Analysis of risk factors influencing diarrheal outbreak among under five children

ANALYSIS OF RISK FACTORS INFLUENCING DIARRHEAL OUTBREAK
AMONG UNDER FIVE CHILDREN IN BURAO GENERAL HOSPITAL
FARDUS FUAD RAAGE
THIS PROJECT SUBMITTED IN PARTIAL FULFILLMENT FOR THE AWARD
OF MASTER’S DEGREE OF PUBLIC HEALTH AT ABAARSO TECH
UNIVERSITY.
FEBRUARY, 2020

i
DECLARATION
Declaration by the candidate
I declare that this project is my own work and has never been presented in any university for
master award.
Name: Fardus Fuad Rage ADM. No………………………..
Date……………………………………………………….
Signature: …………………………………………………..

ii
Declaration by the University Supervisor
I declare that this work has been submitted under my supervision as the University supervisor
Name: Dr. Sa,ad Ahmed Abdiwali
Date: ............................................................................
Signature: …………………………………………………..

iii
ACKNOWLEDGEMENTS
All praise is to ALLAH Almighty, who gave me the energy and chance to accomplish this
work successfully.
I would also like to thank my supervisor, my mentor and teacher. My gratitude goes to, Dr.
Sa,ad ahmed abdiwali Who assisted me in choosing the research topic, patiently stood by
me through all my struggles, His support and positive outlook, being a mentor and source of
inspiration.
In particular I would like to thank dear of mine legend hero Idiris Ahmed Hassan his help
and suggestions, am grateful.
Completing this work would have been all the more difficult were if not for the support and
Friendship provided my brother Zaki Jama Farah
I am in debated to them for their help.
Finally, I would like to thank my lectures in Abaarso Tech University for their help
And encouragement.

iv
DEDICATION
I dedicate this work to my dear parents my mother Khadija omer Mahmud and my father
Fuad rage Mohamed for their prayers, encouragement, and Moral support and for teaching
me the value of education. To my sister‟ Awo, Fuad Rage , brother’ Abdirashid Fuad Rage
and all my brothers and sisters who were very helpful and understanding in my situations,
their support and encouragement helped me a lot in completing this thesis successfully.

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ABSTRACT
Introduction. It’s a recent emerging problem documented in developing countries, diarrheal
outbreak under five children contributes major current health problems (morbidity and
mortality) in several ways. Diarrheal disease remains a devastating problem in many
developing countries affecting over 525 million people causing more than one – half of
children death.
Study objective was to analyzing the diarrheal outbreak of under-five year’s old children in
Burao Hospital burao Somaliland. Method and material. a community based a cross-
sectional study was conducted that triangulated quantitative approach was carried out from
February 2020 to September 2020 among 92 participants in Burao Hospital Burao
Somaliland, sample Random sampling was employed to select the sampled participants,
a sum-structured questionnaire was used to collect the socio-demographic characteristic,
sanitation and hygiene , Breastfeeding and Complementary feeding pattern of the mothers
and contaminated food and water of the children. Results. a descriptive analysis was carried
out to identify factors influence diarrheal outbreak of the children under 5 years old,
age categorized into 0-1 years old were 51%, 2-3years old were 32.0% , and 4-5 years old
were 29% also 5 years above while 6% were 1-2 years old are much numerous of children
in household .
Were 63.0%, of family income father is responsible while 22% come from mother and 7%
other source. 83% of study populations were getting adequate water while other 8% don’t
have adequate water.
Most factors associated diarrhea outbreak which leading mortality and morbidity 30% ,6%
are poor personal hygiene and sanitation respectively while 48% are other causes.
Conclusion. The research also concludes that most of Mothers doesn’t well understand the
Necessary need of child good sanitation and hygiene. So that in this study I recommended
that this needs extra researchers should launch researches factors influence diarrhea because
still there are others factors associated diarrheal outbreak.

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Contents
DECLARATION....................................................................................................................................i
Declaration by the candidate................................................................................................................i
ACKNOWLEDGEMENTS ................................................................................................................ iii
DEDICATION...................................................................................................................................... iv
ABSTRACT........................................................................................................................................... v
LIST OF ABBREVIATIONS .............................................................................................................. x
CHAPTER ONE ...................................................................................................................................1
INTRODUCTION.................................................................................................................................1
1.0 Introduction...................................................................................................................................1
1.1Background of Study .....................................................................................................................1
1.2 Statement of the problem........................................................................................................3
1.3 Purpose of Study.................................................................................................................4
1.4. General objectives........................................................................................................................4
1.4.1 Specific of Objectives....................................................................................................4
1.5 Research Questions.......................................................................................................................4
1.6 Significance of Study....................................................................................................................5
1.7 Scope of Study .................................................................................................................................6
1.8 Study variables..............................................................................................................................7
CHAPTER TWO ....................................................................................................................................8
2.1 Introduction...................................................................................................................................8
2.2 concepts.........................................................................................................................................8
2.2.1. Factors associated with diarrheal disease............................................................................10
2.3 Theoretical Review.....................................................................................................................12
2.4Related studies .............................................................................................................................13
2.4. 1Relationship between Nutrition and Diarrhea..........................................................................16
2.4.2 Diarrhea among under five and water treatment..................................................................30
2.4.3. Socio-Economic Factors .....................................................................................................36
Conceptual framework......................................................................................................................40
2.5 research gap ................................................................................................................................41
CHAPTER THREE............................................................................................................................42
RESEARCH DESIGN AND METHODOLOGY ............................................................................42
3.1 Introduction.................................................................................................................................42
3.2 Research design ..........................................................................................................................42

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3.3 Study area....................................................................................................................................42
3.4 study period.................................................................................................................................42
3.5 study Population..........................................................................................................................43
3.6 sample size..................................................................................................................................43
3.7 Sampling method ........................................................................................................................43
3.8 Data Collection Method..............................................................................................................43
9.1inclusion and exclusion criteria....................................................................................................43
3.9.1. Inclusion..............................................................................................................................43
3.9.2. Exclusion.................................................................................................................................44
3.10 Method of Data Analysis ......................................................................................................44
3.11 Ethical consideration.............................................................................................................44
1.2 Limitations of Study ...................................................................................................................44
3.13 Testing Validity and Reliability............................................................................................44
3.14 Definition of operational terms.............................................................................................45
CHAPTER FOUR: .............................................................................................................................46
RESULTS ............................................................................................................................................46
4.1. Introduction................................................................................................................................46
4.2. Socio-demographic characteristic..............................................................................................46
CHAPTER FIVE ................................................................................................................................59
5.1 Introduction...................................................................................................................................59
5.2. Discussion...................................................................................................................................59
5.3. Summary....................................................................................................................................61
5.5. Conclusion .................................................................................................................................62
5.6. Recommendation .......................................................................................................................63
5.6. Recommendations for further studies ........................................................................................64
REFERENCES....................................................................................................................................65
APPENDIX I: RESEARCH QUESTIONNAIRE............................................................................69
APPENDIX 2: RESEACH BUDGET .............................................................................................lxxv
APPENDIX 3: Work Plan...............................................................................................................lxxvi

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Table of figures
Table 1: socio-demographic characteristic ……………………………..47
Figureb1: house hold children………………………………………….49
Figure 2: family income………………………………………………….50
Figure 3: adequate household water……………………………………..51
Figure 4: source of water………………………………………………….52
Figure 5: cost of water…………………………………………………….53
Figure 6: water treatment…………………………………………………54
Figure 7: tools of storing water ………………………………………..…55
Figure 8 : factors associated diarrheal outbreak………………….……….56
Table 2: breastfeeding …………………………………………………….57
Table 3: contamination food and water ………………………………..58

ix
LIST OF ABBREVIATIONS
WHO: -World Health Organization
AWD:-Acute Watery Diarrheal
CTC: -Cholera Treating Centre
CFR: -Case Fertility Rate
MRN :-Morbidity Rate Number
ixBGH: -Burao General Hospital
BSF: bio sand filter
HWTS: household water treatment
UNICEF: United Nations Children's Fund
LMICs: low and middle countries
Spss: statistical package for social science
NFHS,: National family health survey
Wash: water sanitation and hygiene
AARR: average annual rate of reaction
MDG: minimum development goals
CDD: control of diarrheal disease
ORS: oral rehydration solution
IGA: immunoglobulin

1
CHAPTER ONE
INTRODUCTION
1.0 Introduction
This chapter contains background of study, statement of the problem, , objectives of the
study, purpose of study, significance of study, scope of study, and study variables.
1.1Background of Study
Diarrheal disease is the second leading cause of death in children under five years old, and is
responsible for killing around 525 000 children every year. Diarrhea can last several days,
and can leave the body without the water and salts that are necessary for survival. {WHO,
2017}
A diarrheal disease still remain a major public health threat for developing countries and is
attributed to poor sanitation, unhygienic practices and inadequate supply of purified drinking
water[ Who, 2013.] .
Diarrheal, transmitted via faecal–oral route, is caused by various pathogens, including
bacteria, viruses, protozoa, and helminths. Of the diarrheal diseases, cholera (an acute
diarrheal illness caused by the bacterium Vibrio cholera), alone is responsible for an annual
1.3–4.0 million morbidity and 21,000–143,000 mortality worldwide. [ali, et al 2015.,]
A key epidemiological feature of diarrheal outbreak is its ability to cause outbreaks that can
quickly lead to devastating epidemics, if not controlled .The number of outbreak cases
reported to WHO by its member countries has increased in recent years. , 2016, 38 countries
reported a total of 132,121diarrheal outbreak cases (out of which 54%, 32% and 13% were
from Africa, Hispaniola and Asia, respectively), {WHO, 2016} including 2420 deaths].
A descriptive analysis of diarrheal outbreaks during 2003–2012 demonstrated that more than
two-third of the outbreaks occurred in Southeast Asia, including Nepal {Mahapatra AL, et al.,
2003–2012.}
However, underreporting of the diarrheal cases is a major challenge for the control of the
disease and underreported diarrheal cases have accounted for a significant number of deaths.
These discrepancies in the number of cases reported versus the number that actually occur are
often resultant from poor surveillance systems and inconsistency in case definition and
reporting systems among and within countries. For example, as highlighted in a recent report,

2
the annual number of cholera cases reported to the WHO by the Indian government was
several times lower than the actual number of cases [Sarkar, et al., 2012.].
As at 2 April 2017, Puntland had a cumulative reported case of AWD/cholera since the
beginning of the year at 1,674 and 57 deaths, indicating a case fatality rate (CFR) of 3.4
percent.
In Somaliland, the {AWD} outbreak reportedasat10April in the Buuhole community on the
Somaliland/Ethiopian border was 291 cases and 14 deaths, indicating a CFR of 4.8 percent.
In Somaliland, the reported cases were in the Buuhole district as well as pockets of Teleh in
the Sool region areas in the Togdheer and Awdal region respectively. This brought the total
number of affected regions in Somaliland.{ UNICEF, 2019}
Burao, togdheer Somaliland, 3 July 2017 - The rains that have brought some relief from the
prolonged drought in Somaliland, have led to a devastating outbreak of Acute Watery
Diarrhea (AWD)/cholera which has affected thousands of people – a third of them children
under five years of age .In Burao, one of the largest towns in Somaliland, more than 100
cases are coming in each day to the Cholera Treatment Center (CTC) which has doubled in
size {UNICEF , 2017}

3
1.2 Statement of the problem
Diarrhea kills 2195 children every day—more than AIDS, malaria, and measles com-bined
Of 7.6 million deaths in children younger than 5 years in 2010, 64% (4.879 million) were
attributable to infectious causes. Diarrhea diseases contributed to 9.9% (0.751 million) of all
death. Diarrheal disease causes death by depleting body fluids resulting in profound
dehydration. Diarrhea can have a detrimental impact on childhood growth and cognitive
development. About 88% of diarrhea-associated deaths are attributable to unsafe water,
inadequate sanitation, and insufficient hygiene. Rotavirus is the leading cause of acute
diarrhea and causes about 40% of hospitalizations for diarrhea in children under five years.
Most diarrheal germs are spread from the stool of one person to the mouth of another. These
germs are usually spread through contaminated water, food, or objects. Diarrheal diseases
remain one of the most dangerous killers of children in Somalia -- killing an estimated 8,759
children in 2015, accounting for 14.5% of all deaths of children under the age of 5. Recurrent
cholera outbreaks, enabled by cycles of floods and famine, contribute to high mortality rates
from diarrhea on a yearly basis.(UNICEF , 2017)
In Somaliland, the reported cases were in the Buuhole district as well as pockets of Teleh in
the Sool region areas in the Togdheer and Awdal region respectively. This brought the total
number of affected regions in Somaliland.{ UNICEF, 2019}
Burao, togdheer Somaliland, 3 July 2017 - The rains that have brought some relief from the
prolonged drought in Somaliland, have led to a devastating outbreak of Acute Watery
Diarrhea (AWD)/cholera which has affected thousands of people – a third of them children
under five years of age .In Burao, one of the largest towns in Somaliland, more than 100
cases are coming in each day to the Cholera Treatment Center (CTC) which has doubled in
size {UNICEF, 2017}

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1.3 Purpose of Study
The study was aim to examine analysis of risk factors influencing diarrheal outbreak among
under five children in Burao general hospital Burao Somaliland.
1.4. General objectives
1.4.1. General objectives
To determine risk factors influencing diarrheal outbreak among under five children in burco
general hospital Burco Somaliland
1.4.1 Specific of Objectives
i. To analyses effect of sanitation and poor hygiene on diarrheal outbreak under five children
in Burao General Hospital
ii. To describe relationship between duration of breastfeeding and diarrheal outbreak under
five children of age in Burao General Hospital
iii. To assess relationship between contaminated food and water and diarrhea disease
outbreak under five children in Burco general hospital
14.2: Research questions
i: What is the effect of sanitation and poor hygiene on diarrheal outbreak under five children
in Burao general Hospital.
ii: What is the relationship between duration of breast feeding and diarrheal outbreak among
under five children of age in Burao General Hospital
iii. What are the relationship between contaminated food and water and diarrheal outbreak
among under five children in Burao general hospital

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1.6 Significance of Study
The beneficiaries of this study are Government Local administration; NGO Managers;
Academicians; Students, Researchers. Government benefit this study as a intervention
prevention and control of diarrheal outbreak by implementation of access to safe drinking-
water; use of improved sanitation; hand washing with soap; exclusive breastfeeding for the
first six months of life; good personal and food hygiene; health education about how
infections spread; and rotavirus vaccination.
NGO Managers promote national policies and investments that support case management of
diarrhea and its complications as well as increasing access to safe drinking-water and
sanitation in developing countries; conduct research to develop and test new diarrhea
prevention and control strategies in this area; build capacity in implementing preventive
interventions, including sanitation, source water improvements, and household water
treatment and safe storage; develop new health interventions, such as the rotavirus
immunization; and help to train health workers, especially at community level.
Local admiration they measuring level of diarrheal outbreak also which factor is more
cause the most diarrheal cases otherwise when a emergency acute diarrheal outbreak is
happen and there is no time to carry out primary data to investigate factors associated
diarrhea previous studies including this study it can be use implementation intervention of a
situation .
academic students’ academic student use this study by literature review or related study.
Researchers benefit this study to discover if there is any gab or weaknesses to search a
problem further and provide more findings about this study.
My self during a study I benefit more information about the factors influencing diarrhea
outbreak although many factors associated this disease but some of them are most health
affect also all the under-five children are vulnerable diarrheal disease but young after young
are most vulnerable

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1.7 Scope of Study
1.7.1 Geographical Scope
Somaliland is situated in northwestern Somalia. It is bordered by Djibouti to the west,
Ethiopia to the south, and the Puntland region of Somalia to the east.
Togdheer is bordered by from the north & west, while Ethiopia to the south, and eastern side
of the regions of Sanaag and Sool. With its capital at Burao (Burco), the region's name is
derived from the Togdheer River, which means "Long River" in Somali.
Burco, is the largest city in the Togdheer, Somaliland and also serves as the capital of
Togdheer region.
Buroa General Hospital (BGH) was established 1948 and it has many departments, surgical
departments, medical departments, Emergency department ,pediatric departments, radiology
department, laboratory departments and Obs/Gyn departments.it is located North for Burao
town in sha,ab area. Buroa General Hospital (BGH) is the Regional hospital in the togdheer
region, Buroa district Republic of Somaliland and also the teaching hospital for medical
universities and nursing schools .It is the largest referral hospital in Togdheer region where
many patients visit to seek medical services. {Jamayosuf, march 2020.
1.7.2 Time scope
This study is constrained to the assessment of risk factors diarrheal outbreak on under five
children in Burco general hospital Burco Somaliland. The study is carried out between the
months of February and September, 2020.

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1.8 Study variables
1.8.1. Dependent variables DV
The dependent variable for the study was the diarrhea outbreak of the children under five
years old.
1.8.2. Independent variables IV
The independent variables for the study included social-demographic, sanitation, hygiene,
breastfeeding, malnutrition, contaminated food and water.

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CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
Diarrheal disease is the second leading cause of death in children under five years old, and is
responsible for killing around 525 000 children every year. Diarrhea can last several days,
and can leave the body without the water and salts that are necessary for survival. In the past,
for most people, severe dehydration and fluid loss were the main causes of diarrhea deaths.
Now, other causes such as septic bacterial infections are likely to account for an increasing
proportion of all diarrhea-associated deaths. Children who are malnourished or have impaired
immunity as well as people living with HIV are most at risk of life-threatening diarrhea.
Diarrhea is defined as the passage of three or more loose or liquid stools per day (or more
frequent passage than is normal for the individual). Frequent passing of formed stools is not
diarrhea, nor is the passing of loose, "pasty" stools by breastfed babies. Diarrhea is usually a
symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial,
viral and parasitic organisms. Infection is spread through contaminated food or drinking-
water, or from person-to-person as a result of poor hygiene. Interventions to prevent diarrhea,
including safe drinking-water, use of improved sanitation and hand washing with soap can
reduce disease risk. Diarrhea should be treated with oral rehydration solution (ORS), a
solution of clean water, sugar and salt. In addition, a 10-14 day supplemental treatment
course of dispersible 20 mg zinc tablets shortens diarrhea duration and improves
outcomes.{WHO, 2017}
2.2 concepts
Diarrhea, also spelled diarrhea, is the condition of having at least three loose, liquid, or
watery bowel movements each day.{ Retrieved 9 July 2014.]
This can progress to decreased urination, loss of skin color, a fast heart rate, and a decrease in
responsiveness as it becomes more severe.[ Health Organization. April 2013] Loose but non-
watery stools in babies who are exclusively breastfed, however, are normal. The most
common cause is an infection of the intestines due to a virus, bacteria, or parasite—a
condition also known as gastroenteritis. These infections are often acquired from food or
water that has been contaminated by feces, or directly from another person who is infected.

9
The three types of diarrhea are: short duration watery diarrhea, short duration bloody
diarrhea, and persistent diarrhea (lasting more than two weeks, which can be either watery or
bloody).[April 9 WHO]
The short duration watery diarrhea may be due to cholera, although this is rare in the
developed world. If blood is present, it is also known as dysentery. A number of non-
infectious causes can result in diarrhea.[ Abdelmalak B, Doyle J, eds. (2013).] These include
lactose intolerance, irritable bowel syndrome, non-celiac gluten sensitivity, celiac disease,
inflammatory bowel disease such as ulcerative colitis, hyperthyroidism, bile acid diarrhea,
and a number of medications.[ Abdelmalak B, Doyle J, eds. (2013).][ Hadjivassiliou M, et al.
(February 2012).][ Slattery SA, (April 2014). et al (July 2015).] In most cases, stool cultures
to confirm the exact cause are not required.[ DuPont HL (April 2014).
Diarrhea can be prevented by improved sanitation, clean drinking water, and hand washing
with soap.[WHO , April 2014] Breastfeeding for at least six months and vaccination against
rotavirus is also recommended.[ Retrieved 9 July 2014. ] Oral rehydration solution (ORS)—
clean water with modest amounts of salts and sugar—is the treatment of choice. Zinc tablets
are also recommended. These treatments have been estimated to have saved 50 million
children in the past 25 years.[ WHO 8 November 2010] When people have diarrhea it is
recommended that they continue to eat healthy food and babies continue to be breastfed. If
commercial ORS is not available, homemade solutions may be used.[ Keystone JS (2012).]
In those with severe dehydration, intravenous fluids may be required. Most cases; however,
can be managed well with fluids by mouth.[ Acep 17 May 2014.] Antibiotics, while rarely
used, may be recommended in a few cases such as those who have bloody diarrhea and a high
fever, those with severe diarrhea following travelling, and those who grow specific bacteria
or parasites in their stool.[ DuPont HL (April 2014).] Loperamide may help decrease the
number of bowel movements but is not recommended in those with severe disease.[ The New
England Journal of Medicine.] About 1.7 to 5 billion cases of diarrhea occur per year.[2][
Abdelmalak B. (2013).][ Global Burden of Disease Study 2013]
It is most common in developing countries, where young children get diarrhea on average
three times a year.[2] Total deaths from diarrhea are estimated at 1.26 million in 2013—down
from 2.58 million in 1990.[12] In 2012, it was the second most common cause of deaths in
children younger than five (0.76 million or 11%).[WHO 9 July 2014][13] Frequent episodes
of diarrhea are also a common cause of malnutrition and the most common cause in those

10
younger than five years of age.[ WHO 9 July 2014] Other long term problems that can result
include stunted growth and poor intellectual development.[Global diarrhea burden 24 January
2013. ]
2.2.1. Factors associated with diarrheal disease
Infection: Diarrhoea is a symptom of infections caused by a host of bacterial, viral and
parasitic organisms, most of which are spread by faeces-contaminated water. Infection is
more common when there is a shortage of adequate sanitation and hygiene and safe water for
drinking, cooking and cleaning. Rotavirus and Escherichia coli, are the two most common
etiological agents of moderate-to-severe diarrhoea in low-income countries. Other pathogens
such as cryptosporidium and shigella species may also be important. Location-specific
etiologic patterns also need to be considered.{WHO,2017}
2.2.1.1 Infectious diarrhea
Diarrhea caused by enteric infections is a major factor in morbidity and mortality worldwide.
An estimated 2–4 billion episodes of infectious diarrhea occur each year and are especially
prevalent in infants This review highlights the cellular and molecular mechanisms underlying
diarrhea associated with the three classes of infectious agents, i.e., bacteria, viruses and
parasites. Several bacterial pathogens have been chosen as model organisms, including
Vibrio cholera as a classical example of secretory diarrhea, Clostridium difficult and Shigella
species as agents of inflammatory diarrhea and selected strains of pathogenic Escherichia coli
(E. coli) to discuss the recent advances in alteration of epithelial ion absorption. Many of the
recent studies addressing epithelial ion transport and barrier function have been carried out
using viruses and parasites.{WHO,2017}
2.2.1.2 Malnutrition
Malnutrition: Children who die from diarrhea often suffer from underlying malnutrition,
which makes them more vulnerable to diarrhea. Each diarrheal episode, in turn, makes their
malnutrition even worse. Diarrhea is a leading cause of malnutrition in children under five
years old.{WHO,2017}
2.2.1.3. Source of water
Source: Water contaminated with human faeces, for example, from sewage, septic tanks and
latrines, is of particular concern. Animal faeces also contain microorganisms that can cause
diarrhea.{WHO,2017}

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2.2.2 Diarrheal under five children
Diarrhea is characterized by loose, watery stools or a frequent need to have a bowel
movement. It usually lasts a few days and often disappears without any treatment. Diarrhea
can be acute or chronic. Acute diarrhea occurs when the condition lasts for one to two days.
You might experience diarrhea as a result of a viral or bacterial infection. Other times, it
could be due to food poisoning. There’s even a condition known as traveler’s diarrhea, which
happens when you have diarrhea after being exposed to bacteria or parasites while on
vacation in a developing nation. Acute diarrhea is fairly common.
Chronic diarrhea refers to diarrhea that lasts for at least four weeks. It’s usually the result of
an intestinal disease or disorder, such as celiac disease or Crohn’s disease. {WHO, 2018}
2.2.2.1 Dehydration
Dehydration is a loss of body fluids, which are made up of water and salts. When sick
children have diarrhea, they can lose large amounts of salts and water from their bodies, and
can become dehydrated very quickly. Dehydration can be very dangerous, especially for
babies and toddlers. Children can even die if they are not treated. {UNICEF, 2013}
2.2.2.2 Metabolic acidosis and fluid in balance
For patients with chronic diarrhea, obvious systemic consequences stem from the GI tract’s
inability to digest and absorb nutrients, with the specific nutrient deficiencies dictated by the
portion of the GI tract affected by disease. While it can be easy to pigeonhole the GI tract in
terms of its digestive and absorptive functions and think of it mostly in terms of how we get
nutrients from our food into our bodies, the GI tract also plays a significant role in fluid and
electrolyte regulation. Absorption and secretion along different segments of the digestive
tract, and that look included fluids and electrolytes, H+ and HCO3− among them. In the
words of Gennari and Weiss, “The gastrointestinal tract is a slumbering giant with regard to
acid-base homeostasis. Large amounts of H+ and HCO3− traverse the specialized epithelia of
the various components of the gut every day, but under normal conditions, only a small
amount of alkali (approximately 30 to 40 mmol) is lost in the stool.”1 This loss of
bicarbonate is usually readily offset by renal acid excretion; losing a bit of each keeps their
relative concentrations in balance and it's that balance that determines pH. That stool is
usually slightly alkaline and urine is usually slightly acidic, is part of what keeps our
bloodstream in its happy pH range of 7.35-7.45. But, disease of the digestive tract can cause
fluid loss and electrolyte shifts that overwhelm normal regulatory mechanisms, causing
hypovolemia, acid-base imbalance, and electrolyte disturbances.{WHO, 2013}

12
2.2.2.3 Growth catch up
The relation between infection and nutrition, and in particular the effect of diarrheal diseases
on childhood growth , has been intensively investigated. The short-term effects of diarrhea on
growth have been well documented. In fact, seminal work nearly 30 years ago in Santa
MaríaCauqué, Guatemala, suggested that diarrhea was a determinant of poor weight gain in
children. Subsequent community-based cohort studies in different geographic and social
settings have documented adverse effects of diarrhea on childhood growth, in terms of both
weight and height. However, the finding that recurrent episodes of acute diarrhea lead to
permanent growth retardation has been challenged by several reports suggesting that children
recover (catch up) from their early deficits (15–17). {WHO, 2013}
2.3 Theoretical Review
Diarrhoea is defined as having loose or watery stools at least three times per day, or more
frequently than normal for an individual (UNICEF/WHO, 2009). Acute diarrhea can lead to
significant fluid loss and dehydration which may result in death or other severe consequences
if fluids are not replaced at the first sign of diarrhea Rotavirus is the leading cause of acute
diarrhoea and is responsible for about 40 per cent of all hospital admissions due to diarrhoea
among children under five worldwide (UNICEF/WHO, 2009). Most pathogens that cause
diarrhoea share a similar mode of transmission; from the stool of one person to the mouth of
another (faecal-oral transmission) Pathogens may take different routes while travelling
between individuals, for instance through ingestion of water during drinking, food borne
transmission of faecal-oral pathogens as a result of poor hygiene. Actual exposure to diarrhea
pathogens occurs at the household or individual level although information on both the
exposure and risk is only available at the community orFamily and community practices.
Smith and Haddad (2000) built on UNICEF's framework for analysing the determinants of
child health and conceptualized two important routes for transmission of diseases (diarrhea)
to young children: the behaviors of the child and caregivers (mothers) and the health
environment including social organization and values (WHO, 1992). They argued that child
care practices and hygiene behaviors (both at the household and community level) can either
facilitate or interrupt faecal-oral transmission routes.{ Alberini, et al., 1996}(19%)
categorizes factors linked with the incidence and seventy of diarrhea into two;

13
economic/behavioral and engineering/infrastructure both of which are strongly intertwined
Economic/behavioral factors focus on household behaviors, relationship between appropriate
interventions and the resources and preferences of the households. Resources available to the
family and the community determine the access to which women have maternal and child
health care services while cultural set up influences health seeking behavior as explained in
the Mosley and Chen analytical framework for child survival. The engineering perspective on
the other hand, emphasizes more strongly on the need to provide households with a plentiful
and reliable supply of uncontaminated water and adequate sanitation services (Alberini et al,
1996).
It is widely recognized that exposure to diarrhoea pathogens in developing countries is
conditioned by such factors as socio-economic factors, household sanitary conditions,
nieghbouihood basic sanitation infrastructure, and child related or care related vanables (e.g.
hygiene behavior, anthropometric nutritional status, breastfeeding or intestinal parasitic
infections) (Teran, 1991, Diame, 1990; Timaeus and Lush, 1995; Ryland and Raggers. 1998;
Stallmgs, 2(X)4, Genser, Strina, Teles, Prado and Barreto, 2006). However, ascertaining
exposure to contamination has proved to be very challenging due to variability of
contamination in space and time and the number of contamination routes (Alberini et al.,
1996), creating the need for context specific studies which forms the basis of this research.
2.4 Related studies
The World Health Organization estimated that about 1.1billion people lack access to
improved drinking water and many more drink water that is grossly contaminated
WHO{2007}.Also1.8Million people die every year from diarrhea disease the vast majority
children under five. Studies examining water contamination show that safe storage can be an
effective barrier toward prevention of diarrhea diseases. {Rebort L et al ,2002} however
another study{ Jensen ,p. k et al , 2003} found that it was not enough to prevent occasional
extreme contamination of drinking water. With regards to Point of Use (POU) water quality
evaluation, four studies of flocculant disinfectant measured compliance through product
consumption 20 reported the biggest impact on diarrhoea.Studies on POU flocculants-
disinfectant on reduction of diarrhoea through a case control study. They found a big impact
on diarrhoea approximately 70% reductions as compared to controls. This reduction was
attributed by high compliance rate of refugees which was around 85%. 9Examination of bias
in POU water treatment trials, finding zero impact across five place controlled trials, three of
which were conducted in developing countries they concluded that there is no enough

14
evidence for widespread promotion of household water treatment Schmidt w. {caimcross s et
al 2009}
Some evidence linking the length of trials to reduced effectiveness of water chlorination
intervention. In this report the issue of sustainability of the technologies should be considered
when evaluating their effectiveness. There is therefore a considerable controvers as to the
scalability of the water quality interventions as well as the need for better understanding of
what determine use and performance in the long term {Arnold B. colfored j. 2007}.{ Boschi
pinto C.et al {2008}
In Rwanda it was found that low contamination in water measured at source but significantly
higher contamination levels at Point of use, also another study found a substantial
contamination in household water compared to source water arguing that the 10
recontamination is due to both household collection of water from multiple water sources and
partial recontamination of water in transport and storage , {Gasana, J., et al, 2002}{Kremer,
M. et al., 2009}
A meta-analysis of 32 studies supports the findings that water treatment at the point of use
(POU) particularly flocculation or disinfection is more effective in reducing risk to diarrhoea
disease than water source improvements {Clasen T, et al ,2007).
Three meta-analysis examine the impact of hand washing on diarrhoea risk analyzed {Wright
J, et al , 2003) studies and found that hand washing hygiene reduces the risk of diarrhoea by
50% 19 The World bank independent evaluation Group (IEG 2008:17) concluded that though
there is evidence on improvement of health outcome due to hand washing, sanitation and
point of use water treatment there is no health gain for water treatment at the source.
Interventions to improve water quality particularly when deployed at the household level are
effective means of preventing endemic diarrhoea diseases, a leading cause of mortality and
morbidity in developing countries. The laboratory assessment of gravity fed ultra -filtration
water treatment device at moderate turbidity of (15NTU) the device achievedlog10 reduction
values of 6.9 for Escherichia coli 4.7 for MS2 Coliphage and 3.6 Cryptosporidium oocyst
thus exceeding levels established for microbiological purifiers {Clasen T et al. ,2009).
The bio sand filters (BSF) is a promising household water treatment technology used by more
than 500,000 globally. Randomized study in 2009 to measure the effectiveness of bio sand
filters in reduction of diarrhoea during 6 month period in which 75 BSF households had

15
significantly improved drinking water quality on average as compared with 79 control
households (p<0.001), BSF households had 0.53 times the odds of diarrheal disease as
control household indicating a protective effect against water borne diarrhea disease73 Point
of use water treatment (HWTS) has been advocated as means to substantially decrease the
global burden of diarrhoea and to contribute to the Millennium development goals, however
there is no enough evidence on the acceptability and non-health benefits of the methods .
{Schmidt W, et al (2009).
The argument that the promotion of household water treatment (HWT) among poor
population by Schmidt WP et al is premature that there is no enough evidence for scale up.
This argument is puzzling because more than 850 million people in 58 low and middle
income countries already report treating water at home before drinking and this reduces
morbidity and mortality due to diarrhea {Clasen T et al. 2009).
The reduction of indicator organisms were observed to be slightly higher in households that
used chlorination no significant differences were seen between households with no chlorine
(1.5log10 median reduction for chlorinated households and 0.31-0.55log10 for non-
chlorinated households thus demonstrating less effectiveness of chlorine under field condition
as compared to laboratory condition. This is because of human factors such as improper
storage and chlorine dosing Laura A et al{2009} The study done in 2009 concluded that
further research is need on home water treatment. Technologies used at local level and their
effectiveness on water borne diseases {Wright J, et al .2003).
Diarrheal-related diseases rank high among the top ten diseases and about 54% of diseases
diagnosed and treated in health facilities are water, sanitation and hygiene related According
to Tanzania Ministry of Health and social Welfare report diarrhea was the fourth contributor
of Outpatient visit and the fifth cause of Mortality among children under the age of five years
in the year 2009 67 Data is scarce on factors associated with diarrhoea in relation to
household water treatment. Methods employed at local level and their relationship with
bacterial quality of water.
Several studies have been done on diarrhoea incidences and prevalence in several parts of the
world especially in Asia, Sub-Saharan Africa and South America where the disease is still a
leading cause of mortality and morbidity particularly among children below five years. Most
of the studies have investigated longitudinal factors associated with childhood diarrhoea

16
though very few studies have investigated the dynamic features and hierarchical
interrelationships among the potential risk factors (Genser et ai . 2006)
Most of the studies have generalized findings for all the children below five years with only
a few dealing with a particular age group. Authors have justified such studies by noting that
some of the risk factors are modified as children age hence the need to study all the children
below five years and not just those with the highest risk of contracting diarrhea (WHO ,
20007}
2.4. 1Relationship between Nutrition and Diarrhea
The interaction between malnutrition and diarrheal diseases, as for most infections, is
bidirectional; that is, the nutritional state alters the host response to infection and infectious
illness alters nutritional state (Scrimshaw et al., 1968).
When infections are frequent, especially recurrent diarrheal diseases, the interaction may
become circular, with an increasing frequency of infection and a parallel and progressive
deterioration in host nutritional status that proceeds to overt protein energy malnutrition if the
cycle is not interrupted (Keusch and Scrimshaw, 1986).
Acute, repetitive, or chronic infections are invariably the cause of some degree of nutrient
losses due to associated anorexia, catabolism of nutrient stores, and malabsorption due to
intestinal infection. Nutritional losses occur in virtually all infected hosts, regardless of their
nutritional status at the outset, but the consequences are most visible in those with the least
ability to replace the losses. These losses can be exacerbated by the withdrawal of food
during the infection and by the usual lack of suitable foods in developing countries that
should be fed to convalescents (Beisel, 1977; Keusch and Scrimshaw, 1986; Watson, 1984).
Evidence that malnutrition predisposes the host to diarrheal disease most studies attempting
to investigate whether malnutrition predisposes the host to diarrheal diseases has used
anthropometric measures as the indicator of nutritional status. The reported outcome
measures, such as incidence, duration, or some measure of seventy of diarrhea, have been
more variable. Although it is necessary to control the studies for poverty (which Suggested
Citation:"3 Relationships between Nutrition and Diarrhea." Institute of Medicine. 1992.
Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases, Part II: Diet and
Activity during Pregnancy and Lactation. Can affect both food availability and nutritional
status, sometimes in a seasonal fashion), as well as for environmental factors that govern

17
transmission (including the level of sanitation, hygienic practices, water availability, and
others), this is not commonly done, because resistance to infection is graded rather than being
an all or none phenomenon. Therefore, clinical disease can occur in relatively immune
competent hosts from an inoculum large enough to overcome host defenses. Recent studies
have attempted to control for these variables. The results reveal a consistent finding that
malnutrition has an adverse effect on diarrheal disease, however there is little consistency
from study to study as to the diarrheal disease parameter that is affected. For example,
Tomkins (1981) assessed the attack rate and prevalence of diarrhea in 343 Nigerian children,
aged 6–32 months, who were observed closely for 3 months. No difference in attack rate was
observed between the better nourished children and those with either less than 75 percent of
the weight-for-age or less than 90 percent of the height-for-age standard. In contrast, the
attack rate was significantly greater in children with less than 80 percent weight-for-height (P
< 0.01). On average, the duration of diarrhea appears longer in wasted children. They were
clinically ill with diarrhea 13.6 percent of the time compared with 7.6 percent of the time for
the better nourished children (P < 0.01). {Tomkins 1981)
Assumed exposure to pathogens was similar in all children because they drank the same well
water and consumed food that was contaminated to a similar degree with Escherichia coli.
Thus he concluded that differences in attack rates and number of illness days were
attributable to nutritional state and that malnutrition resulted in impaired resistance to enteric
pathogens. A more recent well-controlled cohort study of children less than 2 years of age
was conducted in Mexico by {Sepulveda et al. (1988).
Subjects were selected by their weight-for-age, morbidity was determined by weekly home
visits, and confounding variables (including seasonal, demographic, and socioeconomic
parameters) were controlled. The incidence of diarrhea in children who were poorly
nourished (60–75 percent of the weight-for-age standard) increased by 80 percent over that in
children who were initially found to be greater than 90 percent of weight-for-age. In addition,
malnourished children were more likely to experience multiple episodes of diarrhea, even
though no difference in the duration of diarrhea was noted. Black et al. (1984b) studied the
relationship of nutritional status and subsequent diarrheal disease morbidity in 197
Bangladeshi children in a longitudinal, community-based investigation. An important feature
of this study was the separation of subjects by etiology of the diarrhea. No difference in
disease incidence was detected among groups that were distinguished by nutritional status;

18
however, the duration of illness was 56 Suggested Citation:"3 percent longer in those infants
with weight-for-length of less than 80 percent of the median National Center for Health
Statistics (NCHS) standard compared with that in infants who were greater than 90 percent of
this bench mark. The effect was also most evident in patients with documented shigellosis or
enter toxigenic E. coli infections. The mean duration of illness in patients infected with
Shigella was 22.2 days compared with 8.8 days in patients in the non-Shigella-infected group.
Black et al. (1984a) concluded that the increased duration of diarrhea could explain the well-
known increase in diarrheal disease prevalence in malnourished children, with no change in
incidence being attributable to poor nutrition. The conclusions are supported by similar data
obtained in a more recent study in the same area of Bangladesh (Bairagi et al., 1987).
Intervention studies represent another source of available data for evaluation of the
relationship between nutritional status and susceptibility to diarrheal disease. {Feachem
1983)
Recently reviewed this topic and found that results of most available studies are inconclusive
because the study designs did not allow discrimination between the preventative and the
therapeutic effects of feeding on malnutrition associated with diarrheal disease. Because of
the close association between diarrheal disease and growth faltering (Black et al., 1984}{a;
Guerrant et al., 1983),
it is difficult to make this distinction, especially in populations with a high burden of
infection (James, 1972; Trowbridge et al., 1981), where crowding, poor sanitation and
personal hygiene, poverty, and inadequate access to health care all contribute to perpetuating
both the high prevalence of infection in general and diarrhea in particular .Nutritional status
can potentially influence the severity of diarrheal diseases. Definition of severity is arbitrary,
however, and no consistent criteria have been applied in different studies. The stool purging
rate in children with enterotoxigenic E. coli or rotavirus infection was inversely related to
weight-or length-for-age in Bangladeshi children (Black et al., 1984b).
This observation is consistent with the more frequent occurrence of severe dehydration in
children with rotavirus diarrhea with a low weight-for-age (Black et al., 1984a).Another
criterion of severity is mortality rate. The relevant question is whether there is an association
between mortality from diarrhea and nutritional state. An often cited major review of
mortality in Latin America concluded that about three-fifths of the infection-related deaths

19
(including those as a result of diarrheal diseases and other infections) in children under 5
years of age occurred in malnourished children, whereas one-third of deaths from other,
noninfectious causes were in poorly nourished children (Puffer and Serrano, 1973).
Similar data have been reported from Bangladesh and India (Chen et al., 1980; Kielmann and
McCord, 1978). Diarrhea- specific deaths were tallied separately, irk the Bangladesh study,
and a child with a weight-for-age of less than 65 percent of the standard was 3.7 times more
likely to die with diarrhea during the following 24 months than children with a better initial
nutritional status. In northern India case fatality rates were 3.5 times higher in severely
malnourished children than moderately malnourished children, but this level was nearly 20
times higher than the rate for mildly malnourished and well-nourished subjects to gather
(Bhan et al., 1986). In addition, {Briend et al. 1987) showed that malnutrition, as indicated by
mid-upper-arm circumference (MUAC) measurements, is a strong predictor of mortality
within a month of the measurement (relative risk of 20), achieving a specificity of 94 percent
and a sensitivity of 56 percent with a MUAC cutoff of less than 110 mm. In the same
population, diarrhea was independently associated with a relative risk of death of 4.8, with a
specificity of 87 percent and a sensitivity of 42 percent; deaths were almost entirely
associated with bloody diarrhea or there was a prolonged duration of greater than 1 week.
Causes of death were not assessed in this population. Mortality data from hospitalized
children show the same trends; however, these data are likely to be biased because of the
admission of children with more clinically severe cases of diarrhea to the hospital. A study
from Bangladesh used multivariate analysis to evaluate the risk factors for death in children
with diarrheal disease (Samadi et al., 1985).
Increased mortality was associated with malnutrition, and all of the increased risk was
accounted for by the use of hyponatremia as a criterion. Case fatality rates were also higher
among patients with Shigella infection, which was more frequently associated with
malnutrition than was infection from other pathogens (Islam and Shahid, 1986).
Deaths in patients with shigellosis also correlate with bacteremia in hospitalized patients;
deaths were caused by either the infecting pathogen itself or other gram-negative organisms
(Struelens et al., 1985). Bacteremia is, in turn, associated with age (patients who are less than
1 year of age), weaning, and nutritional status. Finally, a close relationship between mortality
during an episode of diarrhea and nutritional state on admission, as assessed by MUAC, has
been shown in Bangladeshi children (Briend et al., 1986).

20
Nutritional factors are known to affect immunologic function. Several reviews have
documented and evaluated published data (Chandra and Newberne, 1977; Keusch and
Farthing, 1986; Keusch et al., 1983; Watson, 1984). While the mechanisms and specific
nutritional causes are not yet clear, there is general agreement that single or multiple deficits
in immune function do occur in malnourished hosts. Moreover, a consistent pattern of
immunologic defects is found in the malnourished subjects, including depressed cell-
mediated immunity, as indicated by energy to delayed-type hypersensitivity antigens in vivo;
a reduction in the number of circulating lymphocytes and impaired in vitro responses to
mitogens and specific antigens; diminished activity of the serum complement system,
particularly activation via the alternative pathway; and a reduction in the mucosal secretory
immunoglobulin A (IgA) concentration and specific antibody activity. These various
functional alterations are associated with maturational arrest of T cells at the level of the
thymus gland, increased in vivo degradation and reduced synthesis of serum complement,
and impaired production of IgA. Defects in cell-mediated and/or mucosal immunity could
have important effects on host susceptibility to diarrheal disease pathogens. A direct
relationship between skin test reactivity to a panel of antigens and the subsequent morbidity
from diarrheal diseases in malnourished Bangladeshi children has been reported by{ Koster
et al. 1987).
Nutritional deficits without energy did not explain any of the variance not attributable to
malnutrition with energy. It is not difficult to demonstrate that infections cause deterioration
in nutritional status. {Mata .1978) carried out prospective studies of growth and disease in a
cohort of Mayan Indian children who were studied intensively from birth to 3 years of age.
Diarrheal diseases were very frequent and were strongly associated with diminished food
intake and growth faltering. Using similar methods {Mata .1980)
Found that in comparison, the Guaymi Indians in Costa Rica, who consumed a diet similar to
that of the Mayans that was inadequate in energy and protein, had lower morbidity rates due
to diarrhea and better growth. Other field studies support the contention that infection exerts a
significant negative influence on nutritional status. For example, {Rowland et al. ,1977)
found that diarrheal disease in The Gambia, West Africa, is the major cause of growth
retardation in young children, resulting in a 50 percent decrease in expected monthly weight
gain during the first few years of life. Diarrhea prevalence was associated with a significant
decrement in both linear growth and weight gain. Rowland and colleagues calculated that if

21
diarrhea had not been present, the children would have grown at a velocity equivalent to that
of the NCHS reference population. {Black et al. 1984)
Also found a similar decrease in expected weight gain (34 percent) in Bangladeshi infants
during periods of high diarrheal disease prevalence. The magnitude of the growth faltering
associated with diarrhea is variable and may depend on the age of the individual, the season,
the etiologic agent, dietary intake, and food preparation and feeding practices. Such factors
may vary from place to place. Thus, a significant effect of age was noted by {Martorell et al.,
1975) in Guatemala, but not by {Rowland et al. 1977)
In The Gambia. Rowland et al. (1977) also reported that the effect of diarrhea on weight gain
was least apparent during the months of highest diarrheal disease prevalence, when all
children grew poorly, regardless of the presence of diarrhea. These observations suggest that
other seasonal factors have a greater adverse influence on growth than diarrheal disease does.
Comparisons of morbidity between human milk-fed and formula-fed infants have
demonstrated that there are significantly fewer or less severe illnesses in breastfed infants
(Cunningham, 1979; Duffy et al., 1986; Grulee et al., 1934; Mata et al., 1967; Woodbury,
1922), and a few studies have found no differences (Adebonojo, 1972; Fergusson et al., 1978;
NRC, 1972), but no researchers have reported increases in morbidity among human milk-fed
groups (Feachem and Koblinsky, 1984).
Breastfeeding also protects against mortality (Briend et al., 1988; Victora et al., 1987). Most
studies associate the lowest morbidities in those who are exclusively breastfed and the
highest rates of illness in those who are completely weaned. Morbidity in partially breastfed
infants lies between those extremes (Butz et al., 1984; Habicht et al., 1986).
In one longitudinal study, estimates of the potential impact of exclusive breastfeeding on
rates of diarrhea during the first 6 months of life showed that interventions that successfully
motivate adoption of this feeding practice could dramatically reduce infant morbidity.
Continued breastfeeding for more than 6 months, although not practiced exclusively, was still
associated with reduced risk of illness. The protective effect of breastfeeding may be
explained by reduced exposure to fecally contaminated foods and feeding utensils or by the
anti-infective components of breast milk. Also, growth factors that are present in human milk
may hasten intestinal mucosal renewal and recovery from enteric infections. The benefit
provided by breastfeeding was of greater magnitude for diarrheal prevalence than for

22
incidence (Brown et al., 1989). This suggests that breastfeeding not only lessens the risk of
new illnesses but also shortens the duration of those illnesses that occur. This phenomenon
might be explained by the ingestion of a smaller infectious dose of pathogens by more
intensively breastfed infants, by more rapid recovery from the infection, or by reduced
infection-induced malabsorption and secondary diarrhea. In one clinical study, stool volume
was reduced among breastfed infants with diarrhea compared with that among infants whose
breastfeeding was discontinued during the early phase of therapy; these observations suggest
that breast milk itself may reduce the severity of illness and hasten recovery (Khin-Maung-U
et al., 1985).
Nonetheless, data presented in favor of human milk's direct protective effects are disputed
because of confounding environmental and demographic variables that are difficult to control
(Bauchner et al., 1986; Habicht et al., 1986), e.g., the degree of preventable contamination of
other infant foods, the number of caretakers with whom the index child has contact, and the
behavioral characteristics of the caretaker. Each of these variables is a potential determinant
of morbidity. Three mechanisms have been proposed by which human milk constituents
directly protect the infant from infection. Two are based on the immunologic factors in
human milk, and the third is based on human milk's high nutritive value. The relative
protective contributions of human milk's immunologic and nutrient constituents are difficult
to estimate. Potentially protective proteins in human milk can be classified into antigen-
specific and non-antigen-specific agents. They have been the subject of numerous reviews
(Goldman and Goldblum, 1985; Welsh and May, 1979).
The major functioning important whey proteins are lactoferrin and sIgA. Lactoferrin is a non-
antigen-specific factor. It binds iron avidly, and thereby presumably limits iron availability to
bacteria (Griffiths and Humphreys, 1977). Lactoferrin may also modulate inflammatory
responses by inhibiting complement (Goldman et al., 1986), and has been reported to act
synergistically with sIgA to enhance the antibacterial effects of peroxidase (Moldoveanu et
al., 1982).
Secretory IgA is the major antigen-specific component in human milk Specific activity
against a wide array of enteric and respiratory bacterial and viral pathogens is found in
human milk (Goldman and Goldblum, 1995). The attachment of sIgA to the glycocalyx of
epithelial cells in the microvilli of the small intestine may block the attachment to the
intestinal tract by infectious agents (Nagura et al., 1978). The concentrations of most

23
immunologically active proteins appear to fall after the first 2 or 3 months of lactation and
subsequently either rise (e.g., lysozyme) or remain stable(e.g., lactoferrin and sIgA).
Immunoprotein concentrations generally rise or remain constant after the onset of gradual
weaning (Goldman et al., 1983).
Growth factors also have been identified in human milk (Klagsbrun, 1978; Moran et al.,
1983). These factors may promote the maturation of the infant's gastrointestinal epithelium,
and thereby augment mucosal barriers against the penetration of the gastrointestinal tract by
antigens. The relationships among breastfeeding, specific anti-pathogen activities in human
milk, and specific enteric illnesses have not been examined completely. Breastfeeding
appears to ameliorate shigellosis (Mata et al., 1967).
Although the evidence is mixed, rotaviral diarrhea appears to be milder in breastfed infants,
and not all anti-rotaviral activity is associated with specific antigenic properties (Duffy et al.,
1986). Cholera and infections with Giardia lamblia are less likely in infants of women with
high titers of specific sIgA in their milk (Glass et al., 1983; Nayak et al., 1987).
The enhancement of lactation performance is expected to minimize the need for
supplementary foods to meet the nutrient requirements of infants and to maximize the
protection afforded in the practice of breastfeeding and the immunologic constituents of
human milk. Lactation performance is defined from measurements of the quality and volume
of milk that is produced, the duration of adequate milk production, and/or infant growth.
Available studies suggest that milk volume is more sensitive to maternal nutritional status
than is milk composition (Garza and Butte, 1985).
Most studies have focused on total nitrogen, lactose, and fat. Few studies have measured
micronutrients in milk produced by women whose nutritional status has been documented
carefully (Lönnerdal, 1986). Nonbehavioral maternal and environmental factors that may
influence the duration of lactation also have received limited attention. Generally, the fatty
acid composition and the concentrations of the fat-and water-soluble vitamins of milk are
affected most by diet. Protein concentrations are influenced by selected dietary conditions,
but the effects appear to be relatively limited. Lactose, mineral, trace element, and electrolyte
concentrations appear to be relatively resistant to wide variations in maternal intakes. Effects
of Maternal Nutritional Status on Lactation Performance A relationship between maternal
nutritional status and lactation performance has been demonstrated among poorly nourished

24
women. Longitudinal studies of poorly nourished, lactating Bangladeshi mothers from an
underprivileged, per urban community demonstrated that average milk production and fat and
energy concentrations in milk were similar to those described for well-nourished women. Fat
and energy concentrations in milk and the amounts produced per day were greater in women
with larger triceps skinfold thickness, or arm circumference; and increases in body weight
were associated with increases in the amounts of milk and all macronutrients produced. Milk
production, however, declined significantly before the major harvest period, when food was
least available (Brown et al., 1986).(Manjrekar et al. 1985)
found that women who consumed 1,100 to 1,500 kcal/day produced insufficient volumes of
milk within the first 4 months of lactation. Women who delivered low-birth weight infants
produced insufficient milk volumes by 2 months postpartum. This and other similar studies,
however, are complicated by the early return of women to work outside the home whereby
the frequency of breastfeeding must be reduced or breastfeeding must be stopped entirely.The
effects on lactation performance of superimposing high levels of activity on a woman with a
marginal nutritional status were investigated in The Gambia. Breast milk composition
remained relatively stable through an periods of the year, but breast milk output was minimal
during the farming season, when activity was highest. Reductions in milk output of up to 10
percent were observed in mothers 3 to 12 months postpartum who kept their infants with
them while they worked outside the home; reductions of 25 percent were seen in mothers
who were separated from their older infants during the work day (Roberts et al., 1982).
Impaired lactation performance may result from heightened activity, shortfalls in nutrient
intakes during periods of intense work, or maternal and infant separation.In well-nourished
women with Western life-styles, successful lactation is compatible with gradual weight
reduction and energy intakes of approximately 2,200 kcal/day. The mother's dietary protein,
carbohydrate, and fat intake apparently has no detectable impact on milk quantity. Milk fat
composition is influenced by dietary fat. Most studies of well-nourished women report no
significant interactions between milk quantity and quality and maternal weight, height,
metabolic size, body surface area, change in body fat, prepregnancy weight, and weight gain
during pregnancy (Butte et al., 1984b). Effects of Food Supplementation, on Lactation
Performance Several studies have examined the effects of food supplementation on lactation
performance (Forsum and Lönnerdal, 1980; Girija et al., 1984; Gopalan, 1958).

25
The body of information neither supports nor refutes a positive effect from this type of
intervention. Failure to control complex intervening variables in supplemental trials accounts
substantially for the present state of knowledge. Variations in the degree of malnutrition or
under nutrition, differences in the quantity and quality of the supplement used, the difficulty
in measuring compliance, the possibility that the supplement is used to replace rather than
augment dietary intake, and the wide variability in protocols make available studies difficult
to evaluate. In studies conducted in India, women with baseline diets of 1,700 kcal/day and
40 g of protein/day were provided food supplements that contributed an added 30 g of protein
and 417 kcal/day. Differences in the milk yield of supplemented and un supplemented
women were noted, but only from the third month postpartum on. After that time, the
supplemented group produced 30 percent more milk than control women (Girija et al., 1984).
Studies in animals also have shown a positive influence of supplements during lactation. Not
all studies, however, have concluded that improvements in maternal intakes lead to enhanced
milk production. In studies of Gambian women with baseline diets of approximately 1,600
kcal/day, approximately 700 kcal/day was added to the diet. No changes in milk production
were detected (Prentice et al., 1983) in supplemented groups. Data from protein
supplementation trials published by Edozien et al. (1976),
{Forsum and Lönnerdal (1980), and { Gopalan (1958) suggest that protein supplementation
increases milk volume. The specificity of protein for increasing milk volume, however, is not
certain. Gopalan (1958) attempted to control one confounding variable, energy intake. Energy
consumption was maintained at 2,900 kcal/day both before and after protein supplementation.
A positive effect on milk volume was reported with protein supplementation.Manipulation of
Immunologic Protein Factors in Human Milk Maternal nutritional status appears to influence
the concentrations and total amounts of immunologically active proteins produced in human
milk, but available data are inconsistent. Some studies report decreases in the concentrations
of immunological protein in the milk of undernourished women (Miranda et al., 1983),
whereas others find no differences between such women and control women (Cruz et al.,
1982). Nevertheless, the significant reductions in milk volume that are expected with
maternal under nutrition would reduce the protective effects of human milk if the efficacy of
immunological proteins is dose-related. No effective means of enhancing the concentrations
of nonspecific protective components in human milk have been identified. While the
specificity of IgA in human milk depends on the mother's antigenic exposure, the mechanism

26
responsible for the presence of specific IgA in human milk is understood only partially, and a
successful strategy for the enhancement of specific IgA levels directed against enteric
pathogens has not been demonstrated in humans. Following the period during which
exclusive breastfeeding can support adequate growth, improvement in the nutritional status of
target populations through feeding interventions requires the timely introduction of nutritious
complementary foods and improved dietary therapy of common childhood illnesses. Planning
each of these interventions requires, in turn, knowledge of locally available foods; the
nutritional content and quality of these foods; and the social, economic, cultural, and seasonal
constraints to their appropriate use under different circumstances.The nutrient compositions
of foods can be measured by standard analytic techniques and are usually expressed per unit
weight of raw edible portions. Although the data base for food composition is constantly
expanding, information is currently available primarily for macronutrients (protein, fat, and
carbohydrate), total metabolizable energy (''calories''), and selected vitamins and minerals
(Rand, 1985).
Additional tables of amino acid content, carbohydrate profiles (sugars, starches, and
nonstarch polysaccharides or fiber), fatty acid composition, and trace element concentrations
of limited numbers of foods are also becoming available or are under development. Food
composition tables have been prepared for different regions of the world. These composition
tables consider locally available and commonly consumed products.Unfortunately only small
numbers of samples have been analyzed for each type of food, and it has been found that the
nutrient compositions of individual foods vary greatly. Thus, food composition tables—
although indispensable for planning diets—provide fairly crude guidelines of the actual
amounts of nutrients consumed (Cameron and Hofvander, 1983).
The major nutrient sources are (1) the staple foods, which provide the majority of energy and
protein as well as some vitamins and minerals; (2) fruits and vegetables, which are important
additional sources of vitamins and minerals; (3) animal products, which can supplement the
amount and quality of dietary protein, specific vitamins, and minerals; and fats, oils, and
sugars, which can enhance the energy density of mixed diets. The staple foods include
cereals, such as wheat, rice, maize, and millet; roots and tubers, such as white potatoes, sweet
potatoes, yams, and cassavas; and pulses or legumes, such as peas, beans, and ground
nuts.Cereals are composed mostly of carbohydrate (primarily starch and non-starch
polysaccharides), protein (at a level between 6 and 14 percent of dry weight), and little fat.

27
Nutrients are not distributed equally throughout the anatomic structures of grains, so the final
nutrient composition of a cereal product depends on the degree of milling and other types of
food processing (see Chapter 5).
The outer layers of the grain contain relatively higher concentrations of protein, vitamins, and
fiber, whereas the endosperm is generally higher in starch. The germ is relatively rich in
protein, fat, and some vitamins. The water-soluble vitamins of the husk can be partially
transferred to the endosperm by parboiling, which also improves the storage characteristics of
the grain. Cereals are important quantitative sources of protein, but their protein quality is
limited by the inadequate content of selected essential amino acids (WHO, 1985).
Tubers, like cereals, have a high starch content and may contain reasonably good levels of
protein. However, the water content of unprocessed roots and tubers is substantially greater
than that for cereals. While the concentration of nutrients per unit of raw weight of tubers is
lower than that for cereals, the ratio of protein to energy for some tubers, such as white
potatoes, may be similar to that for some cereals. On the other hand, cassava is very low in
protein, and the limited amount of protein it contains is of poor quality. Unlike the cereals,
fresh tubers contain sizable quantities of ascorbic acid. Legumes are rich in protein and starch
and can be good sources of calcium, iron, and B vitamins. Some (e.g., soybean and
groundnuts) are excellent sources of edible oils. Although dry legumes contain between 20
and 40 percent protein, the digestibility and quality of the protein can be restricted,
respectively, by the presence of protease inhibitors and by a relative deficiency of the
essential amino acid methionine. However, the relative excess of lysine in legumes makes
them excellent complementary protein sources for the cereals, which in turn can compensate
for the inadequate levels of methionine in the legumes (Bressani, 1977).
Sufficient amounts of legumes are provided to overcome the reduced digestibility of
vegetable diets, appropriate mixtures of these vegetable protein sources can yield diets with a
protein quality that is indistinguishable from that of reference animal protein. Fruits and
vegetables are primarily valued as sources of vitamins and minerals. Dark pigmented fruits
and vegetables are major sources of vitamin A precursors and provide ascorbic acid, folic
acid, other B vitamins, iron, and other minerals. Dairy products contain readily digestible
protein of excellent quality and are rich in calcium and vitamins. Animal products are the
only food source of vitamin B12. These foods tend to be expensive, and they often contain
lactose, which may not be well tolerated in amounts greater than 1 g/kg per feeding when

28
provided as the sole source of nutrients for children with diarrhea. However, milk is generally
well tolerated when mixed in small amounts with staple foods, even by children with diarrhea
and by children with clinical evidence of lactose malabsorption (Brown et al., 1980).
Because only small amounts of these products are required to improve protein quality and
content of the diet, the issue of cost and lactose intolerance may not be an important limiting
factor for their use in a mixed diet. Because the bulkiness of the diet may limit the amounts of
nutrients that are consumed, separated fats and oils that contain high amounts of energy per
unit volume can make a valuable contribution to the diet. Likewise, sugars can be considered
dense in energy since they can enter into solution, thereby adding energy to liquid or
semiliquid diets without increasing their volume. Current recommendations to lower the
consumption of fat and cholesterol to reduce the risk of cardiovascular disease is of little
concern to most people in developing countries, where the intakes of fats and animal products
are extremely low after the period of weaning. When fat intakes beyond infancy are greater
than 30 percent of dietary energy and a substantial proportion of the fat is provided by
saturated fatty acids (as in animal fats, coconut oil, and palm oil), some consideration of the
possible cardiovascular risk is warranted. The quality of the mixed diet is a function of the
nutrient content of the diet and the bioavailability of its nutrients. The bioavailability of
nutrients, which can be defined simply as the efficiency of absorption and utilization or
retention of the nutrients that are present in food, can vary substantially and has often not
been well characterized. It is determined in part by nutrient content, food processing, the
physiological status of the host, Age-specific nutrient requirements and recommended intakes
or allowances are published by national and international authorities (WHO, 1985; NRC,
1980).
Recommended allowances of all nutrients except energy are calculated by estimating average
population requirements and by adding a quantity to account for individual variability and
bioavailability from usual food sources. Recommended intakes of energy usually are
calculated by a factorial approach, which is the sum of average estimates of the needs for
maintenance, growth, and activity. Nutrient needs during periods of catch-up growth (5–8
kcal and approximately 0.4 g of protein per gram of desired gain of lean body mass) are
reasonable supplements to baseline requirements if accelerated growth is desirable during
illness-free intervals (NRC, 1985). Estimates of energy intake for a range of weight gains
during convalescence have been published (NRC, 1985).

29
The recommended intakes of most micronutrients are likely sufficient for adequate growth
unless micronutrient deficiency states are present. Estimates of nutrient needs calculated from
recommended levels of intake, however, should not be used by themselves as a target of
strategies to ameliorate or prevent enteric disease. Rather, the morbidity and growth response
of the child should be used to monitor the adequacy of general food safety and dietary intake.
Until recently, little information has been available regarding the relationship between growth
during infancy and the normal volumes and composition of human milk consumed in the first
4 to 6 months of life by breastfed infants (Butte et al., 1984b; Chandra, 1981; Dewey and
Lönnerdal, 1982; Picianno et al., 1981). This has prevented the resolution of apparent
discrepancies between the projected volumes of milk required to meet energy and protein
requirements estimated by factorial approaches and the volumes of milk consumed by
apparently healthy infants (Water low and Thomson, 1979).
With few exceptions, the milk intake of infants of well-nourished women range from 600 to
900 ml/day. Well-nourished, breastfed infants consume approximately 100 to 120 kcal/kg
during the first month of life; their energy intakes decrease to approximately 70 to 90 kcal/kg
by the fourth month and appear to remain at that level for at least 8 to 9 months, even after
solid foods are added to their diet. Those energy intakes appear to be substantially lower than
the intakes of formula-fed infants (Fomon et al., 1971; Montandon et al., 1986).
Most recent studies of infants who live in favorable environments indicate that the
exclusively breastfed infant's weight-for-age, weight-for-length, and less frequently, length-
for-age percentiles demonstrate statistically significant negative trends after the third month
of postnatal life (Butte et al., 1984a; Garza et al., 1987; Hitchcock et al., 1985).
Generally, cohorts of breastfed infants appear to gain weight during the first 2 to 3 months of
life at a more rapid rate than is expected on the basis of the NCHS reference population. In
later months infants appear to reduce the rate of weight gain relative to that of the reference
population, even when supplementary foods are available ad libitum. Although such trends
commonly are not sufficiently severe in economically developed countries to arouse clinical
concern, they support the view that human milk may become limiting by the third or fourth
month of life (Waterlow and Thomson, 1979). That conclusion, however, is based on the
acceptance of NCHS growth curves as normative standards, despite their derivation from
observations of infants who were principally formula-fed. The general persistence of negative
trends in growth percentiles of breastfed infants whose diets are supplemented ad libitum

30
with solid foods and who live in favorable environments suggests that NCHS growth curves
may not be appropriate and that as a result health practitioners may identify growth faltering
prematurely. An important caveat in this discussion is that there are no convincing data to
show that infants in areas with high endemic rates of enteric infections can maintain
comparable rates of growth as their counterparts in more privileged environments, when both
groups of infants consume similar amounts of human milk. If the effects of unsanitary
environments on infant health are to be compensated for by specific human milk constituents,
infants must provide sufficient stimulation to the breast to increase milk production when
needed, and the mammary glands' response to the infant and the environment must be timely.
Failure by either mother or infant may result in progressive nutrient deficits. Most data from
economically developing countries indicate that milk volumes and contents are similar or
lower than those observed in economically developed settings (Brown et al., 1986; Jelliffe
and Jelliffe, 1978; Prentice et al., 1983).
2.4.2 Diarrhea among under five and water treatment
Diarrhea disease accounted for 4.6 Billion cases and 2.16 Million deaths worldwide in the
year 2004 of which more than 50% were from low income countries and most of the cases
were children under five years. In the year 2004, one of the two leading cause of burden of
disease was diarrhea, also diarrhea accounted for 32,203,037 DALYS in Africa and the
majority of which are children under the age of Five years 61 .Also in meta-analysis of 60
studies of diarrhea morbidity and mortality in between1990 to 2000 diarrhea accounted for
21% of all deaths of children under five years annually and mostly from developing countries
{Kosek M, et al 2000}
Africa and South East Asia countries accounted for 75% of all deaths; Tanzania according to
Boschi-Pinto { Boschi-Pinto, C. et al 2008} was among the 15 countries that accounted for
75% of all deaths. World health organization estimates that 88% of all diarrhea diseases are
due to unsafe water supply, inadequate sanitation and poor hygiene practices. For the year
2002 alone an estimated 1.1billion people lacked access to improved water sources {Doocy
S, et al G (2006).
It was found that infectious agents associated with diarrhea are transmitted mainly through
faecaloral routes, which are bacteria, viruses and protozoa excreted in the human faeces
causes’ diarrhea{Byers KE. Et al 2001} Also most of the pathogens that cause diarrhea are
transmitted through ingestion of contaminated water {LECLERC, H.,et al 2001 }. Experts in

31
water quality and safety have developed many interventions for water treatment, these
include Physical removal of pathogens (Filtration, adsorption and Let it stand and settle),
Chemical treatment (assisted Let it stand and settle, chemical disinfection and ion exchange),
heat and ultra violet UV radiation {WHO 199}.
These efforts of improving the quality of water also included steps of maintaining residual
disinfection and improved storage thus the United Nations Mission of reducing to half of the
1.5billion people without access to safe water (UN2000) Meta-analysis of 67 studies found
that improved water quality may results into median reduction of 16% of diarrhea morbidity
{ Feachem RG et al. (1983).}
Another finding indicated that even the safe water can become contaminated during
collection, transport and drawing in the home {WrightJ, et al 2003}.The low cost intervention
of improving and preserving household water quality should be adopted {WHO 2008}
WHO has formulated and sponsoring an international Network for the promotion of safe
household water treatment and safe storage. A brief analysis of 21 controlled field trials over
the last 20 years dealing specifically with interventions designed to enhance microbiological
quality of drinking water at household level showed a median reduction in endemic diarrhea
diseases by 42% compared with the control group {who , 199}
Normally Children with poor nutritional status and overall health, as well as those exposed to
poor environmental conditions including unsafe drinking water, are more susceptible to
severe diarrhea and dehydration than healthy children. Children are also at greater risk than
adults of life-threatening dehydration since water constitutes a greater proportion of
children’s bodyweight. Young children use more water over the course of a day given their
higher metabolic rates, and their kidneys are less able to conserve water as adults {Kosek M,
et al 2003}
Interventions to improve water quality at the source, along with treatment of household water
and safe storage systems, have been shown to reduce diarrhea incidence by as much as 47 per
cent {WHO (2008a).}
Millennium development Goals 7, Target 10, calls for reducing by half the proportion of
people without sustainable access to safe drinking water by 2015. Reaching this target
implies that we need to tackle both the quantity (access) and quality (safety) dimensions to
drinking water provision. According to WHO there are about 37 different technologies for

32
use at household level for treatment of drinking water in the home { Sobsey MD et al (2002).
Few have been assessed for microbial and health impact performance. In Tanzania the
following are common in different places of Country. This is the most widely-practised
means of treating water at the community level; apart from boiling, it is also the method used
most broadly in the home. The source of chlorine can be sodium hypochlorite, chlorinated
lime, or high test hypochlorites (chlorine tablets) which are usually available and affordable.
The sodium hypochlorite solution is packaged in a bottle with directions for users to add one
full bottle cap of the solution to clear water(or two caps to turbid water) in a standard-sized
storage container; agitate; and wait for 30minutes before drinking. Chlorine must be added in
sufficient quantities to destroy all pathogens but not so high that taste is adversely affected.
At doses of a few mg/l and contact time of about 30minutes, free chlorine inactivates more
than 99.99% of enteric pathogens, the notable exceptions being Cryptosporidium and
Mycobacterium species. Its impact in reducing diarrheal diseases has been documented {
Arnold B, 2007}
Household filters potentially present certain advantages over other technologies. They
operate under a variety of conditions (temperature, pH, turbidity), introduce no chemicals
into the water that may affect use due to objections about taste and odour, are easy to use, and
improve the water aesthetically, thus potentially encouraging routine use without extensive
intervention to promote behavior change. Higher quality ceramic filters treated with
bacteriostatic silver have been shown effective in the lab at reducing waterborne protozoa by
more than 99.9% and bacteria by more than 99.9%, and their potential usefulness as a public
health intervention has been shown in development and emergency settings { . Clasen T et al
(2006).{Clasen T, et al 2004}
The improving quality of locally-fabricated silver coated ceramics is particularly promising
as a sustainable and low-cost alternative { Brown J, et al 2007 }Slow-sand filters remove
suspended solids and microbes by means of a slime layer (schmutzdecke) that develops
within the top few centimeters of sand are capable of removing 99% of enteric pathogens if
properly constructed, operated and maintained. Bio-sand filter is a simpler but more advanced
version designed specifically for intermittent use and is more suitable for household
applications. It has been tested both in the laboratory and the field {Hijnin WA, et al 2004} ,
{StauberCE,et al 2006}

33
The most challenge for household-based treatment is how to treat high turbid water, solids
normally use up free chlorine and other chemical disinfectants. Turbidity can be managed by
simple Let it stand and settle and pre-treatment. The use of alum can be effective and low-
cost option for assisted Let it stand and settle but again disinfection is required such forms of
assisted Let it stand and settle have been shown to reduce the levels of certain microbial
pathogens, especially protozoa which may otherwise present a challenge to chemical
disinfectants. Certain manufacturers have combined flocculation and time released
disinfection in a single product that is sold in sachets for household use. One such product
has been shown to reduce waterborne cysts by more than 99.9%, viruses by more than 99.9%
and bacteria by more than 99.99% {Souter PF,et al 1984}Boiling or heat treatment of water
with fuel is effective against the full range of microbial pathogens and can be employed
regardless of the turbidity or dissolved constituents of water. WHO recommend bringing
water to a rolling boil for 1minute; this is mainly intended as a visual indication that a high
temperature has been achieved; even heating to pasteurization temperatures (60º C) for a few
minutes will kill or deactivate most pathogens. However, the cost and time used in procuring
fuel, the potential aggravation of indoor air quality and associated respiratory infections pose
a threat to public health. Pouring turbid (cloudy) water through a piece of fine, clean cotton
cloth will often remove a certain amount of the Suspended solids contained in the water. If
the cloth is dirty, additional pollutants may be introduced! Purpose-made monofilament filter
cloths can be used in areas where guinea worm disease (dracunculiasis) is endemic. Such
cloths are effective in straining out the copepods in the water. These tiny water creatures act
as intermediate hosts for the larvae which transmit the disease. Some guinea-worm
eradication projects supply a large-diameter drinking straw with a filter mesh on one end so
that copepods are strained out when water is sucked up the straw. Storing water for just one
day can result in the die-off of more than 50per cent of most Bacteria; conditions in storage
vessels are usually not conducive to their survival! Longer periods of storage will lead to
further reduction. The cercariae, which are an intermediate host in the life cycle of
schistosomiasis, can only live for 48 hours after leaving a snail if they do not reach a human
or animal host. So storing water for more than two days effectively prevents the transmission
of this disease In some of the poorest countries of the world, one in five children fail to reach
their fifth birthday, mainly owing to infectious diseases related to the environment (WHO
2001).

34
Infectious and parasitic diseases (communicable diseases) account for 14 million deaths per
year and are the world's leading killers of children. These diseases, which have intimate links
to environmental conditions and poverty, affect the lives of poor people disproportionately
and pose a serious threat to health and economic development. According to millennium
development goals report of 2011, the highest levels of under-five mortality continue to be
found in sub-Saharan Africa. Estimates show that at least one in eight children die before the
age of five (129 deaths per 1000 live births) which is nearly twice the average in developing
regions and around 18 times the averagein developed regions (UN 2011).
In Eastern and Southern Africa region, the observed average annual rate of reduction
(AARR) in the under-five mortality rate (U5MR) for 1990-2006 period was 1.4 percent
which is viewed as insufficient to attain MDG 4 and would require an AARR of 9.6 percent
between 2007 to 2015 if MDG 4 is to be achieved by countries in this region (UNICEF,
2008). The situation is Kenya is no different. Although there has been a decline in under-five
mortality, Kenya is still very far from the country's MDG target of targets 33 deaths per 100
live births. The 2008-09 KDHS estimates that the under-five mortality for Kenya is at 74
deaths per 1000 live births, which is more than double the set out target with only three years
to go. Each year, an estimated 2.5 billion cases of diarrhea occur among children under five
years of age (UNICEF/WHO 2009).
Estimates suggest that overall incidence has remained relatively stable with more than half of
the cases occurring in Africa and South Asia where in most cases it results in death or other
severe outcomes including malnutrition (UNICEF/WHO 2009).
Globally, pneumonia and diarrhoea are responsible for an estimated 40 per cent of all child
deaths. Fifteen percent of all deaths in children Efforts to reduce incidences of diarrhea, to
prevent and treat its complication and to improve its case management through oral
rehydration therapy in Kenya have been focused through the policy statements on Control of
Diarrhea Diseases (CDD) formulated in 1993 (GoK, 2010). The policy set numeric targets to
be achieved through mass media (IEC) on health issues, promoting breast feeding and proper
weaning practices, by improving environmental sanitation, by enlarging access to clean
environment and safe drinking water and establishing health units specifically for ORT.
According to the 2008-09 KDHS, more than one-third of Kenyan households get their
drinking water from a non-improved source, mainly surface water from lakes, streams, and
rivers with wide disparities between urban and rural areas; only 6 percent of urban

35
households use non-improved sources for drinking water compared to 46 percent in rural
areas. Nationally, 41 percent of the population still depends on surface water; over 2 4
million children are water-deprived (GoK& UNICFF, 2010)
The KDHS report also indicates that less than one-quarter of households use an improved
toilet facility that is not shared, with urban households only slightly more likely than rural
households to have an improved toilet facility; 30 percent and 20 percent, respectively (GoK,
2010). The most common type of toilet facility in rural areas is an open pit latrine or one
without a slab (47 percent of rural households), while in urban areas toilet facilities are
mainly shared with other households (52 percent). Overall, 12percent of households have no
toilet facility at all; they are almost exclusively rural, accounting for 16 percent of rural
households.
Despite the disparities in service provision between rural and urban areas, there is only a
small variation in diarrhea incidences between rural and urban areas (GoK, 2010); depicting
that the causes are not merely sanitation related bui mediated through other variables.
Numerous studies in Africa and Asia have confirmed that age of the child plays an important
role in the occurrence of diarrhea In most studies diarrhea is least common among children
below six months and peaks between children aged 7-23 months with the low incidences in
children below six months being the effect of exclusive breastfeeding; diarrhoea peak among
children aged 6-23 is due introduction of supplementary feeding and environmental factors as
most of this children spent most time playing on contaminated ground (WoldemicaeL,et al
1994-2001)
In Salvador Brazil, a community-based longitudinal study of 902 children (below the age of 3
years) was conducted to investigate risk factors associated with childhood diarrhea. The study
was conducted between October 2000 and January 2002 taking into account both the time-
varying variables and autoregressive effect of past diarrhoea episodes. The study established
that diarrhoea role varied substantially with age peaking at 5.9 episodes/child-year in children
aged 7 to 12 months and decreased with increasing age to 0.9 episodes/chiId-year in children
aged 43 to 48 months. Incidence rate was also found to be decreasing with time-on-study
which was partially explained by age; the age adjusted rate decreased from 7,6 episodes/chi
Id-year during the first 3 months to l.l episodes/child-year after 14 months Evidence of
autoregressive effect of past diarrhoea of which increases the risk of diseases. Maternal age is
considered as a proxy for a host of factors including family size, educational level,

Analysis of risk factors influencing diarrheal outbreak among under five children

Analysis of risk factors influencing diarrheal outbreak among under five children

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