Acute diarrhoeal diseases ppt for community medicine UG students

1. Acute Diarrhoeal Diseases
&
Its Prevention in the
Community
DR.C.SASHIDHARAN
ASSISTANT PROFESSOR
MAPIMS

2. Introduction
• One of the most common cause of death in
children (9% of under 5 children)
• In 1980s mortality rate of under five children of
developing country was about 5 million/year
• At present we are able to decrease the mortality
to 2.2 million/year
• Diarrhea affects growth by
• Reducing appetite, altering feeding patterns
• Decreasing absorption of nutrients
• Reducing cognitive and school performance

3. Global Burden
• 80% of deaths from pediatric diarrhea
occur in first 2 years of life
• 3 episodes per child-year of under five age
• 1 in 200 children who contract diarrhea will
die from it

4. What Is Diarrhea?
• The passage of loose, liquid or watery stools.
Usually >3 times/day.
• Recent change in consistency and character of
stool is more important than the number of
stools
• Acute diarrhoea – a sudden onset of attack
which lasts 3 to 7 days but may last up to 10 to
14 days.

5. • Persistent Diarrhea: Diarrhea lasting for
14 days or more
• Chronic Diarrhea: Diarrhea lasting for
more than 21 days
• If blood visible in stools the condition is
called dysentery

6. What’s Not Diarrhea?
• Passage of frequent formed stools
• Passage of pasty stools in a breast fed
baby
• Passage of stools during or immediately
after feeding
• Passage of frequent greenish yellow
stools in the 3rd or 4th day of life
(Transitional Diarrhea)

7. Causes
• VIRUSES
Rotaviruses Coronaviruses
Astroviruses Enteroviruses
Adenoviruses Norwalk group
Calciviruses
BACTERIA
Campylobacter Jejuni Vibrio Cholerae
Escherichia Coli V.Parahaemolyticus
Shigella Bacillus Cereus
Salmonella
OTHERS
E. Histolytica Cryptosporidium
Giardia Intestinalis Intestinal Worms
Trichuriasis

8. Other causes
• Parenteral infection: Respiratory, UTI,
malaria, teething
• Nutritional: Kwashiorkar, sprue, pellagra,
• Drugs
• Inborn errors of metabolism
• Severe infection: septicemia

9. Socioeconomic Factors
• Poverty
• Overcrowding
• Poor sanitation
• Contamination of
water
• Inadequate food
hygiene

10. Behavioural Factors
• Failure to breast-feed
exclusively for the first
4-6 months of life
• Failure to continue
breast-feeding until
two years of age
• Using infant bottles
• Storing food at room
temperature
• Contaminated
drinking water
• Failure to wash hands
• Failure to dispose of
feces hygienically

11. Persons At Risk
• Rota virus diarrhea: Young infants & < 2 years
• Cholera: 2 years & above, uncommon in young
infants
• Shigellosis: Children < 5 years
• E.coli: Occur at any age
• Amebiasis: More common among adults

12. Transmission
• Fecal – oral
Water-borne
Food-borne
Direct transmission via
fingers, fomites or
dirt which may be
ingested by children
• Person – person
• Through air, Nosocomial

13. Clinical Presentation
• Signs & symptoms of
dehydration:
» Irritability
» Thirst
» Depressed fontanelle
» Sick looking child
» Dry mucous membrane
» Dry inelastic skin
» Rapid thready pulse
» Oliguria
» Anuria

14. Continued…
• Depending on causative organism
Features Viral diarrhea Bacterial diarrhea
Non invasive Invasive
Stool character watery Watery or
semisolid with
mucus
Semisolid small
amounts with
blood
Vomiting Severe Slight Moderate
Pyrexia Slight Nil Mod-high
URTI + - -
Seizures - - Occasional
Toxemia - - slight

15. Complications
1. Dehydration
2. Malnutrition
3. Electrolyte imbalance
4. Tetany
5. Convulsions
6. Hypoglycemia
7. Renal Failure

16. Assessment Of Dehydration
Look At No
dehydration
Some
dehydration
Severe
dehydration
Condition Well, alert Restless,
irritable*
Lethargic/uncon
sciousness*
Eyes Normal Sunken Very sunken &
dry
Tears Present Absent Absent
Mouth & tongue Moist Dry Very dry
Thirst Not thirsty Thirsty* Not able to
drink*
Feel
Skin pinch
Goes back
quickly
Goes back
slowly*
Goes back very
slowly*
Treatment Plan A Plan B Plan C

17. 5 Steps In Management
1. Dehydration – Person with diarrhea is like a pot of salt
water with a hole in its bottom
2. Rehydration – Like filling the pot with salt water. It must be
done quickly before it reaches the danger level
3. Maintenance – It is like keeping the pot full while
leak continues & at the same time making the
patient stronger by feeding him with proper food
4. Cure – when the leak stops and the pot is full
5. Prevention – stopping the further leaks by keeping
people healthy

18. Plan A
• Aims at preventing dehydration in early
diarrhea
• Treated at HOME by MOTHER
• Home available fluids: ganji, buttermilk,
coconut water,
• 3 rules for home treatment of diarrhea
• Give the child MORE fluids than usual
• CONTINUE feeding the child
• Watch for SIGNS of dehydration

19. Plan B
• Treated in health centre or hospital
1. Rehydration therapy:75ml/kg of ORS in first 4
hours
AGE <4m 4-11m 1-2 y 2-4 y 5-14 y >15 y
Weight < 5 kg 5- 7.9 Kg 8- 10.9
Kg
11- 15.9
Kg
16- 29.9
Kg
30 Kg or
more
ORS
(ml)
200-
400
400-600 600-800 800-
1200
1200-
2200
2200-
4000
Glass 1-2 2-3 3-4 4-6 6-11 12-20
2. Maintenance therapy
10-20ml/kg body weight for each liquid stool
3. Provision of normal daily fluid requirement

20. Plan C
Can you give IV fluids immediately •Start IV fluids
•Give ORS while the drip is set up
•Give 100ml/kg RL
Age 30ml/
kg
70ml/
kg
Infant 1 hr 5 hr
Older 0.5 hr 2.5 hr
NO
Is IV treatment available nearby?
(within 30 min)
yes
•Send the patient for IV treatment
•Provide ORS till then
yes
NO
Is nasogastric tube
available?
yes
•Start rehydration by tube
•20ml/kg/hr for 6 hours
NO
Can the patient drink? •Start rehydration by mouth
•20ml/kg/hr for 6 hours
NO
Urgently send the patient for IV therapy
yes

21. Oral Rehydration Solution
• Types
– Bicarbonate ORS
– Citrate ORS
– Reduced osmolarity
ORS
ORS
mmol
/L
Redu
ced
osm
ORS
Glucose 111 75
Sodium 90 75
Potassium 20 20
Chloride 80 65
Citrate 10 10
Total
osmolarity
311 245

22. Composition of Citrate ORS
ORS Reduced
Osmolarity ORS
Sodium chloride 3.5 g 2.6 g
Trisodium Citrate 2.9 g 2.9 g
Potassium
chloride
1.5 g 1.5 g
Glucose
anhydrous
20 g 13.5 g

23. Reduced Osmolarity ORS
• Total osmolarity 245 mmols/l
• Sodium – 75
• Glucose – 75
• Advantages
• Reduces stool output
• Reduces vomiting
• Reduces the need for unscheduled iv
fluids

24. Approaches To Improve ORS
Super ORS – contains more complex sugars
Types
• Food based
• Starch free
Advantages
• Reduces stool output
• Reduces stool frequency
• Reduces the duration of diarrhea
• Gives increased calories
• Prevents disaccharide intolerance

25. 10 Things About
Rehydrating A Child
1. Wash the hands with soap & water before
preparing
2. Prepare a solution in a well cleaned container,
with 1L of clean drinking water & 1 packet
ORS
3. Wash the hands of the baby & oneself before
feeding
4. Offer as much as it needs frequently
5. Give alternate fluids such as breast milk &
juice

26. Continued…
6. Continue to feed solids if child is > 6 months
7. After 24 hours, prepare fresh solution
8. ORS doesn’t stop diarrhea. It prevents body
from drying up. Diarrhea will stop by itself
9. If child vomits, wait ten minutes & give it ORS
again
10. If diarrhea increases and/or vomiting persists,
take child over to a health clinic

27. Role Of Drugs
• Antimicrobials to be used only when the cause
is known
Cause Drug of choice Alternatives
Cholera Doxycycline Co-trimaxazole
Furozolidone
Shigella Ciprofloxacin Ampicillin
Co-trimaxazole
Nalidixic acid
Typhoid Ciprofloxacin
Ofloxacin
Chloramphenicol
Amoxicillin
Co-trimaxazole
Azithromycin
ceftriaxone
Amoebiasis &
giardiasis
Metronidazole tinidazole

28. Prevention & Control
• Prevention at individual level:
– Wash the hands before food and after defecation
– Boil the water and cool it before drinking
– Immunizing the child against measles
• Prevention at family level:
– Stools and urine should not be passed into or near the
drinking water source
– Drinking water should be from the cleanest possible
source
– Food should be stored properly
• Prevention at community level:
– Provision of safe water supply
– Proper disposal of wastes
– Adequate supply of ORS, IV fluids at PHC and sub-
centre
– Training programmes for health workers

29. Prevention
The aim of prevention is to reduce transmission.
This is done through various methods:
Sanitation
Health Education
Immunization
Fly control

30. Sanitation
Improve water supply
Improve excreta disposal
– Each family should have a clean and functioning latrine
– If the family does not have one, they should defecate at a
distance from the house
Improve hygiene
Simple hygienic measures should be promoted. Eg.
Washing hands before cooking and eating
Improve food and food storage
– Contaminated foods are a major sources of transmission
– Food should be thrown away properly, and stored in a proper
manner

31. Health Education
Educational support should be given to the
family and health worker.
Promote adoption and maintenance of
preventive practices
– Breast-feeding
– Improve weaning
– Clean drinking water
– Hygiene
– Use of latrine
– Proper disposal of stools

32. Immunization
Not as important, however vaccination
can be an intervention for diarrhoea
control
Measles vaccine can prevent 25%
diarrhea death in children under 5 years of
age
Rota virus Vaccine:
Rotarix: 2 doses.2m,4m
Rotateq: 3 doses.2,4,6m

33. Fly Control
Flies breeding is associated with human
feaeces
These can cause diarrhoea and therefore
the control of flies can further prevent
transmission

34. Control of Epidemics
This requires strengthening of epidemiological
surveillance system.
Primary health care:
– Delivery of a package of curative and preventive to
the community.
– Approach should be centered upon:
Water supply
Excreta disposal
Communicable disease control
Mother and child health
Nutrition
Health education

35. Diarrheal Disease Control
Programme
• Started in the year 1978
• National ORT programme
since 1985-86
• Components
• Short term
– Appropriate clinical
management
• Long term
– Better MCH care practices
– Prevention strategies
– Prevention of diarrheal
epidemics

36. • The integrated Global action plan for
the prevention and control of
Pneumonia and Diarrhoea (UNICEF)

37. Other Related Programmes
• National water supply and sanitation
programme
• Integrated disease surveillance project
• National surveillance programme for
communicable diseases
• National rural health mission
• 20 point programme
• Minimum needs programme

38. Recent Modalities

39. con’t
• Promote better nutrtion
• Better hygiene
• Better weaning habits
• Better sanitations
• Promote antenatal visits
• Promote immunizations
• Clean water supply
• Promote breastfeeding
• Deworming

40. Interventions
 Key measures to reduce the number of cases of diarrhoea
include:
• Access to safe drinking water.
• Improved sanitation.
• Good personal and food hygiene.
• Health education about how infections spread.
 Key measures to treat diarrhoea include:
• Giving more fluids than usual, including oral rehydration salts
solution, to prevent dehydration.
• Continue feeding.
• Consulting a health worker if there are signs of dehydration or
other problems.

41. Specific protection
Disinfectant Amount per litre Percent
1.Bleaching powder 50 g 5
2.Crude phenol 100 ml 10
3.Cresol 50 ml 5
4.Formalin 100 ml 10

42. How To Make Special Drink?
• Take half litre of clean
drinking water in a clean
vessel
• Add 3 finger pinch of salt,
brush off any extra salt
that is stuck to the fingers
• Stir the mixture with a
clean spoon till the salt
has dissolved
• Taste a spoonful of drink,
it should not be more
salty than tears
• Add a fistful of sugar &
stir till it dissolves

43. Food During Diarrhea
• Less than 6 months:
– Continue breast feeding but give it often
• More than 6 months:
– Give freshly prepared mashed food containing cereals, pulses, vegetables.
– Add 1 to 2 tsp vegetable oil to each servings
– Give fresh fruit juice or mashed banana to provide potassium
– Encourage the child to eat, offer food at least 6 times/day
– After diarrhea stops, give an extra meal each day for two weeks

44. 5 rules for prevention
1. Breastfeed your child as long as possible
2. Always fill water from a pump or tube well
3. Make sure you wash your hands with soap after
going to toilet
4. Keep all food and drinking water covered to keep
out dirt and flies. Wash all fruits & vegetables
before eating
5. Wash your hands with soap before feeding your
child or cooking a meal

45. Conclusion
• Prevention is always better than cure.
• Sanitation ,hygiene & ORT play a more
important role in diarrhoea prevention.

46. •Thanks for attention!