EPIDEMIOLOGY AND CONTROL OF ACUTE DIARRHEAL DISEASES

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

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• 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.

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• 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

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• WHAT CAUSES DIARRHOEA?
• Infectious Disease Agents
• SHIGELLAEInvasive, 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.

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• 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.

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

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

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HOW SHOULD ACUTE WATERY DIARRHOEA IN CHILDREN BE
MANAGED? ASSESSMENT OF DEHYDRATION DOES THE
CHILD HAVE SIGNS OF DEHYDRATION? IS DEHYDRATION
MILD OR SEVERE?
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• 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 Absent 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 gt 10 of body weight
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• 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

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• 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)

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• 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

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• 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

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• 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.

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• 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.

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• 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

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• 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

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• 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 gt 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.

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MCQs 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

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• 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
• Ans- A

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• 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

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• 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
• Ans- C