2.
Diarrhoea 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)
Clinical types:-
1. Acute watery diarrhoea - which lasts several hours to
days
2. Acute bloody diarrhoea - also called dysentery.
3. Persistent diarrhoea - which lasts 14 days or longer.
4. Diarrhoea with severe malnutrition (marasmus and
Kwashiorkor)
Introduction
3.
Diarrhoea is the second major killer of children
under 5
Killing around 525 000 children every year.
Rivalled in importance only by respiratory infection
It killed more than 1,300 children under 5 yrs of age
every day in 2016
Accounts for 8 % of all under-five deaths - a loss of >
4.8 lakh child lives in 2016, mostly in < 2yrs
Problem statement
5.
Data showing the high rate of diarrhoea morbidity among
children below 5 years
6.
In India - acute diarrhoeal disease accounts for about 11%
of deaths in under-5 years age group
About 12.92 million cases with 1,331 deaths
were reported in India in 2017
Leading cause of death during complex emergencies and
natural disasters
Polluted water sources, inadequate sanitation, poor
hygiene practices, contaminated food and malnutrition -
affect the spread and severity of diarrhoea
Lack of adequate health services and transport reduces
the likelihood of prompt and appropriate treatment
Problem statement cont..
8. Diarrhoea prevention indicators
(1) Percentage of population using:
(a) improved drinking water sources (urban, rural, total); (For India -
urban 97%, rural 90% and total 92%)
(b) improved sanitation facilities (urban, rural, total);
(For India - urban 58%, rural 23% and total 34%)
(2) Percentage of one year old immunized against measles; (lndia-74%)
(3) Percentage of children who are :
- under-weight (moderate and severe) - 0 to 59 (India-43%)
- stunted (moderate and severe) months age - 0 to 59 (India 38.7%)
- exclusive breast fed – 0-5month ( India 46%)
- breast-fed with complementary food - 6 to 9 months (India 57%)
- still breast feeding – 20-23 months (India 77%)
(4) Vitamin A supplementation coverage rate (per cent full coverage) - 6 to
59 months (India-53%)
Indian data generated by demography and health survey 2005-06
9.
Diarrhoea treatment Indicators
Percentage of children under-five years with diarrhoea
receiving:
(1) ORT with continuous feeding (India 33%)
(2) ORS packet (India 26%)
(3) Recommended home made fluids (India 20%)
(4) Increased fluids (India 10%)
(5) Continued feeding (India 70%)
Indian data generated by demography and health survey 2005-06
10.
Percentage of children under-five years with diarrhoea
receiving oral rehydration therapy (ORS packet or
recommended home-made fluids or increased fluids with
continued feeding)
(1) Gender - male, female
(India - male 34%, female 31%)
(2) Residence - Urban, rural
(India - urban 38%, rural 31 %)
(3) Wealth index quintiles - poorest, second, middle,
fourth, richest
(India - 29%, 29%, 31%, 35% and 45%)
Use of oral rehydration therapy
Indian data generated by demography and health survey 2005-06
12.
Pathogen % of cases
Viruses Rotavirus 15-25
Bacteria Enterotoxigenic
Escherichia coli
10-20
Shigella 5-15
Campylobacter jejuni 10-15
Vibrio cholerae 01 5-10
Salmonella (non-
typhoid)
1-5
Enteropathogenic
Escherichia coli
1-5
Protozoans Cryptosporidium 5-15
No pathogen found - 20-30
Pathogens frequently identified in children with acute
diarrhoea in treatment centres in developing countries
13.
Rotavirus, first discovered in 1973, has emerged as the
leading cause of severe, dehydrating diarrhoea in
children aged <5 years globally
With estimated 25 million out-patient visits and more
than 2 million hospitalizations
Severe rotavirus gastroenteritis is largely limited to
children aged 6-24 months.
Fatal outcomes in children, estimated to be
approximately 4,20,000-4,94,000 in 2008 , occur
predominantly in low-income countries
In tropical settings rotavirus occurs year round
a) Viruses
14.
V cholerae 01 , Salmonella, Shigella, enterotoxigenic E.coli
and Campylobacter jejuni are the most frequent cause of
diarrhoea.
The less-known pathogens which cause diarrhoea are
Yersinia enterocolitica, and V parahaemolyticus.
Enterotoxigenic Escherichia coli (ETEC) is an important
cause of acute watery diarrhoea in adults and children,
In developing countries ETEC causes 280-400 million
diarrhoeal episodes annually in children under 5 yrs, 100
million episodes in children aged 5-14 years & about 400
million cases per year in adults
b) Bacterial causes
15.
ETEC causes one-third to one half of all diarrhoeal
episodes in travellers to Africa, Asia and Latin
America
There are two ETEC toxins, heat labile (LT) and heat
stable (ST). LT toxin is closely related to cholera
toxin.
Salmonella cause inflammation of the bowel
epithelium
Salmonella and cholera are endemic in India
cholera accounts for not more than 5 to 10 % of all
acute diarrhoeas yearly
b) Bacterial causes cont...
16.
Shigella accounts for a high percentage of mortality due to
diarrhoeal disease.
Estimated 1 million deaths every year in children aged
under-5 years, mostly in the developing countries.
About 164.7 million Shigella episodes are estimated
worldwide, with 69 per cent of all episodes in young
children.
It is a major cause of diarrhoea in India
Campylobacters are slim, highly motile, S-shaped, gram
negative rods, formerly classed as vibrios-one of the
commonest causes of enteritis
b) Bacterial causes cont...
17.
Amoebiasis, giardiasis and other intestinal parasitic
infections are associated with diarrhoea
Giardiasis is a recognized cause of diarrhoea
Cryptosporidium is a coccidian parasite that causes
diarrhoea in infants, immunodeficient patients, and a
variety of domestic animals
In immunodeficient patients, such as those
with severe malnutrition or AlDS, cryptosporidium
is an important cause of persistent diarrhoea with
wasting
c) Others
18.
Diarrhoea may be caused by a parenteral infection (non-
digestive origin) and particularly so in younger children,
these include ENT infections, respiratory or urinary
infections, malaria, bacterial meningitis, or even simple
teething
Malnutrition may lead to certain nutritional diseases such
as kwashiorkor, sprue, coeliac disease and pellagra which
are all associated with diarrhoea
Diarrhoea in the newborn is unusual and may be due to
inborn errors of metabolism such as congenital enzyme
deficiencies
An episode of diarrhoea lasting more than 30 days,
according to the WHO definition of AIDS in children
c) Others cont…
19.
For some enteric pathogens, eg .., enterotoxigenic E.
coli, shigella spp., V cholerae, Giardia lamblia and E.
histolytica, man is the principal reservoir and thus
most transmission originates from human factors
For other enteric pathogens, animals are important
reservoirs and transmission originates from both
human and animal faeces; examples are
Campylobacter jejuni, Salmonella spp and Y.
enterocolitica.
For viral agents of diarrhoea, the role of animal
reservoirs in human disease remains uncertain.
Reservoir of infection
20.
Diarrhoea is most common in children especially those
between 6 months and 2 years.
Incidence is highest in age group 6-11 months, when weaning
occurs. It reflects the combined effects of declining levels of
maternal antibodies, lack of active immunity, introduction of
contaminated food , and direct contact with human or animal
faeces when the infant starts to crawl.
Also common in babies under 6 months of age fed on cow's
milk or infant feeding formulas .
More common in persons with malnutrition. Malnutrition
leads to infection and infection to diarrhoea which is a well
known vicious circle.
Poverty, prematurity, reduced gastric acidity,
immunodeficiency, lack of personal and domestic hygiene
and incorrect feeding practices are all contributory factors
Host factors
21.
In temperature climates, bacterial diarrhoea occur
more frequently during warm season, whereas viral
diarrhoea, particularly diarrhoea caused by rotavirus
peak during the winter.
In tropical areas, rotavirus diarrhoea occurs
throughout the year, increasing in frequency during
the drier, cool months, whereas bacterial diarrhoeas
peak during the warmer, rainy season.
The incidence of persistent diarrhoea follows the
same seasonal patterns as that of acute watery
diarrhoea
Environmental factors
22.
Most of the pathogenic organisms that cause
diarrhoea are transmitted primarily or exclusively by
the faecal- oral route.
Faecal- oral transmission may be water-borne; food-
borne, or direct transmission via fingers, or fomites,
or dirt which may be ingested by young children
Mode of transmission
23.
Its now obvious that some known and unknown
organism probably causes diarrhoea .
Regardless of the causative agents or age of patient; the
sheet anchor of treatment is oral rehydration therapy as
advocated by WHO/ UNICEF
The Diarrhoeal Diseases Control (DDC) Programme of
WHO was started in 1978, with the objective of reducing
the mortality & morbidity due to diarrohoeal diseases.
Currently DDC is a part of NRHM
CONTROL OF
DIARRHOEAL DISEASES
24.
Intervention measures recommended by WHO are:-
1. Short-term
a . Appropriate clinical management.
2. Long-term
b. Better MCH care practices.
c. Preventive strategies.
d. Preventing diarrhoeal epidemics.
Components of a Diarrhoeal
Diseases Control Programme
25.
(I) ORAL REHYDRATION THERAPY :
The main aim of oral fluid therapy is to prevent
dehydration and reduce mortality.
Oral fluid therapy is based on the observation that
glucose given orally enhances the intestinal
absorption of salt and water and is capable of
correcting the electrolyte and water deficit.
a) Appropriate clinical management
26.
At 1st the composition of ORS ( oral rehydration salt
) recommended by WHO was sodium bicarbonate
based
INCLUSION OF TRISODIUM CITRATE IN PLACE
OF SODIUM BICARBONATE
made product more stable
reduces stool output
increase intestinal absorption of sodium & water
I) ORAL REHYDRATION THERAPY
cont…
27.
This ORS formulation focuses on reducing osmolarity of
ORS solution; .
-to avoid adverse effects of hypertonicity on net fluid
absorption by reducing concentration of glucose and sodium
chloride in solution.
I) ORAL REHYDRATION THERAPY
cont…
28.
Reducing the sodium concentration of ORS solution
to 75 mOsmol/L , improved the efficacy of ORS
regimen for children with acute non-cholera
diarhoea.
Since January 2004 new ORS formulation is the only
procured by UNICEF .
INDIA was 1st country in world to launch this ORS
formulation since JUNE 2004
I) ORAL REHYDRATION THERAPY
cont…
30.
Dehydration
Mild Severe
Patient’s appearance Thirsty, alert, restless Drowsy, limp, cold,
sweaty, maybe
comatose
Radial pulse Normal rate and
volume
Rapid, feeble,
sometimes impalpable
Blood pressure Normal Less than 80mmHg,
maybe unrecordable
Skin elasticity Pinch retracts
immediately
Pinch retracts very
slowly (more than 2
seconds)
Tongue Moist Very dry
Ant. Fontanelle Normal Very sunken
Urine flow Normal Little or none
% body weight loss 4-5% 10% or more
Estimated fluid deficit 40-50ml/kg 100-110ml/kg
Assessment of dehydration
31.
Age Under 4
months
4-11
months
1-2 yrs 2-4 yrs 5-14 yrs 15 yrs or
over
Weight
(kg)
Under 5 5-7.9 8-10.9 11-15.9 16-29.9 30 or
over
ORS
solution
(ml)
200-400 400-600 600-800 800-1200 1200-
2200
2200-
4000
Guidelines for oral rehydration therapy (for all
ages) during the first four hours
The patient's age should only be used if weight is not known
Amt. of ORS sol.= wt. of child X 75 ml / kg
32.
Mothers should be taught how to administer ORS
by a nurse or by a health worker
for children under age 2 years, give a teaspoon every
1 to 2 minutes, and offer frequent sips out of a cup for older
children
After each loose stool, give - children
under 2 years of age : 50-100 ml (1/4 to 1/2 large cup) of fluid;
children aged 2 up to 10 years : 100- 200 ml { 1/2 to 1 cup);
and older children and adults : as much fluid as they want
signs of dehydration should be checked until they subside
33.
Intravenous infusion is usually required only for initial
rehydration of severely dehydration pt. who is in shock or
unable to drink . Such patients are best transferred to nearest
hospital or treatment Centre .
Solution recommended by WHO for intravenous infusion
are…….
1.RINGER LACTATION SOLUTION
Its also known as Hartmamm’s solution for injection.
It is the best commercially available solution .
It supplies adequate concentration of sodium and
potassium and the lactate yields bicarbonate for
correction of the acidosis.
2. INTRAVENOUS REHYDRATION
34.
2.DIARRHOEAL TREATMENT SOLUTION ( DTS )
Recommended by WHO as ideal polyelectrolyte solution
for intravenous infusion .
It contains in one litre
Sodium Acetate- 6.5g,
Sodium Chloride- 4g,
Potassium Chloride- 1g
Glucose- 10g.
Normal saline can also be given but its poorest fluid
because it will not correct the acidosis and will not replace
the potassium losses.
2. INTRAVENOUS REHYDRATION
cont…
35.
Plain glucose and dextrose solution should not be
used as they provide only water & glucose.
The initial rehydration should be fast until an easily
palpable pulse is present .
Reasses the patient every 1-2 hours.
After infusing 1-2 litres of fluid , rehydration should
be carried out at a somewhat slower rate until pulse
and blood pressure return to normal.
It is most helpful to examine skin elasticity and pulse
strength ,both of which should be normal.
2. INTRAVENOUS REHYDRATION
cont…
36.
After the sign of dehydration has been corrected oral
fluid should be used for maintenance therapy
3.MAINTENANCE THERAPY
Amount of diarrhoea Amount of oral fluid
Mild diarrhoea
(not more than one stool every 2
hours or longer, or less than 5 ml
stool per kg per hour)
100 ml/kg body weight per
day until diarrhoea stops
Seuere diarrhoea
(more than one stool every
2 hours, or more than 5 ml of stool
per kg per hour)
Replace stool losses volume
for volume; if not measurable
give 10- 15 ml/kg body
weight per hour
37.
Normal food intake should be promoted as soon as the
child whatever its age, is able to eat
If the child is breast-fed , nursing should be pursued
during treatment with ORS solution.
New-born infants with diarrhoea who show little or no
signs of dehydration can be treated by breast-feeding
alone.
Commercially carbonated beverages , commercial fruits &
sweetened tea should not be given as it causes osmotic
diarrhoea and hypernatraemia.
Rice water ,unsalted soup ,yoghurt drinks , green coconut
water should be given
4 . APPROPRIATE FEEDING
38.
Unnecessary prescription of antibiotics and other
drugs will do more harm than good
Antibiotics should be considered where the cause of
diarrhoea has been clearly identified as shigella,
typhoid or cholera
Drug of choice for cholera DOXICYCLINE
TETRACYCLINE, TMP-SMX
Drug of choice For diarrhoea due to shigella is
ciprofloxacin. As shigella is resistant to ampicillin &
TMP-SMX.
5 . Chemotherapy
39.
Zinc supplement given during an episode of acute
diarrhoea reduces the episode's duration and
severity.
WHO and UNICEF recommends daily 10 mg of zinc
for infants under 6months of age, and 20 mg for
children older than 6 months for 10- 14 days as it
lowers the incidence of diarrhoea in the following 2
to 3 months
6 . ZINC SUPPLEMENT
40.
(a) MATERNAL NUTRITION :
Improving prenatal nutrition will reduce the low
birth weight problem.
Prenatal and postnatal nutrition will improve the
quality of breast milk.
b. Better MCH care practices
41.
(i) Promotion of breast-feeding:
Breast-fed child is at very much less risk of severe
diarrhoea and death than the bottlefed child.
Strong efforts to limit the use of commercial and artificial
formulas.
Breast feed as long as possible.
(ii) Appropriate weaning practices :
child should be weaned neither too soon, nor too late,
not earlier than the sixth month of life
using nutritious and locally available foods,
should be hygienically prepared and given.
(b) CHILD NUTRITION
42.
{iii) Supplementary feeding : necessary to improve the
nutritional status of children aged 6- 59 months.
(iv) Vitamin A supplementation : reduces the duration,
severity and complications associated with diarrhoea
(b) CHILD NUTRITION cont…
43.
1 . SANITATION
2 .HEALTH EDUCATION
3 . IMMUNISATION
4 . FLY CONTROL
c. Preventive strategies
44.
It emphasis on personal & domestics hygiene like
hand washing with soap before preparing food
before eating ,
before feeding a child,
after defecation ,
after cleaning a child who has defecated and
after disposing off a child’s stool
Sanitation
45.
An important job of health worker is to prevent
diarrhoea by convincing and helping community
members to adopt and maintain preventive
measures like breast feeding,
improved weaning ,
clean drinking water
use of plenty of water for hygiene,
use of latrine,
proper disposal of stools of young children etc.
Health Education
46.
Immunization against measles is a potential
intervention for diarrhoea control.
Measles vaccine can prevent 25% of diarrhoeal
deaths in children under 5 yrs. of age
IMMUNISATION
47.
There are two vaccines
ROTARIX –TM ( monovalent human rotavirus
vaccine)
ROTA Teq-TM ( pentavelent bovine-human vaccine)
Rotarix-TM …… 2 -dose schedule to 2 -4 months
aged child
1 . DOSE - 6 weeks - 12 weeks
2 . DOSE - upto 16 weeks & no later than 24 weeks.
Rota Teq-TM……3 oral dose at ages 2,4,6 months
ROTAVIRUS VACCINE
48.
Flies breeding in association with human or animal
faeces should be controlled.
(iu) FLY CONTROL
49.
Requires strengthening of epidemiological
surveillance systems
An intersectoral approach centered upon PHC
involving activities
in fields of water supply & excreta disposal ,
communicable disease control,
mother & child health ,
nutrition & health education is regarded as essential
for ultimate control of diarrhoeal diseases
Control and prevention of
diarrhoeal epidemics
50.
The protect, prevent and treat framework of integrated
global action plan for prevention and control of pneumonia
