M. MOORE ETAL. New Parameters fr Evaluating Oral Rehydratin Therapy: One Year's Experience in a Majr Urban Hspital in Zaire by Melinda Mre, MD, MPH, Farzin Davachi, MD, L. Bng, MD, H. Seruvug, K. Mushiya, Jeannel A. Ry, and Mambu-ma-Disu, MD Department f Pediatrics, Mama Yem Hspital, Kinshasa, Zaire Summary Oral rehydratin therapy (ORT) is a simple treatment fr diarrheal dehydratin that mst be administered crrectly t be effective. In August 1984 an ORT service was established at Mama Yem Hspital in Kinshasa, Zaire. Daring the first 12 mnths, 5530 children with diarrhea were treated, and their clinical histry and treatment evaluated. We used indicatrs traditinally used fr individual case management as peratinal tls t mnitr the quality f treatment n the ORT service as a whle. These included quantity f liquids prescribed and given, time spent at the centre, weight gained during rehydratin, and discharge status. Analysis using these indicatrs shwed that adverse utcme (death r hspitalizatin), when it did ccur, was nt assciated with inadequate ORT treatment Instead, it was assciated with clinical antecedents including fever, measles r 'ther' cmplaint. We cnclude that indicatrs reflecting quality f treatment are useful in identifying peratinal prblems assciated with ral rehydratin services and that ur frequent cnferences with the pediatric persnnel helped t rectify these prblems. T ur knwledge, this study represents the largest hspital-based ORT ppulatin yet reprted, and the first f its kind frm an African cuntry. Intrductin Diarrhea is a leading cause f mrbidity and mrtality in yung children thrughut the develping wrld, particularly in Africa. 1-2 Oral Rehydratin Therapy (ORT) has revlutinized the health cmmunity's apprach t the prblem f diarrhea as a simple yet effective treatment t reduce diarrhea mrtality due t dehydratin. Health fficials nw recgnize the imprtance f mnitring nt nly the use f ORT, but als its crrect use. 3 In Zaire, the natinal diarrheal disease cntrl (CDD) prgramme became active in 1984 and included the develpment f a netwrk f ORT treatment centres. One such centre was established in the pediatric service f the 2000-bed Mama Yem Hspital in the capital city f Kinshasa. This was the first majr ORT centre in Zaire. Great emphasis was given t the develpment and use f a new and effective evaluatin cmpnent. This reprt describes cases This study was supprted in part by the USAID funded Cmbatting Childhd Cmmunicable Diseases Prject (698-0421). Crrespndence: Dr Melinda Mre, Kinshasa, Agency fr Internatinal Develpment, Washingtn DC 20523, USA. treated during the first 12 mnths f the ORT service, frm mid-august 1984 thrugh mid-august 1985. Methds The ORT service in the pediatric emergency ward (EW) was launched fllwing a series f rientatin cnferences fr pediatric medical and nursing staff. At that time indicatrs fr mnitring the quality f ORT were prpsed. These included: quantity f fluid prescribed (per kilgram f bdy weight), quantity f fluid administered (per kg), weight gain during acute phase f rehydratin, number f hurs spent at the EW ORT centre, and clinical utcme. There were guidelines fr each indicatr, accrding t the degree f dehydratin (WHO classificatin. 3 Evaluatin f ORT activities was based n a ne-page patient frm that includes clinical histry and detailed infrmatin regarding treatment at the centre. Peridic prgress cnferences were held fr physicians and nurses t reprt summary infrmatin n cases treated. In August 1985, an independent review f hsptial recrds was undertaken t evaluate diarrhea case admissins and mrtality in the EW. We estimated the number f diarrhea case admissins by mnth amng children <5 years ld by extraplating data Jurnal f Trpical Pediatrics Vl. 35 August 1989 Oxfrd University Press 1989 179
r M. MOORE ET AL. 2500 2000 CAS BER 1500 1000 500 FIG. 1. frm a randm sample f 100 recrds fr each mnth during the preceding 3-year perid. Diarrheaassciated mrtality was assessed based n exhaustive review f the pediatric EW mrtality register. Diarrhea case fatality rates (CFR), prprtinal diarrhea mrtality, and age-specific EW fatality rates were calculated. NONE (PLAN A) MODERATE (PUN B) SEVERE (PLAN C) DEGREE OF DEHYDRATION EW SERVICE Eg] DISPENSARY Distributin f diarrhea cases, by degree f dehydratin and service. Results Especially during the early mnths f the EW ORT service, patient frms were nt cmpleted fr all diarrhea admissins, and frms that were available were ften incmplete. The nature and degree f selectin bias cannt be determined with certainty. Hwever, we are cnfident that cases were generally treated in the same fashin, thus minimizing the ptential bias. Descriptinfcases Patient frms were available fr 3700 cases seen during the first 52 weeks f the EW ORT service. Of this number, age was reprted fr 3486 (94 per cent). Apprximately 90 per cent f cases were less than 2 years ld, including 61 per cent under 1 year f age and 20 per cent under 6 mnths. Of the ttal, 55 per cent were male, and 45 per cent were female. In additin t the 3700 EW cases, 1830 frms were available fr children seen in the dispensary ORT service during the same time pend. Of the ttal 5530 utpatient diarrhea cases seen by the tw services cmbined, 2056 (41 per cent) f the 5000 with cmplete infrmatin were classified as Plan A (n apparent dehydratin), 2133 (43 per cent) as Plan B (mderately dehydrated), and 811 (16 per cent) as Plan C (severely dehydrated; Fig. 1). Whereas 67 per cent f cases in the dispensary were Plan A and 33 per cent were Plan B, the EW cases tended t be mre severely dehydrated. In general, Plan A cases treated in the EW were thse arriving after the dispensary service was clsed. A cmparisn f cases in Plans A, B, and C shws an verall tendency fr yunger children t be mre severely dehydrated than lder children (mean age Plan A =12.3 mnths, v. Plan C = 11.3 mnths, Z' = 0.04). Clinical characteristics and hme ORT use by cases in each plan are shwn in Table 1. Certain factrs were significantly assciated with increasing degree f dehydratin: vmiting, liquid stls, fever, measles, and 'ther' clinical cmplaints (primarily respiratry diseases). Descriptin f ORT treatment indicatrs A summary f ORT treatment indicatrs, by degree f dehydratin and 3-mnth perid, is presented in Fig. 2. The 'quantity prescribed' was cnsidered a minimum quantity, crrespnding apprximately t the net fluid t be retained. The 'quantity administered' shuld always be greater than the minimum quantity prescribed, t allw net fluid retentin in the face f nging lsses during treatment. The 'percentage weight gain' was used as a guide t assess treatment in additin t clinical evidence f recvery. The mean values fr mst indicatrs increased favurably ver time, with sme drp-ff in the furth quarter. The duratin f treatment decreased favurably ver time. Weight gain was nt assciated with age, sex, r duratin f treatment at the centre. Thse with 'adequate' shrt-term weight recvery tended t have a shrter duratin f diarrhea prir t seeking hs- 180 Jurnal f Trpical Pediatrics Vl. 35 August 1989
M. MOORE ET AL. TABLE 1 Summary f clinical characteristics by degree f dehydratin Degree f dehydratin A Nn-apparent B Mderate C Severe Ttal Number bservatins (average) Mean number f days with diarrhea Percentage with chrnic diarrhea (> - 14 days) Number stls previus 24 hurs Vmiting* Number times vmited preceding 24 hurs Liquid stlsf Mucpuruknt stls Bldy stls FeverJ Measles Other cmplaint H SSS used at hme Number days SSS used = 34.07, df- 2, P < 0.0001. = 24.65,df=2, /> = 4.11 x 10' J = 27.08,df=2,/><10-'. - 13.15,df= 2, P=0.0001. <100 sen a. ity C a cr c 20 80 60 40 20 0 / " ^ -. 1 ^U ^120 \ 1,100 D E 5 80 t 'c E "g 60 1 40 20 0 2 3 4 1 2 3 / 975 5.0 7.1 4.1 545 (55 /.) 3.1 699 (70%) 152(15%) 64 (6%) 502 (50%) 78 (8%) 156(16%) 155(16%) 3.2 r / / / 1595 4.8 6.7 4.5 998 (62%) 3.3 1227(76%) 292(18%) 67 (4%) 929 (58%) 131 (8%) 409(25%) 242(15%) 2.4 810 5.0 8.2 4.9 560 (69%) 3.6 660(81%) 129(16%) 46 (6%) 514(63%) 100(12%) 282 (35%) 151 (19%) 2.9 3380 4.9 7.2 4.5 2103 (62%) 3.3 2586 (76%) 573(17%) 177 (5%) 1945(57%) 309 (9%) 847 (25%) 548 (16%) 2.7 Quarter Quarter Quarter p Plan A Plan B lan C FIG. 2. Summary f ORT peratinal indicatrs: mean values, by quarter and by treatment plan. pital treatment, greater likelihd f liquid stls r vmiting, and less likelihd f presenting with dysenteric stls. Clinical utcme A summary f clinical utcme, by treatment plan and by 3-mnth perid, is presented in Fig. 3. In general, clinical utcme imprved ver time: mre children in each treatment grup were rehydrated and sent hme, and fewer children were hspitalized r died. Hspitalizatin and case fatality rates increased as the degree f presenting dehydratin increased. Jurnal f Trpical Pediatrics Vl. 35 August 1989 181
M. MOORE ET AL. PERCEI JTAGE 100 80 60 40 20 PLAN A PLAN B PLAN C il 1 2 3 4 1 2 3 4 1 2 3 4 QUARTER (13-WEEK PERIOD) V77\ REHYDRATED ES3 HOSPITALIZED DIED FIG. 3. Clinical utcme f diarrhea cases, by treatment plan and quarter, 1984-1985. TABLE 2 Summary f factrs assciated with adverse clinical utcme by degree f dehydratin Plan A (n apparent dehydratin) Number bservatins (average) Number days f diarrhea Measles 'Other' cmplaint Fever Plan B (mderate dehydratin) Number bservatins Measles Fever Plan C (severe dehydratin) Number bservatins (average) Measles Bldy stls Fever Rehydrated 525 4.7 7% 14% 48% 788 5% 56% 248 7% 4% 60% Table 2 summarizes factrs that were significantly assciated with adverse clinical utcmes. These included measles fr all three treatment categries, plus duratin f diarrhea, fever, 'ther' clinical cmplaints, r bldy stls in specified categries. Prer utcme als tended t be assciated with increasing age, althugh these differences were nt significant. Adverse clinical utcme was generally nt assciated with smaller quantities f fluids prescribed, smaller quantities administered, r fewer hurs at the treatment centre. Impact n hspital admissins Data frm patient frms indicate majr reductins in Hspitalized 102 8.1 17% 26% 62% 239 13% 59% 215 19% 8% 68% Died (2) 18 22% 31 23% 55% Pvalue 0.0001 (nest) 0.005 0.005 0.01 2.15x10-' 0.01 7.65x10-' 0.06 0.06 hspitalizatin rates f nn-severely dehydrated children between the first and the furth quarters: frm 24 t 5 per cent (79 per cent reductin) fr Plan A cases, frm 34 t 18 per cent (47 per cent reductin) fr Plan B cases, and frm 30 t 12 per cent (60 per cent) fr Plan A and Plan B cases cmbined (Fig. 3). There was nly an 8 per cent reductin in hspitalizatin rates amng severely dehydrated (Plan Q cases, frm 39 t 36 per cent. The verall hspitalizatin rate (all plans) drpped by 33 t 36 per cent. The verall hspitalizatin rate (all plans) drpped frm 33 t 17 per cent (49 per cent reductin). During the same perid, the hspital recrd review shwed a 31 per cent reductin (frm 42 t 29 per cent) in the pr- 182 Jurnal f Trpical Pediatrics Vl. 35 August 1989
M. MOORE ETAL. TABLE 3 Age-specific diarrhea case fatality rates by 3-mnth time perid frm hspital recrd review <1 year 1-4 years Ttal <5 years Deaths/ Cases CFR Deaths/ Cases CFR Deaths Cases CFR Befre ORT service December 82-January 85 (Feb NA) 1983 March-May June-August September-Nvember 1984 December-February March-May June-August Since ORT service 1984 September-Nvember 1985 December-February March-May June-August 25-448 62/1689 43/1682 54/2279 33/1459 33/1809 21/1319 prtin f all hspitalizatins fr diarrhea in the 0-4-year grup. The prprtin f diarrhea hspitalizatins fell by 17-30 per cent frm cmparable 3- mnth perids during the year preceding the start-up f EW ORT services. 5.6% 3.7% 2.6% 2.4% 2.3% 1.8% 1.6% Impact n diarrhea CFR Data frm patient frms indicate substantial reductins in EW diarrhea case fatality rates between the first and furth quarters: frm 18.1 t 3 per cent (81 per cent reductin) fr Plan C cases, frm 4.3 t 1.2 per cent (72 per cent reductin) fr Plan B cases, and frm 6.9 t 1.2 per cent (83 per cent reductin) fr Plan A, B, and C cases cmbined (Fig. 3). It must be nted, hwever, that discharge status was mitted frm a large prprtin f cases, especially during the early mnths f the EW ORT service. In additin, there was n fllw-up f the ultimate utcme f children hspitalized frm the EW. Thus, these data represent CFR estimates nly frm the EW itself. Data frm the independent recrd review suggest that the diarrhea CFR amng all EW cases <5 years fell frm 2.6 t 1.2 per cent (53 per cent reductin) between the first and the furth quarters f the new ORT service (Table 3). Because the hspital recrds were incmplete fr mst mnths prir t December 1983, admissins fr diarrhea fr that perid culd nt be accurately estimated. Hwever, where cmparisns were pssible, the data indicate apprximately 50-60 per cent reductins in diarrhea CFR between a given quarter during the year prir t ORT activities and the same quarter 1 year later. Review f age-specific diarrhea CFRs fr cmparable 3-mnth perids befre and after the ORT service began shws reductins f 38-59 per cent fr the < 1-year grup and f 11-69 per cent fr the 1-4-year 19/684 30/961 23/1237 42/1394 29/1175 10/1030 7/923 2.8% 3.1% 1.9% 3.0% 2.5% 1.0% 0.8% 44/1132 92/2650 66/2919 96/3673 62/2634 42/2839 28/2242 3.9% 3.5% 2.3% 2.6% 2.4% 1.5% 1.2% age grup. By the secnd half f the first year, the prprtin f diarrhea deaths amng all EW deaths fell by apprximately 40-50 per cent fr the < 1-year grup and 50-60 per cent in the 1-4-year grup frm cmparable time perids in the previus year. Finally, verall mrtality amng EW patients < 5 years fell by 13-30 per cent during the first year f the ORT service, frm cmparable time perids the preceding year. Discussin The treatment ppulatin described in this reprt appears t be cmparable t thse studied elsewhere. Amng the 5530 diarrhea cases seen at the EW and dispensary ORT services cmbined, i.e., amng the ttal pediatric utpatient ppulatin, 16 per cent were classified as severely dehydrated. This falls well within the 2-40 per cent range reprted frm inpatient and utpatient services at varius hspital centres thrughut the develping wrld. 4 " 17 The higher prprtin f such cases in the EW (24 per cent) v. dispensary (< 1 per cent) reflects the system f triage f utpatients. We feel that the cntributin f this study is the systematic use f peratinal indicatrs that reflect specific aspects f ORT treatment. These generally imprved during the first year f the ORT service, with sme deteriratin in the furth quarter. We feel this was partly related t the timing f review cnferences fr pediatric persnnel. These were held after weeks 1,16,26, and 52. Thus, there was n cnference at the end f the third-quarter, and furth-quarter statistics declined. It was ur impressin that pediatric persnnel had particularly respnded t the persisting high percentages cnsidered 'inadequate' when these were presented at the prgress cnferences, and Jurnal f Trpical Pediatrics Vl. 35 August 1989 183
M. MOORE ET AL. that they were mtivated t achieve better ORT treatment in each categry. Clinical assessment plus weight upn admissin are traditinally used t estimate a child'sfluiddeficit and hence the amunt f fluid t be replaced. This methd is incrprated as well int the WHO guidelines fr evaluatin and treatment f diarrheal dehydratin. 2 Evaluatin f weight gain after cmplete rehydratin is cmmn pediatric practice in industrialized cuntries and has been reprted in clinical studies frm many areas f the wrld. 8 ~ 12le ~ 20 We used weight gain as a rugh guide t judge the shrt-term curse f rehydratin in individual cases, and as ne indicatr f ORT quality in grups f cases. Nt surprisingly, 'adequate' weight gains were mre cmmn amng cases with greater quantities f fluid prescribed and administered. We fund favurable increases in shrt-term weight recvery in each treatment categry ver the curse f the first year at the ORT centre. Finally, clinical utcme at the ORT centre als tended t imprve ver time, as shwn frm bth the patient frms and the independent recrd review. Pr utcme (hspitalizatin r death), when it did ccur, was significantly related t cmplicating clinical factrs such as measles, fever, r 'ther' clinical cmplaints. Pr clinical utcme did nt appear t be assciated with indicatrs f ORT treatment, such as lessfluidprescribed r given r t little time at the centre. Althugh this was a surprising finding, it was reassuring frm the pint f view f the ORT prgramme. The significant reductin in diarrhea hspitalizatins and case fatality rate is cnsistent with reprts frm ther cuntries. 21-22 We feel that ORT at Mama Yem Hspital has been successful in reducing mrtality and patient lad in an extrardinarily busy pediatric service. Our experience during the first year f this ORT service leads us t cnclude that simple patient mnitring is feasible and that regular data analysis and feedback t the clinical staff can lead t imprvement in ORT treatment and patient utcme. Parameters related t quftlity f ORT can and shuld be mnitred. While aiming fr the best ORT treatment pssible, we must als realize that sme diarrhea hspitalizatins and deaths will nt be prevented by ORT alne. The verall cntrl f diarrheal disease mrbidity and mrtality will include nt nly the crrect administratin f ORT, but als apprpriate feeding during and after diarrhea, selective use f antibitics, and adptin f measures t prevent diarrhea cases frm ccurring. References 1. Snyder JD, Mersn MH. The magnitude f the glbal prblem f acute diarrheal diseases: a review f active surveillance data. Bull Wld Hlth Org 1982; 60: 605-13. 2. Wrld Health Organizatin. A manual fr the treatment f acute diarrheafr use by physicians and ther senir health wrkers. Prgramme fr the Cntrl f Diarrheal Diseases, WHO, 1984, WHO/CDD/SER/ 80.2/REV/(1984). 3. Wrld Health Organizatin. Mnitring perfrmance, Prgramme fr the Cntrl f Diarrheal Diseases, Supervisry Skills curse mdule. 4. Mazumdar H, Zingde KX. Oral rehydratin in gastrenteritis in children. Ind Pediat 1973; 10: 315-22. 5. Taindel C, et al. A simple, efficient methd fr restring water-electrlyte balance rally in children with acute enteric infectins. Rev Pediat Obst Gynecl (Pediat) 1977; 26: 71-8. 6. Pi2arr D, et al. Evaluatin f ral therapy fr infant diarrhea in an emergency rm setting: the acute episde as an pprtunity fr instructing mthers in hme treatment. Bull Wld Hlth Org 1979; 57: 983-6. 7. Rberts AB, et al. Chlera in the Gilbert Islands: II. Clinical and labratry findings. Am J Trp Med Hyg 1979; 28: 685-91. 8. Pizarr D, Psada G, Levine MM, Mhs E. Oral rehydratin f infants with acute diarrheal dehydratin: a practical methd. J Trp Med Hyg 1980; 83: 241-5. 9. Pizarr D, et al. Oral rehydratin and its maintenance in patients 0 t 3 mnths ld with diarrheal dehydratin. Bl Med Hsp Infantil Mex 1980; 37: 879-91. 10. Bai KI, Kumar CR, Reddy CG. A study f ral rehydraun therapy in childhd diarrhea. Ind J Pediat 1980; 47: 279-82. 11. Ghislfi J, et al. Oral treatment f acute infantile diarrhea with sucrse-electrlyte slutin. Arch Fr Pediat 1980; 37: 93-8. 12. McLean M, et al. Etilgy f childhd diarrhea and ral rehydratin therapy in Nrtheastern Brazil. Bull Pan Am Hlth Org 1981; 15: 318-25. 13. Manfredi L, el al. Preliminary reprt n a scheme fr ral rehydratin in acute diarrheal dehydratin. Rev Hsp de Nins (BSAS) 1981; 23: 169-74. 14. Pizarr D, Psada G, Mata L. Treatment f 242 nenates with dehydrating diarrhea with an ral glucseelectrlyte slutin. J Pediat 1983; 102: 153-6. 15. Pizarr D, et al. Oral rehydratin in hypernatremic diarrheal dehydratin. Am J Dis Childh 1983; 137: 730-4. 16. Baqui AH, Yumus MD, Zaman K. Cmmunity perated treatment centres prevented many chlera deaths. J Diarr Dis Res 1984; 2:92-«. 17. Srivastava VK, et al. Cmparisn f ral and intravenus rehydratin amng hspitalized children with acute diarrhea. J Diarr Dis Res 1985; 3: 92-5. 18. Ludan AC. The efficacy f ral electrlyte fluid in the therapy f diarrhea in Apache children. J Philip Med Ass 1973; 49: 243-52. 19. Sunt el al. Treatment f acute infantile gastrenteritis. Paediat Indn 1977; 17: 351-60. 20. Varavithya W, Chernit L, Wngsarj P. Cmparisn f ral rehydratin with electrlytes slutin and sy milk in acute diarrhea. J Med Ass Thailand 1980; 63: 593-7. 21. Lasch EE, et al. Evaluatin f the impact f ral rehydratin therapy n the utcme f diarrheal disease in a large cmmunity. Isr J Med Sci 1983; 19: 995-7. 22. Wrld Health Organizatin. Impact f ral rehydratin therapy n hspital admissin and case fatality rates fr diarrheal disease: results frm 12 hspitals in varius cuntries. Wkly Epidem Rec 1984; 59: 361-3. 184 Jurnal f Trpical Pediatrics Vl.35 August 1989