28 Epidemiology of diarrhoeal - World Health Organization

762 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005

Epidemiology of diarrhoeal diseases
among children under age 5 years in
Dakahlia, Egypt

A.H. El-Gilany1 and S. Hammad1

ABSTRACT Using multistage cluster sampling, we conducted a household survey of diarrhoea among 4458
children under age 5 years in Dakahlia governorate from June 2002 to May 2003 to determine the preva-
lence and determinants of diarrhoeal diseases. Frequency of diarrhoea in the previous 2 weeks and last 24
hours were 23.6% and 8.7% respectively. Oral rehydration solution use rate was 24.3% among children with
diarrhoea in the past 2 weeks. The frequency of diarrhoea was significantly higher among children in rural
areas, those aged 6–24 months and of higher birth order, in the summer, when mothers were younger, had
lower education or were not working, and when fathers had lower education or were farmers or manual
labourers. Overcrowding, improper refuse disposal and non-flush toilets were also significantly correlated
with diarrhoea incidence.

Épidémiologie des maladies diarrhéiques chez les enfants de moins de 5 ans à Dakahlia (Égypte)
RÉSUMÉ À l’aide d’un sondage en grappes à plusieurs degrés, nous avons réalisé une enquête dans les
ménages sur la diarrhée chez 4458 enfants de moins de 5 ans dans le gouvernorat de Dakahlia entre juin
2002 et mai 2003 afin de déterminer la prévalence des maladies diarrhéiques et d’identifier leurs détermi-
nants. La fréquence de la diarrhée au cours des 2 semaines précédentes et des dernières 24 heures était
respectivement de 23,6 % et 8,7 %. Le taux d’utilisation de la solution de réhydratation orale était de 24,3 %
chez les enfants souffrant de diarrhée au cours des 2 semaines précédentes. La fréquence de la diarrhée
était significativement plus élevée chez les enfants vivant en zone rurale, chez ceux âgés de 6 à 24 mois et
de rang de naissance plus élevé, pendant la saison d’été, lorsque la mère était plus jeune, peu instruite ou ne
travaillait pas, et lorsque le père était peu instruit ou était agriculteur ou manœuvre. Le surpeuplement,
l’élimination inappropriée des ordures et des toilettes sans chasse d’eau étaient significativement corrélés à
l’incidence de la diarrhée.

1Community Medicine Department, Faculty of Medicine, Mansoura University, Egypt (Correspondence to
A.H. El-Gilany: [email protected]).

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Introduction this, we measured period (last 2 weeks)
and point (last 24 hours) prevalence rates
Diarrhoea is a leading cause of illness and of diarrhoeal diseases among children and
death among children under 5 years of age evaluated the association of these diseases
in developing countries [1,2]. Many fac- with sociodemographic, environmental and
tors, including sociodemographic, environ- housing characteristics. Both rates were
mental and housing characteristics, affect measured as recommended by the Word
the prevalence of diarrhoea. Health Organization and in order to allow
comparison with other studies. We also
In Egypt, the widespread use of oral re- gathered information about the treatment of
hydration therapy has successfully less- diarrhoeal episodes, especially the use of
ened the severity of diarrhoeal episodes and ORS and its determinants.
sharply reduced the number of subsequent
deaths, but the incidence of diarrhoeal dis- Methods
eases has not declined [3,4]. This indicates
that the causative agents of diarrhoea and Dakahlia governorate is in the north-eastern
their environmental sources are still with Nile Delta and is inhabited by more than 4
us. On average, children under 3 years of million people. According to the Statistical
age suffer 3 bouts of acute diarrhoea per Department of the Health Directorate of
year [3,4]. Dakahlia (2001), about 12% of the popula-
tion were children under 5 years of age.
Acute diarrhoea of all etiologies can be
safely treated with oral rehydration solution In 2002, the Egypt Demographic and
(ORS). The routine use of antibiotics and Health Survey reported that among children
anti-parasitic medicines should be avoided. aged under 5 years, 13.4% had had diar-
Antidiarrhoeal drugs should never be used rhoea in the last 2 weeks [8]. We aimed to
as none has proven practical and some are be within 0.01 of the actual proportion and
dangerous [5,6]. When a breastfed child therefore set our target sample at approxi-
has diarrhoea, continued breastfeeding is mately 4458 children under 5 years of age
important [7]. (1 month to less than 60 months of age), or
5% probability of significance. We calcu-
Information on morbidity and treatment lated sample size as [9]:
of diarrhoea can be obtained from the re-
ports of the various health facilities. None- n = P(1 – P)(Za)2/(d)2
theless, cases seen at these health facilities
may represent only a fraction of the actual where n was the required sample size, P
cases occurring in the community since was the proportion of interest, Za was 1.96
many cases may be treated at home or may and d was the distance, or how close we
recover without treatment. Even if a high required our estimate to be to the propor-
proportion of cases is seen at the health fa- tion of interest.
cilities, reporting is likely to be incomplete.
Therefore, we conducted a household sur- Data were collected from 1 June 2002
vey to measure the magnitude of the prob- to 31 May 2003, i.e. over the course of a
lem. year to sample all 4 seasons.

The aim of our study was to collect A multistage random sample of the tar-
current and reliable information on the get children was chosen. Three districts
prevalence and determinants of diarrhoeal (Mansoura, Mitghamr and Dekernis) were
diseases among children under 5 years of
age in Dakahlia governorate, Egypt. To do

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selected randomly from the 12 districts of get child who had had at least one episode
the governorate and an urban sector and 2 of diarrhoea within the past 2 weeks, and
rural villages were randomly chosen from recorded details of the diarrhoea and treat-
each of these 3 districts. We selected our ment practices. Diarrhoea was defined as
sample with the cluster sampling tech- the passing of liquid or watery stools at
nique. A total of 100 clusters were used (25 least 3 times in one day [5]. Accompanied
clusters per season) and each cluster com- by a nurse from the local health facility, we
prised 40–50 children less than 5 years of visited and interviewed the families. Ob-
age. The sample was distributed among the server bias was considered to be minimal
urban and the rural areas of the chosen dis- as both researchers were experienced in
tricts in proportion to the population size. such data collection. As regards recall bias
In each cluster, the starting house was ran- for medication, the family member was re-
domly selected. We replaced empty houses quested to show any prescriptions, the
and non-participating families (7 families) drug itself, or the container
with the neighbouring house.
Data were analysed using Epi-Info, ver-
We designed and pre-tested 2 question- sion 6.02. The chi-squared test was used to
naire forms. The first form was completed test the difference between groups. Statis-
for every child less than 5 years of age and tical significance was set at P ≤ 0.05.
covered data related to the child as well as
sociodemographic characteristics of the Results
parents and the housing conditions. The
social score of each family was calculated The period (last 2 weeks) and the point (24
as per Fahmy and El-Sherbini [10]. This hours) prevalence rates of diarrhoeal dis-
scoring system encompassed the education eases among children under age 5 years
and occupation of the parents, income, were 23.6% and 8.7% respectively (Table
family size and housing conditions. The 1). Both rates were significantly higher
second form was completed for every tar-

Table 1 Overall prevalence of diarrhoeal diseases and its variation
according to residence and season

Variable Total Diarrhoea during the last:
No. %
2 weeks 24 hours

No. % No. %

Overall 4458 100 1052 23.6 390 8.7

Residence 1471 33.0 307 20.9** 96 6.5***
Urban 2987 67.0 745 25.0 294 9.8
Rural
858 19.2 120 14.0*** 49 5.7***
Season 805 18.1 199 24.7 76 9.4
Winter 1527 34.3 464 30.4 166 10.9
Spring 1268 28.4 269 21.2 99 7.8
Summer
Autumn

**P ≤ 0.01; ***P ≤ 0.001.

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Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 765

among rural than among urban children and feeding had no significant effect either (Ta-
in the summer than in the other seasons. ble 2).

Both period and point prevalence rates Parents’ education had a strong correla-
of diarrhoea decreased significantly with tion with diarrhoeal diseases (Table 3).
increased age apart from the first 6 months Both period and point prevalence rates
of age. These rates were highest in the age were significantly lower among children of
group of 6 months to less than 12 months higher educated parents compared with
and were lowest among children aged 48 those of less educated parents. Both rates
months to less than 60 months. Both rates were also significantly higher among chil-
were significantly higher among higher dren of mothers who did not go out to
birth order children compared with lower work and whose fathers were farmers
birth order children. However, the sex of compared with those who were profes-
the child had no significant effect on both sionals or semi-professionals. In addition,
prevalence rates of diarrhoea and among both rates were significantly higher among
children under 24 months of age, breast- children whose mothers were less than 25

Table 2 Prevalence of diarrhoeal diseases according to children’s
characteristics

Variable Total Diarrhoea during the last:
No. %
2 weeks 24 hours

No. % No. %

Overall 4458 100 1052 23.6 390 8.7

Age (months) 954 21.4 237 24.8*** 99 10.4***
<6 560 12.6 226 40.4 104 18.6
6–< 12 655 14.7 213 32.5 11.0
12–< 24 568 12.7 153 26.9 72 10.7
24–< 36 712 16.0 114 16.0 61
36–< 48 1009 22.9 109 10.8 33 4.6
48–< 60 21 2.1
2295 51.5 567
Sex 2163 48.5 485 24.7 209 9.1
Male 22.4 181 8.4
Female 1539 34.5 374
2052 46.0 447 24.3* 146 9.5*
Birth order 15.0 170 21.8 154 7.5
First 667 25.5 9.6
Second and third 200 4.5 61 30.5 64 13.0
Fourth and fifth 26
Sixth or higher 1614 74.4 488 12.3
555 25.6 188 30.2 199 13.7
Currently breastfeedinga 33.9 76
Yes
No

*P ≤ 0.05; ***P ≤ 0.001.
aIncludes children < 24 months of age only (n = 2169).

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Table 3 Prevalence of diarrhoeal diseases according to parents’ characteristics

Variable Total Diarrhoea during the last:
No. %
2 weeks 24 hours

No. % No. %

Overall 4458 100 1052 23.6 390 8.7

Maternal age (years)a 1651 37.1 471 28.5*** 170 10.3*
< 25 2357 52.9 486 20.6 185 7.8
25–< 35 10.0 21.3 7.9
35+ 445 95 35
55.5 10.4***
Maternal educationa 2471 12.0 699 28.3*** 257 6.7
No schooling 537 32.5 109 20.3 36 6.7
Primary/middle school 244 16.9 97
Secondary school and higher 1445 16.5 5.6***
83.5 122 16.6*** 41 9.4
Maternal employmenta 733 930 25.0 349
Working outside the house 3720 3.8 9.5
Housewife 57.8 46 27.2 16 9.2
169 38.4 632 24.6 236 8.1
Father’s age (years)b 2574 372 21.8 138
< 25 1707 51.7 10.0***
25–< 35 15.4 637 27.7*** 231 9.2
35+ 2299 32.9 156 22.8 63 6.5
685 257 17.5 96
Father’s educationb 26.5 6.5**
No schooling 1466 13.6 190 16.1*** 76 10.5
Primary/middle school 47.1 166 27.3 64
Secondary or higher 1177 12.8 564 26.9 203 9.7
607 130 22.8 47 8.2
Father’s employmentb
Professional or semi- 2095
professional 571
Farmer
Manual labourer
Otherc

*P ≤ 0.05; **P≤ 0.01; ***P ≤ 0.001.
a5 mothers were dead.
b8 fathers were dead and 2 of their children had diarrhoea in the last 2 weeks.
cTradesmen, members of the armed forces, unemployed, etc.

years old, although the father’s age was not from the house), non-flush toilets and no
significant. available television or radio. Both rates
were significantly higher among children
Period and point prevalence rates of di- whose families used kerosene or biomass
arrhoea were not significantly related to as fuel (Table 4).
floor type or water source (Table 4). Both
rates were significantly higher for children Table 5 shows that both period and
in homes with high crowding indices, im- point prevalence rates of diarrhoea were
proper refuse disposal (in front of or away significantly higher among children from

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Table 4 Prevalence of diarrhoeal diseases according to housing conditions

Variable Total Diarrhoea during the last:
No. %
2 weeks 24 hours

No. % No. %

Overall 4458 100 1052 23.6 390 8.7

Floor 2480 55.6 609 24.8 226 9.1
Earth 1978 44.4 443 22.4 164 8.3
Cement/tile
3957 88.8 882 22.3*** 317 8.0***
Crowding index 501 11.2 170 33.9 73 14.6
<3
3 or more 3468 77.8 813 23.4 296 8.5
990 22.2 239 24.1 94 9.5
Water source
Piped water 679 15.2 126 18.6*** 46 6.8***
Hand pump 879 19.7 247 28.1 111 12.6
2900 65.1 679 23.4 233
Refuse disposal 8.0
Municipal collection 905 20.3 114 12.6*** 41
In front of house 3553 79.7 938 26.4 349 4.5***
Away from house 9.8
3807 85.4 838 22.0*** 293
Toilet 599 13.4 193 32.2 90 7.7***
Flush 52 40.4 7 15.0
Non-flush 1.2 21 13.5
3741 21.9*** 295
Fuel for cooking 717 83.9 821 32.2 95 7.9***
Bottled gas 16.1 231 13.2
Kerosene
Biomass

Television or radio
Present
Absent

***P ≤ 0.001.

large families, those of low income or of medicines other than ORS. Antidiarrhoeals
low or very low social scores. and antibiotics were the most frequently
used drugs (Table 8) and were usually pre-
Among children with diarrhoea during scribed by private doctors or parents while
the past 2 weeks, the ORS use rate was ORS was usually prescribed by public sec-
24.3%; 71.0% received increased amounts tor doctors (Table 9).
of fluids and 74.7% were given drugs (Ta-
ble 6). ORS use rate was significantly high- Discussion
er among children of rural residence, of
younger age, and those with older mothers Diarrhoeal diseases rank with acute respi-
and less educated mothers (Table 7). ratory infections as among the major caus-

Of the 1052 children with diarrhoea in
the last 2 weeks, 786 (74.7%) were given

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Table 5 Prevalence of diarrhoeal diseases according to family size, income
and social score

Variable Total Diarrhoea during the last:
No. %
2 weeks 24 hours

No. % No. %

Overall 4458 100 1052 23.6 390 8.7

Family size 2573 57.7 574 22.3** 201 7.8*
< 5 people 1434 32.2 347 24.2 138 9.6
5–6 people 10.1 131 29.0 11.3
7 or more people 451 51
37.9 451 27.9*** 10.2***
Income per capita/montha 45.7 462 23.2 165 9.3
69 16.6 181 5.8
(Egyptian pounds)b 9.7 2.8
6.7 21 7.4 24
< 50 1618 8 12.3***
22.5 301 30.0*** 9.4
50–99 1949 39.0 481 27.6 123 7.1
29.3 231 17.7 163 2.7
100–149 416
9.2 39 9.6 93
< 150 284 11

Social score 1002
Very low 1741
Low 1307
Middle
High 408

*P ≤ 0.05; **P≤ 0.01; ***P ≤ 0.001.
aFor 191 children, the family income was unknown.
bUS$ 1 = 6 Egyptian pounds at the time of the study.

es of morbidity and mortality among chil- rhoeal mortality and morbidity among
dren under 5 years of age [11]. The World young children in developing countries. In
Health Organization started the Diarrhoeal their estimate of the global burden of diar-
Disease Control Programme (DDCP) in rhoeal diseases, Kosek et al. found that de-
1980 with the objective to decrease diar- spite improving trends in mortality rates,
there was no concurrent decrease in mor-
Table 6 Treatment practices among 1052 bidity rates attributed to diarrhoea [11].
children with diarrhoea in the last 2 weeks Persistent high rates of morbidity are of
concern because early childhood diarrhoea
Treatmenta No. % may have long-term effects on linear
growth and physical and cognitive function
Increased intake of fluids 747 71.0 [12–14].
Continued feeding 918 87.3
Oral rehydration solution 256 24.3 The National Diarrhoeal Disease Con-
Drugs 786 74.7 trol Programme (NDDCP) of Egypt began
Care sought outside the home 622 59.1 in 1981 and became fully operational by
1984. Its principal strategy was to improve
case-management of diarrhoea through re-
hydration and better feeding, by educating

aTreatments were not mutually exclusive.

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Table 7 Oral rehydration solution (ORS) use and its
determinants in diarrhoea occurring during the past 2
weeks

Variable Total diarrhoeal ORS use
cases
No. %
No. %
256 24.3
Overall 1052 100.0
58 18.9**
Residence 307 29.2 198 26.6
Urban 745 70.8
Rural 98 20.9*
44.8 130 26.7
Mother’s age (years) 471 46.2
< 25 486 28 29.5
25–34 9.0
35 or more 95 188 26.9*
66.4 23 21.1
Mother’s education 699 10.4 45 18.4
No schooling 109 23.2
Primary/middle school 244 22 18.0
Secondary and higher 11.6 234 25.2
88.4
Mother’s employment 35 14.8***
22.5 109 48.2
Working outside the home 122 21.8
20.2 71 33.3
Housewife 930 14.5 31 20.3
10.8 10 8.8
Child’s age (months) 237 10.4
<6 226 0 0.0
6–11 213 53.9
12–23 153 46.1 144 25.4
24–35 114 112 23.1
36–47 109 35.6
48–<60 42.5 89 23.8
16.2 108 24.2
Child’s sex 567
Male 485 5.8 43 25.3
Female 16 26.2

Birth order 374
First 447
Second or third 170
Fourth or fifth
Sixth or higher 61

*P ≤ 0.05; **P ≤ 0.01; ***P ≤ 0.001.

families through the mass media and by theless, diarrhoeal diseases remain the lead-
training health workers. It has been one of ing cause of morbidity among infants and
the most successful national oral rehydra- young children in Egypt.
tion programmes in decreasing child
mortality due to diarrhoea [15,16]. None- In our study, 23.6% of children under 5
years of age were reported to have had di-

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Table 8 Frequency and type of drugs used in was 35% and 43% respectively [18]. In
the 1052 children with diarrhoea 1991, the 2-week period prevalence of di-
arrhoea in rural Menoufia was 26.2% [19].
Drug typea No. of % During the winter season of 1993, the 2-
children week period prevalence was 14.3% and the
given drugs point prevalence of diarrhoea was 5.6%
(n = 786) [8]. In 1994, the 2-week and point preva-
lence rates in Dakahlia were 19% and 2.2%
Antibiotics 290 36.9 respectively [20]. These figures indicate no
Antidiarrhoeals 581 73.9 specific trend. Differences in the preva-
Antiemetics 131 16.7 lence estimates of diarrhoea in the studies
Antiprotozoal might be due to differences in recall abili-
Antipyretics 45 5.7 ties of mothers, differences in mothers’
Antispasmodics 107 9.6 perceptions of diarrhoea, and differences in
Unidentified 1.7 methodology and times at which the stud-
13 18.6 ies were carried out.
146
In our study, both period and point
aDrugs used were not mutually exclusive. prevalence rates were significantly higher
among rural children than among urban
arrhoea in the 2 weeks preceding the sur- children. This may be attributed to better
vey (period prevalence rate) and 8.7% housing facilities and environmental condi-
were reported to have had diarrhoea in the tions in urban areas [20–22]. In Jordan, a
24 hours preceding the survey (point prev- neighbouring country, however, the preva-
alence rate). In 1985, the point prevalence lence of diarrhoea with residence was not
of diarrhoea among children under 3 years significant [23].
of age in Dakahlia (our locality) was
28.2%, whereas it was 15.2% in Giza and Mother’s age, but not father’s age, was
16.2% in Alexandria [17]. In a survey in significantly correlated with diarrhoea mor-
Cairo and in 8 other governorates, the prev- bidity. Diarrhoea was more likely to occur
alence of diarrhoea in the previous week among children of younger mothers (< 25

Table 9 Prescriber of oral rehydrant solution (ORS) and
drugs

Prescriber ORS (n = 256) Drugs (n = 786)

No. % No. %

Public sector doctor 109 42.6 122 15.5
410 52.2
Private sector doctor 104 40.6 189 24.0

Parent 31 12.1 54 6.9
11 1.4
Pharmacist 9 3.5

Othera 3 1.2

aIncludes nurses, other relatives, barbers or traditional healers.

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Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 771

years), perhaps because of their inexperi- decline in maternally acquired antibodies
ence with childcare. Father’s age may have and the introduction of weaning foods that
been less important because they were less are potentially contaminated. In addition,
likely to be involved in childcare. The Sinai crawling usually begins at this age and the
Consultation Group reported similar find- risk of ingesting contaminated materials is
ings, but in other developing countries, high, especially in unhygienic environments
Zaire and Nigeria, this was not the case [18,21,24,25].
[21,24,25].
No significant sex difference in the
Childhood diarrhoea morbidity de- prevalence of diarrhoea was observed.
creased significantly with higher educa- Boys and girls were probably equally ex-
tional levels of the parents. Better-educated posed as the risk factors associated with
mothers tended to marry similarly advan- diarrhoea are environmental and sociode-
taged men with higher education and to en- mographic, rather than biological [8,18,
joy a relatively higher standard of living. 19,25].
Also, education was reflected in child rear-
ing and child health care practices during First-born children and children with
illness. Educated parents married later, de- birth order of 4 or higher were more likely
layed the onset of childbearing and had to have diarrhoea than others. With the
fewer children than less educated parents. first-born child, maternal experience in
Similar associations have been previously childcare might be lacking. With higher
reported from Egypt and Zaire, although birth order children, the distribution of ma-
this was not true for Saudi Arabia or Nige- ternal attention and care to a large number
ria [8,22,24,25]. of children may consequently mean more
exposure to enteropathogens [8,22].
Diarrhoea morbidity was significantly
lower among children of mothers who Among children under 2 years of age,
worked outside the home and professional breastfeeding had no significant effect on
or semi-professional fathers. Other studies the prevalence of diarrhoea, probably due
have varied on this point [8,21,22,25,26]. to the introduction of water and supple-
Higher prevalence of diarrhoea among chil- ments along with the breast milk. These
dren of mothers who did not work outside supplements increase the risk of diarrhoea,
the home may be explained by their lower particularly in unhygienic environments
educational attainment. It may also be that [27,28]. Most studies have found that
these mothers observe their children more breastfeeding protects against diarrhoea
closely and worry more about their health [29,30]. In infants under 1 year of age,
status than other caretakers and that they breast milk has been associated with a low-
therefore report more diarrhoea [26]. er incidence of rotavirus diarrhoea [31].

Apart from the first 6 months of life Children from large families were more
when maternally acquired immunity and likely to have diarrhoea. Again this may be
breastfeeding without supplementation as a result of a greater chance of contact
played a protective role, diarrhoea morbidi- with enteric pathogens, of less attention
ty decreased significantly with the increase given to children or of a deterioration in
of the child’s age. The prevalence of diar- hygiene with large family size, although
rhoea was highest at 6–< 12 months (the some have reported no association between
age when weaning began) and declined family size and diarrhoea morbidity [28].
thereafter. This might be the result of the
Low income was associated with high
prevalence of childhood diarrhoea in our

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study and others [30,32], but not all [25]. time of consumption if it is improperly
In our study, socioeconomic standard and stored or handled. Other researchers have,
diarrhoea morbidity were inversely associ- however, reported an association between
ated. In families of high social status, both diarrhoea and water source [21,25]. Previ-
parents tended to be highly educated and to ous studies have not found an association
work as professionals or semi-profession- between the flooring in the home (whe-
als, with high income and small family size. ther earth or cement/tile) and diarrhoea
These characteristics were reflected in bet- [22,25,35].
ter hygiene, child rearing and childcare.
Our finding was in agreement with others Oral rehydration treatment, including
[33]. rehydration and maintenance fluids with
ORS, was the most beneficial treatment.
Diarrhoea was more prevalent during Treatment with ORS is simple and facili-
the summer months, probably because hot tates the management of uncomplicated
weather encourages the growth of patho- cases of diarrhoea of any etiologic agent at
genic organisms in contaminated food. home [36]. Our study showed that 71.0%
Summer is also the breeding season for of diarrhoea cases during the previous 2
flies that act as mechanical vectors con- weeks had received increased fluids and
veying enteropathogens to food and water 87.3% of them had continued feeding.
[4]. These results were similar to NCDDP and
National Acute Respiratory Infections Pro-
Children living in unsanitary households gramme reports from Dakahlia during 1994
were the primary victims of diarrhoea in [20]. The high rates of use may be due to
our study and others [21,26,34]. Diarrhoea intensive communication, training activities
was encountered more often among chil- and public education. In the past 2 weeks,
dren in homes where refuse was disposed approximately one-quarter of the children
of in front of the house and flush toilets with diarrhoea had received ORS and
were absent. These conditions provide three-quarters had received drugs. Drugs
breeding sites for flies and other insects were more likely to be prescribed by pri-
that convey enteropathogens from refuse vate rather than public sector doctors. ORS
to food and water. The use of refuse col- use is standard policy in the public health
lectors usually reflects high standards of system, whereas in the private sector its
living. The use of kerosene and biomass as use is more open to the physician’s choice.
a fuel source was also associated with a These results are similar to other studies of
higher prevalence of diarrhoea, again re- diarrhoea in Egypt [16,20,37]. The barriers
flecting low socioeconomic status. The to ORS use for diarrhoeal disease include
presence of television or radio in the home cultural practices, lack of parental knowl-
was associated with a low prevalence of edge and lack of training of health profes-
diarrhoea, probably because they dissemi- sionals [36]. Antibiotics and antidiarrhoeal
nate health messages to households. In drugs were the most frequently prescribed
agreement with a previous study in rural drugs (73.9% and 36.9% respectively).
Egypt, diarrhoea was independent of the Even these figures may be underestimated
source of water supply to homes [35]. since 18.8% of diarrhoea cases were given
Availability of piped water does not neces- unidentified drugs. These drugs may be
sarily mean its uninterrupted flow and the used frequently because mothers and phy-
potential cleanliness of the piped water sicians may be more interested in treat-
source does not ensure water safety at the

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774 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005

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