Description about epidemiology and control of acute diarrhoea in India.

1. EPIDEMIOLOGY AND CONTROL
OF ACUTE DIARRHEAL DISEASES
Dr. Anish Khanna
Associate Professor
Department of Community Medicine and Public Health
K.G.M.U, Lucknow.

2. WHAT IS DIARRHOEA?
 Diarrhoea is the passage of loose, liquid or watery
stool.
In many regions Diarrhoea is defined as passage of
three or more loose or watery stools in 24 hour
period.
However it is the recent change in consistency and
character of stool than the number of stools that is
more important.
In most cases the mother knows what is abnormal
stool for her child.
It is a killer disease in children.
One in four deaths in children under the age of 5yrs.
is due to diarrhoea.

3. WHAT CAUSES DIARRHOEA?
Infectious Disease Agents Causing Diarrhoea.
BACTERIA
1. Escherichia coli
It produces heat labile (LT) and heat stable (ST)
entertoxins.
E.COLI - COULD BE
 Enteropathogenic- Causes infantile diarrhoea.
 Entero toxigenic – Causes travellers diarrhoea.
 Enteroinvasive- Dysentery type of diarrhoea.
 Enteroadherent
 Enterohaemorrhagic
VIBRIO CHOLERAE- produces enterotoxins
 Vibrio para haemolyticus- Invasive.
 Non-Cholerae vibrios

4. WHAT CAUSES DIARRHOEA?
Infectious Disease Agents
SHIGELLAE–Invasive, produce bloody diarrhoea or
Dysentery.
 CAMPYLOBACTER JEJUNI – invasive.
 SALMONELLAE OTHER THAN S.TYPHI- invasive.
 STAPHYLOCOCCUS AUREUS- entrotoxins
 CLOSTRIDIUM PERFRINGENS- enterotoxins.
3. VIRUSES
 Rotavirus – invasive.
4. PARASITES
 E. histolytica- invasive.
 Giardia Lamblia- non invasive.

5. WHAT IS THE MAGNITUDE OF THE PROBLEM?
WORLD WIDE?
IN INDIA?
 NFHS- 2 data highlights morbidity profile of under 3 yrs.
Fever- (27%)
A.R.I. - (17%)
Diarrhoea – (13%)
Under Wt. (43%)
 Often due to a combination of these conditions.
 Diarrhoeal diseases are a major public health problem
among children under 5yrs. of age.
 Around 8-11 million cases are being reported annually in
India.

6. WHAT IS THE EPIDEMIOLOGY OF
DAIRRHOEAL DISEASES?
 RISK FACTORS OR DETERMINANTS
 AGENT FACTORS
 HOST FACTORS
 ENVIRONMENTAL FACTORS
 RESERVOIR OF INFECTION.

7. HOW MANY TYPES OF
DIARRHOEA ARE THERE?
 ACUTE WATERY DIARRHOEA.
 DYSENTRY (BLOOD IN STOOLS).
 PERSISTENT DIARRHOEA.

8. HOW SHOULD ACUTE WATERY
DIARRHOEA IN CHILDREN BE MANAGED?
ASSESSMENT OF DEHYDRATION
DOES THE CHILD HAVE SIGNS OF
DEHYDRATION?
IS DEHYDRATION MILD OR SEVERE?

9. ASSESSMENT OF THE CHILD WITH DIARRHEA
FOR THE DEGREE OF DEHYDRATION AND
MANAGEMENT
Degree of dehydration signs Mild Severe
a. Look for
General condition
Eyes
Tears on cry
Mouth and tongue
Thirst
Restless, irritable
Sunken
Absent
Dry
Thirsty (drinks eagerly)
Lethargic, floppy, unconscious,
Deeply sunken and dry
Absent
Very dry
Very thirsty but (drinks poorly
or unable to drink)
b. Feel for
Skin pinch Goes back slowly, takes 1 to 2
seconds
Goes back very slowly, takes
more than 2 seconds
c. Decide there is some dehydration. There is severe dehydration.
d. Treatment Plan B
With WHO recommended ORS
solution to correct some
dehydration.
Plan C
With IV infusion urgently to
correct severe dehydration and
to prevent death
Fluid deficit is 5-10% of body weight > 10% of body weight

10. AFTER CLINICAL ASSESSMENT WHAT
SHOULD BE DONE?
 LABORATORY INVESTIGATIONS
 FEEDING DURING DIARRHOEA
 RATIONAL USE OF DRUGS
# What is the role of anti Diarrhoeals?
 FLUID THERAPY

11. FLUID THERAPY IN DIARRHOEA
 WHAT IS THE PURPOSE OF FLUID THERAPY.
 APPROPRIATE FLUID THERAPY
- ORS
Basis of ORS
What is the mechanism of action of ORS?
 OTHER FLUIDS
HAF
-SSS (Sugar salt solution)

12. WHAT SHOULD BE THE TREATMENT
OF CASES OF ACUTE WATERY
DIARRHOEA
 THREE CATEGORIES OF CASES.
 Cases with No Signs of dehydration- Plan-A.
 Cases with some signs of dehydration- Plan-B
 Cases with severe dehydration-Plan -C

13. HOW CAN DIARRHOEA BE
PREVENTED?
PREVENTIVE STRATEGIES.
 Sanitation
- Hand washing
- Exclusive breast feeding
- Clean food
 Environmental sanitation
 Elimination of Reservoirs
 Breaking the channel of transmissions

14. PREVENTION OF DIARRHOEA?
ELIMINATION OF RESERVOIRS
 Prevention of dehydration
 Correction of dehydration
 Maintenance of hydration
 Chemotherapy
 Restoration of Nutritional Status.
 Diarrhoea- Leads to malnutrition
 Increase in Breast feeding frequency
 Increase in diet.

15. OTHER PREVENTIVE STRATEGIES?
 Vitamin –A prophylaxis
 Improved Nutrition
 Immunization
- Measles immunization
ROTA VIRUS VACCINE
 Two live oral attenuated rotavirus vaccines were licensed
in 2006. Now there are three.
 Monovalent human rotavirus vaccine (Rotarix).
 The pentavalent bovine- Human reassortant vaccine
(Rota Teq)
 They Provide 75-80% protection against rotavirus
diarrhoea
and 90-100% protection against rotavirus disease.

16. WHAT ARE THE NATIONAL PROGRAMS
FOR DIARRHOEA IN INDIA
National diarrhoeal disease control program
(NDDCP)
 Diarrhoeal disease control program started in 1978.
 1985 – 86 National Oral Rehydration Therapy Program
 Case management of diarrhoea by HAF & ORS.
 Improvement of maternal knowledge and practices
with egard to HAF

17.  Since CSSM Program became a part of RCH program
in 1997, Integrated Management of Child hood
Illness (IMCI) has been adopted in India.
 IMCI deals with all children not only sick children
- Diarrhoea
- Pneumonia
- Measles
- Malaria
- Health promotion
- Immunization
- Breast feeding
- Vit. A & Iron Supplementation

18.  WHAT ARE THE REVISED GUIDELINES FOR
MANAGEMENT OF DIARRHOEA?
GOI & IAP (Indian Academy of Pediatrics)
 Low osmolarity ORS
 Zinc (10mg Elemental Zinc for infants 2-6 month of
age 20mg Zinc for children > 6 months for 14 days)
 Feeding of energy dense foods in addition to Breast
feeding
 HAF
 Hygiene
 Antimicrobials for gross blood in stools or shigella +
culture.

19. MCQ’s in Diarrhoea
 1. WHO ORS contains:
 A) Sodium Chloride 2.5 gm
 B) Potassium Chloride 1.5 gm
 C) Glucose 20 gm
 D) Sucrose 10 gm
 E) Potassium Bicarbonate 2.5 gm
 Ans- B,C,E
 2. For controlling an outbreak of Cholera all of the following measures are
recommended except:
 A) Mass chemoprophylaxis
 B) Proper disposal of excreta
 C) Chlorination of water
 D) Early detection and management of cases
 Ans- A

20.  3. In ORS the concentration of sodium chloride is:
 A) 3.5 gm
 B) 2.5 gm
 C) 2.9 gm
 D) 1.5 gm
 Ans- A
 4. Drug of choice for carriers of typhoid is:
 A) Ampicillin
 B) Chloramphenicol
 C) Co-Trimoxazole
 D) Clindamycin
 Ans- A

21.  5. Typhoid oral vaccine is given:
 A) 1,3,5 days
 B) 1,2,3 days
 C) 1,2,4 days
 D) 1,7,14 days
 Ans- A
 6. In WHO-ORS concentration of Sodium is:
 A) 60 mEq/l
 B) 50 mEq/l
 C) 40 mEq/l
 D) 90 mEq/l
 Ans- D

22.  7. True about citrate in ORS:
 A) Nutritious
 B) Cheaper
 C) Increases shelf life
 D) Tastier
 Ans- C
 8. A convalescent case of Cholera remains infective for:
 A) less than 7 days
 B) 7 to 14 days
 C) 14 to 21 days
 D) 21 to 28 days
 Ans- C