Acute Diarrhoeal Diseases

ACUTE DIARRHOEAL DISEASES
Diarrhoea is defined as the passage of loose, liquid or watery stools.

These liquid stools are usually passed more than three times a day.
However, it is the recent change in consistency and character of stools rather than the number
of stools that is more important.
CLINICAL TYPES
(1) Acute watery diarrhoea - which lasts several hours to days .
(2) The main danger is dehydration, weight loss also occurs if feeding is not continued.
The pathogens that usually cause acute diarrhoea include V. cholerae or E. coli bacteria , as well as rotavirus.
(2) Acute bloody diarrhoea - which is also called dysentery

The main dangers are damage of the intestinal mucosa, sepsis and malnutrition; other complications including
dehydration, may also occur.
The most common cause of bloody diarrhoea is shigella
(3) Persistent diarrhoea - which lasts 14 days or longer.

The main danger is malnutrition and serious non-intestinal infection , dehydration may also occur.
Persons with other illness , such as AIDS, are more likely to develop persistent diarrhoea .
(4) Diarrhoea with severe malnutrition (marasmus and Kwashiorkor) –

The main dangers are severe systemic infection, dehydration, heart failure, and vitamin and mineral deficiency.
Problem statement
When the WHO initiated the Diarrhoeal Diseases Control Programme in 1980, approximately 4.6 million children used
to die each year of the dehydration caused by diarrhoea.
Diarrhoea is still a major killer of children under 5. although its toll has dropped by a third over the
past decade. It killed more than 1,300 children under 5 years of age every day in 2016.
It accounts for 8 per cent of all under-five deaths - a loss of more than 0.48 million child lives jn 2016.
Most of these deaths occur among children less than 2 years of age (2).
The current estimates in under-five children suggest that there are about 1. 7 billion episodes of diarrhoea per year
with 123 million clinic visits annually and 9 million hospitalizations worldwide, with a loss of 62 million disability-
adjusted life years (DALYs) (3).
In India , acute diarrhoeal disease accounts for about 10 per cent of deaths in under-5 years age group. During the
year 2017 , about 12.92 million cases with 1,331 deaths were reported in India (4).
Diarrhoea is a leading cause of death during complex emergencies and natural disasters
At the same time, the lack of adequate health services and transport reduces the likelihood of prompt and
appropriate treatment of diarrhoea cases.
Diarrhoeal disease causes a heavy economic burden on the health services.

changes in treatment recommendations and preventive measures
(A) Diarrhoea prevention indicators

(1) Percentage of population using:
(a) improved drinking water sources (urban, rural, total); (For India - urban 97% , rural 90% and total 92%)
(b) improved sanitation facilities (urban, rural, total); (For India - urban 58%, rural 23% and total 34%)
(2) Percentage of one year old immunized against measles; (lndia-74%)
(3) Percentage of children who are : -

-under-weight (moderate and severe) - 0 to 59 months age (India-43%)
- stunted (moderate and severe) - 0 to 59 months age (India- 38. 7%)
- exclusively breast-fed - 0 to 5 (India-46%) months age
- breast-fed with complementary - 6 to 9 food months age (lndia-57%)
- still breast-feeding - 20 to 23 months age (India-77%)
(4) Vitamin A supplementation coverage rate (per cent full coverage) - 6 to 59 months (India-53%)
(B) Diarrhoea treatment Indicators
Percentage of children under-five years with diarrhoea receiving:
(1) ORT with continuous feeding (India 33%)
(2) ORS packet (India 26%)
(3) Recommended home made fluids (India 20%)
(4) Increased fluids (India 10%)
(5) Continued feeding (India 70%)
(C) Use of oral rehydration therapy

Percentage of children under-five years with diarrhoea receiving oral rehydration therapy (ORS packet or
recommended home-made fluids or increased fluids with continued feeding)
(2) Gender - male, female (India - male 34%, female 31 %)
(2) Residence - Urban, rural (India - urban 38%, rural 31 %)
(3) Wealth index quintiles - poorest, second, middle, fourth, richest

(India - 29%, 29%, 3 1 %, 35% and 45%).
Epidemiological determinants
1]Agent factors
Reservoir of infection
For some enteric pathogens, man is the principal reservoir and thus most transmission originates from human
factors ; examples are enterotoxigenic E. coli, shigella spp., V cholera, Giardia lamblia and E. histolytica .
For other enteric pathogens, animals are important reservoirs and transmission originates from both human and animal
faeces; examples are Campylobacter jejuni, Salmonella spp and Y. enterocolitica.
2]Host factors
Diarrhoea is most common in children especially those between 6 months and 2 years.
Incidence is highest in the age group 6-11 months, when weaning occurs.
also common in babies under 6 months of age fed on cow's milk or infant feeding formulas (16).
Malnutrition leads to infection and infection to diarrhoea which is a well known vicious circle.
Poverty, prematurity, reduced gastric acidity, immunodeficiency, lack of personal and domestic hygiene
and incorrect feeding practices are all contributory factors.
3]Environmental factors
Distinct seasonal patterns
Bacterial diarrhoea occur more frequently during the warm season,
whereas viral diarrhoea, particularly diarrhoea caused by rotavirus peak during the winter.
Mode of transmission – faeco- oral route

Faecal- oral transmission may be water-borne; food-borne, or direct transmission which implies an array of other faecal-oral
routes such as via fingers, or fomites, or dirt which may be ingested by young children
Components of a Diarrhoeal Diseases Control Programme
1. Short-term
a . Appropriate clinical management.
(I) ORAL REHYDRATION THERAPY
(II) (II) INTRAVENOUS REHYDRATION
(III) (III) MAINTENANCE THERAPY
(IV) IV) APPROPRIATE FEEDING
V) CHEMOTHERAPY
(VI) ZINC SUPPLEMENTATION When a zinc
2. Long-term
b. Better MCH care practices.
c. Preventive strategies.
d. Preventing diarrhoeal epidemics.
(I) ORAL REHYDRATION THERAPY
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.
It is focussed on reducing the osmolarity of ORS solution to avoid possible adverse effects
Decreasing the sodium concentration of ORS solution to 75 mOsm/1 improved the efficacy of the ORS regimen
for children with acute non-cholera diarrhoea.
The need for unscheduled supplemental intravenous therapy in children given the new ORS fell by 33 per cent,
the stool output decreased by 20 per cent and vomiting was reduced by 30 per cent.
The reduced osmolarity (245 mOsm/1) solution also appears to be as safe and effective as standard ORS for use in children
with cholera (19).
supervision respecting "the following rules :
- for children under age 2 years, give a teaspoon every 1 to 2 minutes,
- and offer frequent sips out of a cup for older children.
- Adults may drink as much as they like.
Try to give the estimated required amount within a 4-hour period.
As a general guide, after each loose stool, give

- children under 2 years of age : 50-100 ml (a quarter to half a large cup) of fluid ;
- children aged 2 up to 10 years : 100- 200 ml {a half to one large cup
- older children and adults : as much fluid as they want.
- if the child vomits, wait for 10 minutes

(II) INTRAVENOUS REHYDRATION
only for the initial rehydration of severely dehydrated patients who are in shock or unable to drink.
a) Ringer's lactate solution (also called Hartmann's solution for injection) It is the best
commercially available solution.
(b) Diarrhoea Treatment Solution (DTS): Also recommended by WHO as an ideal polyelectrolyte solution
for intravenous infusion
If nothing else is available, normal saline can be given because it is often readily available.
Plain glucose and dextrose solutions should not be used as they provide only water and glucose.
(IV) APPROPRIATE FEEDING :
Medical profession has reeled for centuries under the mistaken assumption that it is important to "rest the gut" during
diarrhoea.
The current view is that during episodes of diarrhoea, normal food intake should be promoted as soon as the child whatever
its age, is able to eat.
(V) CHEMOTHERAPY
Unnecessary prescription of antibiotics and other drugs will do more harm than good in the treatment of diarrhoea
For diarrhoea due to cholera the drug of choice is doxicycline, tetracycline, TMP-SMX ~nd erythromycin.
For diarrhoea due to shigella, the drug of choice is ciprofloxacin
(VI) ZINC SUPPLEMENTATION

Reduces the episode's duration and severity.
In addition, zinc supplements given for 10 to 14 days lower the incidence of diarrhoea in the following 2 to 3 months.
WHO and UNICEF therefore recommend daily 10 mg of zinc for infants under 6 months of age,
and 20 mg for children older than 6 months for 10- 14 days (19).
b. Better MCH care practices
(a) MATERNAL NUTRITION : Prenatal and postnatal nutrition will improve the quality of breast milk.
(b) CHILD NUTRITION :

(i) Promotion of breast-feeding:
(ii) Appropriate weaning practices : neither too soon, nor too late
{iii) Supplementary feeding
(iv) Vitamin A supplementation :
c. Preventive strategies
(i) SANITATION :
(ii) HEALTH EDUCATION
(iii) IMMUNIZATION : Immunization against measles is a potential intervention for diarrhoea control.
Rotavirus vaccine
Two live, oral, attenuated rotavirus vaccines were
monovalent human rotavirus vaccine (Rotarix™) and
pentavalent bovine-human,reasortant vaccine (Rota Teq ™).
(iu) FLY CONTROL : Flies breeding in association with human or animal faeces should be controlled.
d. Control and/or prevention of diarrhoeal epidemics
This requires strengthening of epidemiological surveillance systems.
e. The Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD)

Acute Diarrhoeal Diseases

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ACUTE DIARRHOEAL DISEASES

Diarrhoea is defined as the passage of loose, liquid or watery stools.

(2) Acute bloody diarrhoea - which is also called dysentery

(3) Persistent diarrhoea - which lasts 14 days or longer.

(4) Diarrhoea with severe malnutrition (marasmus and Kwashiorkor) –

Diarrhoeal disease causes a heavy economic burden on the health services.

(A) Diarrhoea prevention indicators

(2) Percentage of one year old immunized against measles; (lndia-74%)

(3) Percentage of children who are : -

(2) ORS packet (India 26%)

(3) Recommended home made fluids (India 20%)

(4) Increased fluids (India 10%)

(5) Continued feeding (India 70%)

(C) Use of oral rehydration therapy

(2) Gender - male, female (India - male 34%, female 31 %)

(2) Residence - Urban, rural (India - urban 38%, rural 31 %)

(3) Wealth index quintiles - poorest, second, middle, fourth, richest

Mode of transmission – faeco- oral route

As a general guide, after each loose stool, give

- if the child vomits, wait for 10 minutes

(VI) ZINC SUPPLEMENTATION

(b) CHILD NUTRITION :

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