Oral rehydration therapy is a very simple and cheap treatment that saves many lives every day, but it has taken a surprisingly long time for people to realize this.
Over the past decades, the world has made significant progress in reducing deaths from diarrheal diseases. Back in 1990, 2.6 million people died from diarrheal diseases. Since then, the number of deaths from diarrheal diseases has fallen by about 1 million each year.
Progress in reducing child mortality from diarrhea has been even more impressive: mortality among children under five has fallen by two-thirds since 1990.
In this article, I would like to focus on an intervention that has been instrumental in reducing mortality among children with diarrhea worldwide and has the potential to save many more lives in the future: oral rehydration therapy.
Diarrhea can lead to life-threatening dehydration, so effective treatment must target fluid loss. Oral rehydration therapy (ORT, also called ORS) is one of the most common treatments used to prevent dehydration caused by diarrhea.
ORT is a very simple treatment: a mixture of water, salt and sugar. It can be used orally without special medical care. Despite its apparent simplicity, the medical journal The Lancet called ORT “the most important medical advance of the 20th century” .
When we talk about “medicine’s biggest breakthroughs” and life-saving interventions, we often think of expensive drugs and complex procedures discovered and perfected in cutting-edge laboratories. ORT refutes these expectations. Not only is it low-tech and cheap (only about $0.50 per treatment), but it was also developed in often difficult conditions far from the world’s leading hospitals.
The first hospital trials of ORT were conducted in Dhaka (today’s Bangladesh) by doctors Richard Cash and David Nalin in the late 1960s. The most common treatment for diarrhea at the time was the much more expensive intravenous fluid therapy (IVT), which involved the administration of intravenous saline in a hospital setting. Although IVT is an effective treatment option, Cash and Nalin recognized the need for alternative treatments because diarrheal diseases disproportionately affect those who do not have access to clinical sites where IVT is available. Moreover, the potential for expanding the use of IVT during large-scale disease outbreaks such as cholera epidemics is limited.
In the late 1960s, Cash and Nalin conducted a series of small clinical trials during a cholera epidemic in the region that showed promise for ORT. However, the most important evidence of the effectiveness of ORT comes from the desperate situations during the 1971 Indo-Pakistan War. War conditions were exacerbated by the rainy season, which forced millions of people into refugee camps, ultimately leading to a catastrophic cholera outbreak. At the beginning of the epidemic, almost 30% of patients died due to insufficient treatment of IVT. Forced by disastrous circumstances, Dr. Dilip Mahalanabis decided to start distributing packets of salt and sugar dissolved in water to people in the camp. Dr. Mahalanabis’ decision turned out to be correct: within just a few months, the mortality rate from cholera and cholera-like diarrhea among patients receiving ORT dropped to less than 4%, compared with the previously observed rate of 30%. This success is an important step towards wider implementation of ORT. .
Although ORT is a simple, low-tech solution for treating diarrhea, a major public health problem, it took many years for its use to become generally accepted. It was not until 1978 that the World Health Organization (WHO) developed a diarrheal disease control program that helped popularize the use of ORT worldwide. By comparison, it took us more than ten years to implement ORT. We’re landing on the moon.
There are many reasons for the slow adoption and acceptance of ORT in rich countries. Western doctors are skeptical of treatments tried in developing countries and consider them substandard. The idea of drinking a simple solution of water, sugar and saline works just as well as a “complicated” IV drip. At the time it seemed radical. And even today, ORT treatment seems counterintuitive because while it reduces the likelihood of death and speeds recovery, it does not actually prevent or stop diarrhea.
How many lives did ORT save? In some ways, exact numbers are impossible to know because many other interventions and treatments have reduced deaths from diarrheal diseases. However, during the last two decades of the 20th century there was an incredible decline in child mortality from diarrheal diseases (from approximately 4.8 million deaths per year in 1980 to 1.2 million in 2000), and at the same time the global use of ORT also is expanding. Many researchers believe that this sharp decline is not just a coincidence, but is directly caused by the increase in ORT use. Twelve years ago, Fontaine, Garner and Bhan estimated that ORT saved more than 50 million children between 1982 and 2007—an average of 2 million deaths per year. According to these estimates, ORT could have saved more than 70 million children from 1982 to 2019. Whatever the exact number of lives saved, it is no exaggeration to say that many adults would not be alive today without the discovery of ORT.
Although definitions are clearly useful, in practice it is not always possible to count all episodes of diarrhea in a child. Moreover, mothers in different settings and countries may use different definitions based on their life experiences: a mother in the United States may have a child with diarrhea differently than a mother in rural Bangladesh.
It is also important to note that diarrhea as the cause of death is usually determined by oral examination rather than by actual autopsy. Lack of autopsy may result in the cause of death being diarrhea and underlying causes such as specific viral infections, malaria, etc. not being recorded.
Diarrhea is dangerous and life-threatening as it can lead to severe dehydration and loss of electrolytes. Although drinking water can compensate for some water loss, in cases of severe diarrhea, passive absorption of water by intestinal cells is not enough to fully compensate, and loss of electrolytes in feces can negatively affect many body functions.
ORT works through molecular mechanisms that control the absorption of sugar and sodium in the intestines. The cells that make up the intestinal mucosa have special receptors on their surface that allow them to actively absorb sugar molecules. Research by Robert K. Crane et al suggests that the presence of sodium ions in the intestinal lumen is critical to this process.
The increase in intracellular sugar and sodium also leads to increased absorption of water and chloride ions. The loss of these essential ions and molecules in people with diarrhea can be compensated for by giving patients a mixture of sugar and salt dissolved in water.
Recommended formulations for electrolytes and sugars in ORT have changed over time. It is now common practice to supplement with other recommended fluids and zinc, which has been shown to reduce recovery time and reduce the likelihood of diarrhea returning in the short term.
Although ORT is a low-tech solution, it is very effective.
Post time: Apr-18-2024