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In Latin America Diarrheal Disease and Health Services in Latin America ALFRED YANKAUER, M.D., and N. K. ORDWAY, M.D. PERCENT of deaths from diar¬ deaths in children under 5 years of age occurred NINETYrhea in the middle and southern sections during the first 6 months of life while in Co¬ of the Americas are in children under 5 years lombia the proportion is almost one-third. of age. It is estimated that this disease has The incidence of diarrhea appears to vary been the cause of death of almost a fourth of with infant feeding practices related to supple- the million young children who die annually mentation of or substitution for breast milk. in this part of the world. If the diarrheal dis¬ Some Latin countries show reduced morbidity ease death rates of North America were to pre- as early as the sixth month and others as late as vail throughout the Western Hemisphere, the the third year of life. number of deaths would exceed by 98 percent Diarrhea in young children is frequently the number expected. associated with other infeetions and with pro- Diarrhea is conceived of as a disturbance of tein-calorie malnutrition. The epidemiologic intestinal motility and absorption, which once relationship between diarrheal disease and mal¬ and by whatever means initiated may become nutrition has been extensively documented in self-perpetuating as a disease through the pro¬ recent studies carried out by The Institution of duction of dehydration and profound cellular Nutrition in Central America and Panama (3). disturbances, which in turn favor the continu¬ A recent study by Heredia and associates (4) ing passage of liquid stools (1). suggests that the effect of educational efforts in The age-specific mortality from diarrhea is reducing subsequent diarrhea may be more pro¬ the first of life. The ductive when directed toward families of chil¬ highest during year dren with diarrhea concentration of deaths that occur dur¬ complicating malnutrition heavy than when directed toward the families of all ing the first few months after birth was pointed children with diarrheal disease. out some years ago by Verhoestraete and Puffer (2). It is emphasized by more recent data from Venezuela and Colombia (tables 1 Specific Etiology and Chemotherapy and In Venezuela almost half of the 2). Most cases of diarrhea are considered to origi- nate as enteric and in of the Dr. Yankauer is adviser in maternal and infeetions, parts regional world where this is and causes child health to the Pan American Sanitary Bureau, malady frequent Washington, D.C. Dr. Ordway, professor of pedi- many deaths, a recognized causative agent can atrics, Yale School Medicine, New frequently be isolated. University of of and Salmonella have Haven, Conn., is now in Cali, Colombia, as visiting Species Shigella long professor of pediatrics at the University of Valle been recognized as causatives of diarrheal dis¬ Medical School, on sabbatical from Yale. This ease. In the past decade enteropathogenic paper was adapted from a working document pre¬ strains of Escherichia coli have become incrimi- pared for the technical discussions of the llfih Pan nated with frequency in the production of noso- American Health Organization meeting of the direct¬ comial epidemics in young infants and fre¬ ing council, Washington, D.C, September 1963. quently may be recovered in endemic diarrhea, Vol. 79, No. 10, October 1964 917 particularly in children under 1 year of age. Table 2. Distribution of deaths from diarrhea Entamoeba has been recovered with under 5 years of age, by age at death, histolytica 19601 frequency in cases of diarrhea with bloody stools Colombia, even in children under 2 years of age (5,6). Prevalence of the disease appears to be con¬ siderably greater in certain areas (5, 7-13). Of particular interest has been the recent im- migration of large numbers of country dwellers into city slum areas in Venezuela. This popu¬ lation move has been associated with a consider¬ able upsurge in cases of diarrhea. The relative importance of viruses in endemic diarrhea is at the moment disputable. What¬ ever their role, no antiviral chemotherapy is 1 Includes deaths from diarrhea of newborn in 1961 available. and from dysentery and gastroenteritis, 1960. Clinically, there is little to distinguish among diarrheal infeetions due to viruses or bacteria. recent studies continue to show the ineffective- Perhaps 15 percent of all cases of diarrheal dis¬ ness of antibiotics in altering the clinical picture eases are associated with the passage of bloody of diarrheal disease (4,7,10,11). For example, stools, although this percentage may rise to in a double blind study in Caracas (15), the nearly 50 percent in Shigella infeetions (H). effect of chloramphenicol was indistinguishable Only Shigella and enteropathogenic E. coli from that of a placebo. have been shown to be effectively eliminated It is reasonable to conclude that the identifi¬ from the body with chemotherapy. The use of cation of an infectious agent and the chemo¬ appropriate antibiotics has been important in therapy of a case of diarrheal disease are of the therapy of newborn infants with E. coli in¬ limited usefulness except for infeetions due to feetions, but the same antibacterial effectiveness enteropathogenic E. coli in nursery epidemics of a variety of drugs against Shigella has not or E. histolytica. Antibacterial agents are ex¬ been attended with comparable clinical im¬ pensive as well as ineffective on the whole. provement of the patient. Among the potentially harmful results of their From a statistical standpoint, it is known that use is the production of diarrhea or the possible the duration of diarrhea may be somewhat invitation to enteric infection by resistant or¬ shortened if Shigella can be eliminated, but most ganisms such as Staphylococcus aureus. My- cotic infeetions and bone marrow depression Table 1. Distribution of deaths from diarrhea have been reported. The potential hazards as¬ under 5 years of age, by age at death, sociated with the routine use of chemotherapeu- Venezuela, 1961 * tic agents very likely outweigh their possible benefits. Despite lack of documented effectiveness, an¬ tibacterial therapy enjoys widespread accept¬ ance. Suppression of Diarrhea Except for withholding food, the short-term usefulness of which will be commented on when oral fluid therapy is discussed, measures de¬ signed to suppress the passage of loose stools are notably unsuccessful. Paregoric can be used to the point of depressing the central nerv¬ 1 Deaths certified by a physician as due to diarrhea (gastroenteritis and diarrhea of the newborn). ous system without affecting the frequency or 918 Public Health Reports character of the stools. Use has not proved the The prevention of dehydration, as opposed to practical or theoretical effectiveness of proprie¬ the prevention of diarrhea itselfa is a basic fea¬ tary preparations designed to: (a) absorb hypo¬ ture in all programs for the control of diarrheal thetical toxins, (b) soothe the inflamed intes¬ disease. The important features of this ther¬ tinal mucosa, (c) alter intestinal function by apy are: changing bacterial flora, or (d) disguise liquid 1. Providing liquids by mouth which, at least stools by the hygroscopic action of inert solids. theoretically, approximate in content and vol¬ Reduction in fecal loss of water and electrolytes ume the aggregate of those fluids lost abnor- has not been demonstrated with these prepara¬ mally in the diarrheal stools and normally via tions nor has it been shown that they selectively lungs, skin, and kidneys. remove only noxious substance from the gut. 2. Suspending all food intake for a brief pe¬ riod. Twelve hours of calorie starvation usu¬ Dehydration ally suffice and may be more than adequate. Rarely should 24 hours be exceeded. The Except for certain rare complications, death child's usual food does not cause diarrhea but from diarrhea is due to dehydration or its may briefly aggravate it. Prolonged restric- serious consequence, shock. Treatment of diar¬ tion of food can only enhance the malnutrition rheal disease thus resolves itself into averting or that is frequently present without fundamen- repairing dehydration through appropriate tallybenefiting the diarrheal process. fluid therapy. Vomiting associated with diarrheal disease is When dehydration occurs, fluid therapy be¬ infrequent in the course of the illness but makes comes more complex in that deficits must be re- its appearance in most children as dehydration paired.much different from simply giving becomes more severe. Early oral fluid therapy fluids and electrolytes to replace those being averts not only dehydration but also vomiting lost from the body by normal and abnormal which makes oral administration of fluids dif¬ routes. ficult or impossible. Vomiting frequently can The goals of rehydration are threefold and be controlled by giving teaspoonfuls of the hy- indissoluble: prevention or treatment of shock, drating solution at intervals of 5 minutes or restoration of effective renal function, and re- more. In unrelenting vomiting, drugs includ¬ plenishment of deficient water and electrolytes. ing tranquilizing agents in small dosage, have These are assured through restoration and main¬ been used with success. tenance of an adequate circulating volume of Solutions for oral therapy in general use in blood. Latin America vary in composition from boiled Rehydration progresses in two phases: (a) water and sweetened tea, which have essentially a rapid phase of repairing deficits of sodium no electrolyte content, through one-third to one- chloride and water and (b) a more gradual half isotonic solutions, to Ringer's solution, phase of restoring deficient potassium, adjusting which is isotonic. (Isotonicity refers to the residual deficits and osmotic and acid-base dis- normal osmotic concentration of body fluids, ap¬ turbances, and return to normal alimentation. proximately 300 mOsm/1.) Examples of such The requisite fluids for these two phases are solutions are listed in table 3.
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