent most cases of diarrhoea.8

Research shows that diarrhoea is closely linked to socioeconomic status and has the most adverse effects in South Africa’s impoverished communities.9 South African children living in poverty are approximately 10 times more likely to die from diarrhoea than their more privileged counterparts.9

Says Omarjee: “Many of these under-privileged children in South Africa do not have adequate access to clean, potable water and quality early childcare and development, and they experience limited access to health and nutrition services. KwaZulu-Natal (KZN), for example, is experiencing outbreaks of diarrhoea and other water-borne diseases due to the recent floods.”

Although government and NGOs have been working tirelessly to distribute clean, potable water to affected areas in the province, many communities continue to face challenges and intervention is needed to not only provide clean water to the communities, but also to manage the high risk of diarrhoea and related water-borne diseases.

“Sanofi has therefore embarked on an ambitious campaign, in partnership with a non-profit organisation, Save the Children South Africa, from October 2022 to assist these areas in need, and to impact over 2,000,000 lives through hygiene education and access to water,” says Omarjee.

Sanofi, working together with Save the children South Africa, will donate water tanks to Early Childhood Care and Development (ECCD) centres in the communities identified, based on Save the Children’s baseline assessment, and will ensure access to clean, potable water.

The provision of information, counselling, education and support to children and their caregivers is also limited, which translates into low use of services and uptake of practices promoting good health. Education campaigns on healthy hygiene habits will be rolled out to children and their caregivers and will be run through the Child Health Awareness Days (CHAD) events, training of ECCD centres practitioners, and community health workers.

Sanofi is committed to ensuring that no child dies of a preventable disease, especially when there are effective treatments available. Says Omarjee: “Healthcare professionals need to encourage parents and caregivers to act promptly and seek assistance when instances of diarrhoea in children under age five do not abate swiftly.”

  1. Awotione, O.F., et al. 2016. Systematic review: Diarrhoea in children under five years of age in South Africa (1997-2014). Tropical Medicine and International Health, 21(9), 1060-1070.
  2. Cleary, K. 2020. In-depth: The long shadow of malnutrition in South Africa. Available from: https://www.spotlightnsp.co.za, accessed 29 September 2022.
  3. Nel, E. 2010. Diarrhoea and malnutrition. South African Journal of Clinical Nutrition, 23, suppl 1, 15-18.
  4. Child Healthcare. n.d. What is the relationship between diarrhoea and malnutrition? Available from: https://childhealthcare.co.za, accessed 29 September 2022.
  5. Govender, L., et al. 2021. Assessment of the nutritional status of four selected rural communities in KwaZulu-Natal, South Africa. Nutrients, 13(9), 2920.
  6. Centers for Disease Control. 2003. Managing acute gastro-enteritis among children. MMWR, 52(RR16), 1-16.
  7. Solis, B. et al. 2002. Probiotics as a help in children suffering from malnutrition and diarrhoea. European Journal of Clinical Nutrition, 56, S57-59.
  8. Child Healthcare. n.d. How can the risk of diarrhoea be reduced? Available from: https://childhealthcare.co.za, accessed 29 September 2022.
  9. Chola, L., et al. 2015. Reducing diarrhoea deaths in South Africa: costs and effects of scaling up essential interventions to prevent and treat diarrhoea in under five children. BMC Public Health, 15, 394.