A brief description on Acute Diarrhoeal diseases. Its definition, types, epidemiology its prevention and control, vaccines available.

5. Acute diarrhoeal
diseases (ADD)

6. Introduction
 Diarrhoea is defined as the passage of loose, liquid or watery
stools more than three times a day
 It is the recent change in consistency and character of stools
rather than the number of stools that is more important
 Intestinal and respiratory infections are a major cause of death
in children under 5 yrs of age

7.  Diarrhoea is a leading cause of death during natural disasters
and other emergencies
 Displacement of population into overcrowded shelters,
polluted water sources, inadequate sanitation, poor hygiene
 Lack of adequate health services, transport etc

8. Clinical types of diarrhoeal disease
1) Acute watery diarrhoea: usually lasts several hours to days; main
danger is dehydration, weight loss. The usual pathogens are Vibrio
cholerae, E.coli and Rotavirus
2) Acute bloody diarrhoea: also called “dysentery”. The main
dangers are damage to intestinal mucosa, sepsis and malnutrition. It
is marked by visible blood in stools. The common cause is Shigella.

9. 3) Persistent diarrhoea: lasts 14 days or longer. The main danger is
malnutrition, sepsis. Persons with AIDS are more likely to develop
persistent diarrhoea
4) Diarrhoea with severe malnutrition (marasmus and kwashiorkor) :
the main dangers are severe systemic infection, dehydration,
vitamin and mineral deficiency, heart failure

10. WHO Factsheet
• Diarrhoeal disease is the third leading cause of death in children 1–59
months of age. It is both preventable and treatable.
• Each year diarrhoea kills around 4,43,832 children under 5 and an
additional 50,851 children aged 5 to 9 years.
• A significant proportion of diarrhoeal disease can be prevented
through safe drinking-water and adequate sanitation and hygiene.
• Globally, there are nearly 1.7 billion cases of childhood diarrhoeal
disease every year.
• Diarrhoea is a leading cause of malnutrition in children under 5 years
old.

11. Epidemiological determinants - Agent
1) Viruses - Rotavirus, Astrovirus, Adenovirus, Coronavirus,
Enterovirus, Cytomegalovirus
2) Bacteria - Campylobacter jejuni, Escherichia coli, Shigella,
Salmonella, Vibrio cholerae, Vibrio parahaemolyticus,
Staphylococcus aureus, Clostridium perfringens, Yersinia
enterocolitica, Chlamydia, Neisseria gonorrhoeae
3) Others - E. histolytica, Giardia intestinalis, Cryptosporidium,
Cyclospora

12. Infections causing diarrhoea
 Rotaviruses- shed in high concentrations for many days in stool
and vomit of infected individuals. Transmission occurs primarily
by faeco-oral route
 Bacterial causes- (a) E. coli cause acute watery diarrhoea in
adults and children. It is the most common cause of traveller’s
diarrhoea
 (b) Salmonella cause inflammation of bowel epithelium
 (c) Shigella accounts for a high percentage of mortality due to
diarrhoeal disease

13.  Others - (a) Giardiasis is a recognised cause of diarrhoea. It
flourishes in duodenum and jejunum
 (b) Cryptosporidium causes diarrhoea in infants,
immunodeficient patients and domestic animals. It can cause
persistent diarrhoea and wasting

14.  Diarrhoea may be caused by parenteral infections like ENT
infections, respiratory or urinary infections, malaria, bacterial
meningitis etc.
 Malnutrition may lead to certain nutritional diseases like
kwashiorkor, sprue, coeliac disease and pellagra which are all
associated with diarrhoea

15. Reservoir of infection
 For E. coli, shigella, V cholerae, Giardia lamblia etc. man is the
principal reservoir
 For other enteric pathogens, animals are reservoirs. Examples
are C. jejuni, Salmonella

16. Host factors
 Diarrhoea is common in children between 6 months and 2 yrs of age
when weaning occurs
 It occurs when there is decline of maternally acquired immunity,
introduction of contaminated food, contact with faeces etc
 Malnutrition and diarrhoea for a vicious circle
 Poverty, immunodeficiency, lack of hygiene are contributory factors

17. Environmental factors
 In tropical areas, rotavirus diarrhoea occurs throughout the
year
whereas
 bacterial diarrhoea peak during rainy season

18. Mode of transmission
 Pathogenic organisms are transmitted by faeco - oral route -
via water, food, fomites

19. Control of Diarrhoeal diseases
 The Diarrhoeal Diseases Control (DDC) Programme of WHO has
advocated several intervention measures which centre around the
practice of “Oral rehydration therapy”
 The intervention measures may be classified into :
1. Short term- (a) Appropriate clinical management
2. Long term- (a) Better MCH care practices
(b) Preventive strategies
(c) Preventing diarrhoeal epidemics

20. Clinical management
1) Oral rehydration therapy:diarrhoea can often be cured solely
with oral rehydration therapy. ORS (oral rehydration salt) is
effective against dehydration as well as reduces the stool output
Reduced osmolarity
ORS
gm/litre
Sodium chloride 2.6
Glucose, anhydrous 13.5
Potassium chloride 1.5
Trisodium citrate 2.9
Total weight 20.5

21.  Assessment of dehydration is done before ORS is given
 When obvious signs of dehydration exists, the water deficit is 50-
100ml/kg body wt.
 The ORS solution required during initial 4 hrs may be calculated by
multiplying patient’s weight (in kg) by 75ml/kg
 The actual amount given will depend on the patient’s desire to
drink and by observing signs of dehydration

22.  If the person vomits, wait for few minutes and then try again
 In case of children, give ORS in a teaspoon every 1-2 minutes and
if being breast fed, nursing continued along with ORS
 Introduction of ORS has reduced cost of treatment and made
possible treatment at homes by family members/ primary care
workers

23.  Assessment of dehydration
Patient parameters Dehydration
Mild Severe
1 Patient’s appearance Thirsty, alert,
restless
Drowsy, limp, cold, sweaty,
comatose
2 Radial pulse Normal rate and
volume
Rapid, feeble, sometimes
impalpable
3 Blood pressure Normal Less than 80 mm Hg ; may be
unrecordable
4 Skin elasticity Pinch retracts
immediately
Pinch retracts very slowly
5 Tongue Moist Very dry
6 Anterior fontanelle Normal Very sunken
7 Urine flow Normal Little or none
% body wt loss 4-5 % 10% or more
Estimated fluid deficit 40-50ml/kg 100-110 ml/kg

26. • 2) Intravenous rehydration:the solutions recommended by WHO
for IV infusion are: (a) Ringer’s lactate solution (2) Diarrhoea
treatment solution (DTS)
• 3) Maintenance therapy : after initial fluid and electrolyte
deficit has been corrected, oral fluid is used for maintenance
• 4) Appropriate feeding: normal food intake should be promoted
as soon as child is able to eat. This is relevant especially in
breast fed babies

27. Treatment Plan for Rehydration Therapy
Age First give 30ml/kg in Then give 70ml/kg in
Infants 1 hour 5 hours
Older 30 mins 2 ½ hours

28. Maintenance Therapy
Amount of Diarrhoea Amount of oral fluid
Mild diarrhoea
(Not more than one stool every 2 hours or
longer, or less than 5 ml stool/ kg/ hour)
100 ml/kg body weight/ day until
diarrhoea stops
Severe diarrhoea
(More than one stool every 2 hours, or more
than 5 ml of stool/ kg/ hour)
Replace stool losses volume for volume; if
not measurable, give 10 – 15ml/kg body
weight/ hour

29. • 5) Chemotherapy: antibiotic therapy should be considered only if
cause of diarrhoea has been identified as shigella, typhoid or
cholera.
• DOC of cholera – Doxicycline, Tetracycline.
• DOC of diarrhoea due to Shigella – Ciprofloxacin.
• 6) Zinc supplementation: It reduces the duration and severity of
diarrhoea. Zinc supplements are given for 10 – 14 days to lower
the incidence of diarrhoea in the following 2 to 3 months

30. MCH care practices
1) Maternal nutrition: improve prenatal and postnatal nutrition
2) Child nutrition:
(a ) promotion of breast feeding
(b) appropriate weaning practices
(c ) supplementary feeding
(d) Vitamin A supplementation

31. Preventive
strategies
1. Sanitation - improved hygiene, safe
water supply, proper disposal of
waste, hand hygiene practices
2. Health education: convince people
to adopt healthy practices
3. Immunisation: Measles vaccine has
a role in diarrhoea control
4. Fly control

32. Rotavirus vaccine
1. Rotarix – monovalent human
rotavirus vaccine.
2. It is administered orally in a 2-
dose schedule to infants of
approximately 2 and 4 months
of age.
3. Interval between the doses
should be at least 4 weeks

33.  Rota Teq – pentavalent bovine-human vaccine.
 The recommended schedule is 3 oral doses at ages 2, 4 and 6
months.
 The first dose administered between ages 6-12 weeks and
subsequent doses at intervals of 4-10 weeks.

34. Diarrhoeal Diseases Control Programme in India
The Diarrhoea Disease Control Programme was
started in 1978
Current focus is on strengthening case
management in children below 5 yrs of age
Improved maternal knowledge related to
use of ORS and home available fluids

36. THE CASE MANAGEMENT PROCESS
 The case management process is presented on a series of
charts, which show the sequence of steps and provide
information for performing them. The charts describe the
following steps:
 Assess the young infant or child
 Classify the illness
 Identify treatment
 Treat the infant or child
 Counsel the mother
 Give follow-up care

38. Thank you