The document outlines Nepal's history of programs to control diarrhoeal diseases among children, beginning in 1983 with the Control of Diarrhoeal Disease program and evolving into the current Community-Based Integrated Management of Childhood Illness program, which integrates management of newborn care and aims to reduce under-five mortality from diarrhoea and other illnesses through improved case management, health systems, and community care practices.

1. CONTROL OF
DIARRHOEAL
DISEASE IN NEPAL
Prepared by:
Deepa Manandhar
Lecturer
Community Health Nursing

2. Introduction
• Passage of unusually loose or watery
stools usually at least 3 times in 24hrs
period.
• During diarrhea there is an increase loss
of water and electrolytes in the liquid stool.

3. Introduction….
• Dehydration occurs when these losses are
not adequately replaced and a deficit of
water and electrolytes develops.

4. Introduction….
• Diarrhoea among children under-five is a
serious public health problem in many
developing countries, including Nepal.

5. History of Programme
• In Nepal, Child survival intervention began
when Control of Diarrhoeal Disease (CDD)
Program was initiated in 1983.
• Further, Acute Respiratory Infection (ARI)
Control Program was initiated in 1987

6. History….
• In 1997/98, ARI intervention was
combined with CDD and named as CB-AC
(Community Based ARI and CDD)
program.
• One year later two more components,
nutrition and immunization, were also
incorporated in the CBAC program.

7. History….
• IMCI program was piloted in Mahottari
district and was extended to the
community level as well.

8. History….
• Finally, the government decided to merge
the CBAC into IMCI in 1999 and named it
as Community-Based Integrated
Management of Childhood Illness (CB-
IMCI).

9. History….
• CB-IMCI included the major childhood
killer diseases like pneumonia, diarrhoea,
malaria, measles, and malnutrition.

10. History….
• The strategies adopted in IMCI were
improving knowledge and case
management skills of health service
providers, overall health systems
strengthening and improving
community and household level care
practices.

11. History….
• After piloting of low osmolar ORS and Zinc
supplementation, it was incorporated in
CB-IMCI program in 2005.
• Nationwide implementation of CBIMCI was
completed in 2009 and revised in 2012
incorporating important new interventions.

12. History….
• ‘Community-Based New Born Care
Program (CB-NCP)’ was designed in
2007, and piloted in 2009

13. History….
• Considering the management of similar
kind of two different programs, MoH
decided to integrate CB-NCP and IMCI
into a new package that is named as CB-
IMNCI.

14. History….
• CB-IMNCI is an integration of CB-IMCI
and CB-NCP Programs as per the
decision of MoH on 2071/6/28 (October
14, 2014).

15. History….
• This integrated package of child-survival
intervention addresses the major problems
of sick newborn such as
- birth asphyxia,
- bacterial infection,
- jaundice,

16. History….
- hypothermia,
- low birth weight,
- counseling of breastfeeding.

17. History….
• It also maintains its aim to address major
childhood illnesses like
- Pneumonia,
- Diarrhoea,
- Malaria,

18. History….
- Measles and
- Malnutrition
among under 5 year’s children in a holistic
way.

19. Goal
• Improve newborn and child survival and
healthy growth and development.

20. Targets of Nepal Health
Sector Strategy (2015-2020)
• Reduction of Under-five mortality rate (per
1,000 live births) to 28 by 2020
• Reduction of Neonatal mortality rate (per
1,000 live births) to 17.5 by 2020

21. Objectives
• To reduce neonatal morbidity and mortality
by promoting essential newborn care
services

22. Objectives….
• To reduce neonatal morbidity and mortality
by managing major causes of illness
• To reduce morbidity and mortality by
managing major causes of illness among
under 5 years children

23. Strategies
• Quality of care through system
strengthening and referral services for
specialized care

24. Strategies….
• Ensure universal access to health care
services for new born and young infant
• Capacity building of frontline health
workers and volunteers.

25. Strategies….
• Increase service utilization through demand
generation activities
• Promote decentralized and evidence-
based planning and programming

26. Achievements
• CB-IMNCI program has created enabling
environment to health workers for better
identification, classification and treatment
of diarrhoeal diseases.

27. Achievements….
• As per CB-IMNCI national protocol,
diarrhoea has been classified into three
categories: ‘No Dehydration’, ‘Some
Dehydration’, and ‘Severe Dehydration’

28. Achievements….
• In FY 2074/75, a total of 1,148,238
diarrhoeal cases were reported out of
which about
- one third (33%) were reported from health
facilities and ORC and
- rest two third (67%) by FCHVs which
showed similar trend like that of previous
year.

29. Achievements….
• Among registered cases in Health Facilities
and PHC/ORC
- more than three fourth (83%) were
classified as having no dehydration,
- about one fifth (16.7%) some dehydration.
- Severe dehydration remained below 1%
across all provinces and in national level.

31. • As shown in table 4.2.6, Incidence of
diarrhoea per thousand under age 5
children was 385 in FY 2074/75, being
highest at Karnali (709) followed by Sudur
Pachhim (648).
• Further, the lowest incidence was in
province 3 (262).

32. • Total diarrhoeal death in health facility and
PHC/ORC was 47 which increased by 42%
than the last fiscal year.
• Case fatality rate across all the provinces
was below 1 per thousand

34. • In FY 2074/75, the proportion of diarrhoeal
cases treated with ORS and Zinc as per
IMNCI national protocol at national level
was 95.2% which was slightly higher than
that of previous year (92.14%).
• Highest proportion was seen in Sudur
Pachhim (98.82%) and lowest in province 1
(89.76%).

35. Elements
• Assess
• Classify
• Identify
• Treatment
• Counsel
• Follow up care

36. IMNCI CASE MANAGEMENT
PROCESS
• Assess a child
• Classify a child’s illnesses
• Identify treatments for the child.
• Treatment instructions

37. IMNCI CASE MANAGEMENT
PROCESS….
• Counsel the mother to solve any feeding
problems and her own health.
• When a child is brought back to the clinic
give follow-up care and if necessary
reassess the child for new problems

38. 1.Assess
• A child by checking first for danger signs
(or possible bacterial infection in a young
infant), asking questions about common
conditions, examining the child, and
checking nutrition and immunization
status.
• Assessment includes checking the child
for other health problems

39. 2. Classify
• A child’s illnesses using a colour-coded
triage system. Because many children
have more than one condition, each illness
is classified according to whether it
requires:
- urgent pre-referral treatment and referral
(red), or

40. 2. Classify….
- specific medical treatment and advice
(yellow), or
- simple advice on home management
(green).

41. 3. Identify
• Specific treatments for the child.
• If a child requires urgent referral, give
essential treatment before the patient is
transferred.

42. 3. Identify….
• If a child needs treatment at home,
develop an integrated treatment plan for
the child and give the first dose of drugs in
the clinic.
• If a child should be immunized, give
immunizations

43. 4.Treatment
• Provide practical treatment instructions,
including teaching the caretaker
- how to give oral drugs,
- how to feed and give fluids during illness,
and
- how to treat local infections at home.

44. 4.Treatment….
• Ask the caretaker to return
- for follow-up on a specific date, and
- teach her how to recognize signs that
indicate the child should return
immediately to the health facility

45. 5. Counsel
• Assess feeding, including assessment of
breastfeeding practices, and counsel to
solve any feeding problems found.
• Then counsel the mother about her own
health.

46. 6. Give follow-up care
• When a child is brought back to the clinic
as requested, give follow-up care and, if
necessary, reassess the child for new
problems.

47. 6. Give follow-up care….
• The case management process for sick
children age 2 months up to 5 years is
presented on three charts titled:
- ASSESS AND CLASSIFY THE SICK
CHILD
- TREAT THE CHILD
- COUNSEL THE MOTHER

48. 6. Give follow-up care….
• If the child is not yet 2 months of age, the
child is considered a young infant.
• Management of the young infant age up
to 2 months is somewhat different from
older infants and children.

49. 6. Give follow-up care….
• It is described on a different chart titled:
- ASSESS, CLASSIFY AND TREAT THE
SICK YOUNG INFANT

50. Management of diarrhoea
based on CBIMNCI
For young infants
The steps to assess and classify during
an initial visit are
• Rapidly appraise all waiting infants.
• Ask the mother what the young infants
problem are.

51. Management of diarrhoea
based on CBIMNCI….
• Check for possible serious bacterial
infection, very severe disease, pneumonia
or local bacterial infection
• Then, check for jaundice

52. Management of diarrhoea
based on CBIMNCI….
• Ask about diarrhoea. If the infant has
diarrhoea, assess for related signs.
• Classify the young infants for dehydration
• Also classify for persistent diarrhoea and
dysentery if present.

58. Management of Persistent
Diarrhoea
• If there is diarrhoea for 14 days or more
then it is classified as severe persistent
diarrhoea. Treat the young infant as
follows:
- If there is no bacterial infection then treat
dehydration before referral
- Refer to the hospital.

59. Management of dysentery
• If there is presence of blood in stool then:
- Administer first dose gentamycin (IM) and
ampicillin (IM).
- Referral to health facilities
- Continue breastfeeding and maintain
temperature of the infant.

60. Follow up care

61. Management of diarrhoea
based on CBIMNCI
For older child (2 months- 5year)
• Ask the mother what the child's problems
are.
• Determine if this is an initial or follow-up
visit for this problem. If follow-up visit, use
the follow-up instructions.

62. Management of diarrhoea
based on CBIMNCI….
• If initial visit, assess the child as follows:
• Check for general danger signs.
- Ask about presence of cough or breathing
difficulty.
- Ask about diarrhoea.

63. Management of diarrhoea
based on CBIMNCI….
- Ask about fever.
- Ask about ear problem
- Check for malnutrition

64. Management of diarrhoea
based on CBIMNCI….
- Check for anemia
- Check for HIV infection
- Check for immunization, vitamin A and
deworming status.

75. Follow up care

77. • Second line
- Add metronidazole (Syp 200 mg per 5 ml).
Give for 5 days TDS(1 yr-3 yrs:2.5ml, 3
yrs- 5yrs:5 ml).
- Advise the mother to return in 3 days

78. Roles of nurse in controlling
diarrhoeal disease
Some the important roles are as follows;
Health educator
Motivator
Counselor
Health care provider
Supervisor

79. Roles of nurse in controlling
diarrhoeal disease
Manager
Change Agent
Researcher
Co-ordinator
Evaluator
Facilitator