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5살 미만 어린이 사망 원인 2위,
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한겨레 등록 : 2013.04.11 15:45
http://www.hani.co.kr/arti/international/international_general/582365.html

Diarrhoeal disease

Key facts

• Diarrhoeal disease is the second leading cause of death in children under five years old. It is both preventable and treatable.
  
• Each year diarrhoea kills around 700 000 children.
  
• A significant proportion of diarrhoeal disease can be prevented through safe drinking-water and adequate sanitation and hygiene.
  
• Globally, there are nearly 1.7 billion cases of diarrhoeal disease every year.
  
• Diarrhoea is a leading cause of malnutrition in children under five years old.

Diarrhoeal disease is the second leading cause of death in children under five years old, and is responsible for killing around 700 000 children every year. Diarrhoea can last several days, and can leave the body without the water and salts that are necessary for survival. Most people who die from diarrhoea actually die from severe dehydration and fluid loss. Children who are malnourished or have impaired immunity as well as people living with HIV are most at risk of life-threatening diarrhoea.

Diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). Frequent passing of formed stools is not diarrhoea, nor is the passing of loose, “pasty” stools by breastfed babies.

Diarrhoea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms. Infection is spread through contaminated food or drinking-water, or from person-to-person as a result of poor hygiene.

Interventions to prevent diarrhoea, including safe drinking-water, use of improved sanitation and hand washing with soap can reduce disease risk. Diarrhoea can be treated with a solution of clean water, sugar and salt, and with zinc tablets.

There are three clinical types of diarrhoea:

• acute watery diarrhoea – lasts several hours or days, and includes cholera;
  
• acute bloody diarrhoea – also called dysentery; and
  
• persistent diarrhoea – lasts 14 days or longer.

Scope of diarrhoeal disease

Diarrhoeal disease is a leading cause of child mortality and morbidity in the world, and mostly results from contaminated food and water sources. Worldwide, 780 million individuals lack access to improved drinking-water and 2.5 billion lack improved sanitation. Diarrhoea due to infection is widespread throughout developing countries.

In developing countries, children under three years old experience on average three episodes of diarrhoea every year. Each episode deprives the child of the nutrition necessary for growth. As a result, diarrhoea is a major cause of malnutrition, and malnourished children are more likely to fall ill from diarrhoea.

Dehydration

The most severe threat posed by diarrhoea is dehydration. During a diarrhoeal episode, water and electrolytes (sodium, chloride, potassium and bicarbonate) are lost through liquid stools, vomit, sweat, urine and breathing. Dehydration occurs when these losses are not replaced.

The degree of dehydration is rated on a scale of three.

• Early dehydration – no signs or symptoms.
  
• Moderate dehydration:
  
  
  
  • thirst
    
  • restless or irritable behaviour
    
  • decreased skin elasticity
    
  • sunken eyes
  
  
• Severe dehydration:
  
  
  
  • symptoms become more severe
    
  • shock, with diminished consciousness, lack of urine output, cool, moist extremities, a rapid and feeble pulse, low or undetectable blood pressure, and pale skin.

Death can follow severe dehydration if body fluids and electrolytes are not replenished, either through the use of oral rehydration salts (ORS) solution, or through an intravenous drip.

Causes

Infection: Diarrhoea is a symptom of infections caused by a host of bacterial, viral and parasitic organisms, most of which are spread by faeces-contaminated water. Infection is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning. Rotavirus and Escherichia coli are the two most common etiological agents of diarrhoea in developing countries.

Malnutrition: Children who die from diarrhoea often suffer from underlying malnutrition, which makes them more vulnerable to diarrhoea. Each diarrhoeal episode, in turn, makes their malnutrition even worse. Diarrhoea is a leading cause of malnutrition in children under five years old.

Source: Water contaminated with human faeces, for example, from sewage, septic tanks and latrines, is of particular concern. Animal faeces also contain microorganisms that can cause diarrhoea.

Other causes: Diarrhoeal disease can also spread from person-to-person, aggravated by poor personal hygiene. Food is another major cause of diarrhoea when it is prepared or stored in unhygienic conditions. Water can contaminate food during irrigation. Fish and seafood from polluted water may also contribute to the disease.

Prevention and treatment

Key measures to prevent diarrhoea include:

• access to safe drinking-water;
  
• use of improved sanitation;
  
• hand washing with soap;
  
• exclusive breastfeeding for the first six months of life;
  
• good personal and food hygiene;
  
• health education about how infections spread; and
  
• rotavirus vaccination.

Key measures to treat diarrhoea include the following:

• Rehydration: with oral rehydration salts (ORS) solution. ORS is a mixture of clean water, salt and sugar. It costs a few cents per treatment. ORS is absorbed in the small intestine and replaces the water and electrolytes lost in the faeces.
  
• Zinc supplements: zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume.
  
• Rehydration: with intravenous fluids in case of severe dehydration or shock.
  
• Nutrient-rich foods: the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient-rich foods – including breast milk – during an episode, and by giving a nutritious diet – including exclusive breastfeeding for the first six months of life – to children when they are well.
  
• Consulting a health professional , in particular for management of persistent diarrhoea or when there is blood in stool or if there are signs of dehydration.

WHO response

WHO works with Member States and other partners to:

• promote national policies and investments that support case management of diarrhoea and its complications as well as increasing access to safe drinking-water and sanitation in developing countries;
  
• conduct research to develop and test new diarrhoea prevention and control strategies in this area;
  
• build capacity in implementing preventive interventions, including sanitation, source water improvements, and household water treatment and safe storage;
  
• develop new health interventions, such as the rotavirus immunization; and
  
• help to train health workers, especially at community level.

For more information contact:

WHO Media centre
Telephone: +41 22 791 2222
E-mail: mediainquiries@who.int

Haiti Earthquake Relief, Phase Two — Long-Term Needs and Local Resources

출처 :

Volume 362:1858-1861		May 20, 2010		Number 20

http://content.nejm.org/cgi/content/full/362/20/1858

A month and a half after January’s devastating earthquake in Haiti, the National Organization for the Advancement of Haitians, a U.S.-based nonprofit organization with a division dedicated to improving health care in Haiti, sent in teams of U.S. physicians and other health care professionals, primarily of Haitian descent, as the acute phase of disaster response was ending. As part of this group, I worked in a makeshift hospital in Tabarre, a section of northeast Port-au-Prince.

As a first-generation Haitian-American and an internist, I expected to be prepared for the situation I was walking into. Haiti was a country I knew, I spoke the language, I understood the people, and by this point I had been watching the disaster on television daily for over a month. I knew that with the threat to life no longer minute to minute but week to week, the long-term recovery phase was beginning. According to my relatives in Haiti, the initial shock was passing. Dead victims had been cleared from the streets, families were either reunited or mourning their losses, the roads were somewhat drivable, and food and water were slowly making their way to survivors. Yet when I came face to face with the disaster, I realized that the media hadn’t even begun to capture the extent of the devastation. Seeing Haiti through a framed television screen had given me only a snapshot of destroyed buildings, misplaced families, and stories of loss and survival.

When you’re on site, there is no television to turn off, no place to avert your gaze, no way to avoid hearing endless conversations about loss and devastation — and fears about worse to come. Nor could I turn off the unrelenting heat, or the airborne dust from the rubble of destroyed buildings, or the smoke rising from burning bodies, wood, and rubber. As I looked around, not a single standing building interrupted my line of sight in any direction. Every street was spilling over with masses of displaced people, many of them young children, stuck in a strange purgatory with no place to stay and no place to go.

I soon saw that the Haitian people were paralyzed by fear. In the middle of the night, while coworkers and I were asleep inside a small home that had survived the earthquake, a minor tremor (measuring 4 on the Richter scale) knocked me out of bed. Immediately, people were screaming in the streets, afraid that “the next big one” was upon them. Neighbors yelled frantically, telling us to get out, that they could hear the building cracking. The next thing I knew, I was sleeping in a tent — the most secure and comfortable option. At that point, my only solace lay in focusing on what I could control — what little I could offer as a physician.

View larger version (37K): [in this window] [in a new window]   Postoperative Care for a Young Amputee. Helene Garcon, a medical student, examines a boy who lost both of his legs below the knees after being trapped in the rubble of his collapsed home after the earthquake. Courtesy of Marie Berjorie Cadet.

 
At our makeshift hospital, we were past the heroic stage of rescuing bodies from the rubble and performing emergency lifesaving surgeries. Now the delayed effects of the earthquake, which affected an estimated 1.4 million people, were manifesting themselves. Inconsistent wound care and rehabilitation for trauma victims and amputees resulted in a multitude of patient visits for infections, disabilities, and complications from delayed treatment, such as gangrene and sepsis. The dust and smoke in the air led to respiratory illnesses, including severe asthma, flares of chronic obstructive pulmonary disease, bronchitis, and pneumonia. According to the World Health Organization (WHO), respiratory infections are now the main cause of illness, followed by trauma or injury, diarrhea, and suspected malaria.¹ Crowding and poor sanitation in rapidly growing tent settlements were creating or exacerbating medical problems, particularly in children. Mobile clinics from Tabarre provided targeted, large-scale treatment of postoperative infections and therapies for outbreaks of lice and scabies in orphanages. Before the earthquake, diarrheal illness accounted for 17% of deaths in children under the age of 5 years. Now, in addition to the already contaminated water supplies and poor sanitation, the rainy season will increase the risk of acute respiratory infection, diarrhea, and waterborne and vectorborne diseases, including dengue, typhoid, and malaria. In anticipation of this onslaught, the WHO is undertaking large-scale vaccination campaigns and tasking mobile health clinics with identifying outbreaks quickly in order to limit the associated morbidity and mortality.

In addition, the chronic diseases that patients had been ignoring since the earthquake were rearing their ugly heads. Several patients arrived after having interrupted their treatment for tuberculosis or HIV, with no records of their previous regimens. Large numbers of patients — some who had had no regular health care before the earthquake and others whose care had been interrupted — now presented with acute manifestations of their uncontrolled chronic diseases, in the form of hypertensive emergencies, strokes, seizures, and diabetic ketoacidosis. Although many medications were available, donors had provided a supply of drugs that generally were not targeted to chronic health problems. In Tabarre, despite the fact that we limited each patient to only 10 to 15 pills at a time, the medications in highest demand — such as basic antibiotics, asthma inhalers, and hypertension and diabetes medications — became scarce, while boxes of others, such as intravenous amiodarone, remained untouched.

View larger version (40K): [in this window] [in a new window]   Emergency Room at a Field Hospital. An open structure at a small amusement park has been converted into an acute care facility. Courtesy of Dominique Bayard.

 
Public health problems affecting women, ranging from sexual violence to a lack of obstetrical care, were also exacerbated by the earthquake. We treated women and girls as young as 12 years of age for newly acquired sexually transmitted infections (STIs). Many women reported being the victims of forced sexual encounters in the tent settlements. Though these reports are unconfirmed, increasing numbers of reports by health care workers of STIs and sexual violence have led to an official WHO investigation and a targeted assessment of women’s health care needs.^2,3

Ultimately, it became clear to me that the most important resource for the ongoing relief effort is the one most threatened by the earthquake: the local people. Though I had not been back to Haiti in 15 years and was there for only 2 weeks, the local people were what enabled me and my colleagues, both emotionally and logistically, to provide care to more than 800 patients a day. Local volunteers — who constituted about half our staff, though they could easily have been devoting time to their own recovery instead — spent every day, sunrise to sunset, making it possible for us to provide care. They triaged patients, organized the physicians, distributed medications, and rose to any necessary task. Patients were grateful that the Haitian diaspora was returning to help. Despite their own loss and tragedy, they would laugh at my American-accented Creole and tell me how proud they were of me for coming back. Neighbors living in tents in their backyards cooked a full breakfast and dinner for me and several coworkers every day. In exchange for our provision of a 2-week proverbial Band-Aid, the people helped, encouraged, and took care of us. While international volunteers come and go, the local people will remain the backbone of the recovery process, and integrating them into international relief efforts will be vital.

The road to recovery will be long, and with the rainy season beginning, circumstances will get worse before they get better. Six months after the 2005 earthquake in South Asia, a similar pattern of respiratory infections, diarrhea, infectious disease outbreaks, poor sanitation, and insufficient shelter persisted and worsened despite a strong initial relief response.⁴ In Haiti, the initial response has also been strong, and we have learned from previous disasters what to anticipate in the months and years to come. Clear insight into the changing medical needs, together with the collaboration of the strong-willed Haitian people, will drive an effective effort to rebuild Haiti and, I hope, make it stronger than ever.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

Source Information

Dr. Bayard is an editorial fellow at the Journal.

This article (10.1056/NEJMp1003839) was published on April 14, 2010, at NEJM.org.

References

1. Pan American Health Organization. Haiti health cluster bulletins — earthquake, January 2010: update, March 10, 2010. (Accessed April 13, 2010, at http://new.paho.org/disasters/index.php?option=com_content&task=view&id=1108&Itemid=1.) 
   
2. UNICEF. Haiti emergency response update: March 17, 2010. (Accessed April 13, 2010, at http://www.reliefweb.int/rw/RWFiles2010.nsf/FilesByRWDocUnidFilename/MDCS-83PC9M-full_report.pdf/$File/full_report.pdf.)
   
3. United Nations Office for the Coordination of Humanitarian Affairs. Haiti earthquake situation report #30. (Accessed April 13, 2010, at http://www.reliefweb.int/rw/RWFiles2010.nsf/FilesByRWDocUnidFilename/VVOS-83PQ24-full_report.pdf/$File/full_report.pdf.)
   
4. Brennan RJ, Waldman RJ. The south Asian earthquake six months later — an ongoing crisis. N Engl J Med 2006;354:1769-1771. [Free Full Text]

10 facts on children’s environmental health

출처 : WHO, December 2009
http://www.who.int/features/factfiles/children_environmental_health/en/index.html

All children need healthy, safe and protective environments to ensure normal growth, development and well-being.

Nearly one-third of the nine million under-five child deaths every year are associated with environment-related causes and conditions. Environmental risk factors often act in concert, and their effects are exacerbated by adverse social and economic conditions – particularly conflict, poverty and malnutrition.

Read the fact file on children’s environmental health

Related links

Preventing disease through healthy environments: Towards an estimate of the environmental burden of disease

The global burden of disease: 2004 update

World Health Statistics 2009

Global burden of disease and risk factors [pdf 2.90Mb]
World Bank, World Health Organization, Fogarty International Center and National Institutes of Health, 2006.

© UNICEF/NYHQ2009-0815/Ramoneda

Tasleem Mondy pours a cup of therapeutic milk, providing treatment for her undernourished 18-month-old son, Mohammed, at their home in Karachi, Pakistan.

By Chris Niles

NEW YORK, USA, 11 November, 2009 – As the number of hungry and malnourished people passes 1 billion, a new UNICEF report identifies undernutrition as one of the major causes of death among young children.

VIDEO: Watch now

‘Tracking Progress on Child and Maternal Nutrition’, released today, says that undernutrition in mothers and children is a factor in a third of all deaths of children under five. At the same time, the global financial crisis and rising food prices have left many more families struggling to put nutritious food on the table.

“The report we have launched draws attention to the fact that 200 million children under the age of five in the developing world suffer from chronic undernutrition. That’s a very high number,” said UNICEF Associate Director of Nutrition Werner Schultink.

As the report shows, the problem is concentrated in just a few regions, and 80 per cent of all chronically undernourished children are found in just 24 countries. Among children who suffer from stunting – a consequence of chronic nutritional deprivation that begins before birth if the mother is undernourished – 90 per cent live in Africa and Asia.

Impact of women’s status
“An important factor in almost all of these countries is the situation of women,” noted Mr. Schultink. “Women do not have enough decision-making power to either take care of themselves or of their children and, in general, are seen as lower-class citizens.”

Inadequate nutrition in early childhood makes children more susceptible to diseases such as pneumonia and diarrhoea – and it can impair them for life.

Undernourished children “will perform less well in school, they will be able to do less well as an adult and, even worse, their health situation in adult life may be negatively affected,” said Mr. Schultink. “They are more likely to suffer from chronic diseases such as heart disease or diabetes.”

Urgent international action
The ‘Tracking Progress’ report calls for urgent international action to reach those who do not have adequate nutrition.

© UNICEF/NYHQ2004-0573/Ramos

A boy eats corn at a health and education support programme for local families in the municipality of San Juan Chamula, located in Chiapas, Mexico.

UNICEF will continue to work with its partners on successful programmes that work to improve nutrition for the children and families most at risk. Among other achievements to date, the organization has provided vitamin A supplementation to about 80 per cent of vulnerable children targeted for assistance in the least developed countries. And it has helped to ensure that some 70 per cent of all households in developing countries now consume adequately iodized salt.

Advances have also been made in Africa, with programmes that encourage exclusive breastfeeding for at least the first six months of a baby’s life.

“If these countries were able to do these things, if they were able to protect children,” said Mr. Schultink, “many more countries should be able to do the same.”