Issue no. 36 - March 1989
version of this
There is much information in this issue that is valuable
and useful. Online readers are reminded, however, that treatment guidelines and health
care practices change over time. If you are in doubt, please refer to
WHO's up-to-date Dehydration Treatment
Pages 1-8 Dialogue on Diarrhoea Online Issue 36 -
on Diarrhoea Online Issue 36 March 1989
Page 1 2
Care with food cuts diarrhoea risk
Without food and water, people cannot survive, but these basic essentials for life can
easily spread dangerous disease causing organisms. Customs and taboos about how to handle
water and food are found in most societies. Many traditional controls make a great deal of
sense in the light of the scientific discoveries on which modern public health practices
are based. But, unless there is genuine understanding about how a disease like diarrhoea
is caused and carried, risky contamination of both food and water is likely to continue.
People are not born with hygiene know-how: it has to be learnt. A worldwide problem This issue of DD looks at food related diarrhoea as a significant health risk in
the so-called developed countries as well as in the Third World, particularly among poor
urban communities and the most vulnerable age groups - the young and the old. The
incidence of this type of diarrhoeal disease is noticeably on the increase, for example in
the UK (see="#page3">page 3). Problems of food hygiene vary between countries
at different levels of industrialisation. There are, however, many practical ways to
prevent food borne infections which can be appropriately adapted to local cultures and
resources. Dialogue readers may like to add their own suggestions to those
described in the following pages.
Hygienic food preparation helps to prevent food related diarrhoeal
Always remember ORT
In all episodes of acute diarrhoea in all countries, whatever the source of infection,
dehydration is the immediate danger, and oral rehydration therapy is the most effective
response. The value of ORT obviously still needs to receive much greater stress in the
education of all health professionals worldwide, as well as being conveyed to the general
KME and WAMC
|In this issue:
- Improving environmental hygiene
- Practical advice on preventing food borne infections
- Health extra: Practical hygiene
on Diarrhoea Online Issue 36 March 1989 1 Page 2 3
Good food is essential for good health, and is one of the greatest pleasures in
life. Despite advances in technology, providing food that is safe to eat and keeping it
safe is still a worldwide public health problem, Illness, especially diarrhoea, caused by
contaminated food is a major cause of suffering and death, and also contributes to
malnutrition in the developing world. Precise figures for food borne illness are not available in many countries, but WHO
estimates that only a tiny proportion is currently recognised, and an even smaller
fraction reported. In developing countries, the ratio of actual to reported cases may be
as high as a hundred to one, while in industrialised countries, food related health
problems reported may be less than ten per cent of the actual total. It is not surprising,
therefore, that the impact on health of food borne disease has been a neglected subject.
(1) It has been estimated that, in 1980, more than a thousand million cases of acute
diarrhoea occurred in developing countries (excluding China) in children under the age of
five and that five million of those children died.(2) While there are several ways
in which diarrhoea causing agents can be transmitted, contaminated water was until
recently thought to be the most common. However, scientists now recognise that
contaminated food is also an important source of the germs that cause diarrhoea. (1,3) A universal concern The more industrialised countries also have serious food safety problems. Food safety
legislation needs to be improved, as does public health education about hygiene and safe
food storage and preparation. For example, recent estimates of the extent of food borne
disease in the USA range from 6.5 million acute episodes, with 9,100 deaths every
year, (4) to much higher estimates of 24 to 80 million acute food borne disease
episodes a year. (5) In industrialised countries, a few factors are responsible for most cases of food borne
disease: preparation of food too far in advance of eating; prepared food left for too long
at a temperature which allows bacteria to multiply; inadequate reheating; and an infected
person handling food.(1) In developing countries, these factors are significant, but
there are also others which need to be identified and taken into account in order to plan
preventive action. Few countries have integrated food safety into their primary health care systems.
Reducing the rate of food borne illness requires understanding of hygienic food handling
at all levels: in factories, shops, markets and at home. (6)
Always wash your hands before preparing food.
The World Health Organization regards illness due to contaminated food as one of the
most widespread health problems in the contemporary world. In infants and the elderly, the
consequences can be fatal. Protect your family by following these simple rules. They will
reduce the risk of food borne disease significantly.
The WHO Golden Rules for safe food preparation
- Choose foods processed for safety
- Cook food thoroughly
- Eat cooked foods immediately
- Store cooked foods carefully
- Reheat cooked foods thoroughly
- Avoid contact between raw and cooked foods
- Wash hands before preparing food and after using the toilet
- Keep all kitchen surfaces clean
- Protect foods from rodents, insects and other animals
- Use clean, uncontaminated water to prepare and cook foods
A poster listing these Rules for Safe Food Preparation in more detail is
available from Dr Kaferstein at the address below. Dr F K Kaferstein, Manager, Food Safety Unit, World Health Organization, 1211 Geneva
27, Switzerland. 1. The role of food safety in health and development, 1984. WHO Report of a joint
FAO/WHO Expert Committee on Food Safety: WHO/TRS 705.
2. Snyder, J D and Merson, M H, 1982. The magnitude of the global problem of acute
diarrhoeal diseases. Bull. WHO 80: 605.
3. Barua, D and Kaferstein, F K, 1983. The role of food in the epidemiology of
acute enteric infections and intoxications. Report of WHO meeting. WHO offset document
4. Cohen, M L, 1987 Prepared statement, in Hearing before the Committee of
Agriculture, Nutrition and Forestry, US Senate, 100th Congress, First Session, June 4 1987
page 28. US Government Printing Office, Washington D. C.
5. Archer, D L and Kvenberg, J E, 1985. Incidence and cost of foodborne diarrhoeal
disease in the United States. J. Food Protect. 48: 887
6. Kaferstein, F K, 1988. The Pleasures and Pitfalls of Eating. World Health,
on Diarrhoea Online Issue 36 March 1989 2 Page 3 4
Hygiene, food safety and diarrhoea
In many industrialised countries food borne diarrhoeal disease is actually
increasing. ORT is the most appropriate treatment anywhere in the world for dehydration
caused by diarrhoea, and education about food hygiene is relevant everywhere. Leeds is an industrial city in the north of England with a population of about 700,000.
Cases of diarrhoea are not formally recorded, but cases of dysentery and food poisoning
are notified by doctors to the City Council. In 1988, 373 cases of dysentery were notified
in the city and 1,800 cases of food poisoning came to the attention of the Environmental
Health Department. Most of the dysentery is due to Shigella sonnei which
mainly attacks groups of young children in the poorer parts of the city. Food poisoning
(in all age groups) has been increasing both in numbers affected and in severity in recent
years. The greatest single problem has been found to be salmonella infection, principally
associated with eggs and poultry.
Wherever you buy your food, safe food preparation is important. It is interesting to consider possible causes of this increase. There are more
processed foods now available in shops and supermarkets. Processed foods look attractive
and can be cooked quickly - a real help for busy people. Food manufacturers like to
produce these 'ready to eat' meals because there is a large profit on them.
Unfortunately they do not have a long shelf life, and keeping them in a refrigerator
for several days may not prevent contamination. (One cold-loving food poisoning organism, Listeria
monocytogenes, grows at cold temperatures). A quarter of homes in England now have a microwave oven, which heats up food very
rapidly, but does not always kill food poisoning organisms. Self defrosting refrigerators
are now common, and are not cleaned out as frequently as older models which have to be
defrosted regularly. This allows unhygienic conditions to develop. 'Progress' in the
kitchen is not without its pitfalls! Outbreaks and management
The management of diarrhoea is carried out by general practitioners and can be very
varied. Many patients are still told not to eat any solid food until their condition
improves. Far too few UK doctors give positive advice about diet, and a few still
recommend the exclusion of all milk (breast and bottle) from the diet of a child with
diarrhoea. Unfortunately the teaching of medical students hardly touches this important
subject. Most of what is taught is about the disturbance of electrolyte levels and the
need to correct these 'laboratory findings'. Looking at the patient as a person, and
encouraging the use of oral rehydration therapy still need to be emphasised. When notifications are received, they are usually investigated and followed up with
control measures where appropriate. One of the biggest problems is getting people to
remember what food they have eaten before the onset of the illness. Specially trained
infectious disease nurses seek to obtain histories to find out where the patient picked up
the infection, whether or not other people are ill, and whether others are also at risk
from the primary source or from the infected person. Food handlers and people working with
the very young, the very old, or patients with damaged defence mechanisms are asked to
stop work until they have recovered, and are helped if need be by compensation from the
City Council. Shigella infections are rarely food borne in the UK. In nurseries and schools,
infection is most likely to occur where toilets are poorly maintained (with no towels,
soap or hot water, for example), and where children do not wash their hands after
defaecation. Inspections of nurseries and schools in this city show that maintaining good
hygiene in toilet areas is often a low priority. The main tools available to deal with
outbreaks are good history taking, screening by stool examination and close attention to
personal and environmental hygiene arrangements. Dr Martin Schweiger, Specialist in Community Medicine, Leeds Eastern Health
Authority, Meanwood Park Hospital, Tongue Lane, Leeds LS6 4QD, UK.
on Diarrhoea Online Issue 36 March 1989 3 Page 4 5
Preventing food borne infections
In many communities, there may be no-one to teach and promote basic health education
relating to hygiene, and protection of food from contamination. Recent WHO policies and,
in particular, the publication of 'The Community Health Worker', (1) promote self-help in
food hygiene as well as in other areas. This book contains information which primary
health care workers need to help village communities raise hygiene standards. Food safety
Food should be kept clean at every stage - from production until it is eaten. Stale or
contaminated food can cause diarrhoea and other diseases. Clean water is needed for
washing foods before eating and for cooking.
Vegetables may have been fertilised with human or animal faeces and therefore they should
always be well washed and properly cooked before they are eaten. Vegetables to be eaten
raw must be well washed in clean water.
Eating raw or undercooked meat (including poultry) can be dangerous. Eating infected or
contaminated meat can cause severe vomiting and diarrhoea, infestation with worms and
other serious illnesses. At home, surfaces on which meat is cut and knives used for
cutting it should be very well washed and dried with a clean cloth before and after use.
To prevent spoilage, meat may be dried, salted or cooked immediately. Cooked meat should
be eaten at once or within a very short time of cooking.
Fish can go bad very quickly in warm climates, sometimes within a few hours of being
caught. Shellfish can spread disease, especially if caught in water contaminated with
sewage, or if eaten raw or undercooked. Fresh fish should always be gutted as soon as
possible, kept out of hot sunlight and as cold as possible, and cooked and eaten without
To avoid diseases spread by milk, it may be wise to boil it before drinking and to store
it in a clean container (for example, one in which water has been boiled or which has been
rinsed out with hot water). If milk has to be stored for use during the day, reboil it if
possible every four or five hours if there is no means of keeping it cool. Pasteurised
milk is usually safer than raw milk.
All eggs should always be thoroughly cooked.
Fruit should be eaten as soon as possible after being washed or peeled.
Basic food hygiene rules Following these basic rules will protect food from contamination.
- Wash your hands (with soap, if possible) before food preparation, eating, and after
using the toilet.
- Any person who is ill, particularly if suffering from diarrhoea, should not handle or
- Wash your hands again if you handle clothes or waste material, or attend to children
(for example, changing nappies) while food is being prepared.
- Raw foods should be stored and handled separately from cooked food, to prevent
- All surfaces, cooking dishes and other utensils should be cleaned thoroughly after the
preparation of raw foods.
- Do not prepare food too far in advance of when it is to be eaten (if food must be
prepared in advance at all). Food for infants should preferably be freshly cooked or
prepared for each meal.
- Food should be cooked thoroughly, not part-cooked or undercooked and, wherever possible,
should be served immediately while still hot. Cooking food to a high temperature kills
disease causing organisms.
- Store cooked foods carefully. If food is prepared in advance, it must be kept either hot
(above 60°C) or cool (below 10°C). Leaving cooked food to stand in warm conditions
allows germs to multiply; the longer food is left, the greater the increase of germs, If
food is kept, it should be reheated thoroughly to a high temperature (boiling or bubbling)
to kill germs.
- Food to be eaten cold should be covered during cooling and storage especially if it is
perishable, like meat or fish. It should be kept as cool as possible.
- Food should be protected from contamination at all times. Keep cats, dogs, other
animals, waste water and rubbish containers away from food. Do not allow rubbish to
accumulate where preparation and cooking of food takes place. Protect stored food from
rodents and insects.
- Use clean, uncontaminated water for washing and cooking food or making ice for
drinks (or boil it first to kill any dangerous germs).
Mr M Jacob, Environmental Health Officer, Department of Health and Social Security,
Alexander Fleming House, London SE1 6BY, UK. 1. WHO, 1982 The Community Health Worker. WHO: Geneva. (ISBN 924 156097
2. Roberts, Diane, 1987 Common sense in the kitchen. World Health, March.
on Diarrhoea Online Issue 36 March 1989 4 Page 5 6
Breaking the chain of infection
Interrupting the transmission of food borne pathogens can reduce diarrhoeal
disease rates. Robert Black and Dirk Schroeder
show how weaning foods can become contaminated, and suggest appropriate interventions to
prevent this from happening. Weaning food contamination is an important cause of high rates of diarrhoea in infants.
This is particularly true under less hygienic conditions where disease causing organisms
(pathogens) commonly contaminate supplementary foods and liquids. Delaying exposure of a
baby to contaminated foods is one of the many good reasons for encouraging exclusive
breastfeeding for the first four to six months of life. After this age, however, the
rapidly growing infant requires more nutrients than breastmilk alone can provide.
Therefore, understanding how weaning foods become contaminated, and how to reduce or
eliminate pathogen transmission, is of the utmost importance. Weaning foods may become contaminated at several stages:
- before food reaches the household;
- during preparation;
- during storage; and
- during feeding.
Before food reaches the household
In societies which use human or animal faeces as agricultural
fertilisers, lack proper
waste disposal and sanitation systems or have inadequate standards of hygiene in food
handling, raw foods are often contaminated. Some foods have characteristics which increase
the risk of contamination, for example, whether they grow in or near the ground, or have a
high moisture content and moderate pH. Vegetables or fruits which are not peeled,
unrefrigerated animal (including dairy) products, and mixtures made using impure water are
particularly dangerous. Unfortunately, contamination at this level is often determined by agricultural
production and transport methods outside the control of the individual family.
Consequently, strategies to reduce food contamination are necessary at the household
Assume that food may be contaminated and must be properly prepared for safe
consumption. Peeling and washing raw foods may decrease numbers of micro-organisms, but it
is difficult to make raw foods completely safe just by washing them. This is particularly
true in areas where water is scarce or is itself contaminated. Cooking is preferable.
Boiling, frying or baking for example, at high temperatures and for a sufficient period of
time, are good ways to kill pathogens. Unfortunately, due to shortage of fuel and time,
foods are not always cooked for long enough at high enough temperatures. An alternative approach, to prevent bacteria multiplying, is the souring (lowering the
pH) of food mixtures. Many traditional weaning foods (particularly in Africa) are prepared
by fermentation with lactobacilli. Nutritionists designing improved weaning foods could
consider souring as an approach to reducing risk of food contamination. Even if a food is free of pathogens when preparation begins, contamination may occur if
the food is handled with unwashed hands or comes in contact with dirty utensils or kitchen
implements. Poor personal hygiene, especially inadequate handwashing, appears to be a
particularly important factor in secondary contamination. Field investigations have
measured substantial reductions in diarrhoeal rates with adoption of improved handwashing
techniques, although it is still unclear which components of handwashing (e.g. quantity of
water and/or soap) most effectively limit transmission. Storage In poorer households, food is usually stored without refrigeration. Hot and humid
environments provide ideal conditions for bacterial growth. Typically, a busy mother will
prepare a weaning mixture at one point in the day and store the remainder to be eaten
later. If a food mixture has been contaminated during preparation, it is likely that
pathogens will multiply during storage, resulting in higher risk at subsequent feedings.
Storage at cold or very hot temperatures will prevent bacterial multiplication. If this is
not possible, fresh preparation before each serving, or thorough reheating, is necessary. Feeding The utensils used to feed a weanling infant can influence transmission of pathogens.
Feeding bottles and bottle nipples have been shown consistently to be contaminated,
probably because they are difficult to clean. Studies suggest that adequate disinfection
of bottles is nearly impossible in most developing country situations. Thus, actively
discouraging the use of feeding bottles is appropriate; in Papua New Guinea, virtual
elimination of feeding bottles (by legislation) has led to lower diarrhoea rates. Although
bowls and spoons used for feeding may also be contaminated, the levels of contamination
are significantly less than those of bottles. Bowls and spoons are also much easier to
clean. Dirty hands can transmit germs directly to the infant during feeding, so proper
handwashing is always necessary before feeding. Many of the strategies to reduce contamination of weaning foods are technically quite
simple; it is lack of knowledge and limited resources at the local level which prevent
improvements. Appropriate interventions which are sensitive to local culture and
conditions, and which include health education, can reduce infant diarrhoea worldwide. Professor Robert Black and Dirk Schroeder, Department of International Health, The
Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland 21205, USA.
on Diarrhoea Online Issue 36 March 1989 5 Page 6 7
|Improving environmental hygiene
How to plan a community based project
Eileen O'Rourke and Mahamadou Kaya
give guidelines for the community based, self-financing disposal of refuse, one way to
improve environmental hygiene while encouraging community development. Failure to involve the community intended to benefit in any environmental hygiene
project will almost certainly result in the project's failure. (1) If participation
begins at the planning stage, members of the community have the opportunity to discuss
what they believe to be their environmental hygiene problems. If they do not think they
have a problem, then it is unreasonable to expect the community to participate. In such
cases, it is best to begin with health education, and then to reassess changes in
attitude. Where community needs can be clearly identified, the next step is to ensure that
any technology introduced is culturally acceptable, affordable and can be
successfully used to meet those needs. Our experience of community based environmental hygiene projects was in a Sahelian
town, of approximately 80,000 people, in West Africa. Due to lack of money there is little
government support for hygiene projects. Our projects therefore had to be self-generating
and self-financing. Refuse collection
After a series of meetings with local officials and community leaders, we started to
build stabilised mud and cement brick refuse dumps all over the town. The dumps were
emptied every day by a team using donkeys and carts. The refuse was mainly organic waste
and household sweepings, which proved to be a useful and saleable product for filling in
holes to prepare land for housebuilding, and for composting. We used the common 'Chinese
high temperature' composting system' (2) (but with organic waste from the town abbatoir
instead of human excreta, the handling of which is unacceptable in Muslim societies). The
compost was used as fertilizer. All labour and materials used in the project, except the cement, were locally
available. A group of displaced people learnt to make bricks and construct the refuse
dumps, and so acquired useful construction skills. The donkeys and carts are a more
appropriate form of transport for the narrow, crowded streets of the town, than an
expensive refuse lorry. The refuse workers were paid by having the use of the donkeys and
carts after work, and with a small salary from the sale of the refuse. This simple system proved to be an effective and appropriate technology. The community
could understand and benefit from the improved town hygiene, local employment and refuse
General guidelines for community development
- Survey existing hygiene practices and try to include what people perceive to be their
needs in any new programme.
- Respect the views and wishes of the community which must have confidence in your ability
and sincerity. Time must be allowed for this relationship to develop.
- Use appropriate technology, with emphasis on local materials and labour as this
facilitates self-reliance and sustainability.
- The community should contribute directly to the project, either financially or by
supplying labour or materials. The degree of community participation will depend on
household incomes and perceived needs.
- Community participation is different in rural and urban environments, but personal
contact, dialogue and timing are important in both.
- Incorporate education programmes within a working project and present the community with
feasible solutions or alternatives.
- Wherever possible, use educators who are accepted members of the community and who are
aware of local customs and speak the local languages.
- Give special emphasis to women in community education projects, because women are
responsible for childcare and hygiene in the home. It is more difficult, but often more
important, to change attitudes than to introduce a new technology.
- When planning a project, it is usually better to take a long term view and an integrated
environmental health approach, rather than concentrating on one factor in isolation.
- It is important to have the support and permission of the local institutions and
administration. Work with them, if possible, as they may eventually be responsible for the
maintenance and continuation of the project and for the development of related projects in
the community, for example community latrines or washing facilities.
Eileen O'Rourke, 1 York Road, Rathmines, Dublin 6, Eire, and
Mahamadou Kaya, Regional Director of Hygiene and Sanitation, Mopti, Republic of Mali. 1. World Bank, 1980. Appropriate Technology for Water Supply and Sanitation: a
Planners' Guide. Volume 2.
2. Winblad, Uno, et al., 1978. Sanitation Without Water. Sundt Offset: Stockholm.
(Pages 30-32 include more detailed information on the composting technique mentioned
on Diarrhoea Online Issue 36 March 1989 6 Page 7 8
|Improving environmental hygiene
Environmental health in the Caribbean
The Environmental Health Officer is required to perform a wide range of functions,
all of which have a bearing on community health, and on diarrhoeal diseases in particular. The role of the Public Health Inspector, or EHO, is largely a preventive one, because
s/he is concerned with the environment. The environment and conditions in which people
live affect health status and the types of illness suffered by the community. Public education
An important function is that of educator: the EHO needs not only scientific knowledge,
but also to be able to tell people about health hazards both immediate and potential, and
generally to stimulate and develop community health consciousness.
The Environmental Health Officer informs people about immediate
as well as potential health hazards and how to avoid them. The EHO has a responsibility for checking the fitness of buildings, both for living and
working in. The adequacy of floor and air space and ventilation, quality and quantity of
water supplies (for personal, domestic and industrial purposes), proper lighting,
protection against dampness in buildings, and the proper provision of drainage and
sanitation (especially in relation to places where people live) must all be considered.
Another important activity is the checking of foodstuffs intended for sale in shops and
markets. The EHO also provides statistical data used to plan and organise future health
programmes, as well as for keeping the appropriate authorities aware of current
As a result of effective public health programmes over the years, the health status of
people in the Caribbean has improved considerably. But this success is threatened by lack
of financial resources and shortages of staff, drugs and other supplies. The migration of
trained health workers out of the Caribbean is also a major problem.
In response to
these problems, Caribbean governments have agreed on a new approach: the 'Caribbean
Co-operation in Health' initiative which is being carried out in conjunction with the Pan
American Health Organization (PAHO) and the Caribbean Community (CARI-COM). The following
six areas have been identified as health priorities:
- environment protection and vector control;
- human resource development;
- chronic non-communicable diseases and accidents;
- strengthening health systems;
- food and nutrition; and
- maternal and child health and population control.
Projects will be developed in these areas, with emphasis on more productive use of
The Caribbean Association of Environmental Health Officers
(CAEHO) is a regional,
non-profit, voluntary association. Formed in 1970, it represents national member
associations in Antigua and Barbuda, Barbados, Dominica, Grenada, Guyana, Jamaica, St
Lucia, St Vincent and the Grenadines, and Trinidad and Tobago. The Canadian Public Health
Association (CPHA) has been assisting CAEHO since 1986, when a collaborative project was
started. This project aims to strengthen member associations and enhance the professional
status of the Environmental Health Officer (EHO).
Key activities include improving communication between member associations and
The project assists in organised in-service continuing education programmes and
supports the establishment of a post-basic degree programme in the Caribbean for senior
Mr H I Bell, Chief Public Health Inspector of Barbados (retired), c/o
Dr L Harvey, CAEHO, 2nd floor, NUPW Building, Dalkeith Road, St Michael, Barbados.
on Diarrhoea Online Issue 36 March 1989 7 Page 8
ICORT III conference report: ensuring sustainability
The Third International Conference on Oral Rehydration Therapy
(ICORT III) was held in
Washington D. C. in December 1988. Over three hundred invited experts on all aspects of
health and policy relating to the prevention of diarrhoeal diseases attended. Previous ICORTs, held in 1983 and 1985, focused on promoting the use of oral
rehydration solution and developing more widespread use of ORT. The theme of the Third
Conference was 'ensuring sustainability' of ORT and CDD activities into the 1990s. In his
opening address, Mr Alan Woods of the US Agency for International Development (AID
sponsored the meeting in co-operation with UNICEF, UNDP, the World Bank and WHO)
emphasised AID's commitment to long term sustainability. This requires:
- ensuring that all families have access to appropriate information about the use of ORT;
- increasing ORS production and distribution capacity within developing countries; and
- developing financially independent national CDD programmes.
Broad approach to CDD
Other speakers included James Grant, Executive Director of UNICEF, Hiroshi Nakajima,
Director-General of WHO, and representatives from national CDD programmes. Many speakers
referred to the need for a broad approach to the control of diarrhoeal diseases, and to
move away from a single intervention focus. ORT remains crucial, but is most effectively
implemented in conjunction with other CDD activities. Alfredo Bengzon, Secretary of Health for the Philippines, reminded the Conference of
the vital role of social change in improving health standards. Outlining national progress
and problems, Dr Bengzon stressed the importance of training and motivating health workers
in particular, but also whole communities. In Dr Bengzon's view, sustainability in ORT,
and any other force for social improvement, depends on a sustained effort against poverty
and ignorance, corruption and exploitation. New developments
Giving a global overview on behalf of the World Health Organization, CDD Programme
Director Michael Merson pointed out the significance of universal endorsement for a single
solution - ORS - to treat dehydration resulting from any diarrhoeal disease, whatever the
cause, in people of all ages and nutritional status. Dr Merson also acknowledged the
usefulness of fluids available in the home for the early treatment of dehydration. The
lack of uniform measuring utensils and of adequate, consistent training means that mothers
often do not prepare sugar-salt solutions accurately. WHO now considers that cereal-based
fluids may be more appropriate for the prevention and early treatment of diarrhoea,
although they are not a substitute for adequate feeding during and after diarrhoea. Integration Key issues brought out during the Conference included the need to:
- plan CDD programmes as part of long term health development projects;
- develop permanent infrastructure, (including reliable, effective communications
channels, training, monitoring and evaluation services) rather than short term campaigns
for the delivery of health care;
- reach the most isolated and needy communities, especially the urban poor and those
without access to the formal health sector;
- accept and stimulate community participation in ORT;
- promote good hygiene and nutrition, especially breastfeeding and good weaning practices,
to prevent diarrhoea and reduce the severity of its effects; and
- educate mothers and children as the best way to ensure changes in the behaviour of
All these issues are connected by the theme of integration. Many speakers at ICORT III
concluded that ORT and other CDD activities are more likely to be successful and sustained
if they are integrated with other development projects and not attempted in isolation. As
Dr Bengzon put it, "Diarrhoea is a worldwide problem, but the world has more problems
than just diarrhoea", and ORT can usefully be seen as just part of a larger scheme to
address these problems. Child-to-child
The Child-to-child Programme was started in 1979, the International Year of the Child,
to promote communication and development by schoolchildren to other children, their
parents and communities. The Programme has proved to be a successful way of integrating
primary health care into primary school education. Those who would like to receive
information on Child-to-child activities, or who could pass on reports of activities known
to them, please write to: Child-to-child, Room 833, Institute of Education, 20 Bedford
Way, London WC1H OAL, UK. Follow up A letter published in DD32 by Dr Inkisar Ali
raised the question of ORS for newborn babies. Dr Ali would like us to make clear that he
is concerned about the misuse of sugar-salt solution given as food to newborns without
diarrhoea. Dr Ali recognises ORT to be the best treatment for dehydration caused by
diarrhoea, and acknowledges the safety of giving ORS to newborns, but draws the attention
of DD readers to the danger of adding salt to the initial feeds of newborn babies,
which can cause hypernatraemia (sodium poisoning).
Scientific editors Dr Katherine Elliott and Dr William Cutting
Managing editor Kathy Attawell
Editorial advisory group
Professor J Assi Adou (Ivory Coast)
Professor A G Billoo (Pakistan)
Professor David Candy (UK)
Professor Richard Feachem (UK)
Dr Shanti Ghosh (India)
Dr Michael Gracey (Australia)
Dr Norbert Hirschhorn (USA)
Dr Claudio Lanata (Peru)
Professor Leonardo Mata (Costa Rica)
Dr Jon Rohde (USA)
Dr Mike Rowland (UK)
Ms E O Sullesta (Philippines)
Professor Andrew Tomkins (UK)
Dr Paul Vesin (France) With support from AID (USA), ODA (UK), UNICEF, WHO Publishing partners
Grupo CID (USA)
Consultants at University Eduardo Mondlane (Mozambique)
Issue no. 36 March 1989
This edition of Dialogue on Diarrhoea Online is produced by Rehydration Project. Dialogue on Diarrhoea was published four times a year in English, Chinese, French, Portuguese, Spanish, Tamil,
English/Urdu and Vietnamese and reached more than a quarter of a million readers worldwide. The English edition of Dialogue on Diarrhoea was produced and distributed by Healthlink Worldwide. Healthlink Worldwide is committed to strengthening primary health care and
community-based rehabilitation in the South by maximising the use and impact
of information, providing training and resources, and actively supporting
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updated: 21 April, 2014
updated: 21 April, 2014