How much has ORT reduced child mortality?

In 1979 oral rehydration therapy (ORT) using oral rehydration salts (ORS) solution became the cornerstone of the global effort, initiated by WHO, to reduce deaths of young children from diarrhoea, then estimated at 4.6 million annually (1). National programmes to control diarrhoeal diseases (CDD) were eventually developed in more than 110 countries. These gave priority to ensuring an adequate supply of ORS packets and to teaching health workers and mothers how to treat or prevent dehydration at home using ORS solution, sugar-salt solution, and various home fluids. The programmes also promoted other effective measures for preventing or treating diarrhoea. The effects of this effort on indicators of programme implementation, and on diarrhoea morbidity and mortality, were monitored throughout the 1980s and 1990s by periodic surveys, including the WHO Household Survey, the Demographic and Health Survey (DHS) supported by USAID, and UNICEF's Multiple Indicator Cluster Survey (MICS). The results have been remarkable. Access to treatment with ORS solution rose from essentially zero in 1979 to 80% in 1995, and ORT use rates (children with diarrhoea given either ORS solution or increased home fluids) reached 58 to 81% in different regions. Although diarrhoea-morbidity rates did not change appreciably, estimated mortality from diarrhoea in children aged 0-4 year(s) declined by 1990 to 2.9-3.3 million/year (2,3) and by 1999 to 1.5 million/ year (4). Thus, in two decades estimated diarrhoea deaths fell by 3.1 million/year or 67%. Although these figures are global extrapolations from a limited number of national surveys and the confidence limits of the estimates are wide, the consistent direction of change and its magnitude are persuasive. Moreover, these estimates are supported by a nearly universal observation that the number of young children presenting at health facilities with severe dehydration and the number requiring admission to hospital for treatment of diarrhoea have declined markedly (4). It is unclear, however, to what extent the efforts of national CDD programmes to promote effective case management, including the use of ORT at home and in health facilities, caused this dramatic change. Declining rates of infant mortality from all causes, which have fallen by 73% in 50 years (5), and other concurrent interventions might be largely responsible. In their recent report (4), Victora and his colleagues have attempted to answer this question by reviewing WHO reports on the achievements of national CDD programmes and summaries by UNICEF of survey data, including WHO Household Survey, DHS and …