Correspondence

308 www.thelancet.com Vol 382 July 27, 2013

1 Munos MK, Walker CL, Black RE. The eff ect of oral rehydration solution and recommended home fl uids on diarrhoea mortality. Int J Epidemiol 2010; 39: i75–87.

2 Snyder JD, Yunus M, Wahed MA, Chakraborty J. Home-administered oral therapy for diarrhoea: a laboratory study of safety and effi cacy. Trans R Soc Trop Med Hyg 1982; 76: 329–33.

3 Bhutta ZA, Das JK, Walker N, et al. Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost? Lancet 2013; 381: 1417–29.

4 Nathoo KJ, Glyn-Jones R, Nhembe M. Serum electrolytes in children admitted with diarrhoeal dehydration managed with simple salt sugar solution. Cent Afr J Med 1987; 33: 200–04.

5 Wilson S, Morris SS. Gilbert SS, et al. Scaling up access to oral rehydration solution for diarrhea: Learning from historical experience in low- and high-performing countries. J Glob Health 2013; 3: 10404.

the broadening of recommended home fluids—from semi-quantified mixtures of sugar and salt to soups, juices, and even plain water—led to the reporting of almost universal diarrhoea treatment coverage, whereas children continued to die of dehydration.

We focused on interventions that have a clear eff ect on mortality, and standard oral rehydration solutions have clear benefi ts in contrast to other alternatives including recommended home fl uids.

Despite challenges with supplies, substantial progress has been made in coverage of oral rehydration solution (ORS) . Recent analysis of ORS use from relevant population-based national surveys shows a slow but steady increase overall (appendix). Not only Bangladesh, but also Thailand and Mexico have been able to scale up appropriate use of ORS for childhood diarrhoea and to reduce the proportion of diarrhoea deaths in children.4 Wilson and colleagues5 noted that one of the clearest differentiators between countries that have successfully scaled up ORS and those that have not was the choice to promote a clear, unambiguous message about the treatment of choice.

That many children still have more than three episodes of diarrhoea per year stresses that they need to receive treatments of proven effectiveness instead of haphazardly prepared home solutions. Why is ORS being singled out as a problematic intervention when community health-worker programmes in Africa and Asia are providing much more complex interventions, such as antiretroviral drugs, antimalarial drugs, and antibiotics for pneumonia? We declare that we have no confl icts of interest.

*Zulfi qar A Bhutta, Robert E Black, Mickey Chopra, Saul S Morriszulfi qar.bhutta@aku.edu

Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan (ZAB); SickKids Center for Global Child Health, Toronto, Canada (ZAB); Johns Hopkins University School of Public Health, Baltimore, MD, USA (REB); UNICEF, New York, USA (MC); and Bill & Melinda Gates Foundation, Seattle, WA, USA (SSM)

School of Public Health, University of the Western Cape, Cape Town, 7535 South Africa (DS, TD); Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa (TD); Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA (JM); University of the Witwatersrand, Johannesburg, South Africa (HC); and Institute for Global Health, University College London, London, UK (AC)

1 Chopra M, Mason E, Borrazzo J, et al. Ending of preventable deaths from pneumonia and diarrhoea: an achievable goal. Lancet 2013; 381: 1499–506.

2 Walker CL, Rudan I, Liu L, et al. Global burden of childhood pneumonia and diarrhoea. Lancet 2013; 381: 1405–16.

3 Chandani Y, Noel M, Pomeroy A, Andersson S, Pahl MK, Williams T. Factors aff ecting availability of essential medicines among community health workers in Ethiopia, Malawi, and Rwanda: solving the last mile puzzle. Am J Trop Med Hyg 2012; 87: 120–26.

4 Chowdhury AM, Karim F, Sarkar SK, Cash RA, Bhuiya A. The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used? Health Policy Plan. 1997; 12: 58–66.

5 Munos MK, Walker CL, Black RE. The eff ect of oral rehydration solution and recommended home fl uids on diarrhoea mortality. Int J Epidemiol 2010; 39: i75–87.

Authors’ replyWe thank David Sanders and colleagues for their comments focusing on the need for community health workers to promote home fluids for the management of diarrhoea in countries with weak health systems and supply change. This debate is not new.

Children with diarrhoea should receive fl uids and continued feeding, but no evidence shows that the use of home fl uids can save lives.

In the review by Munos and colleagues,1 the studies were based on dehydrated patients in hospital or clinic settings and assessed sugar-salt solution and cereal-salt solutions; none assessed other fluids such as plain water or rice water. Although evidence from clinical studies shows that sugar and salt solutions when prepared in the hospital pharmacy work for hydration,2 translation of this intervention to community application has been a failure. Most sugar-salt programmes have been abandoned because of variability in ingredients quality and concentrations, and risks of electrolyte abnormalities in children with severe diarrhoea.3 Furthermore,

Hospital admission rates for measles and mumps in England: historical perspective Following the recent outbreaks of measles and mumps,1,2 we write to add the perspective of hospital admission rates for these infections in England over the past fi ve decades.

Cases of measles and mumps that were serious enough to warrant hospital admission were reasonably common until the mid-1980s (figure). Immunisation against measles was introduced in England and Wales in 1968,3 but its coverage was incomplete: 33% of 2-year-olds had completed primary courses in 1968, rising to 76% in 1985.4 Triple vaccine immunisation against measles, mumps, and rubella (MMR) was widely introduced in England from 1988.3 Routine collection of English national hospital statistics collapsed in 1985, and usable data did not become available again until 1990; but data in the Oxford record-linkage study5 continued, and the latter data show the decline in hospital admission at that time (figure). Admissions were very few during the 1990s and early 2000s (fi gure). Before the unsubstantiated

See Online for appendix