WASHINGTON, D.C.—An intensive program of handwashing education and promotion in Pakistan decreased the incidence of diarrhea by more than 50 percent among children, according to a study in the June 2 issue of the Journal of the American Medical Association (JAMA), a theme issue on Global Health.

Stephen P. Luby, M.D., of the Centers for Disease Control and Prevention, Atlanta, presented the findings of the study today at a JAMA media briefing at the National Press Club in Washington, D.C.

Nearly 2 million children worldwide die annually from diarrheal disease, according to background information in the article. Previous studies have estimated that handwashing promotion interventions could prevent 1 million child deaths per year. Washing hands with soap prevents diarrhea, but children at the highest risk of death from diarrhea are younger than 1 year, too young to wash their own hands. Previous studies could not adequately assess the impact of household handwashing on diarrhea in infants.

Dr. Luby and colleagues evaluated whether promotion of handwashing with soap among adult and children household members decreased diarrhea among children at the highest risk of death from diarrhea. The study was conducted among 36 low-income neighborhoods in urban squatter settlements in Karachi, Pakistan. Eligible households located in the study area had at least 2 children younger than 15 years, at least 1 of whom was younger than 5 years.

As part of the intervention, field workers visited participating households at least weekly from April 2002 to April 2003 in 25 neighborhoods to provide education to all household members old enough to understand about proper handwashing with soap after defecation and before preparing food, eating, and feeding a child. They used slide shows, videotapes, and pamphlets to illustrate health problems resulting from contaminated hands. Within intervention neighborhoods, 300 households (1,523 children) received a regular supply of antibacterial soap and 300 households (1,640 children) received plain soap. A total of 11 neighborhoods (306 households and 1,528 children) were randomized to the control group, which did not receive handwashing education or soap.

The researchers found that children younger than 15 years living in households that received handwashing education and plain soap had a 53 percent lower incidence of diarrhea compared with children living in households that did not receive such education or soap. "Infants living in households that received handwashing promotion and plain soap had 39 percent fewer days with diarrhea vs. infants living in control neighborhoods. Severely malnourished children younger than 5 years living in households that received handwashing promotion and plain soap had 42 percent fewer days with diarrhea vs. severely malnourished children in the control group," the authors write.

The authors found similar reductions in diarrhea in households using both plain and antibacterial soap. The authors report, "We found no significant difference in diarrheal disease among persons living in households receiving antibacterial soap compared with plain soap. This is not surprising because triclocarban [in the antibacterial soap] is a bacteriostatic agent that inhibits the growth of some gram-positive bacteria but is not effective against gram-negative bacteria, viruses, or parasites that cause infectious diarrhea." The authors note that the act of handwashing with soap physically removes pathogens that may cause diarrhea from hands that might otherwise transmit these pathogens to vulnerable infants.

WASHINGTON, D.C.—An incentive-based program that now reaches 4.5 million families in Mexico is associated with lowering the rate of anemia and improving growth in low-income, rural infants and children, according to a study in the June 2 issue of the Journal of the American Medical Association (JAMA), a theme issue on Global Health.

Lead author Juan A. Rivera, Ph.D., Director of the Center for Nutrition and Health, National Institute of Public Health, Cuernavaca, Mexico, presented the findings of the study today at a JAMA media briefing at the National Press Club in Washington, D.C.

According to background information in the article, more than half of the yearly 10.8 million deaths of children younger than 5 years worldwide are attributed to malnutrition. Malnourished children who survive have a high risk of impaired health and function throughout life, which contributes to the intergenerational continuation of poverty. In developing countries more than one-quarter of all children younger than 5 years, about 150 million total, are estimated to be malnourished. Existing malnutrition interventions are effective under controlled conditions; however, little information is available on their effectiveness in large-scale programs.

Rivera and colleagues conducted a study to determine the short-term nutritional impact of the large-scale, incentive-based development welfare program in Mexico, Progresa (Program for Education, Health, and Nutrition, currently called Oportunidades). Progresa has been applied by the Mexican federal government since 1997. As part of the program, children and pregnant and lactating women in participating households received fortified nutrition supplements called papilla, and the families received nutrition education, health care, and cash transfers.

The families received the cash transfers if they complied with requirements concerning school attendance and maintaining certain health care appointments for services such as immunizations, well baby care and growth monitoring of children, prenatal and postnatal care, check-up visits for other family members, and a mandatory session on nutrition and health education.

The study included 347 communities randomly assigned to immediate incorporation to the program in 1998 (intervention group; n = 205) or to incorporation in 1999 (crossover intervention group; n=142). A random sample of infants in those communities was surveyed at baseline and at 1 and 2 years afterward. Participants were from low-income households in poor rural communities in 6 central Mexican states. Infants (N = 650) 12 months of age or younger (n = 373 intervention group; n = 277 crossover intervention group) were included in the analyses.

The researchers found that participating in the Progresa program was associated with better growth in height among the poorest and younger infants. Adjusted height was greater by 1.1 cm (.4 inch) (26.4 cm [10.4 inches] in the intervention group vs. 25.3 cm [9.9 inches] in the crossover intervention group) among infants younger than 6 months at baseline. The rate of anemia in 1999 was 10.6 percentage points lower in the intervention group (44.3 percent) after 1 year in the Progresa program relative to that in the crossover intervention group (54.9 percent), who had not yet received Progresa benefits that year. In 2000, rates of anemia in the two groups were no longer significantly different after both groups had been in the program during the previous year.

WASHINGTON, D.C.—Reallocation of treatment resources could substantially decrease the problem of unmet need for treatment of mental disorders among serious cases in developed and developing countries, according to the findings from The World Health Organization (WHO) World Mental Health Surveys published in the June 2 issue of the Journal of the American Medical Association (JAMA), a theme issue on Global Health.

Ronald C. Kessler, Ph.D., from Harvard Medical School, Boston, presented the findings from the study today at a JAMA media briefing held at the National Press Club in Washington, D.C.

Co-Principal Investigators of the Survey, Dr. Kessler and Dr. T. Bedirhan Üstün from the World Health Organization, together with co-authors from The WHO World Mental Health Survey Consortium analyzed data from 60,463 face-to-face household surveys with adults in 14 countries (6 less developed, 8 developed) to estimate the prevalence, severity, and treatment of mental disorders. The surveys were conducted from 2001 - 2003 in the Americas (Columbia, Mexico, United States), Europe (Belgium, France, Germany, Italy, Netherlands, Spain, Ukraine), the Middle East and Africa (Lebanon, Nigeria), and Asia (Japan, separate surveys in Beijing and Shanghai in the People's Republic of China). The six countries classified as less developed by the World Bank are China, Colombia, Lebanon, Mexico, Nigeria, and Ukraine.

All surveys used the World Mental Health -Composite International Diagnostic Interview (WMH-CIDI), a structured diagnostic interview to assess disorders and treatment. Disorders considered included anxiety disorders, mood disorders, disorders that share a feature of problems with impulse control (for example, bulimia [episodic binge eating followed by compensatory behaviors]), and substance abuse disorders.

The researchers found that the prevalence of having any mental disorder in the prior year varied widely from 4.3 percent in Shanghai to 26.4 percent in the United States. "Between 33.1 percent (Columbia) and 80.9 percent (Nigeria) of 12-month cases were mild," the researchers report. "Serious disorders were associated with substantial role disability [inability to carry out usual activities]. Although disorder severity was correlated with probability of treatment in almost all countries, 35.5 percent to 50.3 percent of serious cases in developed countries and 76.3 percent to 85.4 percent in less-developed countries received no treatment in the 12 months before the interview." The authors continue, "Due to the high prevalence of mild and subthreshold cases, the number of those who received treatment far exceeds the number of untreated serious cases in every country." The term "subthreshold case" refers to people who received treatment even though they did not meet full criteria for a mental disorder.

WASHINGTON, D.C.—The rising global burden of chronic diseases needs a coordinated effort from policy makers, advocates and health professionals, according to a special communication in the June 2 issue of the Journal of the American Medical Association (JAMA), a theme issue on Global Health.

Derek Yach, M.B.Ch.B., M.P.H., from the World Health Organization, Geneva, Switzerland, presented the special communication today at a JAMA media briefing at the National Press Club in Washington, D.C.

According to background information provided by the authors: "Chronic diseases are the largest cause of death in the world, led by cardiovascular disease (17 million deaths in 2002, mainly from ischemic heart disease and stroke) and followed by cancer (7 million deaths), and chronic lung diseases (4 million), and diabetes mellitus (almost 1 million). These leading diseases share key risk factors: tobacco use, unhealthful diets, lack of physical activity, and alcohol use."

Yach and colleagues write that the "global prevalence of all the leading chronic diseases is increasing, with the majority occurring in developing countries and projected to increase substantially over the next 2 decades." The authors note that "between 1990 and 2020, mortality [death] from ischemic heart disease in developing countries is expected to increase by 120 percent for women and 137 percent for men." The authors add that risks for chronic diseases are also rising with higher rates of smoking and obesity levels among adolescents in developing countries.

"Chronic diseases have not simply displaced acute infectious ones in developing countries. Rather, such countries now experience a polarized and protracted double burden of disease. India, the second most populous country, has the highest number of diabetics in the world and annual coronary deaths are expected to reach 2 million by 2010. At the same time, around 2.5 million children in India die from infections such as pneumonia, diarrhea, and malaria every year. In South Africa, infectious diseases account for 28 percent of years of lives lost while chronic diseases account for 25 percent." The authors add that the health services in these countries are being strained by the double burden.

"In most developing countries inadequate financing and lack of manpower to address chronic diseases have been major impediments to chronic disease control." The authors continue, "Many key decision makers still believe chronic diseases afflict only the affluent and the elderly and arise only from freely acquired risks and that their control is ineffective and too expensive and should wait until infectious diseases are addressed." The authors point out that "chronic diseases in developing countries are not just diseases of the elderly, since cardiovascular disease accounts for as many deaths in young and middle-aged adults as HIV/AIDS. Also, in developing countries chronic diseases affect a much higher proportion of people during their prime working years than in developed countries."

HAND-WASHING DRAMATICALLY REDUCES RISK OF DEATH FROM DIARRHEA AMONG CHILDREN - PLAIN SOAP AS EFFECTIVE AS ANTIBACTERIAL SOAP