In this next chapter I’d like to look at some childhood diseases that are particularly common in low-income countries and focus particularly on diarrhea and pneumonia, as they provide some very interesting examples of both how to prevent as well as how to treat these conditions so that the mortality and morbidity continues to go downward. The pie chart indicates the prevalence of each of these conditions in today’s world. You can see both diarrhea and respiratory diseases make up a large segment. And in some parts of the world, malaria is a major contributor as well. This is mostly in sub-Saharan Africa. Now here’s a child with a severe dehydration caused by diarrhea. Dehydration is the loss of fluid from the body. It’d be like if you took a grape and made it into a raisin or a plum into a prune. And you can see the child’s eyes are sunk back.His breathing would be deep and rapid. His pulse would be rapid. He’d have very little urine output. All signs of the loss of fluid and electrolytes. And here is a, a much younger child. And here you see the top of the head is depressed. This is called a fontanel, soft spot to many of us, before it closes. And here the dehydration has led to this sort of depression of the fontanel. Sometimes mothers would actually put mud or other substances there to try to draw this out, not recognizing that it might be due to dehydration. For a long time, in the summer months particularly through out the world, America, Europe and in lower-income countries you would see this scene in hospitals. Bed after bed after crib with children with diarrhea. And you could see here the dehydration, the loss of food and electrolytes are being replaced by I.V- intravenous solution. That’s fine if you have that solution, but in some parts of the world, this was very hard to come by. The IV solution wasn’t available or if it was available, it was expensive. You needed the tubing and the needle to insert and someone to do it. So there was a search for many years to find something that could be given orally, as this would eliminate the need or greatly obviate the need for interven…intravenous fluids. Now I show you this picture of a cholera cot, which is a wonderful piece of appropriate technology designed to be used with someone who significant diarrhea. And it’s simply a, a jute cot with a plastic sleeve that fits over it with a hole right where the buttocks would be. And that plastic sleeve goes into a bucket. So the liquid stool goes through the hole, through the sleeve, into the bucket. And one can then measure how much fluid has been lost. And the simple way of treating diarrhea is the patient gets exactly in what they have lost. And a way of measuring the level of hydration of course is whether they’re putting out urine and the concentration of that urine. Here’s a little girl who’s severely dehydrated. You can see again, that face that she looks. Again her pulse would be rapid. Urine output very low, rapid deep breathing. Now the mother is giving her an oral solution with the proper amount of electrolytes and glucose, that’s the magic ingredient. And to hydrate her. She’s alert enough to take it by mouth. And just a few hours later, here’s that little girl again and you can see a tremendous difference in the way she looks. The basic principle is simply this, a plant without water and you restore that plant by giving water and in the, in the case of diarrhea, electrolytes. Now what is the oral rehydration solution? It’s simply sodium chloride- table salt; sodium bicarbonate or Trisodium citrate; potassium chloride, and potassium is found in bananas and various fruits, citrus fruits; and glucose. Glucose is the key. And you can see on the other side that the sodium chloride, potassium bicarbonate and glucose are the millimoles per liter. In today’s solution, the sodium would be down to about 75 millimoles and the bicarbonate would be somewhat lower. And…. But that would be the major changes. Lower sodium chloride, slightly lower glucose and so on. But the basic principle and the basic composition remains the same. The message of course is to hydrate, hydrate, hydrate, because without the hydration other things can occur that will be a detriment to the individual, including circulatory collapse. To remind you, the…another side effect of continuous episodes of diarrhea is under-nutrition. Oftentimes because the mother will not necessarily feed the child, sometimes doctors recommend against it, unfortunately, and also the child may lose their appetite. Here’s a child who’s got severe marasmus. You can see the thin extremities. The child seems to be sensitive to light. The hair is thinning. And this is obviously a very poor family. Also the giving of a bottle of milk through the bottle can also be problematic if the water is not clean and if it sits out in the sun and bacteria are allowed to grow. Here’s a child who’s had multiple episodes of diarrhea and formula feeding. And you can see he has severe marasmus. So breastfeeding should always continue. And mothers should continue to feed their children if they have any appetite whatsoever, with whatever food is presently given to the child. So if the child wants to eat and the child is hungry, the child should be encouraged to eat. The teaching of this is best done of course in the community itself with three or four women who are taught now to prepare, shown how to prepare it and actually prepare it, which is what is being conducted here. You also notice lots of children around and these kids are picking up the message, just like their mothers are. And since children learn quicker than adults do, they’re going to carry the message into the community as well. One of the early tests of the oral rehydration therapy was in a refugee camp in 1971, refugee camps, where people from, refugees from what was then East Pakistan fled into West Bengal. And here they took up residence essentially in the pipes that were going to be placed in the ground to take away sewage. And when one lives in these kind of circumstances, you can guarantee that diarrhea is going to be a major problem unless there is strict attention paid to water and sanitation. And if that occurs then the treatment of this both in adults and children is essential. Another example of that is this is from a flood that occurred in Bangladesh. These occur periodically. This was 2007. And you can see individuals in an urban setting are trying to get clean water, even through a, a tube well pump which is almost totally submerged. This led to a major outbreak of diarrhea where up to 44,000 patients were seen at a treatment center within a nine-week period. What is interesting about this picture is that the family members are very much engaged in the treating of their loved ones. This is very critical because in these huge outbreaks it’s very difficult if not impossible for the medical staff to treat everyone. So one can engage family members who can be taught rather quickly how to deliver oral therapy and how to feed the patients and so on. And in that 44,000 cases, there was no one death from diarrhea and dehydration. This is a, an example of a packet that was found. This is for 500 cc’s which is now the standard in many countries. One liter is the standard in many other countries. So this, these salts can be given through a distribution scheme of these packets, as long as the packets are designed for whatever standard container people have. The next area I’d like to address is pneumonia, especially bacterial pneumonia, because this is what kills children. A number of years ago WHO developed what’s called an algorithm, a way of looking at pneumonia and deciding how to treat it given the severity. So in this particular algorithm you’ll notice on top that very severe pneumonia is defined as when the patient is confuse…cyanosis has set in. That is the child looks a bit blue, their lips look blue. They’re unable to drink. They’re unconsciousness, state of consciousness may be reduced. They’re clearly very, very sick. Severe pneumonia is when the lower chest in-drawing occurs and these children also need antibiotics. Where the respiratory rate is accelerated in the next box, going down, either above 50 is the child is two to eleven months or above 40 is one to four months, pneumonia is also the diagnosis. But if none of these occur, the child need not be treated for pneumonia. Now fortunately there are a number of vaccines that can prevent acute respiratory infection, many of which lead to pneumonia. Pertussis vaccine, diphtheria. Measles is a very important component, a very important vaccine. As is HiB conjugate vaccine, and the pneumococcal conjugate vaccine, two vaccines that have appeared on the scene in the last number of years that can make a significant impact on the incidence of disease. I put in meningitis because although it doesn’t cause pneumonia, it is a respiratory infection. Lastly I have this last picture in to remind us that malaria in some parts of the world can be a devastating disease to young children. This is simply an Aedes aegypti female, cause it’s only the female that takes a blood meal to help to grow her eggs. And you can tell the kind of mosquito by the white banding on the legs. So malaria can be a devastating disease to children, especially in low-income areas of sub-Saharan Africa. So what I’ve tried to do in the, in this chapter to point out that infectious diseases are certainly still with us and a major cause of morbidity and mortality, especially from diarrhea and pneumonia. But both of these conditions can be treated with oral solutions or I.V if necessary for diarrhea and antibiotics or other supportive measures for pneumonia. And both of them can be prevented through clean water and sanitation or vaccines, depending on the type of illness we’re talking about. The same by the way is true for malaria where the use of bed nets and early diagnosis can dramatically reduce the incidence of malaria, particularly in high incident countries.