Epidemiology and Control of acute Diarrheal Diseases

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

2. 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.

3. WHAT CAUSES DIARRHOEA?
Infectious Disease Agents Causing
Diarrhoea.
BACTERIA
1. 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.

4. 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.

5. 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.

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

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

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

9. 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 > 10% of body weight

10. 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

11. 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)

12. 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

13. 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

14. 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.

15. 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

16. 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

17.  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

18.  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.

19. 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

20. 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

21. 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

22. 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