1. An investigation was conducted into an epidemic of diarrhoeal diseases to determine its scope, contributing factors, and cause. 2. The investigation aimed to define the extent of the outbreak, identify the conditions and factors responsible, and determine the source of infection and mode of transmission in order to control the epidemic. 3. Standard methods of outbreak investigation were followed, including establishing a case definition, analyzing epidemiological data on time, place, and person, formulating and testing hypotheses, and making recommendations to prevent future outbreaks.

1. Investigation of an epidemic
with relevant to Diarrhoeal
diseases
Presentedby:
Dhanpal Singh
Aishwarya Thakur

2. 1)Dr Q.H Khan(Prof and Head of
the Dept)
2)Dr K P Brahmapurkar
3)Dr V K Brahmapurkar
4)Dr Teeku Sinha
5)Dr P.K Srivastava
6)Dr VKS Chauhan
8)Dr Durgesh Naidu
9)Dr Vandana Zargar
10)Dr Akhilesh badge

3. Main motives of investigation
To define the magnitude of the
epidemic outbreak or involvement in
terms of time, place and person.
To determine the particuar condition
and factors responsible for the
occurrence of the epidemic

4. To identify the cause source of
infection and mode of transmission to
determine measures necessary to
control the epidemic.
To make recommendation to prevent
reoccurrence

5. What do you mean by epidemiology?
Epi = upon, among
Demos= people
Ology= science, study of
Epidemiology=the science or the study of what is upon the
people.

6. Definition of epidemiology:
Epidemiology has been defined by John
M. Last in 1988 as-
“The study of the distribution and
determinants of health related states or
events in specified population and the
application of this study to the control of
health problems.”

7. Occurrence of more cases of disease than expected
- in a given area
- among a specific group of people
- over a particular period of time
What is an Outbreak?

8. l. To stop the current outbreak from spreading.
ll. Prevent future similar outbreaks.
lll. Provide scientific explanation of the event.
lV. Provide knowledge for the understanding of the
disease process which includes:
the cause , source(s) of infection and modes of
transmission.
V. React to and calm public and political concerns
Vl. Train epidemiologists
Importance of outbreak investigation

9. :If the local health officials request
assistance, the regional epidemiologist
should try to acquire as much
information about the disease and the
population at risk as possible.
: As soon as the initial information on
an outbreak reaches, the regional
health coordinator must determine
whether the information is correct.
: The plan should be based on
situational analysis & taking
technical, economical & political
factors into account.
Recognitio
n &
response
Check
initial
information
Formulate a
plan of action
Initial steps :-

10. Report:-
Information to be included in the final report on an
epidemic
Report
1.Background Geographical location
Climatic conditions
Demographic status
Socio economic situation
Organization of health
services
surveillance
Normal disease prevalence

11. REPORT
2.Historical data Previous occurrence of epidemics
-Of the same disease
-Locally or elsewhere
Occurrence of related diseases , if
any
-In the same area
-In other areas
3.Methodology of
investigations
Case definition
Questionnaire used in
epidemiological investigation
Survey teams
household survey
retrospective survey
collection of lab specimens
lab techniques
Continued….

12. Report
4.Analysis of data Clinical data:
-frequency of signs and
symptoms
-course of disease
-differential diagnosis
-death rates
Epidemiological data:
-mode of occurrence-time ,place , population
groups
Modes of transmission:
-sources of infection
-routes of excretion and portal
of
entry
Lab data:
-isolation of agents
-serological confirmation
-significance of results

13. Report
5.Control measures Definition of strategies &
methodology of implementation
-constraints
-results
Evaluation:
-significance of results
-cost/effectiveness
Preventive measures.
The written report should be submitted, in a standardized format, to the public health
authorities including the ministry of health & remain confidential until it has been
given official permission.
Report contd…

14. Steps of an outbreak
investigation
1. Prepare for field work
2. Verify diagnosis
3. Confirmation of an existence of an
epidemic
4. Case definition
5. Data analysis
6. Formulate and testing of hypothesis
7. Evaluation of ecological factors
8. Further investigation
9. Implement control measures
10. Writing the report

15. Consider
your self
as
an investigator…..

16. BEFORE LEAVING FOR THE FIELD, WE SHOULD:
1.Research the disease and gather the supplies and
equipment we will need.
Step 1:- Prepare for field work ..
2. Identify the team members &assign responsibilities.

17. Composition of typical field
team:
Specialists Auxillaries
1. Epidemiologist 1. Nurses
2.Physician 2. Specialist assistants
3. Microbiologist 3. Secretary/Interpreter
4. Veterinarian 4. Driver
5. Entomologist
6. Mammalogist
7. Sanitary engineer
8. Toxicologist
9. Information Specialist
10. Laboratory technician

18. IMPORTANCE OF VERIFICATION OF DIAGNOSIS:-
first- we must ensure that the problem has been
properly diagnosed—that it really is what it has been
reported to be.
second- for outbreaks involving infectious or toxic-
chemical agents, we must be certain that the increase in
diagnosed cases is not the result of a mistake in the
laboratory.
Step 2 :-Verify the diagnosis..

19. Verifying the diagnosis requires review of:
-the clinical findings (the signs and symptoms)
- laboratory results for the people who are affected.
 laboratory investigation whenever applicable are most useful to
confirm diagnosis
But in Epidemiological investigation should not be delayed until
the laboratory results are available and diagnosis should be made
based on clinical examination.

20. For e.g., in case of diarrhoea verification of the
diagnosis should be made whether it is a acute
watery diarrhoea or acute bloody diarrhoea
• Acute watery
diarrhoea
• Pathogen- V.cholerae
or E.coli
• Characterstics of stool-
Liquid or watery stool
of normal colour.
• Complication-
dehydration, weight
loss
• Treatment- antibiotic
Acute bloody diarrhoea
• Pathogen-shigella
• Characterstics of stool-
Blood tinged loose
stool mixed with
mucous.
• Complication-
intestinal mucosal
damage,
sepsis,malnutrition
• Treatment-
metronidazole

21. step 3:- confirmation of existence of
epidemic..
 First step , is to verify that a suspected epidemic is
indeed a real epidemic .
For this
Analyze expected
frequency based on past
experience
If the number of cases
exceed the expected
frequency , then it is an
epidemic.

22. How, then, do we determine what is expected?
Usually we can compare the current number of cases with the number
from the previous few weeks or months, or from a comparable period
during the previous few years.
- The sources of these data vary:
1.For a notifiable disease (one that, by law, must be reported), we can use
health department surveillance records.
2.For other diseases , we can usually find data from local sources such as
hospital discharge records, death records, and cancer or birth defect
registries.
Continued…

23. If local data are not available:
-we can make estimates using data from
neighboring states or national data.
- or we might consider conducting a telephone
survey of physicians to determine whether they
have seen more cases of the disease than usual
-or we could even conduct a survey of people in
the community to establish the background level of
disease..

24. Continued….
Even if the current number of reported cases exceeds the
expected number, the excess may not necessarily indicate an
epidemic. Reporting may rise due to
-changes in local reporting procedures,
- changes in the case definition
- increased interest because of local or national awareness,
-improvements in diagnostic procedures.
Finally, particularly in areas with sudden changes in population
size, such as resort areas, college towns, and migrant farming
areas, changes in the number of reported cases may simply
reflect changes in the size of the population.

25. Step 4:- Case definition
Our next task as an investigator is to establish a
case definition.
Case definition- standard set of criteria for deciding
whether, in this investigation, a person should be
classified as having the disease or health condition
under study.
A case definition usually includes four components:
1. clinical information about the disease. Eg:- as
defined y WHO diarrhoea is defined as passage of
3 or more liquid or loose stools per day ( or more
frequent passage then is normal for individual).
Frequent passing of formed stool is not diarrhoea
nor is the passing of loose pasty stool by

26. 2. characteristics about the people who
are affected- eg- during the first 6
month infants may keep on passing 8-
10 loose motion per day and still gain
weight. If the child is active and
normal on examination he should not
be labeled as having diarrhoea.
Passage of motion immediately after
a meal due to gastro colic reflex
should not be taken as diarrhoea.

27. 3. Information about the location or
place-eg : reports of diarrhoea are
high in areas having high percent of
malnourishment or natural calamities.
4.Specification of time during which the
outbreak occurred- eg :cases of
diarrhoea increase during the rainy
season.

28. Identification of case
A. Medical survey
 A medical survey should be carried out
in the defined area to identify all cases
including those who have not sought
medical care and those possibly exposed
to risk
 Lay health workers may be trained to
administer the epidemiological case sheet
or questionnaire to collect relevant data

29. B. Epidemiological Case Sheet:
 Epidemiological case sheet is made for
collecting the data from the cases and from
person apparently exposed but unaffected.
 Relevant information to be collected in a case
sheet are:-
 Name
 Age
 Sex
 Occupation
 Address
 Socioeconomic status

30. Other relevant data:
-personals contacts at home,work ,school and
other places
-Travel
-Special events such as parties attended,foods
eaten and exposure to common vehicles such
as water ,food and milk
-Attendance at large gatherings

31. Relevance of the information
collected:-
 To avoid duplication of cases.
 To ensure completeness and consistency
of data collection.
 Address is helpful to contact patient for
additional information.
 To notify about laboratory resuts.
 Address also allow to map the
geographical extent of problem.

32. C. Searching for more cases
 Ask the patient if he knew of other
cases in the home, family,
neighborhood, workplace.
 Cases admitted to the local hospital
should also be taken into
consideration.
 This may reveal not only additional
cases but also person to person
spread.

33. Recognizing the uncertainty of some
diagnoses, investigators often classify cases
as "confirmed," " probable," or "possible."
Confirmed cases -must have laboratory
verification.
Probable cases -have the typical clinical
features of the disease without laboratory
confirmation.
Possible cases- have fewer of the typical
clinical features

34. The data collected should be analyzed on ongoing basis, using
the classical parameters – time, place and person.
Identify when patients became ill (time), where patients became
ill (place) & what characteristics the patients possess (person).
Characterizing an outbreak by these variables is called
descriptive epidemiology
-The number of cases is plotted on the y-axis of an epi curve; the
unit of time, on the x-axis.
Step 5:- DATA ANALYSIS..

35. 1. Time
 The pattern of disease may be described
by the time of its occurrence.
 A graph of the time distribution of
epidemic cases is called the “epidemic
curve”.
 Epidemic curve may suggest
(a) magnitude of epidemic
(b) mode of spread
(point source or person to person or
both)
(c) possible duration of epidemic
Epidemic show short term fluctuation in
epidemic curve

37.  The epidemic curve rises and falls
rapidly, with no secondary curve.
 All cases develop within one
incubation period.
 Eg – food poisoning

38.  Secondary waves are formed in these
case.
 Exposure from the same source may
be prolonged.
 Eg- well of contaminated water

39.  Secondary wave is formed after a brief
pause.

40.  Gradual rise and forms a plateau
which tails off after a long period of
time.
 The origin is of infectious agent.
 Epidemic is initiated from a common
source.

41. 2. Place
It provides major clues regarding the source of agent and/or
nature of exposure. Spot maps show a pattern of distribution of
cases .
1. Spot map show at glance area of high or low frequency, the
boundaries and pattern of disease distribution.
2. if the map shows clustering of cases, it may suggest a
common source of infection or common risk factor shared by all.

43.  Place distribution tells about international variation,
national variation , urban –rural variation and local
distribution of the disease.
 Geographic distribution provides evidence about the
source of disease and its mode of spread. By relating
events the variations to agent, host and environment,
we can device the source of disease.

44. 3. Person
Person distribution of the epidemic is characterized by
determining –
Age
Sex
Ethnicity
Marital status
Occupation
Social status
Behaviour

45. Importance of person distribution in
epidemiology:-
 Variation in distribution of disease can
be a starting point for an
epidemiological enquiry
 Formulation of etiological hypothesis.
 It also helps in determining “high risk
groups”.

46.  High risk groups of diarrhoea are
children of age 6month to 2 years i.e.
children of weaning period.
 Undernourished children suffer from
long lasting diarrhoea and are at 15-
20 times greater risk of dying compare
to well nourished children with
diarrhoea.

47. 1. Hypothesis : it is a supposition arrived at by data
analysis.
Hypothesis should specify:-
the population
the specific cause
outcome
relationship with time
Step 6:- Formulation and testing of hypotheses:

48. disease
Risk
factors
Agent’s
reservoir
Vehicles
Transm-
ission

49. The next step is to evaluate the credibility of the hypotheses.
There are two approaches that can be used, depending on the nature of the
data:
1) Comparison of the hypotheses with the established facts and
2) Analytic epidemiology, which allows to test the hypotheses.
first method is used when evidence is so strong that the hypothesis does not
need to be tested.
For e.g. - investigation of an outbreak of vitamin D intoxication of a place xyz.
Step Evaluation of hypotheses :
Milk of a dairy of
place xyz
People drank
that milk
people
affected
Investigators
hypothesized
Source-dairy of
excess vit D
Vehicle-milk of
excess vit D
Investigators
visited dairy
Found more than
the
recommended
dose of vit D
added for no
purpose
No further
analysis
required

50. The second method, analytic epidemiology, is used
when the cause is less clear.
With this method, hypotheses is tested by using a
comparison group to quantify relationships between
various exposures and the disease
.
ANALYTIC STUDIES:
COHORT:
Consists of two
groups:
1.Exposed to risk
factor
2.Not exposed
CASE –CONTROL
STUDIES:
Compares:
1.People with
disease(case patients)
2.People without
disease(control)

51. Cohort studies
A cohort study is the best technique for analyzing an outbreak in
a small, well-defined population.
For eg, we would use a cohort study if an outbreak of
gastroenteritis occurred among people in a wedding, and a
complete list of wedding guests was available.
In this situation, question asked to each attendee:
potential exposures ( foods and beverages consumed at
the wedding)
whether become ill with gastroenteritis.

52. Ate that item
(mushroom)
exposed
+
Didn’t ate that item
Not exposed
no of people didn’t ate that item
got ill
Total no of people didn’t ate that
item
Identification of source of outbreak – look for an
item
High incidence-exposed Low incidence -not
exposed
After collecting this information from each guests, calculate the incidence of
disease
Relative risk=incidence exposed/incidence not
association
between
exposure
&illness for that
item
incidence
=
No. of people ate that item
and got ill
Total no of people ate that
item
Incidence=

53. Attributable risk:
 Difference in incidence rate among exposed
and not exposed.
Incidence of disease rate among exposed –
incidence of disease among non-exposed X100
incidence rate among exposed

54. CASE -CONTROL STUDIES:
USED FOR ANALYSING OUTBREAK IN A POORLY
DEFINED POPULATION . This study does not prove that a
particular exposure caused the disease but effective in obtaining
possible cause of disease . In this odd ratio is calculated
IN THESE STUDY QUESTIONS ARE ASKED ABOUT
EXPOSURE TO BOTH:
CASE PATIENTS
CONTROL
The controls must not have the disease, but should be from the
same population as the case-patients.
 Commonly it consists of neighbors and friends of case-patients
and people from the same physician practice or hospital as case-
patients.

55. For e.g. ,suppose we are investigating an outbreak of diarrhoea in a small
town, and we suspects that the source is a favorite restaurant A of the
townspeople. After questioning case-patients and controls about whether they
had eaten at that restaurant, our data might look like this:
Odds ratio = ad = 30 × 70 = 5.8.
bc 36 × 10
Conclusion-This means that people who ate at Restaurant A were 5.8 times
more likely to develop diarrhoea than were people who did not eat there.
-
Ate at
restaurant A
Case
patients
control total
yes a=30 b=36 66
no c=10 d=70 80
total 40 106 146
Continued…

56. Step 7 :Evaluation of ecological
factors
A study of environmental conditions & the dynamics of its
interaction with the population & etiologic agents will help to
formulate the hypothesis on the genesis of the epidemic.
Ecological factors that should be investigated are:
-Sanitary status of eating establishments ,
-water and milk supply ,
- movement of human population
-atmospheric changes like temperature, humidity and air pollution
population dynamics of insects and animal reservoirs..etc

57. It is done to study population at risk.
1.It consists of collecting & testing appropriate specimens.
2. To identify the etiologic agent, the collection need to be properly
timed.
3.Examples of specimens include:–
- food & water,
-other environmental samples (air settling plates), and
-clinical (blood or stool) samples from cases & controls.
Step 8 : further investigation

58. This is done by-
 medical examination
 Screening test
 Examination of suspected food,
faeces, blood and water.
 Biochemical studies
 Assessment of immunity status

59. Implementation of control measures, should be aimed at specific links
in the chain of infection, the agent, the source, or the reservoir.
for eg, an epidemic might be controlled by destroying contaminated
foods, sterilizing contaminated water, destroying mosquito breeding
sites, or requiring an infectious food handler to stay away from work until
he or she is well.
-In other situations, we might direct control measures at interrupting
transmission or exposure.
for eg, to limit the airborne spread of an infectious agent among
residents of a nursing home, we could use the method of "cohorting" by
Step 9: Implement Control Measures:

60. Continued…
Finally, in some outbreaks, we would direct control measures at
reducing susceptibility.
for eg, immunization against rubella and malaria
chemoprophylaxis (prevention by taking antimalarial medications)
for travelers.

61. The epidemiologists may want to perform more detailed &
carefully executed studies as there may be a need to find
more patients:
-To define better the extent of the epidemic .
- Because a new lab method may need to be evaluated.
-Or case finding method may need to be evaluated.
Conduct additional studies:

62. The final task in an investigation is to communicate
your findings to others who need to know. This
communication usually takes two forms:
1) an oral briefing for local health authorities &
2) a written report.
ORAL BRIEFING:
-The oral briefing should be attended by the local
health authorities and people responsible for
implementing control and prevention measure.
Report &communicate the findings:

63.  - This presentation is an opportunity
for us to describe what we did, what
we found, and what we think should
be done about it.
-We should present our findings in
scientifically objective fashion, and we
should be able to defend our
conclusions and recommendations.

64. 1. Data sources are often incomplete & less accurate.
2. Decreased statistical power due to analysis of small
numbers.
3. Publicity surrounding the investigation – community
members may have preconceived ideas.
4. There is a pressure & urgency to conclude the
investigations quickly which may lead to hasty
decisions
Unique aspect of epidemic investigation:

66. 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 & character of stools
rather than the number that is more
important.

67. Duration:
Acute < 14 days
Persistent > 14 days
Chronic > 30 days

68. Frequent loose,
watery stools
Abdominal
cramps
Abdominal pain
Fever
Bleeding
Lightheadedness
or
dizziness
 dehydration
Sign and symptoms

69. SIGNS OF DEHYDRATION

70. CLINICAL TYPES OF DIARRHOEAL
DISEASE
 Acute watery diarrhoea- lasts
several hours to days the main
danger is dehydration.
Start suddenly
Most episodes recover or self
limiting within 3-7 days. These may
last up to 14 days
>75% of all episodes are of acute
watery diarrhoea.

71.  Acute bloody diarrhoea- also
called dysentry the main
dangers are damage of the
intestinal mucosa and sepsis.
Most commonly caused by
shigella.
Diarrhoea with visible blood &
mucus in the faeces.
Also abdominal cramps, fever,
anorexia and rapid weight loss.

72. Persistent diarrhoea- lasts
for 14 days or longer. The
main danger is
malnutrition.
AIDS persons are more
likely to develop persistent
diarrhoea.Incidence is around 5%
i.e. 5% of acute
diarrhoea may persist
beyond 2 weeks

73. Epidemiological determ
Agent –
 COMMON CAUSES OF
DIARRHOEA- BACTERIA

74. –Vibrio cholera
–Shigella
–Escherichia coli
–Salmonella
–Campylobacter jejuni
–Yersinia enterocolitica
–Staphylococcus
–Vibrio parahemolyticus
–Clostridium difficile
–Neisseria gonorrhoea
–Chlamydia
–Aeromasa

75. • Rotavirus
• Adenoviruses
• Caliciviruses
• Astroviruses
• Norwalk group viruses
• Cytomegalovirus
• Coronavirus
COMMON CAUSES OF
DIARRHOEA- VIRUS

76. COMMON CAUSES OF
DIARRHEA- PARASITE
• Entameba histolytica
• Giardia intestinalis
• Cryptosporidium
• Cyclospora
• Trichuriasis
• Intestinal Worms

77. Pathogens % cases
Viruses Rotavirus 15-25
Bacteria Enterotoxigenic
E.Coli
Shigella
Campylobacter
jejuni
Vibrio cholerae
01
Salmonella(non
-typhoid)
Enteropathogen
10-20
5-15
10-15
5-10
1-5
1-5
Pathogens frequently identified in
children with acute diarrhoea in
treatment centre's in developing
countries

78. Host-
 More common in children of
age group 6mnths-2yrs.
 Also there is exposure to
contaminated food and direct
contact with infected faeces.
 In adults it is common in
persons living in unhygeinic
conditions ,malnourished and
immunocompromised

79. Environmental factors-
 Shows a particular geographic
pattern.
 In temperate climates, bacterial
diarrhoea occur more
frequently during the warm
season, whereas viral in peak
during winter.
In tropical areas, rotavirus
diarrhoea occur throughout the
year increasing in frequency
during the drier, cool months
whereas bacterial is in peak

80. Mode of transmission-
 Through the faeco-oral
route.
 Faeco-oral transmission
may be water-borne ,food-
borne or via fingers,fomites
and dust if ingested.

81. Diarrhoeal disease is the 2nd leading cause
of death in children under 5 yrs of age.
Globally, there are about 2 Bn cases of
diarrhoeal disease every yr.
Diarrhoeal disease kills 1.5 Mn children
every yr.
African and South-East Asian regions
together account for nearly 78% of them.
India alone contributes about 20% of all
global under-5yrs diarrhoeal deaths.
MAGNITUDE OF THE PROBLEM:
WORLD

84. COMPONENT OF A
DIARRHOEAL DISEASES
CONTROL PROGRAMME
• Short Term
• Appropriate clinical management
• Long Term
. Better MCH care practices
.preventive strategies
.preventing diarrhoeal epidemics

85. A.Appropriate clinical
management
1. ORAL REHYDRATION THERAPY
• The main aim of oral fluid therapy is to
prevent dehydration and reduce mortality.
• Oral fluid therapy is based on the
observation that glucose given orally
enhances the intestinal absorption of salt
and water and is capable of correcting the
electrolyte and water deficit.

86. • At 1st the composition of ORS ( oral
rehydration salt ) recommended by
WHO was sodium bicarbonate based
INCLUSION OF TRISODIUM CITRATE IN
PLACE OF SODIUM BICARBONATE
• made product more stable
• reduces stool output
• increase intestinal absorption of
sodium & water .

87. This ORS formulation focuses on reducing
osmolarity of ORS solution;
 To avoid adverse effects of hypertonicity on
net fluid absorption by reducing
concentration of glucose and sodium
chloride in solution.
 INDIA was 1st country in world to launch ORS
formulation since JUNE 2004

89. REDUCED
OSMOLALITY
ORS
GRAM/
LITRE
SOD.CHLORIDE 2.6
GLUCOSE,
ANHYDROUS
13.5
POTASSIUM
CHLORIDE
1.5
TRISODIUM
CITRATE ,
DIHYDRATE
2.9
TOTAL WEIGHT 20.5
REDUCED
OSMOLARITY
ORS
Mmol/L
SODIUM 75
CHLORIDE 65
GLUCOSE ,
ANHYDROUS
75
POTASSIUM 20
CITRATE 10
TOTAL
OSMOLARITY
245
Composition of reduced
osmolarity ORS

92. MILD SEVERE
PATIENT APPEARANCE THIRSTY, ALERT ,
RESTLESS
DROWSY, LIMP, COLD
,SWEATY, MAY BE
COMATOSE .
RADIAL PULSE NORMAL RATE &
VOLUME
RAPID , FEEBLE
,SOMETIMES
IMPALPABLE
BLOOD PRESSURE NORMAL <80mm Hg
SKIN ELASTICITY PINCH RETRACTS
IMMEDIATELY
PINCH RETRACTS
VERY SLOWLY
TONGUE MOIST VERY DRY
URINE FLOW NORMAL LITTLE/ NONE
ANTERIOR
FONTANELLE
NORMAL VERY SHRUKEN
% BODY WEIGHT LOSS 4-5% 10% Or MORE
• How to access the
dehydration

93. Look at Eyes for Dehydration
Shrunken
Eyes
• Normal eyes

95. 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-

96. Cases with No Signs of Dehydration
Plan A
 In early stages, when fluid loss is <5% of the body
weight, children may not show any clinical signs of
dehydration
 Plan A involves counselling the child's mother about
the 3 Rules of Home treatment.
 GIVE EXTRA FLUID (as much as the child will
take)
 CONTINUE FEEDING
 WHEN TO RETURN TO DOCTER

97. GUIDELINES FOR ORAL REHYDRATION
THERAPY (FOR ALL AGES /DURING FIRST
FOUR HOURS )
AGE Under
4
months
4-11
months
1-2
yrs.
2-4 yrs. 5-14 yrs. 15 yrs. or
over
WEIGHT
(KG)
UNDER
5
5-7.9 2-10.9 11-15.9 16-29.9 30 OR
OVER
ORS
SOLUTIO
N ( IN ml)
200-
400
400-
600
600-
800
800-
1200
1200-
2200
2200-
4000
Amt. of ORS sol.= wt. of child X 75 ml / kg
Plan-B

98. After 4 hours
Reassess and classify the child
for dehydration
Select the appropriate plan to
continue treatment
Begin feeding

99. Plan-C
 1% diarrhoea may develop severe
dehydration.
 Children with severe dehydration must be
admitted.
 Child is rehydrated quickly by using I/V
infusion.
I/V infusions recommended :
 R/L solution
 N/S when R/L is not available
 1/2 N/S with 5% dextrose is acceptable
Cases with signs of severe
dehydration

100. Rate & Quantities of I/V
infusion for severe dehydration
Age First give
30ml/kg
Then give
70ml/kg
Infant
Under(12month)
1 hour 5 hours
Older 30 minutes 2.5hours

101.  Reassess the infant every 1-2 hrs. until a
strong radial pulse is present.If hydration
status is not improving,givethe IV drip more
rapidly.
Also give ORS (about 5 ml/kg/hour) as soon
as the infant can drink: usually after 3-4
hours
Reassess the infant after 6 hours & classify
dehydration then choose the appropriate
plan (A,B, or C) to continue treatment

103. 2. INTRAVENOUS
REHYDRATION
Intravenous infusion is usually required only for initial
rehydration of severely dehydration pt. who is in
shock or unable to drink . Such patients are best
transferred to nearest hospital or treatment Centre .
Solution recommended by WHO for intravenous
infusion are…….
1.RINGER LACTATION SOLUTION
Its also known as Hartmamm’s solution for injection. It
is the best commercially available solution . It supplies
adequate
concentration of sodium and potassium and the lactate

104. 2.DIARRHOEAL TREATMENT
SOLUTION ( DTS )
Recommended by WHO as ideal polyelectrolyte
solution for intravenous infusion . It contains in
one litre
Sodium Acetate- 6.5g,
Sodium Chloride- 4g,
Potassium Chloride- 1g
Glucose- 10g.
Normal saline can also be given but its poorest
fluid because it will not correct the acidosis and
will not replace the potassium losses.

105. 3.MAINTENANCE THERAPY
• After the sign of dehydration has been
corrected,
Oral fluid should be used for
maintenance therapy .
AMOUNT OF DIARRHOEA AMOUNT OF ORAL FLUID
Mild diarrhoea
(not more than one stool
every 2hrs or longer, or less
than 5ml stool per kg)
100 ml /kg body weight per
day until diarrhoea stops
Severe diarrhoea
(more than one stool every 2
hours, or more than 5 ml of
stool per kg per hour)
Replace stool losses
volume for volume , if not
measurable give 10-15 ml/kg
body weight per hour

106. 4 . APPROPRIATE FEEDING
• Especially relevant for the exclusively
breast-fed infants.
• Rice water ,unsalted soup ,yoghurt
drinks , green coconut water should be
given.

107. • Drug of choice for diarrhoea due to
cholera
DOXICYCLINE
TETRACYCLINE,
TMP-SMX
ERYTHROMYCIN
Drug of choice For diarrhoea due to
shigella
CIPROFLOXACIN
5 . Chemotherapy

108. Symtoms Cholera Shigella
Diarrhoea Acute watery
diarrhoea
Acute bloody
diarrhoea
Fever No Yes
Abdominal pain Yes Yes
Vomiting Yes No
Rectal pain No Yes
Stool >3 loose stoolper
day,watery like rice
water
>3 loose stoolper
day,with blood or pus

109. 6 . ZINC SUPPLEMENT

112. B. BETTER MCH CARE
PRACTICES .
A . Maternal Nutrition
B. Child nutrition
. Promotion of Breast
feeding
. Appropriate weaning
practices
.Supplementary Feeding

113. C. PREVENTIVE
STRATEGIES
1 . SANITATION
2 .HEALTH EDUCATION
3 . IMMUNISATION

114. • It emphasis on personal & domestics
hygiene like hand washing with soap
before preparing food
• before eating ,
• before feeding a child,
• after defecation ,
• after cleaning a child who has defecated
and
Sanitation

116. Health Education
• An important job of health worker is to
prevent diarrhoea by convincing and
helping community members to adopt
and maintain preventive measures like
breast feeding,
• improved weaning ,
• clean drinking,
• Use of plenty of water for hygiene,
• use of latrine,
• proper disposal of stools of young
children etc.

118. • Immunization against measles is a
potential intervention for
diarrhoea control.
• Measles vaccine can prevent 25%
of diarrhoeal deaths in children
under 5 yrs. of age
IMMUNISATION

119. There are two vaccines
ROTARIX –TM ( monovalent human rotavirus
vaccine)
ROTA Teq-TM ( pentavelent bovine-human
vaccine)
Rotarix-TM …… 2 -dose schedule to 2 -4
months aged child
1 . DOSE – upto 6 weeks & no later than 12
weeks
2 . DOSE - upto 16 weeks & no later than 24
weeks.
Rota Teq-TM……3 oral dose at ages 2,4,6
ROTAVIRUS VACCINE

124. NATIONAL DIARRHOEAL DISEASE
CONTROL PROGRAMME
Goals were:
 Reduce diarrhoeal associated mortality in children
<5 years by 30% by 1995 and by 70% by 2000 A.D.
 Improvement in water and sanitation facilities was
the long term goal of NDDCP

125. National ORT Programme was incepted in
1980
From 1992-93 the programme has become a
part of CSSM Programme.
CSSM programme become a part of RCH
programme in 1997
In RCH Programme, policy of IMCI was
adopted
Strategy of IMCI was to address all children
and not only sick children
IMCI focused on life threatening illnesses-

126.  Indian version of IMCI guidelines renamed as
IMNCI.
 Since 2003 - DDCP included in IMNCI which
includes
- Neonates of 0-7 days
- Incorporating national guidelines on
diarrhoea, ARI ,Malaria, Anaemia,
Vit. A supplementation &
Immunizations.
Contd.

127. Reduce mortality from diarrhoea in children
less than 5 years of age to fewer Than 1 per
1000live births
Reduce the incidence of severe diarrhoea by
75% in children less than 5 years of age
compared to 2010 level
Reduce by 40% the global number of children
less than 5 years of age
GOAL- UPTO 2025

129. Thus in this seminar we have
learnt how to investigate an
epidemic and have then learnt
about diarrhoeal diseases which is
a very common .
So by applying knowledge of these
both topics we will be able to study
an epidemic and reduce its
severity and also to prevent any
CONCLUSION

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