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. Most are dis- different as are their rates of administration. pensed as solid concentrates to be dissolved in boiled water and given by the mother. In gen¬ Prevention of Dehydration eral, they have been accepted with eagerness by infants and children. When reluctance has Pediatricians feel that severe dehydration been encountered in Mexico, the addition of cin- to be due diarrhea may averted if oral adminis¬ namon, manzanilla, or yerba buena to the solu¬ tration of fluids is commenced early in the ill¬ tion has made it acceptable. The sucrose ness. Fluids have been given orally to as many contained in several of the solutions provides as half or even more of the children coming to a useful source of calories during the period of rehydration centers in Latin America. Success suspension of other feeding; it also makes the is usually assured if the child is not vomiting. electrolyte solution more palatable.

Vol. 79, No. 10, October 1964 919 The various solutions listed in table 3 have Oral fluid therapy is recommended unequiv- been given to many patients with considerable ocally as the regimen of choice in early mild success. Little is known, however, of their ef¬ cases of diarrhea. It is practiced widely and fect on the electrolyte economy of the body promptly through all facets of the health serv¬ when treatment is unsuccessful. As long as ice in some countries in Latin America, notably renal bloodflow is adequate, the kidney is able in Venezuela, but it is not relied upon every¬ to make extensive adjustments in the interest where to the extent that its promise dictates. of homeostasis of body fluids. A word of caution is in about the use order Fluid Therapy of Dehydration of Ringer's or lactated Ringer's solutions, which are recommended in some parts of Latin Fluids can be given orally with success to America and are dispensed either as the solu¬ many dehydrated children, especially if the tion itself or as powders in packets obtainable child is not vomiting. De la Torre and Larra- without prescription and designed for solution cilla Alegre (8) were successful in 90 percent in a liter of water. Ringer's solution contains of the dehydrated children they attempted to 147 mEq/l. of sodium and has an osmotic con¬ treat. This experience, however, was unusually centration of 309 mOsm/1. Lactated Ringer's carefully supervised, and no net saving in time solution contains 130 mEq/l. of sodium and has of medical and paramedical personnel appears an osmotic concentration of 272 mOsm/1. The to have resulted. potassium content of each solution is negligible Gastroclysis appears today to be enjoying at 4 mEq/l. Neither is suitable for the replace- less extensive use owing in large part to the ment of diarrheal losses. increasing skill of doctors and nurses in intra- Table 3. Useful electrolyte and sugar concentrates available in Latin America to prevent diarrheal dehydration

1 Reference 18. 2 A liquid concentrate is also described, prepared by dissolving salts in 15 ml. of water, then adding 60 ml. of syrup of raspberry instead of the sucrose. Reference 18.

920 Public Health Reports venous techniques. In two Venezuelan States, a 24-hour day, particularly at night, when nurs¬ dehydrated children are being treated exclu¬ ing coverage also may be scanty. Some exist¬ sively with gastroclysis so that this route may ing residency programs make no provision for be compared with the intravenous therapy used nighttime medical supervision except on an elsewhere in that country. Although personal emergency basis, so that care for the critically communication from Dr. Pastor Oropeza notes ill patient again may pass through a succession that results are not yet available, a value judg¬ of physicians who have no continuing aware- ment seems to have been made in that a par¬ ness of the patient's changing needs. These ticularly ill child, instead of being treated by shortcomings come sharply into focus in con- gastroclysis in a rural hydration center, is sidering the care of dehydrated, undernourished usually referred to a hospital for intravenous children, half of whom die during their first therapy. day or two in the hospital. Subcutaneous fluids have been used success¬ The interruption of close medical supervision fully in the treatment of dehydration in South and suspension of supervised fluid therapy of Africa but with poor success in Poland (1). dehydrated children, making necessary their There is no knowledge of their routine use in transfer home for further care while still criti¬ Latin America. cally ill, cannot help but result in fatalities that With severe dehydration, intravenous ther¬ the presence of a qualified attendant might apy and hospital care are mandatory. In Latin prevent. America intravenous fluid therapy is widely practiced, with rare resort to cut-down and Organized Health Care even rarer use of bone marrow infusion. By and large, puncture of superficial veins is a skill We are familiar with organized health care developed to a high degree in medical centers, programs for the control of diarrheal disease in especially among nurses and not infrequently Venezuela, Chile, and Mexico. They represent among auxiliary personnel as well. In certain efforts deliberately planned at a national level parts of Brazil extensive use is made of sub- and executed locally over large areas of these clavicular vein puncture as first described by countries. Aubaniac (16). Venezuela. Venezuela for 27 years has had The complex problems of intravenous fluid an integrated program at the national level, car¬ therapy require more extensive consideration ried out by the division of maternal and child than is possible here. We have surveyed and health of the Ministerio de Sanidad y Asisten- commented on this subject in Latin America in cia Social. Health centers and rural medical another publication (17). centers have been established throughout the Republic. Since 1941 particular emphasis has been on diarrheal and since the Hospital Treatment placed disease, end of 1958 rehydration centers have been cre¬ Although mortality from diarrhea is decreas¬ ated in rapidly increasing numbers as part of ing in many areas of Latin America because the national campaign against gastroenteritis. severe dehydration has been prevented through All physicians assigned to a unit of the health better nutrition, health education, early recog¬ care services dealing with children attend nition of disease, and fluid therapy of afflicted refresher-orientation courses including practi¬ children, the number of deaths of dehydrated cal experience in applying rehydration tech¬ children admitted to hospital and rehydration niques. Efforts by nurses and auxiliaries are centers remains high. aimed at early casefinding and oral administra¬ Treatment of acutely ill persons in many hos¬ tion of an electrolyte solution prepared from pitals and health centers is often fragmented pills distributed throughout the country. by passage of responsibility for patient care Children may be treated on an ambulatory through a succession of physicians who serve basis or detained at the center for intravenous for only a few hours each. In some hospitals therapy if home treatment seems to be in¬ no physician is in attendance during much of adequate. Therapy at the center may last from

Vol. 79, No. 10, October 1964 921 a few hours to a few days. Health centers are municipality to be organized, an open meeting open for emergency care, such as rehydration is held with citizens of the community. Com¬ of a child with diarrhea, 24 hours a day. If munity members are designated as responsible the infant is detained at the center for intra¬ for certain parts of the town or village popula¬ venous fluid therapy, the mother stays with him tion. After further indoctrination and the dis¬ to learn more about the prevention and man¬ tribution of packets of electrolyte powder, the agement of diarrhea. The integrated unit pro¬ "block leaders" carry on educational work in vides a structure for continuity of care and their sector on a family-to-family basis, focus- followup of any associated nutritional disease. ing on the importance of prompt treatment, es¬ The effectiveness of Venezuela's integrated pecially in the young children. Major efforts program may be seen in Caracas, where rehy¬ are timed to coincide with the peak of the diar¬ dration centers have been established not only in rheal season, which is rather sharply limited to the central hospitals but in sectors of the city. 4 or 5 months (May through August). Despite an influx of country dwellers into the Cooperation of rural communities in this cam¬ congested slum areas of Caracas, deaths due to paign has been impressive. Preliminary data diarrheal disease have decreased, especially in suggest an estimated 50 percent reduction in recent years as the specific attack against de¬ deaths from diarrheal disease in communities hydration has been intensified. with organized programs. There is indication Chile. Chile's organized national program that severe diarrheal dehydration is being against diarrheal disease has functioned within reduced while no effect on morbidity of diarrhea the structure of a comprehensive health care has been observed. service. Of particular interest is the operation of services within the city and suburbs of San- Conclusions and Summary tiago. This zone is divided into five maj or areas, Mortality ascribed to diarrheal disease is the each responsible for 500,000 or more persons. most striking pathological characteristic of the Responsible for the health of children and cen¬ middle and southern sections of the Americas. tral to each area is a children's hospital or divi¬ It has been estimated that diarrhea is the cause sion in a general hospital with personnel who of death in almost a quarter of the million supervise and deliver the health care in outlying young children who die annually in this part clinics. After-hours emergency medical care is of the world. available in a centrally located office from which Because of shortages in personnel and sup¬ major problems may be referred to the hospital plies, it is impossible to reach a significant pro¬ if necessary. Exchange of information between portion of this population with methods of pri¬ hospitals and clinics is prompt. Followup after mary prevention that can be expected to reduce hospital discharge is through the nearest clinic. the incidence of diarrheal disease significantly. In the Area Sur of Santiago, the age-specific On the other hand, personal health care serv¬ mortality due to diarrhea in children under 2 ices, when considered as a comprehensive years of age fell from 1,010 per 100,000 in the whole, have unique and important contributions summer of 1960 to 490 in the summer of 1963. to make toward the reduction of preventable Mexico. The Mexican campaign against deaths from diarrheal disease. diarrhea is of special interest because it repre¬ Neither antibacterial therapy nor drugs to sents a direct approach to the community. The suppress diarrhea as a sign are routinely help- people were mobilized to help solve their own ful. Treatment resolves itself into averting or problems, and educational and early treatment repairing dehydration through appropriate efforts were combined. The most successful fluid therapy. efforts to date have been in the areas without Preventing dehydration by early oral fluid ready access to health care services. therapy, as opposed to the prevention of diar¬ The technique of organization is simple. rhea itself, is a basic feature of all programs After consultation with the coordinator of med¬ for the control of the disease. Various types ical services, local physicians and nurses, and of solutions are used as are other forms of fluid community leaders in the central village of each therapy and hospital care programs.

922 Public Health Reports Successful diarrheal disease control programs Nations, Seville, Sept. 17-18, 1962. Mimeo- in Venezuela, Chile, and Mexico have relied graphed. (6) Burgos Courlander, C., et al.: Amebiasis during heavily on early oral rehydration and effective the years 1960 and 1961 in the pediatrics serv- parental therapy promoted in an organized way ice of the Civil Hospital of Maracay. Pre- through existing health care services. sented at the meeting of the Carabobo Aragua The key to the success of health care pro- Chapter of the Venezuelan Society of Pueri- grams in reducing the mortality from diarrheal culture and Pediatrics, Puerto Cabello, May 5, 1962. disease in Latin America lies most importantly (7) De la Torre, J. A.: Chemotherapeutic agents and in measures to reduce dehydration through antibiotics in the teatment of the acute infantile early casefinding and appropriate oral fluid "infectious diarrhea." Bol Med Hosp Infant therapy. Backing this crucial phase of the Mex. To be published. program are emergency hydration centers and (8) De la Torre, J. A., and Larracilla Alegre, J.: The oral route for the rehydration and correction hospital outpatient departments or health units. of the electrolyte imbalance of ambulatory There is a great need for convalescent resources "diarrhea" patients less than two years of age. in day-care centers and institutions for the Bol de la OSP 49: 542-551 (1960). severely malnourished child who has been saved (9) Araujo, C. G., Costa, A., and Bolafnos, R.: from death due to dehydration. Escherichia coli in the etiology of acute infan- tile diarrhea. Bol Inst Puer Univ Brasil 16: Education of the community must be accom- 6-19 (1959). panied by attention to the effectiveness and (10) Maroja, R. C., et al.: Bacteriological studies of availability of treatment and followup care. an epidemic of infantile diarrhea in Fortaleza, A close personal relationship between the physi- Ceard, 1957. (Separate.) X Jornada Brasil cian-medical team and the patient and family Puericult Pediat, Fortaleza, Ceard, 1958. (11) Rouquayrol, M. Z., and Ecilda de Lima, M.: Con- are required. tribution to the study of the treatment of infan- Studies are needed to simplify and perfect the tile diarrheas. J Pediat (Rio) 28: 99 (1963). techniques that can be most efficiently applied (12) Murahocschi, J., et al.: Study on the etiology of by the health care services to save more lives. acute infantile diarrheas and attempt at treat- A program of health care that provides early ment with framycetin sulfate and canamycin sulfate. J Pediat 28: F 1 (1963). and adequate treatment of diarrheal dis- (13) Fossaert, H. C., et al.: Sepsis due to Escherichia eases in young children can significantly reduce coli 0111 :B4 in the newborn. Arch Venes mortality in early childhood. Puericult Pediat 22: 355-394 (1959). (14) Ramos Alvarez, M., and Olarte, J.: Diarrheal dis- REFERENCES ease in children. Amer J Dis Child 107: 218, (1) Ordway, N. K.: Diarrheal disease and its control. March 1964. Bull WHO 23: 73-101 (1960). (15) IrazAbal, J., et al.: Studies of the microbiological (2) Verhoestraete, L. J., and Puffer, R. R.: Diarrheal etiology of diarrheas and therapeutic considera- disease with special reference to the Americas. tions. Bol Hosp Nifios J M de los Rios 4: 583 Bull WHO 19: 23-51 (1968). (1962). (3) Gordon, J. E., B4har, M., and Scrimshaw, N.S.: (16) Aubaniac, R.: The intravenous subclavicular in- Acute diarrheal disease in developing countries. fusion; advantages and technique. Presse In Control of enteric infections. Pan American medicale 60: 1456 (1952). Health Organization Scientific Publication No. (17) Ordway, N. K., and Yankauer, A.: Intravenous 100. Pan American Health Organization, fluid therapy of diarrheal dehydration with Washington, D.C., 1964. special reference to Latin America. In Control (4) Heredia Duarte, A., Benevides, L., et al.: Influ- of enteric infections. Pan American Health ence of health education as a measure for the Organization Scientific Publication No. 100 prevention of infantile diarrhea. Bol Med Hosp (English). Pan American Health Organization, Infant Mex 14: 785 (1960). Washington, D.C., 1964. (5) Fossaert, H. C.: Plans of treatment in the severe (18) Hardy, A.: Control of infant diarrheas in the forms of infantile diarrhea: Etiology of diar- light of recent scientific progress. Bol de la rheas. The Congress of Pediatrics of Latin OSP 37: 801, app. 1 (1954).

Vol. 79, No. 10, October 1964 923 and encourage the youths to seek medical care promptly, thus allevi- ating medical, vocational, and social difficulties. Project for Mentally Retarded In a project of the Hawaii Depart¬ ment of Health's mental retardation Institute on Disease in Elderly dentists and physicians how to un- division, former residents of an insti¬ The Jewish Home and Hospital for cover mouth cancers in the early tution for the mentally retarded meet The tools will be a slide once a week for hours with Dr. Aged, Bronx, N.Y., held an Institute stage. glass iy2 and a wood the chief on the Prevention of Diseases and scraper. Setsu Furuno, psychologist. Cancer of the oral and learn about facili¬ Disability in the Elderly, on Septem¬ cavity They community was for 419 ventilate of isolation ber 24, 1964 for persons profession- pharynx responsible ties, feelings ally engaged in services to the aged. deaths in 1963 in Pennsylvania. and loneliness, and discuss their Speakers emphasized the necessity problems and satisfactions in rela¬ for intensive and for treatment Seat Belts for School Bus Drivers tions with their employers and study families. earlier in life. They also dwelt upon Orchard View Community Schools Dr. Furuno has for a such urgent topics as accident pre¬ in Muskegon Township, Mich., have arranged spe¬ cial YWCA class in for the vention, mental hygiene, and meas¬ installed seat belts for drivers on sewing women in the ures for control of malignant disease. each of the district's 17 school buses. dischargees hope that "they will seek out other recreational Alert for Encephalitis IS.J. Aid for Migrants and skill programs on their own." The New Jersey State Department Flocks of chickens serve as sen- TB Casefinding tinels against any sneak attack by of Health, with funds available from encephalitis in New Mexico. The the Public Health Service, has con¬ In southeastern Michigan, 275 vector control section of the State tracted to pay the National Travelers active cases of tuberculosis were dis¬ health department sets mosquito Aid Association $11,000 for the covered in tuberculin tests of 800,000 school children from 1957 traps within special chicken pens to period May 1,1964, to May 1,1965, to September permit collection of live mosquitoes add services designed to protect the to December 1962. About 1.7 per¬ for weekly identification and virus health of migrant agricultural work¬ cent of the children were reactors. In 33,745 contacts of the an isolations. Chickens are bled ers in New Jersey and after they reactors, additional 116 new cases were found monthly for antibody determination. leave the State. The association has agreed to pro¬ through X-ray. Thus an alert may be early expected vide a caseworker and a mobile unit if the virus becomes encephalitis for visiting labor camps, Mobile Chest Screening Unit of the hospitals, active; knowledge species and other locations; to assure con- A Christmas Seal mobile health carrying the virus, in case it appears, tinuity of planning for the migrant unit, put into service in October 1963, will also be obtained. workers throughout the country, enabled the Buffalo and Erie County through use of the association's (N.Y.) Tuberculosis and Health As¬ Casefinding by Cytology offices; and to encourage effective sociation to screen additional thou¬ Forty-six positive cytology spec¬ relationships among all groups serv¬ sands for chest disease. In 5 imens were uncovered in 1963 among ing the migrant and his family. months, 10,500 X-rays and 2,000 9,275 women examined in the general breathing tests were provided; brief hospital cytology program of the Cancer in the Young medical histories were also taken. New York State Department of Cancer, for some time the leading Special groups served included Health. Additional funds have been fatal disease in the age group 1-14 medical and dental students. allotted to years, is now responsible for more support hospitals carrying "Health-O-Rama" out this program in 1964. than one-fifth of all deaths from Buffalo's disease in that a Ten of the definite cancers were age group. At "Health-O-Rama" held in in more than as carcinoma in in- Buffalo, N.Y., 1963, diagnosed situ, Health Aid to and dicating that at least one-third of Military Rejects 21,000 persons registered 20,000 The State took tests. Twenty-three commu¬ the cases detected had been unsus- Maryland Department of Health has established a counsel¬ nity health agencies participated in a pected and by patient physician. ing and referral service to help the 4-day program of free health screen¬ The Pennsylvania Department of large number of ing tests, exhibits, and demonstra¬ aided a' draft-age youths Health, by $120,000 Public who are rejected for military service tions. Persons tested were in¬ Health Service grant for a 3-year because of physical reasons. Pur¬ formed by mail of results and told program, plans demonstrations in all pose of the program is to promote to inform their physician if results health regions of the State to show early diagnosis of health problems were positive.

924 Public Health Reports