Global & Disaster Medicine

Archive for the ‘Kids-Infants’ Category

The effects of ORT in this sequence of photos of a dehydrated Egyptian child

Beginning of ORT sequence. Image courtesy of Norbert Hirschhorn

Second step in ORT sequence. Image courtesy of Norbert Hirschhorn

Third step in ORT sequence. Image courtesy of Norbert Hirschhorn

Fourth step in ORT sequence. Image courtesy of Norbert Hirschhorn

Final step in ORT sequence

“……You can see the effects of ORT in this sequence of photos below of a dehydrated Egyptian child treated entirely with ORT. These pictures, taken by me, were made into large posters for use by NGOs in Goma.”

Sincerely,

Norbert Hirschhorn, MD
London

 

 

NIH

Oral Rehydration Therapy: A Top Medical Advance of the 20th Century

History of Oral Rehydration Therapy (ORT)

A man being treated for cholera.

Credit: CDC
A man being treated for cholera.

Without treatment, the diarrhea caused by cholera infection can quickly lead to severe dehydration and death. The fluid loss is so rapid that half of those who will die of the disease succumb within 12 hours of developing symptoms. In the 1800s, many physicians believed that cholera destroyed the intestine and that medical intervention was futile. At the time, physicians had little knowledge of microbiology and human physiology, and since the disease was so aggressive, early efforts to rehydrate patients were not successful. There was some experimentation with intravenous (IV) methods to treat the most severely ill patients, but the chemical solutions that were administered tended to be non-sterile and dangerously unbalanced. Oral rehydration treatment was also confounded by immediate reflexive vomiting.

Finding the Right IV Formulation

Progress was slow, but after many years of fine-tuning IV formulations for cholera patients, this method began to reduce mortality. By 1965, improved understanding of physiology and the administration of sterile, well-balanced IV fluids prevented death in almost every case.

However, there were a number of practical limitations to IV administration in cholera-endemic areas such as Bangladesh and India. During seasonal epidemics, for example, hospitals had to admit hundreds of patients each day. The logistical challenges left many patients untreated at home or by the roadside on their way to treatment facilities. With each patient requiring up to 40 liters of sterile IV fluid, supplies quickly ran out.

Exploring Oral Fluid Administration

In the 1960s, a number of physicians began to explore oral fluid administration as a supplemental treatment for cholera patients once IV fluid rehydration had blunted the reflexive vomiting. Pioneering the field was retired Navy Captain Dr. Robert A. Phillips, the third director of the NIAID-funded Cholera Research Laboratory that later became the International Centre for Diarrhoeal Disease Research, Bangladesh (link is external) (ICDDR,B). Dr. Phillips, a pathophysiologist with many years’ experience in cholera research and treatment, had helped to refine IV rehydration methods, but like many physicians, was attracted to the theoretical simplicity and ease of oral rehydration—if it could be accomplished.

The main challenge with oral rehydration was that fluids were not absorbed, and any ingested liquids simply added to the volume of diarrhea. But Dr. Phillips had an idea. Guessing that the strength of the oral fluids was inadequate, he tried adding glucose to the fluids. He immediately noticed that patients drinking glucose-supplemented electrolytes passed less diarrhea, indicating that fluid was being absorbed. Dr. Phillips cautiously reported the phenomenon, and in so doing opened the door to one of the 20th century’s most important medical advances.

Soon afterward, research teams in what are now Dhaka, Bangladesh, and Kolkata, India, conducted careful clinical trials and established that oral rehydration fluids with balanced salts and glucose did indeed result in decreased diarrhea, rapid rehydration and surprisingly quick recovery.

The first clinical trials of what would become known as Oral Rehydration Therapy (ORT) took place in 1968. Patients who were given an oral solution containing glucose and electrolytes were found to need 79 percent less IV rehydration for full recovery than those who did not receive the oral solution. A follow-up study found that patients with mild and moderate cholera cases could be treated with ORT alone. Not only did most patients recover quickly, but the treatment was inexpensive and could be administered by family members in the home, and by other untrained individuals, increasing its effectiveness in emergency and low-resource situations.

Separate studies supported by NIAID showed that administration of the antibiotic tetracycline reduced the need for rehydration fluids by 60 percent. Pathophysiological studies revealed that in contrast to the understanding of earlier years, the cholera pathogen did not destroy the intestine, but used a toxin to alter the transport of solutes across the intestinal membrane. Oral rehydration with the correct fluids sped up recovery by compensating for the activity of the toxin.

ORT Saves Lives Today

ORT remains the current treatment of choice due to its safety, effectiveness, low cost, simple preparation, and easy administration. According to the World Health Organization, up to 80 percent of cholera patients can be successfully treated by ORT alone, the remaining severe cases requiring preliminary IV rehydration before transitioning to ORT. ORT is estimated to save over one million lives per year, and was described in the British Medical Journal’s “Medical Milestones” series as one of the most significant medical advances of the 20th century.

NIAID Research and Future Challenges

Emerging cholera pathogens present a challenge to the power of rehydration therapy and antimicrobials. For example, antimicrobial resistance can affect the ability of the cheap and widely available antibiotic tetracycline to reduce the duration and intensity of disease. In addition, novel cholera pathogens are emerging that possess a particularly active version of the cholera toxin. These strains result in a higher proportion of severe cases that must be immediately rescued with aggressive IV rehydration before receiving ORT. Finally, modern cholera strains are powerfully competitive in the environment, replacing endemic strains and occupying the natural waters upon which hundreds of millions of people depend.

Recent research has shown that these aggressive cholera strains have spread across Asia and Africa, and have recently appeared in Haiti. Cholera remains a fierce pathogen that ruthlessly exploits poverty, inequity, natural and man-made disaster, and poor access to health care. NIAID sponsors a robust research program to understand cholera evolution, develop new therapeutics and vaccines, and collaborate with international partners to continue the fight against this ancient and modern disease.

References

Carpenter CCJ, Sack RB, Mitra PP, Mondal A. Tetracycline therapy in cholera (link is external)Journal of the Indian Medical Association. 43:309-312 (1964).

Chatterjee HN. Reduction of cholera mortality by the control of bowel symptoms and other complications. (link is external) Postgraduate Medical Journal. 33(380):278-284 (1957).

Chin CS, Sorenson J, Harris JB, Robins WP, Charles RC, Jean-Charles RR, Bullard J, Webster DR, Kasarskis A, Peluso P, Paxinos EE, Yamaichi Y, Calderwood SB, Mekalanos JJ, Schadt E, Waldor MK. The origin of the Haitian cholera outbreak strain (link is external)New England Journal of Medicine. 364(1):33-42 (2011).

Fontaine O, Garner P, Bhan MK. Oral rehydration therapy: The simple solution for saving lives. (link is external) British Medical Journal. 334(supp1):s14 (2007).

Nalin DR, Cash RA, Islam R, Molla M, Phillips RA. Oral maintenance therapy for cholera in adults. (link is external) Lancet. 2(7564):370-373 (1968).

Nalin DR, Cash RA, Rahman M. Oral (or nasogastric) maintenance therapy for cholera patients in all age-groups. (link is external) Bulletin of the World Health Organization. 43(3):361-363 (1970).

Phillips RA. Water and electrolyte losses in cholera (link is external)Federation Proceedings. 23:705-712 (1964).

Savarino SJ. A legacy in 20th century medicine: Robert Allan Phillips and the taming of cholera (link is external)Clinical Infectious Diseases. 35(6):713-720 (2002).

Ruxin JN. Magic bullet: The history of oral rehydration therapy. (link is external) Medical History. 38(4):363-397 (1994).

World Health Organization. Fact Sheet No. 107: Cholera (link is external) (2010).


An explosion at the gates of a Chinese kindergarten that killed 8 and injured more than 60 was caused by a 22-year-old suicide bomber

BBC


7 people were killed and 59 injured Thursday in an explosion at the front gate of a kindergarten in eastern China

CBS News

 


Circulating vaccine-derived poliovirus type 2 – Democratic Republic of the Congo

WHO

Disease outbreak news
13 June 2017

In the Democratic Republic of the Congo (DRC), two separate circulating vaccine-derived poliovirus type 2s (cVDPV2s) have been confirmed. The first cVDPV2 strain has been isolated from two acute flaccid paralysis (AFP) cases from two districts in Haut-Lomami province, with onset of paralysis on 20 February and 8 March 2017. The second cVDPV2 strain has been isolated from Maniema province, from two AFP cases (with onset of paralysis on 18 April and 8 May 2017) and a healthy contact in the community.

Public health response

The Ministry of Health, supported by WHO and partners of the Global Polio Eradication Initiative (GPEI), has completed a risk assessment, including evaluating population immunity and the risk of further spread.

Outbreak response plans are currently being finalized, consisting of strengthening surveillance, including active case searching for additional cases of AFP, and supplementary immunization activities (SIAs) with monovalent oral polio vaccine type 2 (mOPV2), in line with internationally-agreed outbreak response protocols.

Surveillance and immunization activities are being strengthened in neighbouring countries.

WHO risk assessment

WHO assesses the risk of further national spread of these strains to be high, and the risk of international spread to be medium.

The detection of cVDPV2s underscores the importance of maintaining high routine vaccination coverage everywhere, to minimize the risk and consequences of any poliovirus circulation. These events also underscore the risk posed by any low-level transmission of the virus. A robust outbreak response as initiated is needed to rapidly stop circulation and ensure sufficient vaccination coverage in the affected areas to prevent similar outbreaks in the future. WHO will continue to evaluate the epidemiological situation and outbreak response measures being implemented.

WHO advice

It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for AFP cases in order to rapidly detect any new virus importation and to facilitate a rapid response. Countries, territories and areas should also maintain uniformly high routine immunization coverage at the district level to minimize the consequences of any new virus introduction.

WHO’s International Travel and Health recommends that all travellers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than four weeks) from infected areas should receive an additional dose of OPV or inactivated polio vaccine (IPV) within four weeks to 12 months of travel. As per the advice of the Emergency Committee convened under the International Health Regulations (2005), efforts to limit the international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC). Countries affected by poliovirus transmission are subject to Temporary Recommendations. To comply with the Temporary Recommendations issued under the PHEIC, any country infected by poliovirus should declare the outbreak as a national public health emergency and consider vaccination of all international travellers.


Circulating vaccine-derived poliovirus type 2 – Syrian Arab Republic

WHO

Disease outbreak news
13 June 2017

A circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak has been confirmed in the Deir Al Zour Governorate of the Syrian Arab Republic. There is evidence of genetic linkage among three isolates of type-2 vaccine-derived polioviruses (VDPV2) isolated in the stool specimens of two acute flaccid paralysis (AFP) cases with dates of onset of paralysis on 5 March and 6 May 2017, and the contact specimen of an AFP case collected on 17 April 2017. Al Mayadeen was also the epi-centre of the wild poliovirus type 1 (WPV1) outbreak in Syrian Arab Republic in 2013. Aggressive multi-country polio outbreak response effectively controlled the WPV1 outbreak and no WPV1 case has been reported in Syrian Arab Republic since 21 January 2014.

Public health response

Since the confirmation of the first VDPV2 during May 2017, AFP surveillance has been intensified in the Governorate, especially in the Al Mayadeen district. As of 6 June 2017, a total of 58 AFP cases have been reported from the Governorate this year. In addition to the two cases that have tested positive for VDPV2, a further 11 have tested negative for polioviruses, with the remaining samples being under process in the laboratories or being transported to the laboratories.

Subsequent to the confirmation of the cVDPV2 outbreak, outbreak response planning is underway, including planning for supplementary immunization activities (SIAs) with monovalent oral polio vaccine type 2 (mOPV2), in line with internationally-agreed outbreak response protocols.

Although access for vaccination is compromised due to prevailing insecurity in Deir Al Zour, the Governorate has been partially reached by several vaccination campaigns against polio and other vaccine-preventable diseases since the beginning of 2016. Most recently, two campaigns have been conducted in March and April 2017 using bivalent oral polio vaccine (bOPV). The most recent full trivalent oral polio vaccine (tOPV) round was conducted in October 2015; while tOPV rounds conducted in the first four months of 2016 only reached part of the target population of the Deir Al Zour Governorate. It is pertinent to mention that Syrian Arab Republic introduced two doses of inactivated polio vaccine (IPV) in the routine infant immunization schedule in 2008. Syrian Arab Republic switched from tOPV to bOPV for routine immunization on 1 May 2016.

A detailed risk analysis is currently being updated, including assessing overall population immunity levels and strengthening active searches for additional cases of AFP. Surveillance and immunization activities are being strengthened in neighbouring countries as well.

WHO risk assessment

The detection of cVDPV2 underscores the importance of maintaining high levels of routine vaccination coverage at all levels to minimize the risk and consequences of any poliovirus circulation. Such events also underscore the risk in areas or regions with continued substantial insecurity that hampers maintaining high population immunity through routine vaccination. A robust outbreak response is needed to rapidly stop the VDPV2 transmission. WHO will continue to evaluate the epidemiological situation and outbreak response measures being implemented.

WHO advice

It is important to complete the ongoing risk assessment as soon as possible to inform the vaccination response with mOPV2 and IPV. The geographical scale of the vaccination response will be in accordance with the findings of the risk assessment. It will be critical to achieve the highest possible coverage during the vaccination response. Given the difficult and challenging security situation in the area, appropriate strategies will be identified and utilized to implement the response. Intensified AFP surveillance should continue.

It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for AFP cases in order to rapidly detect any new virus importation and to facilitate a rapid response. Countries, territories, and areas should also maintain uniformly high routine immunization coverage at the district level to minimize the consequences of any new virus introduction.

WHO’s International Travel and Health recommends that all travellers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than four weeks) from infected areas should receive an additional dose of OPV or IPV within four weeks to 12 months prior to the travel.

As per the advice of an Emergency Committee convened under the International Health Regulations (2005), efforts to limit the international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC). Countries affected by poliovirus transmission are subject to Temporary Recommendations. To comply with the Temporary Recommendations issued under the PHEIC, any country infected by poliovirus should declare the outbreak as a national public health emergency and consider vaccination of all international travellers.


South Sudan: 15 children die in botched measles vaccine campaign

ITV

  • The health ministry blamed the deaths on human error.
  • One syringe was used for all the children
  • The vaccine was not stored properly.
  • All of the children who died were under the age of 5.

 


UNICEF: As many as 150 children die every day in Myanmar before they reach their fifth birthday

The Guardian

  • The child mortality rate is estimated at about 50 per 1,000 live births in Myanmar. In the UK, the rate is four per 1,000.
  • Child rights violations, including the use of children as soldiers.
  • Nearly 30% of children under five suffer from moderate or severe malnutrition
  • More than half of all children live below the poverty line.
  • In western Rakhine state, 120,000 internally displaced people live in camps as a result of inter-communal conflict that erupted in 2012.
  • Violence against Rohingya Muslims, for whom the government does not provide full citizenship rights, has surged since October following attacks on border guard posts.

 


WHO: More than 1.2 million adolescents die every year around the world — an average of 3,000 deaths per day — from causes that are largely preventable

CNN

  • The leading cause of death among 10- to 19-year-olds globally in 2015 was road injury, which killed more than 115,000 people, followed by lower respiratory infections and self-harm.
  • Two-thirds of deaths among adolescents occur in Southeast Asia and Africa.

 


CDC: Global Vaccination Data

- 19.4 million infants didn't complete the basic series of vaccinations needed for protection in 2015. 60% of these babies live in 10 countries: India, Nigeria, Indonesia, Pakistan, Philippines, DR Congo, Iraq, Ethiopia, Ukraine, Angola

- Immunization prevents between 2 & 3 million deaths every year. Yet 1 in 7 kids are missing out. World Immunization Week www.cdc.gov/global

 


Syria: A suicide bomber who killed more than 120 people in Syria lured children toward him by handing out crisps before detonating his explosives.

Daily Mail

“….The bomb….killed at least 126 people including 68 children [as it] tore through buses carrying evacuees from besieged government-held towns….”

 


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