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REDUCING DIARRHEA IN CHILDREN AND CONTROLLING DENGUE VECTOR AEDES
AEGYPTI IN RURAL SCHOOLS IN TWO MUNICIPALITIES IN COLOMBIA.
HEALTHY SCHOOLS: HEALTH-ABSENTEEISM
Results
Sandra Lucía Vargas, María Inés Matiz , Neal Alexander, Víctor Alberto Olano, Juan Felipe
Jaramillo, Diana Sarmiento, Audrey Lenhart, Thor Axel Stenström, Razak Seidu, Hans J.
Overgaard
Diarrhea and dengue are both highly endemic
throughout Latin America and the Caribbean.
Diarrhea is a leading cause of morbidity and
one of the 10 most important in terms of mortality in Colombia,
with an estimated prevalence of 13% in children <5 years old.
Brazil, Venezuela, México, and Colombia have the
highest number of dengue cases in the Americas.
INTRODUCTION
Source: SIVIGILA-INS
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ort
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Source: Así vamos en salud
Dengue. Colombia 1990-2010Mortality rate for diarrhea. Colombia
1990-2010
DENGUE AND DIARRHEA IN COLOMBIA
Origin of dengue cases in Colombia
ORIGINDENGUE SEVERE DENGUE
2012 2013 2012 2013
Head Municipal 80.6% 83% 74.2% 80%
Populated Center 9% 8.6% 14% 11.4%
Dispersed Rural 10.4% 8.4% 11.8% 8.6%
Fuente: Instituto Nacional de Salud. Vigilancia y Control en Salud Pública.
Informe Evento dengue . 2012 y 2013.
OBJECTIVES
Investigate whether interventionsagainst diarrhea and denguewill significantly reduce:
The incidence of diarrheal illness in school children.
The number of absence episodes and length of those
due to these illnesses.
2×2 factorial cluster randomized controlled trial
TRIAL DESIGN
Interventions
Dengue
Inte
rve
nti
on
s
Dia
rrh
ea
+ -
+DIADEN
(8 schools)
DIA
(8 schools)
-DEN
(9 schools)
CONTROL
(9 schools)
LOCATION AND RECRUITMENT OF PARTICIPANTS
Characteristic Anapoima La Mesa
Height and temperature 700msnm y 26°C 1200msnm y 22°C
Rural area population 2013 7383 (57,2%) 13559 (44,5%)
Rural unsatisfied basic needs 2005 36,4% 36,8%
FLOW CHART OF SCHOOL AND PUPIL SELECTION
Rural schools for eligibility
Control
Allocated (n= 9 schools)
Median size: 28 pupils
Average: 23 pupils
Schools lost to follow-up: 0
Children lost to follow-up: 0
No. of pupils: 473No. of schools: 8Median size: 62
Range: 80
Intervention dengue y Diarrhea (DIADEN)
Allocated (n= 8 schools)
Median size: 16 pupils
Average: 25 pupils
Schools lost to follow-up: 0
Children lost to follow-up: 1
No. of pupils: 425No. of schools: 8Median size:38
Range:123
Intervention dengue (DEN)
Allocated (n= 9 schools)
Median size: 18 pupils
Average: 19 pupils
Schools lost to follow-up: 0
Children lost to follow –up: 1
No. of pupils: 454No. of schools: 10Median size: 38,5
Range: 84
Intervention diarrhea (DIA)
Allocated (n=9 schools)
Median size: 20 pupilsAverage: 29 pupils
Schools lost to follows-up: 1
Children lost to follow-up: 0
No. of pupils: 543 No. of schools: 8Median size:45
Range:203
Allocated
Schools excluded due to size, i.e. colegios (> 100 pupils; > 5 grades)
(n= 6)
Follow-up
Enrollment
Final analysis
Randomized
(n=35)
DATA COLLECTION METHODS
Daily record of absences by
professor
The teacher establishes the reason
for absence
Weekly collection of records
Phone call to the family to establish the
reason for absence
Home visit to children who could not establish the reason for
absence
• Rates of absence attributed to each diseases were calculated at the school level, in terms of both numbers of episodes and of numbers of days.
• Rates were calculated per year based on a school year of 185 days.
• These school-level rates were the response variable for a factorial analysis of covariance described by Overgaard et al (2012).
• The explanatory variables were:
a) whether or not the school received the dengue interventions, b) whether or not the school received the diarrhea interventions,
and c) municipio, by which the randomization was stratified.
Analysis
CHARACTERISTICS OF THE STUDY POPULATION
VARIABLE ARM
DIA
n=543
DENGUE
n=454
DIADEN
n=425
CONTROL
n=473
Gender: Male
Female
52,7%
47,3%
56,8%
43,2%
55,5%
44,5%
56%
44%
Years old
Average ± SD
Mínimum
Maximum
8,2±2,2
4
16
7,9±2,2
3
15
7,9±2,1
4
14
8,1±2,3
4
15
Nutricional diagnosis 2012n= 207 n= 152 n= 172 n= 180
Chronic malnutrition 2012
(Low height for age)11,6% 10,5% 10,5% 13,3%
Nutricional diagnosis 2013n= 230 n= 196 n= 158 n= 202
chronic malnutrition 2013
(Low height for age)8,7% 10,2% 8,9% 12,4%
DEMOGRAPHIC CHARACTERISTICS AND NUTRITIONAL STATUS OF SCHOOLCHILDREN
VARIABLE ARM
DIA
n=120
DENGUE
n= 91
DIADEN
n=103
Control
n=82
Sewerage coverage 15,0% 7,7% 3,9% 7,3%
Waste collection 22,5% 17,6% 9,7% 9,8%
Aqueduct coverage 74,2% 63,7% 27,2% 73,2%
Don’t count with sanitary service 17,5% 26,4% 30,1% 17,1%
Highest education level reached by
the head of the household: primary72,5% 76,9% 77,7% 74,4%
Average habitants per home 4,7 4,1 4,7 5,1
SOCIO-ECONOMIC CHARACTERISTICS OF HOUSEHOLDS FROM SCHOOLCHILDREN
SCHOOL ABSENTEEISM
Episodes absenteeism:
Absence of the student throughout the school day or
part of this.
New episode of absence:
When there is a difference of at least three days without absences for the same reason
(illness, travel, etc.) between the last day of absence and a new one.
EPISODES ABSENTEEISM
ABSENTEEISM EPISODES
EpisodesAbsenteeism
4836 (61,6%)
Number of students
La Mesa 1108 (58,5%)
Teacher and other
2929 (60,6%)
Phone Call
1907 (39,4%)
EpisodesAbsenteeism
3014 (38,4%)
Number of students
Anapoima 787 (41,5%)
Teacher and other
1894 (62,8%)
Phone Call1120 (37,2%)
SAKE OF ABSENCE REPORTING THROUGH PHONE CALL
INFORMANT TOTAL %
Mother64,2
Father 23,1
Grandparents 8,1
Stepfather 1,8
Uncles 1,7
Othet1,0
ABSENCE FOR ANY REASON – NUMBER OF EPISODES
Absencereason
CONTROL DEN DIA DIADEN
Any reasonepisodes/year
5,2 5,5 5,0 4,4
Any reasondays/year
8,6 8,9 8,2 6,2
Any diseaseepisodes/year
1,3 1,2 1,2 1,2
Any diseasedays/year
2,6 2,2 2,1 2,1
REASON CONTROL % DEN % DIA % DIADEN % TOTAL %
Disease 24,6 21,4 24,5 28,4 24,7
Lack of incentive 13,2 13,8 10,0 8,6 11,6
Travel 12,4 14,3 13,7 11,7 13,2
Medical / dental appointment 9,7 12,5 15,2 18,1 13,7
Bad weather 8,9 8,2 8,4 6,7 7,6
Others 7,8 4,0 3,3 4,4 4,4
Family commitments 4,8 6,7 5,6 4,8 5,5
Sick mother 3,6 2,9 1,9 2,2 2,7
Had no one to send 2,9 1,2 1,2 1,5 1,7
Caring home / brothers 2,7 3,6 1,5 1,7 2,4
Uniform 2,3 1,0 1,2 1,2 1,5
No date 1,9 2,7 3,3 3,1 2,7
Calamity 1,5 0,6 1,2 1,1 1,1
Indiscipline 1,2 0,6 0,1 0,3 0,6
distance / route 1,2 1,4 2,7 1,2 1,7
family problem 1,0 2,0 1,7 2,6 1,8
Económic 0,2 0,5 0,1 0,1 0,2
REASON SCHOOL ABSENTEEISM
ABSENTEEISM DUE TO ILLNESS
CONTROL27 %
DEN21 %
DIA29 %
DIADEN23 %
0
10
20
30
40
50
60
70
80
CONTROL DEN DIA DIADEN
Pe
rce
nt
ANAPOIMA LA MESA
DISTRIBUTION OF EPISODES OF ABSENCE DUE TO ILLNESS
0,0%20,0%40,0%60,0%80,0%
Masculino Femenino
0,0%
10,0%
20,0%
30,0%
0 1 2 3 4 5
7,9±2,5 7,4±2,3 7,9±2,3 7,4±2,2
DISTRIBUTION OF EPISODES OF ABSENCE DUE TO ILLNESS
Grade school Gender
YEARS OLD
CONTROL DEN DIA DIADEN
Episode: diarrhoea-day is one where a
subject experiences three or more loose
or watery stools in 24 hours or any number
of loose or watery bloody stools.
The length of the illness episode will be defined as
the number of days between the first and last day of
absence.
New episode of absence due to diarrhea: Three
consecutive diarrhoea-free days
has been proposed as an international
standard
EPISODES OF DIARRHEA ABSENTEEISM
ABSENCE DUE TO DIARRHEA – NUMBER OF EPISODES
Rat
ed
iarr
thea
epis
od
es/y
ear
ABSENCE DUE TO DIARRHEA – NUMBER OF DAYS
Dia
rrea
day
s/ye
ar
-
0,02
0,04
0,06
0,08
0,10
0,12
0,14
CONTROL DEN DIA DIADEN
DIARRHEA 2012 DIARRHEA 2013
Rat
ed
iarr
thea
epis
od
es/y
ear
E. Coli drinking water % (n)SchoolsRange
Incidence rate/year
Ausent 55,9 (19) 0,03-0,49
Low 26,5 (9) 0,02-0,37
Medium 8,8 (3) 0,18-0,35
High 5,9 (2) 0,04-0,05
Arm Log10 E. Coli drinking water % schoolsAverage rate
diarrhea/yearC High 11,1 ,053
Ausent 44,4 ,029
Low 44,4 ,127
Total ,075
DEN High 11,1 ,041
Ausent 33,3 ,108
Low 22,2 ,223
Medium 22,2 ,184
NA 11,1 ,000
Total ,131
DIA Ausent 75,0 ,068
High 12,5 ,351
Medium 12,5 ,299
Total ,133
DIADEN Ausent 66,7 ,173
Low 25,0 ,038
Total 8 ,139
Probable dengue cases will be defined accordingto WHO criteria and surveillance protocol for dengue in Colombia. They should have consulted the health service and physician-diagnosed.
Probable dengue case no warning signs:
Febrile illness acute (<7 days) observed in two or more of the following manifestations: headache, retro-orbital pain, myalgia, arthralgia or rash.
EPISODES OF DENGUE ABSENTEEISM
ABSENCE DUE TO DENGUE – NUMBER OF EPISODES
Rat
ed
en
gue
ep
iso
des
/yea
r
ABSENCE DUE TO DENGUE – NUMBER OF DAYS
de
ngu
e d
ay/y
ear
Perc
ent
9
0,000
0,005
0,010
0,015
0,020
0,025
0,030
0,035
0,040
0,045
0,050
CONTROL DEN DIA DIADEN
DENGUE 2012 DENGUE 2013
Rat
ed
en
gue
ep
iso
des
/yea
r
40
,7
37
,0
35
,1
39
,2
10
,4
10
,8
6,9
14
,3
6,6
8,8
8,5
7,5
6,4
8,3
6,7 7,3
5,8 6
,9 7,8
6,6
6,0
3,4
5,6 5,9
5,5
7,6
6,3
5,7
CONTROL D EN D IA D IA D EN
Resfriado Fiebre Diarrea Estómago/vómito Otros Cefalea Trauma
REASONS OF ABSENCE DUE TO ILLNESS AND SYMPTOMS
• The interventions don’t have an effect on diarrhea and dengue incidence. There were no statistically significantly differences between the four study groups in terms of diarrhea and dengue incidence among the school children.
• The main reason for absenteeism was illness. The most frequent symptoms were cold, fever, diarrhea, stomach pain and vomiting.
• Absenteeism rates for diarrhea were higher in the DIADEN arm.
• There was low infestation of Aedes aegypti in rural area and also low incidence rates for dengue. Nevertheless we have to be aware of the presence of entomological risks factors that can favor the transmission of the virus.
• The benefits of a water intervention to improve the quality depend on sanitation and hygiene conditions.
CONCLUSIONS
Ministerio de la Protección Social, Universidad de Antioquia, Facultad Nacional de Salud Pública: Análisis de la situación de salud en Colombia 2002–2007. Bogotá: Tomo IV "Situación de salud de la infancia"; 2010 [http://www.minproteccionsocial.gov.co/Documentos%20y%20Publicaciones/ASISTomo%20IV–Situaci%C3%B3n%20de%20salud%20de%20la%20infancia.pdf].
Profamilia Colombia: Encuestas Nacionales de Demografia y Salud (ENDS).
Bogotá:; 2010 [http://www.profamilia.org.co/encuestas/Profamilia/Profamilia/
images/stories/PDF-capitulos/Capitulo-10.pdf].
Pan American Health Organization: Health situation and trends - summary.
Washington, DC: PAHO; 2012 [http://www.paho.org/english/dd/ais/cp_170.
htm].
REFERENCES
• Dane. Estimaciones de población 1985-2005 y proyecciones de población 2005-2020. Colombia. Disponible en: http://www.dane.gov.co/index.php/poblacion-y-demografia/proyecciones-de-poblacion
• Dane. Necesidades básicas insatisfechas NBI. Resultados Censo 2005. Colombia. http://www.dane.gov.co/index.php/estadisticas-sociales/necesidades-basicas-insatisfechas-nbi
• Baqui AH, Black RE, Yunus M, Hoque AR, Chow- dhury HR, Sack RB. Methodological issues in diar- rhoeal diseases epidemiology: definition of diar-rhoeal episodes. Int J Epidemiol1991;20:1057-63.
• World Health Organization: Dengue - Guidelines for diagnosis, treatment, prevention and control. Geneva: WHO; 2009.
• Ministerio de la Protección Social. Instituto Nacional de Salud. Protocolo de la vigilancia y control del dengue. Colombia: 2010.
REFERENCES
Sandra Lucía Vargas Cruz