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

Diarrhoea is the passage of loose, liquid or watery stool. 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.

WHAT CAUSES DIARRHOEA? Infectious Disease Agents Causing Diarrhoea. BACTERIA 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

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.

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.

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

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

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

Degree of dehydration signs 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 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

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

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)

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

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

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.

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.

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

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

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.

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

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

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

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