~ O R L D H E A L T H aut &I?' ORCANISATION MOND~ALE ORGANIZATION DE LA SANTE

lREGIONAL OFFICE FOR THE BUREAU REOIONAI, DB LA BASTERM MEDITERRANEAN MBDITERRANEE ORIENTALE

REOIONAL COMMITFEE FOR TEIE EASTERN MDITERRANEAN

W/RC 1 4 ~ / ~ e ch is 0 in. 1 December 1964

TECHNTCAL DISCUSSIONS

M l X V P E B ON THE: ~ ~ C A L DISCUSSIONS

Held at the Building,of the Nursing Instltute, Sulaibikhrrt, Kuwait

on Wednesday, 7 October l g 4 , at 9.30 a.m.

C H A M N : Dr. ZEIN EL A 3 D I N IBRAHIM (Sudan)

CONlCENTS

1. Introductfon

2, 'General Discussion

Re~resentatives of Member States

Government

CYPRUS

ETHIOPIA

FRANCE

IRAN

JORDAN

KUWAIT

LEBANON

LIBYA

PAKISTAN

SAUDI ARABIA

SOMALIA

SUDAN

SYRIAN ARAB REPUBLIC

TUNISIA

ED ARAB m r m c

Representative, Altemte or Adviser

A t o Hailu Sebsebie

MBdecin Lieutenant-Colonel Coiktawx't;

Dr. A .H. Samii Mr. 2. Davldian

Dr. Sablh Al-Wahbi Dr. Salrran Tn j-al-Din

Dr. Khaled El S h i

Mr. Youssef Jassim Bijji Dr. A . Kaml El Borai Dr. Yehla Shaker ".,. .,....- ,Dr * ,& *, fimulk&&'r 6r *rT~&b$h ,, Fa,r@a$

,+. * .".. ..-.-**--,-,. -.-. . , .+ Dr. G . ~ r e n c h Idbserver)

Dr. Jarnil A n o u t l

Dr. Abdul Msgid Abdel Hadi

Calanel , . ,--, A .F .M , Borhanuddin Dr. S . Mahfuz A l i

Mr. Adan Farah Abrar

Dr. Zein El Abdin Ibrahim

Dr. M. A 1 khm Mr. Retssem Raslan

Dr. M.T. Hachicha

Dr. M. Abdel Wahab Shukri Dr. Sayed Swellirn Dr. Hashem Mhmoud El Kadl Dr. Abdul Azim Hussein E l Gholmi Dr. Abu El Fotouh Shaheen Dr, fmrn Zaghloul El Sayed

u~rrm KINGD~M OF G ~ T B R Z T A ~ Dr. C ,R. Jones AND NORTHEm r n r A N D

YEMEN Dr. Abdorr- El Zofri

Re~resentatives of Associate Member S t a t e s

QATAR Dr. Mahmoud El Mfshad

World Health ~ ~ g a n i z a t , i o n

Secretary to the Sub-Committee Dr, A A . T a b , Regional Director

Representative of the Director- Dr. P.M. Kaul, Assistant Direa tor - General General

Deputy Secretary to the Sub- Dr. A ,A. EL Halawani , Deputy Regional Committee Dikeec to r

Adviser on Maternal and Child Dr. G. Jallad Health

United Nations and Specialized Aaenotes

UNITED NATIONS and TECHNICAL Mr. S. Kar ASSISTANCE BOARD (WAB)

UNmED NATIONS CMfI;DRl% 'S FUND - (mm)

UNI!TEDr NATf ONS m L D F AND WORKS Dr. M. Sharif AGENCY FOR PALESTINE REF'TJGEES (UNRWA!

J3ew~esentatives and Observers of I n t e r n t i o m 1 Mon-Governmental, Uter-Governmental and National Organiza-bions

TJUGUE: OF ARAB STATES Dr. Ghaith El Zerikly

JNERNATIONAL ASSOCIATION , FGR Dr. Toufic Turk THE PRETENTZON OF BLINDWS

INTERNATIONAL DENTAL FEDBRATZON Dr. George Soudah

I;EAGUF, OF RED CROSS SWETZES Dr. Sabih Al-Wahbi

UNITED STATES NAVAL: MEDICAL Dr. J.D, Northway RESEARCH UNIT NO.3 (US NbMRU 3),~airo

The CHAIRMAN welcomed the Representative of Yemen, who %d :juetljolned the meeting.

The CHAIRMAN said that the subject chosen f o r the technical discussiom at the

fourteenth session of the Sub-committee - I n f a n t i l e Diarrhoea in the Eastern Mediter-

ranean Reglon - was a serious problem in a l l countries of the Region, w h e ~ e , t h e morbi-

dity and m o r t a l i t y from diamhoeal diseases was vevly high among children. Be

requested the Regional Director to '~ntroduce the subJect ,

The REGIONAL DIRECTOR suggested t b t Dr. Jallad be asked to .make the lntroduc8ion.

Dr. JALLAD, Regional Adviser on Maternal and Child Health, dlgew.#a$tention to the

two documents before the meeting. The first, document kM/Rc11C/T@ch.~f~~,/2, had

been prepar d a 4" Regional Office advisers and .the second, dooument EM/~cl4fiech. a n A .

Disc.D,/ by specialfsts from some countries of the Region who had presented their

loca l experience. In orde r t o make document EM/R~14/~ech.~isc./2 as complete as

possible, a questionnaire had been sent t o all Members of the ~egion asking f o r some

detailed information on the problem of infanti le diarrhoe~ in t h e i r countries. r

The informat ion contafmb i.n.dhe. dkepmefit .Qdght be b m r + = d "as folX&dws, . . .. - . - . . " -

Infantile diarrhoea, and especially gastro-enteritis, accounted for<som 60-75 per

cent of the oases seen in health centres and out-patient departments, and for 50 per . . .

cent of mortality among infants. and chlldren under two years of age.

According t o the defini t ion of the WHO Study Group on Diarrhoea1 Diseases that I I , -

met in 1958, dfarrhoea should be held t o be present in children up to two years of

age tf they passed three ' or more so& or l iquid s too ls within 5weive hours, o r a

single s o f t o r l iqu id s too l containlng.blood, . a , pus o r mucus: .and i.n children of three

years or over 1 f they passed two o r more s o f t o r l iquid s'iools wi thin twelve hours

o r a single soft or liquid stool containing blood, pus or mucus.

Although strictly the term "infantile diarrhoean should refer o n l y to the disease

in infants o f 0 - 12 months o f age, it had been used in the document to oover the

disease i n children up t o s i x years of age.

The WHO Study Group had considered t h a t a l l diseases in which diarrhoea was a

leading symptom should be classified as diarrhoea1 diseases. One of the main d i f f1 -

ou l t i ea was the class i f ica t ion of dtarrhoewl diseases; the International Statistical

Classification of Diseases, Injuries, and Causes of Death does not help to clarify the

posi t ion. The Study Group folk that at their next revision of the Classification, an

attempt should be made to rectify the exist ing situation so as t o simplif~ the oollect-

ion of data.

In s p i t e of t h e inadequacy of s t a t i s t i c s of morbidity and mortality from

diarrhoea1 disease, it had been shown from the information available that diamhoeal

diseases caugad considerable lass of life, and even economic loss .

It would be seen from page 4, tables II, In and TV, of the document t h a t f n

1956 there had been 53.3 per cent mortali ty f r o m diarrhoea1 diseases during the first

year of life, and 7 per cent in the second year (UAR). In 1961 the WHO Diarrhoea1

Dfseases Advisory Team had studied diarrhoea1 diseases In children under s i x in three

villages of the United Arab Republic, where they had found mor ta l i i y ratesr of 56, 40

and 27 per cent. f n 'the Sudan the s a k team, in the s m s year, had found 25 and 34 per cent in two v i l l ages among children untler six attending the health centres.

I n Ethiopia, i n 1962, 30 per cent of sick children seen at one paedlatrlc clinic

had had gastro-enteritis. Even higher rates had been found in some other countries

of the Region. Fu~t2ier information dn incidence was gtven on pages 5 and 6 . The

incidence of diarrhoea1 diseases was highest i n young children between six and eight-

een months of age; I t rose in artificially-fed infants and in the weaning period.

In many countries the high number o f artificially-fed infants was due not only tc

short supply of breast-milk i n poorly-nourtshed mothers but also t o the belief that

breast-feeding prevented further pregnancies, However, the value of breast-feeding

was evident; the incidence of gastro-enteritis among breast-fed Infants was 21.1 per

cent, whereas among mixed-fed infants 'it was 70.7 per cent.

Incidence was higher in males than in females in a number of countries in the

Reglon.

Heat and humidity, and the consequent increase In the f l y population, caused a

certain rise in morbidity aid mortality. Data f o r the.various countries were given

on pages 7 and 3,

Unsatisfactory environmental sanitation, and paptlcularly contaminated water,

played an important part in the spread of infantile diarrhoea, as did milk if not

sterilized or pasteurized. Most cases of diamhoeal diseases occurred in the low

socio-economLc groups and malnutrf t ion increased the mortality rate.

Most diarrhseal diseases were of unknown etiology. The various olassifications

that had been made were mentioned on pages410 and 11 pf the.docurnent. The simple

classification divided diarrhoeas into two major divisions: diarrhoeas due t o infect-

ion and diarrhoeas due to malnutrition. The thlrd clinical ent i ty was diarrhoea of

the new-born, caused by infection by bacteria; 2t was a great imporYtanoe i n nurseries.

Other causes were i n t e s t i n a l pamsites, 'food poisoning and unsuitable baby foods.

Various s a l t s acted as poisons if taken In large quantities. Certain nutritional

deficiencies, such as pellagra and beri-beri, caused diarrhoea, and protein deficiency

was the causal fac tor in the diarrhoea of kwashio~kor.

Most acute diarrhoeas were. &f infecttbus origin, the .mo$t. combn agent in children

bein$'Shikello;h The source of'ihfeetion wds almost exclusively man himelf

Shiaella was abaent during the neo-natal period; rare i n infants ' below six month&,

and more prev@lent i n the 1 - .3 age g ~ o u p . The WHO Diarrhoea1 Diqeases 4dvtsory Team

found in lg6l,,in the U d t e d Arab Republic tha t Shiaella, infection was muah hbgher In

children under s i x years of age In rural areas (23.2 pevl cent) than in urban areas

(16 ,,I. per cent) . Details of !.the, team's h c t e r i o l o g i ~ b , Eind$ngs i n .the ,Un l td 'Amb

Republic were given. in table XI, and those in Sudan in t ab la xi1. . From Pakistan 10

h+d bem repqrted that out ofi ,:30Qi :oases, posi t lve result@ of, &ll Jsolated pa$&ogens

were obkatne,d In 55, 26 of which were Shigella.

The re la t ion between viruses and diarrhoeas in infwnts,and chilcjren was discussed

op page ,l5 of the document+ , I n 1959 in t he United Arab Republic enteric virusas had

been isolated from 30 per cent of 56 children with gastro-enter i t is , and a.fa i r lg hlgh

percentage had also been Isolated from aontrols ,

Parasitic agents found in the s't;ools of S t i e n t s w i t h diarrhoea were GiaxWa

(~amblia) and Entmoeba his%ol$tf ca. other 'paras it ic agents were' menbionea ' on

p g e fL5*

Both bacteriology and pa~asitolom showed that the faecal contact due to existing

habits and living conditions was extremely high, wnlch proved that the problem of

diarrhoea1 diseases was essentially a socio-economic one,

The complications met with in diarrhoea1 diseases, and the general management of

cases of acute diarrhoea, were described on pages 15 and 16. Rehydration was a;.

important and. ef f ec t lve restoring factor and lif &-saving measure in' mild, modexgate

and severe 'dehydration. Details were given on S g e s 16 aniS. 22, The al'ectro-

l y t e mixture used in the UNRWA camps in small sealed envelopes had proved successfil

in t reat ing very mild dehydration,

The mea~ilres f o r . prevention and 'control of diarrhoea1 diseases taken' by most

g o v e h e n b Tn the.Region were dealt,with ori pages 16 and l T m

As regards recomeladations, it was essential. t o strengthen and expand t he maternal.

and 'child healkh services i n the Region. Those services should be able to carry out

medical examYnation, Immunization, home-visiting and health education of mother&.

Rewdration.units should be installed in health cehtres and rkternal and child hdl ' th

centres.' ' V i t a l and health statistics should be improved, epidemiological gudeys

carrf ed out' and' laboratory and resear"ch .fat iliC'ies and personnel inc~eased . Moreover,

health educettlon and the improvement of nt t t r i t ton &du-catPon viere impor tan t mtters in

preamtiori and cdntrol. Erne'rgency rehydmtdon centre's should be set up fn eaoh.

hosp'ltal a& there should be a main.~ehydrakion centre where mediaal and .paramedical

personnel would be tralned. A l l reoolnmendations were contained,on pages 21 and 22

of the document.

I n conclusion he thanked a l l governments that had replied to the questionnaire

Fpnt out by the Regional Office and t o the specialists who had contributed the papers

Qpntained in document ~M/RC14/Tech,~isc ./3 and Addale

B, GENERAL DISCUSSI@I

Dr. K, GHOMI (United Arab Republic) thanked Dr. Jallad for his Interesting

Btatement

As reprds infantile diamhoea in the United Arab Republic, he had a few details

t o add to the i n f o r m t i o n already given in document:~~cl4/~ech.~isc./3. The

Incidence of infant i le diarrhoea i n that country was s t i l l high, even higher than the

kigures given by Dr. Abbasy in his ~ e p o r t . In the paediatric section of EinShams

hospital, Cairo , a 41.5 per cent morbidity rate had been found in the last four months.

In 1958, in the Faculty of Mediclne. of Ein Shams, a new serotype of Escherichia.

c& had been discovered. It had been isolated from f t f t een cases of severe infect-

ious gas t ro-en te r i t i s , and later a fur ther seventeen cases had ocourred, w i t h two

deaths. The micro-organism was r e s l s t en t to chloramphenicol. In 1962 candida had

been'found In the gut of s i x mrasmlc cases and a large group of candida had been

recovered from the stoolsl Diagnosis had been Influenced by heat, humidity, dust

and the use of antibiotics, In that connection, it was essential that diagnosis

should be made on c l i n i c a l and bacteriolog5cal gramds and that it should be confirmed

by the use of antltnonolZal agents, In 1957 the Eil l Shams Faculty of Medicine had

made a comparison of dlay-rhoea in n o m l ' a n d marasmic infants, Marasmus was s t i l l

n basic factor .in diarrhoea in the United Arab Republic,

It was anticipated that the Incidence of ihfantf le dtar~hoea i n the country would

drop as a resul t of government action fo r raising the stdndard of l iv ing. In the

meantime, emphasis was on measures t o save l i f e by rehydration. Paediatr ic im

should be trained in rehydmtion methods and rehydration units should be s e t up i n

hospitals, out-patient departments, maternal and child health and other health centres;

there should also be a main rehydration centre, where training would be given.' The

importance of n u t r i t i o n should not 'be neglected, 'since mrasmus was an aggravating

factor in diarrhoea, and therq should be we 11-equipped laboratories i x i the ceritres

to make the pecessaryr~lmlyses. I n addit ion, the population should be urged to seek

early medical advlce, even for cases of mild diarrhoea in infants and young children.

D r . SHAKER (~uwait) thanked Dr. Jallad for his report, which reflected the Interest

of the Regional Office i n the p~oblem of Infantile diarrhoea in the Region. Much work

s t i l l remained to be done and facilities f o r study were not avatlable i n the countries

where most material existed, The termlnologg was st211 confused, which made the

cornparlaon of s t a t i s t i c a l data d i f f i c u l t . The classffioation in t h e I n t e ~ m t i o n a l

Classffication of Diseases was no* satisfactory,

Phe delegation of Kuwhit had submitted. a paper, "A Pre l im ina ry study' of Infantile

DI'Ibrrhoea In ~uwa2t" which had been distributed t o members of the Sub-committee ; Tn

preparing It, hospi ta l in-patien* records had had to be resorted to, owing to the in-

adequacy of statistical reporting. According t o those records, in 1963, among 2887'

admissions to the p e d i a t r i c dlepartment of the A 1 S a b h Hosp i t a l , there had been 1061

cases of dlarrhoeal, diseases; .49 . . cases, in new-bprn babies, 72 ha children we?. two

years of age and the reminder in children between the ages of 4 weeks and 2 years.

He drew at tent ion to table I (page 3) of the document, which gave the number and I .

percentage of cases of and deaths from diarrhoea1 diseases in ohildren, classified ." under age I n 1563 i n f a n t i l e diarrhoea had accounted f o r 43.7 per cent of

the total deaths (400) in the paediatric department, moat of them in mlnourlshed

inf m t s . A number of h c t e r i o l o g i c a l and parasitological examlnatfons of stools had been

carr2ed- out,-- the results of which were given in tables V and VT. NO virological

examinat ions had be en made . Both incidence and case fatality were highest in the age, group 5 - 6 months,

w i t h a. sharp decline in the 7 - 12 months group. The incidence was lowest in child-

ren over one year. No difference in.incidence according to sex had been f o d , .

The very high morbidity and mortality mte during the s ix first months of life

were attributed to artificial feeding, especially w i t h milk, under poor conditiom

of hygiene'. Tha t pointed t o the iinportance'of breast-feeding i n w country such as

Kuwait. The m0s. t important reason f b r the high morbidity and f a t a l i t y rate in Kuwal$,

i n s p i t e of the high standard of living, was that the paediatric department and the

out-patient clinics.had not been able to give effective help, although the required

facilities had been available. Secondary cases had been caused by children discharg-

ed from hosp i ta l s . It would be necessary to.carry out health educatzon work, espe-

cial$y health education of mothers during . their stay i n hospital and their v i s i t s t o

out-patient departments.

An i rd lba t ion o f the r e l a t i on between climate and infantile diarrhoea could be

gained fw'om f igures 1 - 3 . Maximum incidence was in the last three months of the

year, with a slightly lo we^ peak in A p ~ f l , May and June, when both temperature and

humidity were high, but not a% t h e i r highest.' The combination m f high humidity and

moderak&ly btgh temperature seemed to increase the incidence, probably because it

favoured the breeding of f l i e s .

The imid'ence was affected b;y soclo-economio s t a tu s and by metlmtrition, being

highest in kdou in infan ts ,

A s regards the bacte~lological aspects, lack of laboratory f a c i l i t i e s had hampered

bacteriological examinat ion, but the agents most frequently discovered had been Proteus

k o r ~ a n i and Salmonella Newport. I n two cases caused by the la t ter , fa ta l meninaitis

b d occurred.

Further s tudies were needed but would not be possible without better s t a t i s t i c s

and laboratory facilities. Kuwait was concentmting meanwhile on prevention, which

would be best achieved by a health eduoation programme, a home-visiting service, out-

p t i e n t rehydration sewices and improved environmental sani ta t ion, Including fly

con t ro l and sewage disposal .

Colonel BORKANUDDRJ (~akistan) said that details of infantile diarrhoea In

Pakistan were given i n document F$l/Rc14/~ech . ~ i s c .b. E f f o r t s Sn tha t country had

been mainly concentrated on preventing death. As regards preventive measures, 'the

u l t i m a t e solution l a y in improved sanitation, which would t a k e a long time. Mesn-

while, health education was being carried out in maternal and child health centres

and good results had been obtained by teaohing the population to boil water a d milk

and t o give the infan is su i tab le food, encouraging breast-feeding, and by fly control.

The e t l o l o m of In fan t i l e diarrhoea, whioh condftioned the treatment applioable ,

varied from country to country. Research was needed and its results should Ik made

known t o a l l general practitioners. Since the n h b e r of hospital beds was insuffi-

aient , rehydrat ion therapy should be' given in out- p&t ient departments.

Pakistan had carried out extensive studies on infantile diarrhoea and was desiruus

of exchanging experfence with workers from other co&tries in the Region, For tha t

he proposed that a regional seminar on diarrhoea1 diseases should be convened

In the near future.

Dr. ANOUTI (~ebanon) said that the micro-organisms causing diarrhoea - Shigella,

Salmonella, vibrios, enterobacteriaceae, etc. were the same i n adults as in children,

but were more nUmerous in the l a t t e r . In infanks under one year the predominating

micro-organism app,eared to be Escherichi,a&. Diarrhoea was also caused, or exacer-

bated, by staphylococci,

The cause of diarrhoea'in children was usually contaminated milk, both liquld and

dried.

V1ri.w.e~ also played a r8le in the etiology of infantile diarrhoea; . in Mexico and

the United States of America v i r a l agents had been'faund in as many as eighty per cent

of cases .

In same countries diarrhoea had been caused by drinking water containing mapesfa.

In Africa t '~ango diarrhoea was common, in-Lebwngn- the isba -cause of diarrhoea was exoessive consumption of fruit,

As regards prevention, bwleast-feeding.wa8 to be encouraged, at least up to t h e

a&@ of 4 - 5 months, a f t e r which the infants required other foods; and It was the

tadc of the health authorities t o see that sudh other foods were suitable, sufficl,ently.

rich in protein, and free from contamination. As regards milk, the main supplementary

food i n Infant feeding, spec i a l precautions, including preca,utions during transport ,

should be taken to avoid contamination. In his opinion, in any milk dlstributlon

scheme it would be advipable to g;tve> mothers .sterdJiae,d water with ,which to prepwe

the dried mtlk, and to d%vide both milk and water into sepamte portions, each suffi-

c ien t t o make one meal. Nurses and home-visitom should teaoh mothers how to s t e r i l ,

iae, s to re and prepare fe5ding b o t t l e s ,

Dr. FTWNCH (~irectar of Medical Servfces of the Kuwait O i l company) said that .in,

Ahmdi, the Kuwait O i l Company was responsible for.the.health of some 17,000 people,

Twelve thousand were wives and children, and.attended health cl in ics a t least twice 4 ..

monthly:. Active health care and education was oarried out by the Compny in. calla-.

boration wlth the Govement . During 1963 there had be.en 216 cases of gastro-

e n t e r i t i s discharged from hospi tal of which 63 per cent concerned infants under two

years of age.

He then gave details of the, environmental conditions of the population, 3 e t rea t*

ment given in cases of infantile diarrhoea and.the results obtained and p0int.d out

t h a t most cases occurred in a well-known area which it would be difficult to keep

under control and in the neighbourhood of the Souk.

Dr. SAMII ran) said that the m Jor part of the four p p e r s on the subject of

In fan t i l e diarrhoea which had been presented t o the meeting dea l t with cl in ica l aspect8

o f the matter, He then gave an account of the studies which had been carried out in

Iran by an advisory team o f WHO. The results of the study closely resembledthose

whf ch had .been described by previous speakers. The Robat-Kareern area had been

selected f o r the study, ly ing at a distance of 46 kilometres t o the South-West of

Teheran. One vil lage in which the studies had been made had a populatfon of approxi-

mately 2,500, five hundred of whom were pre-school age ahildren. The second area

consisted of f o u r small v i l l a g e ~ l with a t o t a l population of 2,500, some 500 of whom

also were pre~schooi age children, all of the vi l lages having the same l eve l of

development.

He then-gave an account'of:the various typea of Gurney t ha t had been camied out,

tkie health and env t~6men ta l ' cond&t iow o f the population and t h ~ results of the

studies,

There was no doubt that the services of visfting nurses two or three times per

week i n such villages would improve the health conditions considerably and reduce

the incidence o f infant i le diarrhoea there. The simple contact between the nurses

and the villagers would help to raise standards of food and personal hygiene and by

the provision of suitable vitamin tablets any fu r the r medical advice m i g h t become f a r

less urgent.

Dr, TAJ-AL-DIN (~raq) said tha t c lear ly all the participants in the discusston

were convinced of the importance of gastro-enteritis as a " k i l l i n g disease" In the

Region. It was also apparent that the circumstances of its Incfdenae were similar

throughout the Region. Having complimented Dr. Jallad on his excellent report , he

referred to the fact that drled milk was preferable t o fresh milk f o r infants since

there was a far lesser r i s k of it being contaminated. With regard to the contribul-

ion of UNICEF in the form of drled skfmmed mllk, f o r which he expressed apprecla~ion,

he stressed the risk of under-nourishment from its exclusive use for children over

two years of age par t icu la r ly because mothers frequently over-diluted it, It would

be be t t e r fo r skimmed milk Lo be provided only for infants under'two yeras of age,

and f o r feeding bottles, for example; to be provided sfnce the types of bot t le frequent-

ly used in the area could not be sterilized. He a l so referjred t o the importance of

f l i e s as a cause of the disease and suggested tha t a " ~ l y D Q ~ " be held in Iraq, as in

other countries, t o draw public attention to the impowrtance o f flies as disease

carriers. He emphasized the need for central kitchens In hospitals to provide nurse-

trainees with a demonstration of bottle-sterilization and the preparation of milk.

He a l s o very s t h g l y favoured the creation of rehydration centms as recamcnied by

previous speakers.

Dr. N O m I A Y (united States Naval Medical Research Unit No.3) also thanked

Dr. J a l l a d f o r h is report and expressed appreciation of the hospitality received from

theKu~aitIfa-.~ He then gave a summary of t he preliminary results of an

extensive e t i o log i ca l and treatlnent programme for infant i le diarrhoea which NAMRU 3

had carried out.in Cairo in collaboration w i t h . UAR healkh authorities. The obdectives

had been to investigate as khoroughly as pss ib le the etiological f a o t o r s in the cause

of acute infantile diarrhoea and to try to introduce a simple means of calculation and

replaoement of' f luid needs. H e then described the methods of treatment fallowed and

the results obtained. The mortality rate had been 6 -4 per cent, four out of s ix

patlent-deaths having presented severe signs of dehydration and shaokl Preliminary

results had revealed t h a t 75 per cent o f the patients had known pathogenic organism

of one or more types. The result of the vi rus studies were s t i l l pending. Finchernical

results ~ v e a l c d t h a t only e l&% per cent of the pat ients had- evidence of hypertonic

dehydration. Tho Initial conclusion was that known bacterial pathogens were an im-

portant cause of infantile diarrhoea i n Ewpt and that the most important atherapeutic

~ E 4 / ~ ~ 1 4 ~ / T e l c h ~ . ~ i s c ./Mj:d.l page 12

measwe was the.immediate i n s t i t u t t o n of continuous in-trwenous administratim o f

f l u i d s , which reduced the mortality ra te by at least 50 per ,cent . The t h l ~ d cqn-

clusion reached was that antibiotics should be wed but that they could b ~ y i t b l d

until the w t i e n t ' a condi-Lion had improved so that he could tolerate them.

Dr. EL MISHAD (Qatar) said that there was lf ttle he oould add to the exhaustive . '

statements that had been made on the e t io lom of diarrhoea1 diseases. The htgh , i

inoidence d h r ~ n g thb summer mohtths had been at t r ibded t b flie$ .' ow ever, such was not the case in Qatar because there was no decrease in the 'number of infantile

diarrhbeki cases dLif.Png ,tho month of June when, due t o the excessiv&ly high temperature,

there were no Plies. It was dear therefore, that other cbnsiderations were as

important as flies iri causing the disease and he referred in p r t i c u l a r to standards

of personal, food, and immediately envfronmental hygiene. With regad to the dilutfon

of dried milk, it had been found. in Qatar that the recornended dilution was not

tolerated ky infants, probably due to the high tbmperature, and a thinner mixture was

given. No relatiomhip had been found in Qatar between the incidence of the dtsease

and the degree of humidity in the atmosphere. $uch a r e l s t i okh ip had however been

-noticed when milk wad" prepared with water from wells with a high concentfition of

fluorine : the' diarrhoea disappeared in hospital where milk was prepred with dist i l l i d

water.

The mortality rate in the case of male infants was double that of female pa t ien t s

in Qatar.

Two meaaures which would reduce the inoidence of infant i le diarrhoea were

1) to encourage breast feeding and 2) to provide health education f o r mothers.

Dr. FARHAT ( ~ u w a i t ) drew attention t o the salient points of h i s report on.1n-

Patient Paediatric Services in Kuwait in the Year 1962, With Speclal Reference.t~

Infantile Diarulhoea, together w i t h a short description of the management c r f severe

cases of gastro-enteritis, both of .whioh had been circulated to the meeting,

The conclusions reached were that the mortality rate wks highest in the infectious

and contagi~us. diseases af the isolation: ' i n fan t i l e diarrhoea cons$ltuted 41.4 per

cent of the admissions in the general wards, and the fatal3ty pate from infantile

diamhoea' was lowest In summer and highest In autumn.

We stressed the importance of the ffrst twenty-four hours in the management of

severe gastro-enteritis and 'the fact that acidifies milk was very helpful in labile

ml-nourished infanta suffering from recurrent diamhoea.

Dr. SHARXF (united Nations Relief and Works Agency f o r Palestine ~ef 'u~ees) a '

expressed appreciation of the exhaustive discussion which had $aken plaoe and drew

attention t o the series of technical instructions No. HI,/PM/NUTR/~ which UNRWA issued

ha daytime rekydration/nutrition centres, whioh had been circulated to the meeting.

B t w&a abundantly clear that.nutrition played a very important part in the cause of

liarrhoea. 'The rkhydration and restoration of the chemical balance had been appro-

bpiately stressed in connectibn with treatment of the disease. Sufficient a t ten t ion

~md not, however, been laid on the restoratirn of nutrition In the case of Infants;

the UNRWA technical instruction described how the nutrition balance should be restored

through graduated feeding until the intest ines could rever t t o normal feeding.

Attention should be given to that aspect of the problem when the Organization esta-

blished rehydration/nutrition centres, Mothers would need guidance on t he type of

food t o be prepred .and f o r that pu rpose . sml1 kitchew would be necessam at the

centres. particular emphasis should be placed on the recognition of cases of menor

malnutrition when t r a in ing the medical offfcers who would b,e operating rehydration/

nu t r i t i on centres.

Dr. KAMAL, WHO Consultant in Kuwait, observed that the discussions had covered

most of the field, but wished t o draw special a t t en t ion t o the importance of the

environment, whfch was the essential a e t i o log i ca l factor i n all diarrhoeas, i n f an t i l e

o r otherwise.

The three most important causative organisms in the Region were E. coli, Salmo-

nella and Shigella, The first, E. c o l f , hat3 been adequately covered in the documents - dis t r ibuted; but-one point worth emphasizing was that the swab method of taking speci -

mens was no% a satisfactory way to verify i ts presence o r absence; specimens of

actual faecal matter were needed.

With regard to Salmonella, the documentation showed that infection in cer%ain

areas, in. particular among children, was r e l a t i ve ly low, but that was not so in all

areas, as was shown by the results of a study in the &alyub area in the United Arab

Republic, where an examination of blood samples from all children s u f f e ~ i n g from a m

klnd of fever had giv&n.5 per cent posi t ive result f o r Salmonella,

The incidence of S h i ~ e l l a infection was admittedly much higher, but it -too

showed 'wfde variations. ' It was ' d i f f i c u l t t o establish the rate accurately, as

mortality provide& only an indication and 'morbidity figures did not cover an ' ent ire

population or an e n t i r e age group. Moreover, diagnosis was based on only a single

cu l tu re , and it had been proved that if a second oneV'was made after a few days interval

a large percentage of the cases that had formerly given negatfve resul t s proved posi-

t i ve . We emphasized the importance of distinguishing between shigel losis , which was

a severe and often fatal disease, comon up to the age of one year, and asymptomatic

shigella infection which tecame progressively more frequent in higher age groups,

The question had been raised why In fan t i l e diarrhoea, which oacurred a l l the year

wlound, became particularly cormnon in the summer months. Surveys in the United A ~ a b

Republic had shown tha t the annual rise i n incidence began in early spring, which was

~W%C14~/~ech . ~ i s c ./Min .I. page 14

just the time when fly-breedlng was beginning to,increase. When temperatures reached

such a height that f ly -heeding began t o decline, the incidenqe of infection a lso

reached a peak and began to decrease, but not in proport ion as other factors then

came I n t o .play, particularly .contaminati~~ through contact from person to person, due

t o carelessness by the mother and negleot o f her chi ld ' s cleanliness,

In carinection with %he importance of cleanliness, much had been said du~ing the

meeting about the uwideniable neb& for safe water supplies, but the large scale atudy

carried out by Hardy and Watt i n t h e United States of America had shown pa~admlceblly

tha t the essential factoxl in reducing the incidence of diarrhoea was not the purity of

water but i t a availability t o mothers f o r oleaning their hands, their utensils; the

babies themselves, etc. Other s tudies bad shown that, regardless of the purity of

the water supply, the way in which it reached the house was of great importance:

Incidence of diarrhoea was lowest with a piped supply inside the house, higher with

a supply inside the house but not. piped, and highest when water had t o be obtained

from outside the premises.

The relative unimportance of potability compared w i t h availability was less

surprising i f on? considered that children of the age group under consideration rarely . . ... -

drunk water, and that-when it was used Sor t he .p rep ra t ion . ~f their,bottles it was

u sua l ly boiled. The point should be borne i n mind' by public heal th admin$strators .

who were perhaps t ~ o ~ p r o n e to imagine t h a t by in s t a l l i ng a safe water supply in towns

they had done a11 that was needed to free them from diseases associated with f i l th .

Indeed, it was impossible t o put too much emphasis on the importance of cleanli-

ness. As far back as 1940, studies had show. that faecal, so i l i ng of the anal a m a

showed a posi t ive corollation with the incidence of diarrh~ea, A recent article in

the British Mgdioal Journal had confirmed that finding wi$h respect t o s ta$yloooaca l

infectton, SO ft must apply even more strongly in the case of Shigella.

D r . J A U D , WHO Matewlnal and Child Health Adviser, thanked representatives f o r . I

the imformtive discussion which had taken,place. With regard , to the point mlsed b~ Wtar

the Representative of / he had stated In his r e p o r t that the f l y pepulation was one

of the factors influencing the high incidence of the disease especially during the

month of June. He ha8 not, however, been referring to @tgr in particular.

Dr. EL MISHAD. MI tar) repeated that improving; immediately .environmental mgfene

of the infant 'wad .more important than controll ing the f l y populatioli; the- incidence

of the disease did not decrease in June in Qatar when there were no flies.

The CHATRMAN then placed before the meeting the following draft resolution:

The Sub-Commltt ee ,

Having studied with interest the documentation on Infantile Diarrhoea in the Eastern Mediterranean Region, presented by the Regional Director; (1)

Considering that Infantile Diarrhoea is one of the major health problems in thQs Region and the most Importank cause of high morbidity and mortality in infancy and early childhood;

Noting the development of preventive measures taken by various countries in the Region to decrease the incidence of infantile diarrhoea,

1. EXPRESSES its satisfaction with the surveys carried out by the World Health Organization in a few countries of the Region to study the problem related to diarrhoea1 diseases;

2 ENDORSE3 , the recommendat ions made in document E M ~ C I ~ / T ~ C ~ is c ./2 with regard to both the preventive and curative aspects of the problem;

3. RECOMMENDS that the Govements give high priority to Maternal and Child Health and give urgent attention to the development of related services to remedy the p~oblem of Infanti le Diarrhdea 2ncluding:

(a) the establishment of rehydration units in maternal and child health centres;

(b) the establishment of a virus research centre in the Region for investigating the r6le of viruses in the aetiology of infantile diarrhoea;

(c) the holding of a seminar on diarrhoea1 diseases i n the the Region in the near fu ture under the auspices of the World Health Organization;

4, REQ,IX?,STS the Regional Director to explore the possibilities of carrying out fur ther surveys on Diamhoeal Diseases i n the Region and to continue to provide technical assistance t o the Govements as required, in order to develop and promote training facilties for specialized health personnel.

Amendments to operative parag~a$ls 1 and 3 (a), Arabfc t e x t only, wex-e

proposed by Dr. EL BORAI: ( ~ u w a i t ) and approved,

Decision: The draft resolution, as amended, was adopted.

The CHAIRMhE3 said that there was no doubt that the technical discussion had been

extremely useful . Much valuable information had been presented on the et iological

problem confronting all the countries of the Region,

The meeting rose at 12.20 p.m.