acute diarrheal diseases

1. Acute Diarrheal Disease

2. Outline
Definition
Clinical types
Epidemiological determinants
Prevention
Clinical management
Monitorable treatment and prevention indicators

3. DEFINITION:
• Diarrhea-Passage of loose, liquid or watery stools.
• more than three times a day.
(However, it is the recent change in consistency and character of stools rather than
the number of stools that is more important.)
• “Diarrhoeal diseases" - a group of diseases in which the predominant symptom is
diarrhoea.

4. Diarrhea related programs
In India
• 1978- diarrheal disease control program
• 1985-86- national oral rehydration therapy program
WHO
• Diarrheal Diseases Control Programme in 1980
• After implementation of this program incidence of diarrhea have not changed
much, although overall diarrheal mortality has declined.
• Most of these deaths occur among children less than 2 years of age

5. Diarrhea in complex emergencies and natural disasters.
• leading cause of death
• Complex emergency- a major humanitarian crisis that is often the result of a
combination of political instability, conflict and violence, social inequities and
underlying poverty.
• Displacement of population into temporary, overcrowded shelters is often
associated with polluted water sources, inadequate sanitation, poor hygiene
practices, contaminated food and malnutrition - all of which affect the spread
and severity of diarrhea.

6. • At the same time, the lack of adequate health services and transport reduces the
likelihood of prompt and appropriate treatment of diarrhea cases. Diarrheal
disease causes a heavy economic burden on the health services.

7. CLINICAL TYPES OF DIARRHOEAL DISEASES:
Acute watery diarrhoea Acute bloody
diarrhoea (dysentery)
Persistent diarrhoea Diarrhoea with
severe malnutrition
• several hours to days
• main danger-
dehydration
• pathogens –
V. cholerae
E. coli
Rotavirus, etc.
visible blood in the
stools
main dangers-
• damage of the
intestinal mucosa,
• sepsis
• Malnutrition
most common cause-
shigella
lasts 14 days or longer.
main danger-
• malnutrition
• serious non-intestinal
infection
At risk- Persons with other
illness, such as AIDS
(WHO definition of AIDS in
children- an episode of
diarrhoea lasting more
than 30 days).
main dangers -
• severe systemic
infection
• dehydration
• heart failure
• vitamin and
mineral
deficiency.

8. Epidemiological determinants
Agent factors
• In developing countries, diarrhoea is almost universally infectious in origin.
• Pathogens frequently identified in children with acute diarrhea in treatment centers in developing
countries
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

9. ROTAVIRUSES:
• discovered in 1973.
• leading cause of severe, dehydrating diarrhoea in children aged <5 years globally,
• In developing countries, three-quarters of children acquire their first episode of
rotavirus diarrhoea before the age of 12 months,
• in developed countries the first episode is frequently delayed until the age of 2-5
years.
• Severe rotavirus gastroenteritis is largely limited to children aged 6-24 months.
• Fatal outcomes in children, occur predominantly in low-income countries.

10. • Rotavirus reinfection is common, although the primary infection is usually the
most significant clinically.
• Rotaviruses are shed in very high concentrations (>10¹2 particles/gram) and for
many days in the stools and vomit of infected individuals.
• Transmission occurs primarily by the faecal-oral route, directly from person to
person or indirectly via contaminated fomites.
• The universal occurrence of rotavirus infections shows that clean water supplies
and good hygiene are unlikely to have a substantial effect on virus transmission

11. BACTERIAL CAUSES
1. Enterotoxigenic Escherichia coli (ETEC):
• Acute watery diarrhoea- in adults and children in developing
• Spread-contaminated food and water.
• most common cause of traveller's diarrhoea.
(responsible for one-third to one half of all diarrhoeal episodes in travellers to
Africa, Asia and Latin America)
• The illness results in deaths mostly in young children

12. Salmonella- cause inflammation of the bowel epithelium
Vibrio cholerae 01 do not cause inflammation of the bowel epithelium (toxin
based pathology)
• Both are endemic diseases in India.
Campylobacters- one of the commonest causes of enteritis.
• It is not clear how they cause diarrhoea.
Shigella accounts for a high percentage of mortality due to diarrhoeal disease in
children under-5 years, mostly in developing countries.

13. c.Other causes of diarrhea
Parasites
1. Giardia: Ponds, streams, rivers, and other bodies of water can all be sources of
giardia.
2. Cryptosporidium
• Diarrhoea is usually neither severe nor prolonged, except in immunodeficient
patients, such as those with severe malnutrition or AIDS.
• In such individuals cryptosporidium is an important cause of persistent diarrhoea
with wasting.
Diarrhoea may be caused by a parenteral infection (non-digestive origin)
particularly in younger children(eg-COVID, ENT, respiratory, urinary infections etc.)

14. Non-infectious causes of diarrhea
• Malnutrition nutritional diseases(kwashiorkor, sprue, coeliac disease and pellagra)
which are all associated with diarrhoea.
• Recent/past Measles-high risk of developing severe or fatal diarrhoea
• Diarrhoea in the newborn (unusual) indicates:
Inborn errors of metabolism, OR
severe infections like septicemia or necrotizing enterocolitis

15. Reservoir of infection:
• Principal reservoir- Man i.e. most transmission originates from human factors
• Examples- enterotoxigenic E. coli, shigella spp., V. cholerae, Giardia lamblia and E.
histolytica.
• Principal reservoir- animals, transmission originates from animal faeces
• Examples- Campylobacter jejuni, Salmonella spp and Y. enterocolitica.
Mode of transmission,
• faecal-oral route- most common

16. Host factors
• Age- 6 months and 2 years.
(Incidence is highest in the age group 6-11 months, when weaning occurs)
Reason:
• declining levels of maternally acquired antibodies and the lack of active immunity
in the infant
• the introduction of contaminated food, and direct contact with human or animal
faeces when the infant starts to crawl.
• Diarrhoea is more common in persons with malnutrition, Malnutrition leads to
infection and infection to diarrhoea which is a well known vicious circle.

17. Environmental factors
In temperate climates,
• bacterial diarrhoea- warm season.
• viral diarrhoea (rotavirus)- peak during the winter.
In tropical areas,
• bacterial diarrhoeas- warmer, rainy season.
• viral diarrhoea (rotavirus)- throughout the year, increasing in frequency during
the drier, cool months,

18. CONTROL OF DIARRHOEAL DISEASES:
• The Diarrhoeal Diseases Control (DDC) Programme - Recommended intervention
measures
1. Short-term 2. Long-term
Appropriate clinical management
• oral rehydration therapy
• intravenous rehydration
• maintenance therapy
• appropriate feeding
• chemotherapy
• zinc supplementation
• Better MCH care practices.
• Preventive strategies.
• Preventing diarrhoeal epidemics.

19. Short term control measures
a. Appropriate clinical management
(I) ORAL REHYDRATION THERAPY (ORT):
Whom can it be given to?
All age groups
In what conditions can it be given?
All etiologies
All countries

20. • Aim of ORT - to prevent dehydration and reduce mortality.
• Principle of ORT- Glucose given orally enhances the intestinal absorption of salt
and water, and is capable of correcting the electrolyte and water deficit.
• Types of ORS:
1. Sodium bicarbonate based
2. Trisodium citrate based
3. Reduced osmolarity based
4. Super ORS

21. Composition
content Sodium bicarbonate based ORS
(gm)
Trisodium citrate based ORS
(gm)
NaCl 3.5 3.5
Glucose 20.0 20.0
KCl 2.5 1.5
Sodium bicarbonate 2.5 NIL
Trisodium citrate NIL 2.0
Benefits of tricitrate based ORS-
• More stable
• Less stool output in high output diarrhea
• Tri sodium citrate promotes intestinal absorption of sodium and water

22. Composition
Content Regular osmolarity ORS Reduced osmolarity ORS
Na 90 mM 75 mM
Cl 80mM 65 mM
Glucose 110mM 75 mM
K 20mM 20mM
Citrate 10mM 10mM
Total 310mM 245mM
• Since January 2004, the reduced ORS formulation is the only one procured by
UNICEF.
• India was the first country in the world to launch this ORS formulation since June
2004.

23. Advantages of reduced osmolarity ORS:
• Increased efficacy in non cholera diarrhea
• Need for unscheduled supplemental IV therapy in children fell by 33%
• Stool output decreased by 20%
• Vomiting decreased by 30%

24. Assessment of dehydration:
Dehydration
Mild Severe
Appearance Thirsty, alert, restless Drowsy, limp, cold, sweaty, may be
comatose
Radial pulse Normal rate and volume Rapid, feeble, sometimes not palpable
Blood pressure Normal < 80 mmHg / may be unrecordable
Skin elasticity Pinch retracts immediately Pinch retracts very slowly (>2 seconds)
Tongue Moist Very dry
Anterior fontanelle Normal Very sunken
Urine flow Normal Little or none
% body weight lost 4- 5 % 10 % or more
Estimated fluid deficit 40- 50 ml/kg 100- 110 ml/kg

25. • Child's weight is known- amount of ORS solution required during the first four
hours is calculated by setting the deficit at approximately 75 ml/kg.
• Child's weight is not known- the approximate deficit is determined on the basis of
age
• Guidelines for ORT during first four hours:
Age < 4 months 4-11 months 1-2 years 2-4 years 5-14 years ≥ 15 years
Weight (kg) <5 5- 7.9 8-10.9 11-15.9 16-29.9 ≥ 30
ORS (Ml) 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

26. How to administer ORS?
• Before preparing the solution, wash your hands with soap and water
• Prepare a solution in a clean pot, by mixing 1 packet of ORS with one litre of
clean drinking water
• It should not be boiled or otherwise sterilized.
• Stir the mixture till the contents dissolve
• Give the sick child as much of the solution as they need, in small amounts
frequently
• Discard the solution after 24 hours

27. • Packets of "oral rehydration mixture" are now freely available at all primary
health centres, sub-centres, hospitals and chemist shops.
• If the WHO mixture of salts is not available, a simple mixture consisting of table
salt (one level teaspoon) and sugar (6 level teaspoon) dissolved in one litre of
drinking water may be safely used until the proper mixture is obtained.
• Add salt about 3 g/litre to an unsalted drink or soup during diarrhoea.
• Food should never be witheld and the child's usual food should never be diluted.

28. • children with watery diarrhoea- regain their appetite after dehydration is corrected,
children with bloody diarrhoea- often eat poorly until the illness resolves.
• These children should be encouraged to resume normal feeding as soon as possible.
Potentially dangerous fluids:
1. Drinks sweetened with sugar, which can cause osmotic diarrhoea & hypernatraemia.
e.g. commercial carbonated beverages, commercial fruit juices and sweetened tea.
2. Fluids with stimulant diuretic or purgative effect
e.g. coffee and some medicinal tea or infusions
• The earlier the treatment is instituted the better it is for the patient.

29. If the child wants to drink more then estimated amount?
Feed as much as they want
Rehydration completed when
signs of dehydration has disappeared and child refuses to have more ORS, may stop ORS.
If the child is breast fed?
Nursing + ORS
If the child vomits?
Wait for 10 minutes, give ORS again, usually vomiting will stop
If vomiting persists?
Take child over to a health clinic

30. As a general guide, after each loose stool, give –
• < 2 years : 50-100 ml (a quarter to half a large cup) of fluid
• 2 to 10 years: 100-200 ml (a half to one large cup)
• older children and adults: as much fluid as they want.
(II) INTRAVENOUS REHYDRATION
• Intravenous infusion is usually required only for the initial rehydration of severely
dehydrated patients who are in shock or unable to drink.
• Such patients are best transferred to the nearest hospital or treatment centre.

31. The solution recommended by WHO for intravenous infusion are:
1. Ringer's lactate solution (also called Hartmann's solution for injection):
• It is the best commercially available solution.
• It supplies adequate concentrations of sodium and potassium
• lactate Yields bicarbonate for correction of the acidosis.
• It can be used to correct dehydration due to acute diarrhoeas of all causes.

32. 2. Diarrhoea Treatment Solution (DTS):
• Also recommended by WHO as an ideal polyelectrolyte solution for intravenous
infusion.
• One litre DTS contains:
sodium chloride 4 g
sodium acetate 6.5 g
potassium chloride 1g
glucose 10g.
• It must meet purity and sterility requirements of fluid for injection.

33. • If nothing else is available, normal saline can be given because it is often readily
available.
• Normal saline is the poorest fluid because it will not correct the acidosis and will
not replace potassium losses.
• It should be replaced by the above solutions as early as possible.
• Plain glucose and dextrose solutions should not be used as they provide only
water and glucose.

34. • The initial rehydration should be fast until an easily palpable pulse is present.
• Reassess the patient every 1-2 hours.
• If dehydration is not improving give the IV drip more rapidly.
• The use of large-bore needle (No.18) will permit rapid infusion.
• 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.
• When the patient can drink the oral fluids give ORS about 5 ml/kg/hour.

35. • The patient must be examined at intervals during rehydration.
• After 4-6 hours of satisfactory treatment, all signs of dehydration should have
disappeared except that the urine flow may not have yet started.
• Sometimes if too much rehydration fluid is given, the eyelids become puffy; if
this occurs, IV fluid should be stopped.
• It is most helpful to examine skin elasticity and pulse strength, both of which
should be normal.
• Rehydration must continue until all signs of dehydration have disappeared.

36. (III) MAINTENANCE THERAPY
• After the initial fluid and electrolyte deficit has been corrected, fluid should be
used for maintenance therapy.
• Adults and older children- thirst is an adequate guide for fluid needs; they can be
told to drink as much as they want to satisfy their thirst.
• The general principle is that the oral fluid intake should equal the rate of
continuing stool loss, which should be measured.

37. The guidelines for maintenance therapy
Amount of diarrhea Amount of oral fluid
Mild diarrhea
(not more then one stool every 2 hours
or
longer, or less than 5 ml stool per kg per hour)
100 ml per kg body weight per day until
diarrhoea stops
Severe diarrhea
(more then 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

38. (IV) APPROPRIATE FEEDING
• During episodes of diarrhoea, normal food intake should be promoted as soon as
the child is able to eat.
• Newborn infants with diarrhoea who show little or no signs of dehydration can
be treated by breast-feeding alone.
• Those with moderate or severe dehydration should receive oral rehydration
solution.
• Breast milk is source of rehydration and nutrients, it also helps to prevent
further infection.

39. (V) CHEMOTHERAPY
• Unnecessary prescription of antibiotics and other drugs should be avoided
• Antibiotics should be considered where the cause of diarrhoea has been clearly identified as
shigella, typhoid or cholera.
Cholera Shigella
Diarrhoea Acute watery Acute bloody
Fever No yes
Abdominal cramps Yes yes
Vomiting Yes No
Rectal pain No Yes
Stool >3 loose stool per day, watery
like rice water
>3 loose stool per day with
blood or pus
Chemotherapy doxycycline, tetracycline, TMP-
SMX and erythromycin.
ciprofloxacin

40. The medicines that should not be uesd in the treatment of diarrhoea are as follows
• neomycin (damages the intestinal mucosa and can cause malabsorption)
• purgatives (worsen diarrhoea and dehydration)
• tincture of opium or atropine (dangerous for children and dysentery patients
because of decreased intestinal transit time)
• cardiotonics such as Coramine
(shock in diarrhoea must be corrected by intravenous fluids and not by drugs)
• steroids (expensive, useless, and may cause adverseeffects)

41. • oxygen (expensive, unnecessary)
• charcoal, kaolin, pectin, bismuth (no value)
• mexaform (no value and can be dangerous)
(VI) ZINC SUPPLEMENTATION:
• it reduces duration and severity.
• zinc supplements given for 10 to 14 days lower the incidence of diarrhoea in the
following 2 to 3 months.
• WHO and UNICEF recommend daily 10 mg of zinc for infants under 6 months of
age, and 20 mg for children older than 6 months for 10-14 days

45. FOLLOW UP
PERSISTANT DIARRHEA
Follow up after 5 days
Ask- has the diarrhea stopped?
• If No, i.e., ≥3 loose stools per day
Management- do a full reassessment of the child, give any treatment needed, then
refer to hospital
• If yes, ie < 3 stool per day
Then, tell the mother to follow the usual feeding recommendation for the child’s age

46. When to return?
• child becomes sicker,
• unable to drink or breastfeed,
• drinks poorly,
• develops a fever or
• Has started to have blood in the stool

47. Blood in stool
Follow up- after 2 days
Asses and classify the child for diarrhea based on assess and classify chart
• If the child is dehydrated, correct dehydration
• Continue giving zinc supplements for 14 days

48. Ask-
• Are there fewer stools?
• Is there less blood in stool?
• Is there less fever?
• Is there less abdominal pain?
• Is the child eating better?
If yes to all, complete the course of on going antibiotic
If answer to previous questions is no, refer to hospital

49. b. Better MCH care practices
(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) CHILD NUTRITION:
(i) Promotion of breast-feeding
(ii) Appropriate weaning practices (Poor weaning practices are a major risk factor
for diarrhoea).
(iii) Supplementary
(iv) Vitamin A supplementation

50. Preventive strategies
• Sanitation
• Health education
• Immunization (rotavirus vaccines)
• Fly control
Control and/or prevention of diarrhoeal epidemics
This requires Strengthening of epidemiological surveillance systems.

51. Monitorable treatment and diarrhoea prevention indicators.
(A) Diarrhoea prevention indicators (B) Diarrhoea treatment Indicators
(1) Percentage of population using :
(a) improved drinking water sources (Ministry of Jal Shakti)
(b) improved sanitation facilities (Ministry of Jal Shakti)
(2) Percentage of one year old immunized against measles
(3) Percentage of children who are:
• under-weight (low weight-for-age)
• stunted (low height-for-age)
• wasted (low weight-for-height)
• exclusively breast-fed (only breast milk for first 6 months)
• breast-fed with complementary food
• still breast-feeding
4) Vitamin A supplementation coverage rate
Percentage of children under-five years with
diarrhoea receiving:
(1) ORT with continuous feeding
(2) ORS packet
(3) Recommended home made fluids
(4) Increased fluids
(5) Continued feeding

52. THANK YOU