acute diarrhoeal diseases, community medicine, epidemiology, management, social and preventive medicine

1. CONTROL OF
DIARRHOEAL
DISEASES
D R . S A M A R J E E T K A U R
A S S O C I A T E P R O F E S S O R
D E P A R T M E N T O F C O M M U N I T Y M E D I C I N E
G S V M M E D I C A L C O L L E G E , K A N P U R

2. INTRODUCTION
 Diarrhoea is defined as passage of unusually loose or watery
stools, which are usually passed more than three times in a
24 hour period.
 However, the recent change in consistency of the stools
rather than the number is more important.
 The passage of even one large watery stool in young child is
diarrhoea.

3. What is not a diarrhoea?
1. Frequent formed stools
2. Pasty stools in breastfed child
3.Stools during or after feeding
4.PSEUDODIARRHOEA:Small volume of stool frequently (IBS)

4. CLINICAL TYPES OF DIARRHOEAL DISEASE
Acute watery diarrhoea
Acute bloody diarrhoea (dysentery)
Persistent diarrhoea
Diarrhoea with severe malnutrition (marasmus and Kwashiorkor)

5. ACUTE WATERY DIARRHOEA
 Start suddenly, lasts for several hours to days
 The main danger is dehydration, if feeding is not continued then weight
weight loss also occurs.
 >75% of all episodes are of acute watery diarrhoea.
DYSENTERY (ACUTE BLOODY DIARRHOEA)
 Diarrhoea with visible blood & mucus in the faeces.
 Also abdominal cramps, fever, anorexia and rapid weight loss.

6. Persistent Diarrhoea
 Diarrhoea which lasts for > 14 days
 Incidence is around 5% i.e. 5% of acute diarrhoea may persist
beyond 2 weeks
 The main danger is malnutrition and serious non-intestinal
infection, person with other illnesses, such as AIDS are more
likely to develop persistent diarrhoea.

7. Diarrhoea with severe malnutrition (marasmus and kwashiorkor)
The main dangers are severe systemic infections, dehydration, heart failure, and
vitamin and mineral deficiency.

8. Epidemiology of Diarrhoea
Major killer of under 5 children, even though the toll is reduced considerably
10% of under-5 deaths in India
Reduction of mortality is due to rehydration tech including ORS.
In under-5 children – estimate to have 3 episodes per year
Incidence hasn’t changed much but mortality is reduced considerably
Loss of considerable numbers of DALYs
Diarrhoea is the leading cause of death during disasters and other emergencies
Heavy economic burden on : health services and Nation

9. ORGANISMS CAUSING ACUTE WATERY DIARRHOEA
 Bacteria- Account 1/3rd of total causes
E. Coli
V. Cholera
V. Parahaemolyticus
Shigella- bloody diarrhoea or dysentery
S. Typhi
Staph. Aureus
Clostridium perfringens
E. coli

10.  Viruses- 1/3rd of total causes
Rotavirus
Astroviruses
Calciviruses
Coronaviruses
Norwalk group viruses
Enteroviruses
 Rotavirus causes 15-25% diarrhoea cases in developing
countries
Rotavirus

11.  Parasites-
E. histolytica- Dysentery
Giardia intestinalis
Trichuriasis
Cryptosporidium parvum
 1/3rd of causes can’t be pinpointed

12. Pathogens frequently identified in children with acute
diarrhoea in treatment centres in developing countries.

13. RISK FACTORS OF DIARRHOEA
Bottle-fed babies have more chances to develop diarrhoea because
unclean bottles
Flies can also bring germs to uncovered food
Drinking contaminated water
Unclean food, milk, unclean hands & unclean utensils

14. CONTROL OF DIARRHOEAL DISEASES
SHORT TERM
Appropriate clinical management
LONG TERM
Better MCH care practices
Preventive strategies
Preventing outbreaks

15. Management of Diarrhoea

16. The 3 essential elements
The 3 essential elements in management of all
children with diarrhoea are :
•Oral Rehydration therapy
•Zinc supplementation
•Continued feeding

17. Rehydration therapy
During diarrhoea there is an increased loss of water and electrolytes (sodium,
potassium, and bicarbonate) in the liquid stool.
Dehydration occurs when
 These losses are not adequately replaced and
 A deficit of water and electrolytes develops.
The degree of dehydration is graded
 According to symptoms and signs
 This reflects the amount of fluid lost
The rehydration regimen is selected according to the degree of dehydration

18. Zinc supplementation
Zinc is an important micronutrient for a child’s overall health and development.
Zinc is lost in greater quantity during diarrhoea.
Replacing the lost zinc is important to help the child recover and to keep the child
healthy in the coming months.
It has been shown that the zinc supplements given during an episode of diarrhoea
 Reduce the duration and severity of the episode, and
 Lower the incidence of diarrhoea in the following 2-3 months.
For these reasons, all patients with diarrhoea should be given zinc supplements as soon
as possible after the diarrhoea has started.

19. Continued feeding
During diarrhoea,
 A decrease in food intake and nutrient absorption and
 Increased nutrient requirements
Often combine to cause weight loss and failure to grow
And malnutrition in turn can make the diarrhoea
 More severe,
 More prolonged and
 More frequent
 As compared with diarrhoea in non-malnourished children
This vicious circle can be broken by giving nutrient-rich foods during the diarrhoea and when the
child is well.

20. Antibiotics and other drugs
Antibiotics should not be used routinely.
◦ They are reliably helpful only for
◦ Children with bloody diarrhoea (probable shigellosis),
◦ Suspected cholera with severe dehydration, and
◦ Other serious non-intestinal infections such as pneumonia.
Antiprotozoal drugs are rarely indicated.
“Antidiarrhoeal”drugs and anti-emetics
◦ Should not be given to young children with acute or persistent diarrhoea or dysentry
◦ They do not prevent dehydration or improve nutrient status and
◦ Some have dangerous, sometimes fatal side-effects.

21. Assess dehydration
In all children with diarrhoea, decide if dehydration is present and give appropriate treatment
Hydration status should be classified as severe dehydration, some dehydration or no
dehydration (as per the table below) and appropriate treatment given.
Severe dehydration
(I/V rehydration)
Two or more of the following signs:
•Lethargy/unconciousness
•Sunken eyes
•Unable to drink or drinks poorly
•Skin pinch goes back very slowly (≥2 sec.)
Some dehydration
•Give fluid & food
•After rehydration advice
mother
Two or more of the following signs
•Restlessness, irritibality
•Sunken eyes
•Drinks eagerly, thirsty
•Skin pinch goes back slowly
No dehydration
•Give fluids and food
•Advice mother
Not enough signs to classify some or severe dehydration

22. Video
https://youtu.be/fdWSS6H1q8Y
https://youtu.be/q-fPnkWtMjY

23. Skin Pinch

24. sunken eyes

25. Severe dehydration
Children with severe dehydration require rapid IV rehydration with close
monitoring.
Followed by oral rehydration once the child starts to improve sufficiently.
In areas where there is a cholera outbreak, give an antibiotic effective against
cholera.

26. Treat Severe Dehydration Quickly: Diarrhoea Treatment Plan C
Start IV fluids immediately. While the drip is being set up, give ORS solution if the child can drink.
The recommended IV fluid is Ringer’s Lactate (also called Hartman’s Solution)
If Ringer’s lactate is not available, normal saline (0.9% NaCl) can be used.
5% glucose (dextrose) solution on its own is not effective and should not be used.
Give 100 ml/kg of the chosen solution divided as shown in the table below:
Age First, give 30 ml/kg in: Then, give 70 ml/kg in:
<12 months old 1 hour 5 hours
≥12 months old 30 minutes 2 ½ hours

27. Monitoring
Reassess the child every 15-30 minutes until a strong radial pulse is
present.
◦ If hydration is not improving, give the IV solution more rapidly.
◦ Thereafter, reassess every hour, to confirm if hydration is improving.
◦ Skin pinch
◦ Level of consciousness, and
◦ Ability to drink
◦ Sunken eyes recover slower than other signs, therefore less useful for monitoring

28. When the full amount of IV fluid has been given, reassess the child’s hydration
◦ If signs of severe dehydration are still present, repeat the IV fluid infusion.
◦ If the child is improving but still shows signs of some dehydration, discontinue IV treatment
and give ORS solution for 4 hours
◦ If the child is normally breastfed, encourage the mother to continue breastfeeding frequently.
If there are no signs of dehydration, Treatment plan A.

29. Monitoring
Observe the child for at least 6 hours before discharge, to confirm
that the mother is able to maintain the child’s hydration by giving
ORS solution.
All children should start to receive some ORS solution (about 5
ml/kg/hour) by cup when they can drink without difficulty (usually
within 3-4 hours for infants, or 1-2 hours for older children).
When severe dehydration is corrected, prescribe zinc.

30. Some dehydration
In general, the child should be given ORS solution for the first 4 hours at a clinic
while
The child is monitored and
The mother is taught how to prepare and give ORS solution
The amount of ORS to be given in the first 4 hours, is calculated according to the
child’s weight (or age if weight is not known), as shown in the table below:

31. Use the child’s age only when you do not know the weight.
The approximate amount of ORS required(in ml) can also be calculated by multiplying
the child’s weight (in kg) by 75.
If the child wants more ORS than shown, give more.
Age Up to 4 months 4 -12 months 12 months up to 2
years
2 - 5 years
Weight <6kg 6-10 kg 10-12 kg 12-19 kg
Amount 200-400 ml 400-700 ml 700-900 ml 900-1400 ml

32. Demonstrate to the mother, how to give the child ORS solution, a teaspoonful
every 1-2 minutes if the child is under 2 years; frequent sips from a cup for an
older child.
Check regularly to see if there are problems.
◦ If the child vomits, wait 10 minutes; then, resume giving ORS solution more slowly (e.g. a
spoonful every 2-3 minutes)
◦ If the child’s eyelids become puffy, stop ORS solution and give plain water or breast milk.
Advise breastfeeding mothers to continue to breastfeed whenever the child
wants.

33. Reassess the child after 4 hours, checking for signs of dehydration.
If the mother cannot stay for 4 hours,
◦ Show her how to prepare ORS solution and
◦ Give her enough ORS packets to complete the rehydration at home plus for 2 more days.
If there is no dehydration, teach the mother the four rules of home treatment:
◦ Give extra fluid
◦ Give zinc supplements
◦ Continue feeding
◦ When to return

34. No dehydration
Children with diarrhoea but no dehydration should receive extra fluids at home
to prevent dehydration.
They should continue to receive an appropriate diet for their age, including
continued breastfeeding
Treat the child as an outpatient
Counsel the mother on the 4 rules of home treatment.

35. Give extra fluid, as follows :
◦ If the child is being breastfed, advise the mother to breastfeed frequently and for longer at each feed.
◦ If the child is exclusively breastfed, give ORS solution or clean water in addition to breast milk.
◦ After the diarrhoea stops, exclusive breastfeeding should be resumed, if appropriate to the child’s age.
In non-exclusively breastfed children, give one or more of the following:
◦ ORS solution
◦ Food-based fluids (such as soup, rice water and yoghurt drinks)
◦ Clean water
To prevent dehydration from developing, advise the mother to give extra fluids-as much as the child will
take:
◦ For children < 2 years, about 50-100 ml after each loose stool
◦ For children 2 years and above, about 100-200 ml after each loose stool.

36. Tell the mother to give small sips from a cup. If the child vomits, wait 10 minutes and then give more
slowly.
She should continue giving extra fluid until the diarrhoea stops.
Teach the mother how to mix and give ORS solution and give her two packets of ORS to take home.
Advise the mother to return immediately to the clinic if the child
◦ Becomes more sick, or
◦ Is unable to drink or breastfeed, or drinks poorly, or
◦ Develops a fever, or shows blood in the stool.
If the child shows none of these signs but is still not improving, advise the mother to return for the follow-
up at 5 days.

37. Zinc supplementation
Tell the mother how much zinc to give:
◦ Up to 6 months ½ tablet (10 mg) per day for 14 days
◦ 6 months and more 1 tablet (20 mg) per day for 14 days
Show the mother how to give the zinc supplements:
◦ Infants, dissolve the tablet in a small amount of clean water, expressed milk or ORS in a small
cup or spoon.
◦ Older children, tablet can be chewed or dissolved in a small amount of clean in a cup or
spoon.
Remind the mother to give the zinc supplements for the full 10-14 days.

38. Continued feeding
Continuation of nutritious feeding is an important element in diarrhoea management
In the initial 4-hour rehydration period, do not give any food except breast milk.
Breastfed children should continue to breastfeed frequently throughout the episode of diarrhoea.
After 4 hrs, if the child still has some dehydration and ORS continues to be given, give food every 3-4
hrs.
All children over 4-6 months old should be given some food before being sent home.
If the child is not normally breastfed, explore the feasibility of relactation (i.e restarting breastfeeding
after it was stopped or give the usual breastmilk substitute)

39. If the child is 6 months or older or already taking solid food, give freshly prepared food – cooked,
mashed or ground.
The following are recommended:
◦ Cereal or other starchy food mixed with pulses, vegetables and meat/fish, if possible, with 1-2 tsps of
vegetable oil added to each serving.
◦ Local complementary foods recommended by IMNCI in the area
◦ Fresh fruit juice or mashed banana to provide potassium
Encourage the child to eat by offering food at least 6 times a day. Give the same food after the
diarrhoea stops and give an extra meal a day for 2 weeks.

40. The 4 rules of Home Treatment
Give extra fluid
Give zinc supplements
Continue feeding
When to return
◦ Advise the mother to return immediately to the clinic if
◦ The child becomes more sick, or
◦ Is unable to drink or breastfeed, or drinks poorly, or
◦ Develops a fever, or shows blood in the stool.
◦ If the child shows none of these signs but is still not improving, advise the mother to return follow up at 5
days.

41. •Follow up after 2 days in dysentery, after 5 days in acute diarrhoea
Return immediately if the child develops:
 Many watery stools,
 Repeated vomiting,
 Fever,
 Poor or unable to drink and eat/ breastfeed,
 Blood in stool

42. ORAL REHYDRATION SALT(ORS)
 It is a balanced mixture of glucose and electrolytes
 Almost all deaths from diarrhoea can be prevented by ORS
MECHANISM OF ACTION
 Sodium promotes absorption of water from the intestine
 Glucose promotes the absorption of sodium and water from the
intestine

44. Composition of WHO -ORS
Ingredients Normal
(gm)
Low osmolarity
(gm)
Sodium chloride 3.5 2.6
Glucose 20.0 13.5
Potassium Chloride 1.5 1.5
Trisodium citrate dehydrate 2.9 2.9
27.9 gm
(310 mOsm/l)
20.5 gm
(245 mOsm/l)
SGPT:2.6,13.5,1.5,2.9

45. Ingredients Low osmolarity
(mmol/l)
Sodium 75
Glucose 75
Potassium 20
Citrate 10
Chloride 65
245 mOsm/l
Hypo-osmolar ORS
SGPTC:7575,201065

46. Benefits of citrate ORS over bicarbonate ORS
1. Trisodium citrate made the ORS stable
2. Resulted in less stool output
Benefits of low-osmolarity ORS over normal ORS
1. Osmolarity reduced to avoid the adverse effects of hyper-tonicity
2. Need for unscheduled IV management was reduced by 33% in children
with hypo-osmolar ORS
2. Stool output and vomiting decreased
3. India-first country in the world to launch new ORS in June 2004

47. Homemade ORS
1 tsp table salt + 4 heaped tsp sugar
in 1 liter of water
SUPER ORS
Amino acid-based ORS
Amino acids (Alanine, Glycine co-transport the Na+) are used
in place of glucose
Powder of boiled rice (50 mg/L) can be used in place of amino acids
Decrease purging rates and improve absorption

49. ORS

52. National diarrhoea diseases control programme
1. Short-term: Appropriate clinical management
-ORT
-Appropriate feeding
-Chemotherapy
2. Long term
a. Better MCH practices
-Maternal nutrition
-Child nutrition: breastfeeding, proper weaning, supplementary feeding

53. b. Preventive strategies
-Sanitation
-Health education
-Immunization
-Fly control
-Food Hygiene: Boil it, cook it, peel it, or forget it
c. Prevention and control of diarrhoeal epidemics
-Strengthening of epidemiological surveillance

54. Rota virus vaccination
 Rotashield vaccine -1999
 Withdrawn because of its association with intussuscption
 Two new oral, live attenuated rotavirus vaccines were
licensed in 2006 with very good safety and efficacy
 The first dose administered between ages 6-10 weeks .
 subsequent doses at intervals 4-10 weeks.
 Vaccination should not be initiated before 6weeks and after
12 weeks of age.
 All doses should be administered before 32 weeks.

55. Rota Rix vaccine Rota Teq vaccine
Oral, live attenuated
Oral, live attenuated, pentavalent
vaccine. Contains 5 live reassortant
rotaviruses
2 dose schedule
3 dose schedule
1st dose - 2 month of age at 2 month of age
2nd dose- 4 month 4 month of age
…………………………. 6 month of age

56.  -

57. WHO Recommendation for Rota virus
vaccination
 Geneva and Seattle, June 5, 2009 — WHO has
recommended that rotavirus vaccination be included in all
national immunization programmes
 The new recommendation by the WHO's Strategic Advisory
Group of Experts (SAGE),extends an earlier recommendation
made in 2005 on vaccination in the America and Europe,
where clinical trials had demonstrated safety and efficacy in
low and intermediate mortality populations.

58. MESSAGES:
 ORS is best drink.
 A child with diarrhoea needs more food and frequent breast
feeding.
 A child who is recovering from diarrhoea needs an extra meal every
day for at least 2 weeks.
 Medicine other than ORS should not be used except on medical
advice.

59. REFERENCES
MODULES of IMNCI 2003
K.PARK , TEXTBOOK OF COMMUNITY MEDICINE
SUNDER LAL, TEXTBOOK OF COMMUNITY MADICINE.
HARRISONS PRINCIPLES OF INTERNAL MEDICINE 17th edition
IAP GUIDELINES FOR MANAGEMENT OF DIARRHEA
WORLD HEALTH ORGANIZATION (WHO) GUIDELINES ON TREATMENT OF DIARRHEA (2005

60. T
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