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Epidemiologic Notes and Reports Diarrheal Diseases Control Program in the Americas

Diarrheal disease constitutes a clinical syndrome of varied etiology that includes specific infectious diseases, such as shigellosis, salmonellosis, amebiasis, and other diseases caused by bacteria, protozoa, viruses, and helminths.

In Latin America, these diseases constitute a major public health problem, especially among children under 5 years of age. However, in most countries, it is difficult to accurately determine the extent of the problem. Current clinical and laboratory services are not always adequate in either urban and rural areas to identify these infectious agents, and the etiologies of reported diarrhea episodes are often unknown. Furthermore, due to surveillance system limitations, the number of reported cases and deaths does not reflect the magnitude of the problem. More specifically, reliable morbidity data for diarrheal diseases are difficult to collect because of reporting constraints characteristic of many national health systems. The coverage and quality of case reporting varies from country to country and by geographical regions within each country. The extent to which various populations receive health care services and the completeness of disease surveillance by those services also influence the data.

Mortality data offer more opportunities for analysis, but similar shortcomings may exist; e.g., infant deaths may be underreported, and the cause of death may be unknown, inaccurate, or nonspecific. Nevertheless, available mortality data provide some insight into the seriousness of the problem. In interpreting the significance of mortality data in Tables 2 and 3, the wide variations in data compilation and reporting must be considered.

Around 1978, diarrheal diseases* were among the first and second causes of all deaths among children under 1 year of age in 20 of 31 countries reporting data.

Around 1970, for 20 selected Latin American countries, 108,627 deaths due to diarrheal diseases** were recorded among children less than 5 years of age, yielding an age-specific death rate of 456.0 per 100,000 population. Of these deaths, 69,591 occurred among children under 1 year, for an age-specific death rate of 1,346.07/100,000 (Table 2).

For the same countries, around 1978, 80,307 diarrheal deaths were reported among children under 5 years of age, producing an age-specific death rate of 290.2/100,000. In the under-1-year age group, 55,672 deaths occurred, for an age-specific death rate of 934.0 (Table 3). These figures indicate a 26% decrease over the 8-year period in the overall age-specific mortality rate due to diarrheal diseases among children under 5 years of age. This decrease in mortality had occurred by annual proportions in 18 of the 20 countries reporting detailed information.

Although the 1978 age-specific diarrheal mortality rate among children under 5 years was only 5.0/100,000 in North America, the problem was much more acute in the Caribbean and in Central and South America, where the rates were 82.1, 379.4, and 207.6, respectively. Comparing rates for 1970 and 1978, reported age-specific diarrheal disease death rates among children under 5 years of age decreased 54% in the Caribbean and approximately 25% in both Central and South America. *Codes 008 (Enteritis) and 009 (Other diarrheal diseases) of the International Classification of Diseases (9th revision, 1975). Geneva: World Health Organization, 1977. **Defined according to categories of the 8th revision of the International Classification of Diseases, including other salmonella infections (003), bacillary dysentery (004), amebiasis (006), enteritis (008), and other diarrheal diseases (009).

Age-specific diarrheal mortality rates varied considerably throughout the countries of the Americas. In 1978, relatively high diarrheal death rates for the under-1-year age group were reported in Nicaragua (1,409.5), El Salvador (1,345.0), Guatemala (1,311.3), and Mexico (1.258.8). Together these four countries accounted for approximately 68% of all diarrheal deaths registered that year among children under 1 year of age. If a reduction of mortality in this age throughout the countries of the Americas. In 1978, relatively high diarrheal death rates for the under-1-year age group were reported in Nicaragua (1,409.5), El Salvador (1,345.0), Guatemala (1,311.3), and Mexico (1.258.8). Together these four countries accounted for approximately 68% of all diarrheal deaths registered that year among children under 1 year of age. If a reduction of mortality in this age group is to occur, improved maternal and child nutrition activities will be necessary, especially the promotion of breast-feeding and proper preparation of food during the weaning period, and the early introduction of oral rehydration therapy. In 1978, the lowest reported age-specific mortality rates for diarrheal diseases in the Latin American region for the under-1-year age group were in Cuba (122.7) and Dominica (178.5). That same year, the highest diarrheal mortality among children ages 1-4 years was in Guatemala, with a reported age-specific rate of 424.1/100,000 Nevertheless, this represented a 52% decrease from the 1970 rate of 807.6/100,000 in that age group.

As health program coverage extends to scattered rural populations, the number of reported diarrhea cases and deaths is expected to increase, reflecting better information and reporting systems rather than an actual increase in incidence or severity. Treatment and prevention of diarrheal diseases should be an integral part of overall health care services and should incorporate multidisciplinary prevention strategies, such as health education, maternal and child health, water and sanitation, breast-feeding, and nutrition. When these measures and aggressive oral rehydration therapy are effectively introduced in developing countries, a substantial decrease in the number of diarrhea cases and deaths can be anticipated. Reported by Pan American Health Organization. Epidemiological Bulletin 1982;3(3):10-2.

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