Diarrhea in Nicaragua
A recent informal survey of mothers in Gigante, Nicaragua identified gastrointestinal (GI) problems in the children as the most common health concern. As such, one of my visits this winter will focus on GI problems.
Many of the local GI problems are infection-related. In Canada we mostly suffer from viral and occasional bacterial gastroenteritis. Add worms and parasites to the list in Nicaragua. This blog will review viral gastroenteritis and subsequent blogs will review the other causes.
Rotavirus is the most common cause of diarrhea worldwide and diarrhea is the second most common cause of death in children in poor countries. There is no medication that controls Rotavirus. Once a child is infected with Rotavirus, the symptoms will last 5 to 7 days and the virus is shed in the stool for up to 10 days.
A vaccine was introduced in 2006, and in October 2006, Nicaragua was the first developing nation to implement universal infant immunization with the pentavalent Rotavirus vaccine.
Studies in developed countries show an impressive decrease in severe Rotovirus infection of up to 98% after immunization, but there are concerns that the vaccine might not be efficacious in a poor country. Malnutrition, storage issues for the vaccine, distribution of Rotavirus genotypes, simultaneous use of polio vaccine, and other factors can influence the effectiveness of a vaccine. Reassuringly, a study in Leon, Nicaragua, that compared data from 2003 to 2009, showed a statistical decline in diarrhea after the introduction of the vaccine.
Rotavirus infection usually strikes in the first year of life. As such, the vaccine program immunizes children at 2, 4, and 6 months of age. The local health ministry in Leon reported that vaccine coverage in 2007 was 98% for the first dose, 93% for the second dose, and 77% for all three doses. If this data is correct, the Nicaraguan campaign was as effective as similar programs in North America!
Notwithstanding the immunization program there will still be lots of diarrhea. Not all children will be vaccinated, the efficacy of the vaccine will likely be reduced, and there are other viral causes of diarrhea such as Norovirus, Astrovirus, Sapovirus and Adenovirus.
The peak Rotavirus season in Central America is during the dry season from January to March, so I can expect to see infants and toddlers with vomiting and watery diarrhea.
Death due to Rotavirus is usually due to dehydration. With the introduction of oral rehydration solution (ORS) in the sixties and the seventies, the mortality rate fell, and diarrhea is no longer the most common cause of infant mortality worldwide.
However, ORS is not always available or not properly administered. ORS is usually offered as a packet of salts that need to be mixed precisely in clean water. Precisely and clean water are concerns. If the salts are mixed in too little water or too much water the effectiveness is reduced, and when the ratio is way off, the solutions can create problems. Patient education is very important. Well water is contaminated in Nicaragua and tap water should be considered unsafe. Bottled water is the best source but this is expensive for many families. I will take ORS packets with me to Nicaragua and I will purchase supplies of bottled water in one liter containers. I have learned to mix the packets in bottled water at the clinic and to give the pre-mixed solutions to the family to avoid measurement error.
A recent informal survey of mothers in Gigante, Nicaragua identified gastrointestinal (GI) problems in the children as the most common health concern. As such, one of my visits this winter will focus on GI problems.
Many of the local GI problems are infection-related. In Canada we mostly suffer from viral and occasional bacterial gastroenteritis. Add worms and parasites to the list in Nicaragua. This blog will review viral gastroenteritis and subsequent blogs will review the other causes.
Rotavirus is the most common cause of diarrhea worldwide and diarrhea is the second most common cause of death in children in poor countries. There is no medication that controls Rotavirus. Once a child is infected with Rotavirus, the symptoms will last 5 to 7 days and the virus is shed in the stool for up to 10 days.
Scanning Electron Micrograph of Rotavirus Particles, courtesy of CDC.
A vaccine was introduced in 2006, and in October 2006, Nicaragua was the first developing nation to implement universal infant immunization with the pentavalent Rotavirus vaccine.
Studies in developed countries show an impressive decrease in severe Rotovirus infection of up to 98% after immunization, but there are concerns that the vaccine might not be efficacious in a poor country. Malnutrition, storage issues for the vaccine, distribution of Rotavirus genotypes, simultaneous use of polio vaccine, and other factors can influence the effectiveness of a vaccine. Reassuringly, a study in Leon, Nicaragua, that compared data from 2003 to 2009, showed a statistical decline in diarrhea after the introduction of the vaccine.
Rotavirus infection usually strikes in the first year of life. As such, the vaccine program immunizes children at 2, 4, and 6 months of age. The local health ministry in Leon reported that vaccine coverage in 2007 was 98% for the first dose, 93% for the second dose, and 77% for all three doses. If this data is correct, the Nicaraguan campaign was as effective as similar programs in North America!
Notwithstanding the immunization program there will still be lots of diarrhea. Not all children will be vaccinated, the efficacy of the vaccine will likely be reduced, and there are other viral causes of diarrhea such as Norovirus, Astrovirus, Sapovirus and Adenovirus.
The peak Rotavirus season in Central America is during the dry season from January to March, so I can expect to see infants and toddlers with vomiting and watery diarrhea.
Death due to Rotavirus is usually due to dehydration. With the introduction of oral rehydration solution (ORS) in the sixties and the seventies, the mortality rate fell, and diarrhea is no longer the most common cause of infant mortality worldwide.
However, ORS is not always available or not properly administered. ORS is usually offered as a packet of salts that need to be mixed precisely in clean water. Precisely and clean water are concerns. If the salts are mixed in too little water or too much water the effectiveness is reduced, and when the ratio is way off, the solutions can create problems. Patient education is very important. Well water is contaminated in Nicaragua and tap water should be considered unsafe. Bottled water is the best source but this is expensive for many families. I will take ORS packets with me to Nicaragua and I will purchase supplies of bottled water in one liter containers. I have learned to mix the packets in bottled water at the clinic and to give the pre-mixed solutions to the family to avoid measurement error.
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