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Global study lends insights into uptake of effective infant diarrhoea therapy

Taddese Zerfu discusses findings that show an urgent need to continue increasing coverage of oral hydration solution for infants in low- and middle-income areas.

Infant diarrhoea is a leading cause of childhood morbidity, responsible for 1.7 billion cases of illness and about 500,000 deaths in under-fives each year worldwide.

Oral rehydration solution (ORS) – a preparation of salts and sugar which can be mixed with water – is a simple treatment that can be prepared and used at home to prevent mortality due to dehydration and undernutrition in children with diarrhoea.

Although this effective, low-cost oral hydration treatment, which is suitable to those who lack access to intravenous fluids, has been available for more than 50 years, children in many parts of the world remain unable to benefit from access to it.

Welcomed development

Oral rehydration solution was hailed in the Annals of Internal Medicine in 1969 as a medical advance of that century.

The simple, low-cost remedy helps many to recover and is promoted by WHO, UNICEF and others as an effective way to treat infant diarrhoea.

A study by a team at the Local Burden of Disease Collaboration, including researchers from the Global Academy of Agriculture and Food Security, led to the surprising finding that regional coverage of this therapy is still below 50 per cent in low- and middle-income countries (LMICs).

The study compiled and analysed country-specific survey data from 385 nationally representative households in 94 LMICs, and found that the coverage in ORS use among children with diarrhoea remained below 50 per cent in the majority of second administrative-level units.

Specifically, the use of ORS coverage was lowest in central sub-Saharan Africa, parts of western and eastern sub-Saharan Africa, the Middle East, and South America. It was also learned that slow change during the past two decades is reflected in the low avoidance rate and number of untreated children.

Our study, the first of its kind to allow for tracking progress over time and recently published in Lancet Global Health, found that slow change during the past two decades is reflected in the low avoidance rate and number of untreated children.

An estimated 6.5 million children with diarrhoea were not treated with any form of oral hydration therapy in 2017, our statistical analysis found.

We did find a slight uptick in use of oral rehydration solution, corresponding with declining use of Recommended Home Fluids (RHF) – home-made treatments – in many locations, resulting in relatively constant overall ORT coverage during the study period.

In many areas, a rise in use of oral rehydration solution was found alongside a fall in use of RHF and a simultaneous decrease deaths linked to diarrhoea. We estimate that about 52,000 deaths were averted by improved access to oral rehydration solution between 2000 and 2017.

In-country variations

Although oral rehydration solution was uniformly distributed within some countries, geographical inequalities persisted within others. Some 11 countries had at least a 50 per cent difference in one of their regions compared with the country mean.

We found significant increases in ORS coverage nationally and subnationally in Rwanda, Vietnam, Bolivia, Cambodia, and India. In Rwanda, for example, ORS coverage increased almost three-fold with an annualised rate of change of 10.7 percent from 12.0 per cent to 33.9 per cent.

We identified areas in Colombia, Nigeria and Sudan as examples of where diarrhoea deaths remain higher than average, while ORS coverage remains lower than average.

Our statistical analysis allows for many useful insights to be drawn, and the creation of maps to show disparities within countries and allow comparison of ORS accessibility alongside other useful indicators such as diarrhoea-related deaths.

Overall, we believe urgent action is needed to continue increasing coverage of oral hydration solution in low- and middle-income areas, to help infants who will benefit most.

Authorities in many of the LMICs should also consider stockpiling – access to ORS is important for treating everyday instances of disease but also in case of emergencies and infection outbreaks.

Education of caregivers is an important aspect in broadening the coverage of ORS, while determining country-specific drivers of low uptake and local inequalities could enable better uptake.

We hope the wealth of data generated in our statistical analysis will inform efforts to improve availability of oral rehydration solution and prevent further unnecessary childhood deaths.

Image credit: Carlo Navarro on Unsplash