ACUTE DIARRHOEAL

DISEASES

Prepared by:
Norina Pandey
Om Prakash Tandon
Pooja K. C.
Madan Kumar Yadav
OBJECTIVES:
• Define diarrhoea and list it’s clinical types.
• Outline global and national scenario of diarrhoea
• Diarrhoeal epidemiology
• Dehydration in diarrhoea and its treatment
• Control of diarrhoeal diseases
Diarrhoea:

• Passage of loose, liquid ,or watery stools, usually

more than three times a day.

IMPORTANT
• Recent change in consistency and the character of
stool
Clinical types

• Acute watery diarrhoea ,

• Acute bloody diarrhoea ,
• Persistent diarrhoea ,
• Diarrhoea with severe malnutrition.
Acute watery diarrhoea

• Lasts for several hours to days,

• Main dangers :
Dehydration and
Weight loss , weight loss occurs if feeding is not
continued,
• Pathogens responsible: V. cholera or E. coli as well
as Rota virus.
Acute bloody diarrhoea

• Also called dysentery,

• Marked by visible blood in the stool,
• Main dangers :
 Damage to intestinal mucosa,
 Sepsis,
Malnutrition and
Dehydration may also occur,
• Most common cause : Shigella .
Persistent diarrhoea

• Lasts for 14 days or longer,

• Main danger :
Malnutrition,
Serious non intestinal infection and
Dehydration may also occur,
• Person with illness, such as AIDS, are mostly at risk.
Diarrhoea with severe malnutrition

• With marasmus and kwashiorkor

• Main dangers :
 Systemic infection
Dehydration
Heart failure
 Vitamin and mineral deficiency.
Global scenario
• Diarrhoeal diseases account for roughly 530,000
deaths a year,
• 9% of total deaths among children under-five years
of age,
• Second most common cause of child deaths
worldwide.
• Over half of the deaths occur in just five countries:
India, Nigeria, Afghanistan, Pakistan and Ethiopia.
Global Burden of Pneumonia and Diarrhoea
in children under-five

 760,000 diarrhoea
deaths

 Incidence and mortality

are higher in less
developed countries
Countries with largest burden of
diarrhoeal deaths

• 64% of global
diarrhoeal deaths

10 countries with largest

burden of diarrhoea deaths
 Problem statement: Global scenario

From 2000 to 2015:

Total annual number of deaths from diarrhoea among children under 5
decreased by more than 50 per cent.
National scenario
• In FY 2072/73, a total of 1,248,093 diarrhoeal cases
among 2-59 months children were reported.
• The reported number of new diarrhoeal cases has
been decreased substantially in FY 2072/73 compare to
FY 2070/71 and slightly decreased from 2071/72.
• Among total registered cases, more than 92 percent in
all three years were classified into no dehydration.
• At the national level, percentage of severe dehydration
remains almost constant over the last three years and is
below 1 percentage.
FY 2072/2073 (2-59 months of age)

EDR CDR WDR MWDR FWDR NATIONAL

Total diarrhoeal cases 258636 346884 180717 253909 207947 1248093

Estimated <5yrs 635097 1102200 534361 400270 287251 2959179

prone to diarrhoea

Incidence of 407 315 338 634 724 422

diarrhoea /1,000<5yr
population

Diarrhoeal deaths 18 43 6 7 15 89

Case fatality rate 0.07 0.13 0.03 0.04 0.07 0.07

/1,000
 CLASSIFICATION OF DIARRHOEA BY REGIONS
120

100 94.7 93.8 95.4

91.2 92.9

80

60

40

20
6.4 5.4 4.7
3.7 3.1
0.2 0.3 0.2 0.2 0.1
0
EDR CDR WDR MWDR FWDR
no dehydration some dehydration severe dehydration
 National Data- FY 2072/2073
Programme indicators 2070/71 2071/72 2072/2073
(2013/2014) (2014/2015) (2015/2016)

Incidence of diarrhoea per 1,000 under five 629 502 422

years children(new cases)
% of children under five years with diarrhoea 21 20
suffering from dehydration (facility, outreach &
community level)

% of children under five years with diarrhoea 12 11

suffering from dysentery (blood in stool)
% of children under 5 with diarrhoea treated with zinc and 98 93 87
ORS
% of children under five years with diarrhoea treated with IV 2.24 0.64 0.76
fluid
 Treatment of diarrhoeal cases with ORS and Zinc by
regions
100 98.4
97 97.6
96 96 96.4
95
95 94
92.5 93.1
91.4 91.2
89.5
90 88.2
87.4
84.6 84.6 85.2
85

80

75
EASTERN CENTRAL WESTERN FAR WESTERN MID WESTERN NATIONAL
2070/71 2071/72 2072/73
Indicators:
A. Diarrhoea prevention indicators
B. Diarrhoea treatment indicators

A. Diarrhoea prevention indicators

1. Percentage of population using :
(a) improved drinking water sources (urban, rural,
total)
(b) improved sanitation facilities (urban, rural, total)

2.Percentage of one year old immunized against

measles
 3. Percentage of children who are :

• underweight - 0 to 59 months age

(moderate and severe)
• stunted - 0 to 59 months age
(moderate and severe)
• exclusively breastfed - 0 to 5 months age
• breast-fed with - 6 to 9 months age
complementary food
• still breastfeeding - 20 to 23 months age

4. Vitamin A supplementation coverage rate (percentage full

coverage)
B. Diarrhoea treatment Indicators
Percentage of children under five years with diarrhoea
receiving:
1.ORT with continuous feeding
2. ORS packet
3. Recommended home made fluids
4. Increased fluids
5. Continued feeding
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)
1. Gender - male, female
2. Residence - Urban, rural
3. Wealth index quintiles- poorest, second,
middle, fourth, richest
Epidemiological Determinants

Agent

Disease

Host Environment
 Agent factors
1.Viruses
Rotaviruses
Adenoviruses
Astroviruses
Calciviruses
Coronaviruses
Enteroviruses
Norwalk group of viruses
Cytomegaloviruses
 Rota virus
• Leading cause of severe, dehydrating
diarrhea in children < 5years
• First episode of Rota viral diarrhoea:
- in developing countries - <12months
-in developed countries - delayed until 2-5
years
• Rotavirus gastroenteritis is largely limited to
children aged 6-24 months
Agent contd….
2.Bacterias
Campylobacter jejuni
Enterotoxigenic Escherichia coli
Shigella
Salmonella
Vibrio cholerae
Vibrio parahaemolyticus
Bacillus cereus
Staphylococcus aureus
Clostridium perfringens
Clostridium difficle
3.Others
E.histolytica
Giardia intestinalis
Trichuriasis
Cryptosporidium species
Intestinal worms
Cyclospora
Reservoir of infection :

• Can be human or human and animal faeces both

• Human: Enterotoxigenic E. coli, Shigella spp,
Giardia intestinalis, Entamoeba histolytica
• Animal reservoir but transmit from both human
and animal faeces: Campylobacter jejuni,
Salmonella spp, Y. enterocolitica etc
• For viral agents, animal reservoir in human disease
is uncertain.
Host factors :

• Age: most common : 6 months - 2 years

high incidence : 6-11 months, when weaning
occurs.
under 6 months : if fed cow milk or infant
feeding formulas
Causes of highest incidence in 6-11 months
• Declining level of maternally derived antibodies
• Lack of active immunity in infants
• Direct contamination when infant begins to crawl
• Introduction of contaminated food
Host factors (contd…..)

• Malnutrition
• Poverty
• Prematurity
• Reduced gastric acidity
• Immunodeficiency
• Lack of personal and domestic hygiene
• Incorrect feeding practices
Environmental factors :
• Seasonal pattern in many geographical areas.
• Temperature climate : warm season - bacterial diarrhoea
winter season - viral diarrhoea

• Tropic : warmer and rainy season - bacterial diarrhoea

Rota viral diarrhoea throughout the year;
frequency increased in drier ,cool months
Mode of Transmission

Water-borne

Faeco-oral route Food- borne

Fingers
Direct transmission Fomites
Dirt
Dehydration in Diarrhoea
• It is very important to
assess dehydration in
diarrhoea.
• The level of dehydration
is based on the amount of
fluid loss:
 no dehydration – <50
ml/kg
 some dehydration – 50-
100 ml/kg
 severe dehydration -
>100 ml/kg
Assessment of dehydration in patient with diarrhoea
No dehydration Some dehydration Severe dehydration
A Look at
1 Condition Well alert Restless,irritable Lethargic,
unconscious; floppy
2 Eyes Normal Sunken Very shunken & dry
3 Tears Present Absent Absent
4 Mouth and Tongue Moist Dry Very dry
5 Thirst Drinks normally; Thirsty; drinks Drinks poorly & is
not thirsty eagerly unable to drink
B Feel
1 Skin pinch Goes back quickly Goes back slowly Goes back very
slow
C Decide No signs of 2 or more signs of 2 or more signs of
dehydration dehydration dehydration
D Treat Treatment plan A Weigh if possible; Weigh the pt;
Treatment plan B Treatment plan C
urgently
Treatment

• Treatment plan A: treatment of “no dehydration”

 can be treated at home after explanation of
feeding and danger signs to mother/caregivers
 may
AGE be given ORS for use
Amount of ORSat
or home as: of ORS to
Amount
other culturally app provide for use at
fluid to be given after home
each loose stool

<24 mo 50 – 100 ml 500 ml/day

2-10 yr 100 – 200 ml 1000 ml/day
>10 yr Ad lib 2000 ml/day
Danger signs requiring medical attention

• Continuing diarrhoea for more than 3 days

• Increased volume/ Frequency of stool
• Repeated vomiting
• Increasing thirst
• Refusal to feed
• Fever
• Blood in stool
Treatment plan B: treatment for “some dehydration”

• Need to be treated in health center or hospital

• Fluid requirement calculated under:
- Provision of normal daily fluid requirement
- Deficit replacement or rehydration therapy
- Maintenance fluid therapy to replace losses
• Daily fluid requirement
Calculated as: Up to 10 kg: 100 ml/kg
10 – 20 kg : 50 ml/kg
>20 kg : 20ml/kg
Deficit replacement or rehydration therapy
-Calculated as 75ml/kg of ORS to be given over 4 hr
-If still some dehydration persist then another treatment
with ORS to be given
-Oral rehydration therapy maybe ineffective if:
. High stool purge rate of >5 ml/kg body weight/hr
. Persistent vomiting >3 per hr
. Paralytic ileus
. Incorrect preparation of ORS(very dilute solution)
• Maintenance fluid therapy to replace losses
-Begin when signs of dehydration disappear, usually within 4 hr
-ORS administered in volume equal to diarrhoeal losses, usually max of 10ml/kg
per stool
- Plain water can be offered in between
- Breastfeeding and semisolid food are continued after replacement of deficit

>If weight is not known then fluid is given as per

weight:
Age < 4 mo 4-11 mo 12-23 mo 2-4 yr 5-14 yr > 15 yr

Weight < 5 kg 5 -8 kg 8-11 kg 11-16 kg 16-20 kg >30 kg

ORS,ml 200 - 400 400-600 600-800 800-1200 1200- 2200 >2200
Number 1-2 2-3 3-4 4-6 6-11 12-20
of glasses
Treatment plan C : Treatment of “severe dehydration”

• Give intravenous fluid immediately using Ringer lactate

with 5% dextrose.
• A total of 100ml/kg of fluid is given over 6 hr in
children<12 months and over 4 hr in children > 12
month
• If child can feed orally ORS should be started
simultaneously, if Iv fluid cant be given then
nasogastric feeding at 20ml/kg/hr(total 120ml/hr)
• Child should be reassessed every 1-2 hr if abdominal
distension or repeated vomiting then oral or
nasogastric fluids are given slowly.
• If no improvement in dehydration in 3 hrs then first bolus of
100ml/kg of IV fluid is given and reassessed every 15-30 min
for pulses and hydration status.
• Management following intravenous hydration end is to be
done as follows:
- Persistence of severe dehydration: IV infusion is repeated
-Hydration improved ; some dehydration present: IV fluid
discontinued; ORS administered over 4 hrs as treatment B
-There is no dehydration: IV fluid are discontinued :
treatment plan A is followed.
• Child should be observed for at least 6 hrs before discharge.
Control of Diarrhoeal Disease :
WHO – Diarrhoeal Diseases Control (DDC)
Programme 1980

ORAL REHYDRATION THERAPY

Components of DDC

1.Short term
a. Appropriate clinical management.
2. Long term
b. Better MCH care practices.
c. Preventive strategies.
d. Preventing diarrhoeal epidemics.
A) Appropriate clinical management
I. Oral rehydration therapy
II. Intravenous rehydration
III. Maintenance therapy
IV. Appropriate feeding
V. Chemotherapy
VI. Zinc supplementation
Oral Rehydration Solution
ORAL REHYDRATION THERAPY

• Aim : To prevent dehydration and reduce mortality.

• Rationale:
Contains glucose + water
Glucose coupled Na absorption remains intact even when
other mechanisms fail or when intestinal secretion is
excessive( which lacks glucose)
• Oral rehydration therapy can be safely and successfully used
in treating acute diarrhoeas due to - all etiologies
- in all age groups
- in all countries.
 WHO-ORS(1975)
Nacl 3.5g
KCl 1.5g
Na citrate 2.9g
Glucose 20g
Water 1L

Na 90mM
K 20mM
Cl 80mM
Citrate 10mM
Glucose 110mM
Total osmolarity 310mOsm/L
New formula WHO-ORS(2002)
Nacl 2.6g
KCl 1.5g
Trisodium citrate 2.9g
Glucose 13.5g
Water 1L

Na 75mM
K 20mM
Cl 65mM
Citrate 10mM
Glucose 75mM
Total osmolarity 245mOsm/L
ORS- New vs Old
• Trisodium citrate added in place of sodium
bicarbonate as it increases shelf life (Na
bicarbonate powder cakes and becomes brown)
• Low Na, Low Glucose
• Rationale:
Maximum water absorption occurs from a slightly
hypotonic solution and when glucose concentration
is between 60-110mM
At higher concentration glucose appears in
stool(osmotic action)
• Reduced osmolarity of ORS solution to avoid
possible adverse effects of hypertonicity on net
fluid absorption by reducing the concentration of
glucose and sodium chloride .
• Reduced osmolarity solution also appears to be
safe and effective as standard ORS for use in
children with cholera .
• Packets of “oral
rehydration mixture
“are freely available at
all primary health
centres and hospital.
• Contents dissolved in
1L of drinking water .
• Solution should be
made fresh daily and
used within 24 hours.
• It should not be boiled
or otherwise sterilized.
HOME MADE ORS:
If WHO fluid not available :
• Usually recommended are home fluid : at least one
fluid that contains salt.
• Should add about 3g/lit to an unsalted drink or
soup.
Eg: Green coconut water, rice water,
Yoghurt drinks, etc don’t contain salt.
• Few fluids are potentially dangerous and should be
avoided during diarrhea:
o carbonated drinks
o commercial fruit juices
o sweetened tea,
cause osmotic diarrhea and hypernatremia.
 Guidelines for oral rehydration
therapy(for all ages) during the first
four hours
Age Under 4 4-11 1-2 years 2-4 years 5-14 years 15 years or
months months over

Weight(kg) Under 5 5-7.9 8-10.9 11-15.9 16-29.9 30 0r over

ORS 200-400 400-600 600-800 800-1200 1200-2200 2200-4000

solution(m
l)
Guidelines contd..
• The general rule is that the patient should be given
as much ORS solution as they want and that signs
of dehydration should be checked until they
subside.
• The actual amount will depend on patient’s desire
to drink and by surveillance of signs of dehydration.
• Greater amount should be given to those with
greater signs of dehydration and heavier patients.
Guidelines contd.
• Mother should be taught how to administer ORS
solution to the children ,respecting the following
rules:
1. For children under age of 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. As general
guide : – children <2 years: 50-100 ml of fluid
children 2-10 years: 100-200 ml
older children and adult : as much as they want
2. If the child vomits, wait for 10 mins , then try again
,giving the solution slowly – a spoonful every 2 -3
mins.
3. If the child wants to drink more ORS solution than
the estimated amount, and he doesn’t vomit
,there can be no harm in feeding him/her more .
If the child refuses to drink the required amount
and signs of dehydration have
disappeared, rehydration is completed.
4.If the child is breast fed ,nursing should be pursued
during treatment with ORS solution.
Food should never be withheld and the child’s usual
food never be diluted. The infant’s usual diet of
cereals ,vegetables and other foods should be
continued during diarrhea and increased afterwards.
INTRAVENOUS REHYDRATION

• Initial rehydration of severely dehydrated patients

who are in shock or unable to drink.
• Solutions recommended by WHO for intravenous
infusion are:
a. Ringer’s lactate solution ( Hartmann’s solution for
injection)
b. Diarrhoea Treatment Solution (DTS):
NaCl , sodium acetate, KCl , glucose
If nothing available then normal saline can be given.
Treatment plan for rehydration
therapy :
Age First give 30 ml/kg in Then give 70 ml/kg in

Infants 1 hour 5 hours

Older 30 minutes 2.5 hours

MAINTAINENCE THERAPY
Mild diarrhoea 100 ml/kg body weight per
(not more than one stool day until diarrhoea stops
every 2 hours or longer, or
less than 5 ml stool per kg
per hour)

Severe diarrhoea Replace stool losses volume

(more than one stool every 2 for volume; if not measurable
hours,or more than 5 ml of give 10-15 ml/kg body weight
stool per kg per hour per hour.
APPROPRIATE FEEDING
• “REST THE GUT “ during diarrhoea is a wrong
assumption.
• Promote normal food intake as soon as child is able
to eat regardless of age.
• Breast feeding along with oral rehydration solution
given after each liquid stool.
• In exclusively breastfeeding infants breastfeeding to be
continued.
• Optimally energy dense foods with the least bulk should be
offered in small quantities but frequently (every 2-3 hr).
• Staple foods enriched with fat or oil and sugar should be
given.
• Foods with high fibre content should be avoided.
• In non breastfed infants, cow or buffalo milk should be
given undiluted after correction of dehydration together
with semisolid foods.
• Milk should not be diluted with water during any phase of
acute diarrhoea,.
• During recovery, an intake of at least 125% of RDA should be
attempted with nutrient dense food; this should continue
until child reach pre illness weight (ideally normal
nutritional status).
CHEMOTHERAPY
• Unnecessary prescription of antibiotics and other
drugs will do more harm than good
• Antibiotics should be considered only when the
cause of diarrhea is clearly identified as Shigella
,Typhoid, or Cholera
• For diarrhea due to Shigella ciprofloxacin
• For diarrhea due to cholera doxycycline
,tetracycline, erythromycin.
 ZINC SUPPLEMENTATION
• Reduces the duration and severity of diarrhoeal
episode
• Given for 10-14 days :
lowers the incidence

WHO and UNICEF recommend

10 mg of zinc for infant under 6 months of age
20 mg for children older than 6 months for 14 days
 B) BETTER MCH CARE PRACTICES
a. Maternal nutrition:
b. Child nutrition
 promotion of breast feeding
appropriate weaning practices
Supplementary feeding
Vit A supplementation
C) PREVENTION STRATEGIES

• Sanitation
• Health education
• Immunization
Rota virus vaccine
• Two live ,oral
,attenuated Rota viral
vaccine
• Monovalent human
Rota virus vaccine
(Rotarix)
• Pentavalent bovine
human reassortant
vaccine (Rota Teq)
• Rotatrix
Route: Oral
No of doses: 2
Age of administration: 6 wks (no later than 12 wks)
10 wks (no later than 24 wks)
• Rota Teq :
Route: Oral
No of doses :3
Age of administration 2,4 & 6 months
 Vaccination should not be initiated for infants>
12wk - chance of intussuception
D)Control and/or prevention of
diarrhoeal epidemics

• Requires strenghthening of epidemiological

surveillance systems.

• Primary health care : involves delivery of curative

and preventive services at the community level
The integrated Global Action Plan for
prevention and control of pneumonia
and diarrhoea
Goals for 2025

For children under 5 years of age:

• reduce mortality from pneumonia to fewer than 3
per 1000 live births;
• reduce mortality from diarrhoea to fewer than 1
per 1000 live births;
• reduce the incidence of severe pneumonia by 75%
compared to 2010 levels;
• reduce the incidence of severe diarrhoea by 75%
compared to 2010 levels;
• reduce by 40% the global number who are stunted
compared to 2010 levels.
Framework for Protect, Prevent,
Treat
Strategies for preventing and treating
pneumonia and diarrhoea
Diarrhoeal disease control programme
in Nepal
• Infectious disease control guidelines
• CBIMNCI
• WASH programme
• School led total sanitation programme
Infectious Disease Control Guideline

Governmen
of Nepal
Ministry of Health
ACUTE WATERY DIARRHOEA (rice watery stool
with/ without vomiting)
ACUTE BLOODY DIARRHOEA (with fever)
OTHER DIARRHOEA
CBIMNCI
• CB-IMNCI is an integration of CB-IMCI and CB-NCP
Program that is being implemented across the
country after the decision of MoH on 2071/6/28
(October 14,2015)
• Among the age group of 2 months to 59 months
children, it addresses major childhood illnesses like
pneumonia, diarrhoea, malaria, measles and
malnutrition in a holistic way.
• % of under 5 children with diarrhoea treated with
ORS and Zinc is one of the six CB-IMNCI Program
Monitoring Key Indicators
 Interventions towards diarrhoea
Newborn Specific Interventions
• Management of sepsis among young infants (0‐59 days)
including diarrhoea
Child Specific Interventions
• Case management of children aged between 2‐59 months
for 5 major childhood killer diseases (Pneumonia, Diarrhoea,
Malnutrition, Measles and Malaria)
Cross Cutting Interventions
• Behaviour change communications for healthy pregnancy,
safe delivery and promote personal hygiene and sanitation
• Improved knowledge related to Immunization and Nutrition
and care of sick children
Vision 90 by 20
CB-IMNCI program has a vision to provide targeted
services to 90 percent of the estimated population
by 2020 as shown in the diagram below.

Institutional
Delivery

Under 5
children with To provide Service
pneumonia Newborn who
to 90% of target had CHX gel
treated with group by 2020
antibiotic applied

Under 5 children
with diarrhea
treated with ORS
and zinc
Water, Sanitation, and Hygiene
(WASH) Program
• Improves sanitation,
promotes hygiene
behavior, and increases
access to safe drinking
water
• project operates in
Nepal’s Far-Western
Region
School Led Total Sanitation (SLTS)
• Initiated by Government of Nepal and UNICEF in
2006
• Aim : To create demand of sanitation services with
focus of empowering people and change in hygienic
behavior.
• Target : Having 100% toilet coverage leading to
open defecation free (ODF) school catchment area.