CONTROL OF DIARRHOEAL DISEASES

• It is now obvious that many different organism

some known, probably many unknown- causes
diarrhea. It is also clear that they do not act same
way to cause diarrhoea. But from an
epidemiological point of view, they are
considered together because of common
symptoms, diarrhoea. It is now firmly established
that regardless of causative agent or age of the
patient , the sheet anchor of treatment is ORAL
REHYDRATION THERAPY such as the one
advocated by WHO/UNICEF
• The Diarrhoeal Disease Control (DDC) Programme of
WHO has since its inception in 1980, advocated several
intervention measures to be implemented
simultaneously with mutually reinforcing and
complementary impacts. These measures centre round
the wide spread practice of “ oral rehydration therapy”
• Components of Diarrhoeal Diseases Control Programme
The intervention measures recommended by WHO may
be classified as below…….
1. Short term
a) Appropriate clinical management.
2. Long term
b) Better MCH care practices
c) Preventive strategies
d) Preventing diarrheal epidemics
 a) Appropriate clinical management
• Management acute diarrhea should be
planned under following headings……..
1. Prevention and treatment of dehydration
2. Drug therapy
3. Nutritional management
4. Management of special situation
 1. PREVENTION AND TREATMENT OF
THE DEHYDRATION
• All cases of acute watery diarrhea should be
started on oral fluid from the first episode of
diarrhea. The WHO recomends -
1. treatment plan A---- for no dehydration
2. Treatment plan B----- for some dehydration
3. treatment plan C----- for severe dehydration
 Treatment plan A- prevention of
dehydration
Patient with acute diarrhea who show no physical signs of
dehydration require fluids to prevent dehydration this can
be achieved by :
a) provision for normal daily fluid requirements
i.e breast milk for those who are breast fed, full strength
artificial milk for the top fed other fluids and plain water
normally taken by the child should be continued.
b) Replacement of ongoing losses due to diarrhea and
vomiting can be possible by
i. Home available fluids: examples of such fluids are plain
water, lemon water, coconut water, curd water, rice kanji,
dal without salt etc.
 Most of these fluids lake a glucose precursor or
salt or both. Therefore these are likely to be
effective only in presence of continuing feeding
which provide starch and protein to promote
luminal sodium absorption. Home available fluids
together with food should be started from the
first loose stool.
Soft drinks , sweetened fruit juices and tea do not
contain salts, therefore are unsuitable and
potentially dangerous. Plain glucose water
without salt may cause osmotic diarrhea.
ii) Food based solution: examples are rice water
(50gms of rice in liter of water) and dal mixed with salt, lassi
with salt, and soups with salt the salt amount should be a 2
finger pinch(0.8gm) per 200ml. These solution contain
acceptable amounts of starch and sodium and are suitable.
iii)Sugsr salt solution: it is a home made mixture of 1two
finger pinch(0.8gm) of salt, 1heaped teaspoon (8gms) of
sugar to be mixed in one glass (200ml) of water. Properly
prepared and consumed in adequate quantities , it makes a
scientifically sound repalcement when ORS is not available.
However , it has been shown that solution prepared have
high sodium concentration despite proper instruction
sometimes causing hypernatremia.
iv) Oral rehydration salt (ORS) : ORS is appropriate for both
prevention and treatment of dehydration. Preparation is
easier than the home formula mentioned above.
• Composition of ORS
The composition of standard ORS and low
osmolarity ORS recommended by WHO shown
below
 Preparation of ORS
• The ORS is available in powder form in packets of
two sizes – a small and a large. The mother
should be asked to wash her hands with soup and
water before preparation of the solution a small
packet should be mixed thoroughly in 200 ml of
water and large packet in 1 litre of water. the
powder should be stirred properly so that there is
no residual powder at the bottom of the
container. it should be kept covered. Once
prepared it should be used within 24 hrs or
discarded.
 Procedure for feeding ORS
The actual amount given will depend on the patient
desire to drink and by surveillance of signs of
dehydrations.
The general rule is that patient should be given as much
ORS Solution as they want and the signs of
dehydration should be checked until they subsides.
The older children and the adult should be given as much
water as they want in addition to the ORS solution.
One teaspoonful should be given every 1-2 mins for a
child under 2 yrs. If the child vomits wait for 10 mins
then start more slowly i.e. 1 spoon every 2-3 mins.
The amounts of ORSto be given after every loose
motion , for prevention of Dehydration
Age Amount after every loose stool
Less than 2years 50 to 100 ml
2years to 10 years 100 to 200 ml
10 years or more As much as desired

Advice to the Mother as regards when to call on the doctor.

The mother should be advice to call on the doctor or a health worker if
the child doesnot get better in 5 days or immediately, if the child
developed any ofb the following signs
i. Many watery stools
ii. Repeated vomiting
iii. Marked thirst
iv. Eating or drinking poorly
v. Fever
vi. Blood in stool.
 Treatment plan B: Rehydration therapy for
patients with physical signs of Some
Dehydration
• All cases with signs of dehydration should be
admitted to hospital and treated. The child
should be given ORS. It should be started as early
as possible.
• Components of Oral Fluid Therapy
1. Deficit therapy which consist of correction of
existing fluid and electrolyte deficit.
2. Replacement of ongoing loss due to continuing
diarrhoea or vomiting.
3. Provision of normal daily fluid requirement.
 Amount of fluid to be given
• The amount of fluid to be given includes the fluid which the child
has already lost( deficit therapy) + replacement of ongoing losses
for continuing diarrhoea and vomiting + the normal daily
maintainance fluid.
1. Deficit therapy : 75 ml of ORS per kg in first 4 hours. However if
the child wants more ORS than the calculated amount, it should
be given.
2. Replacement of ongoing losses :
a. ORS, 10 to 20 ml per kg body weight after every liquid stool
b. Plain water in between ORS
c. Breast feeding should be continued in breast fed babies

3.Normal daily requirement should be calculated according to the

age of the child.
 Monitoring and assessment
• The child should be closely monitored every 1 hour and
assessed. After four hours if the child still continues to have
some dehydration, another 4 hours treatment with ORS
should be repeated. If dehydration increases to severe
degree, the child should be treated with treatment plan C.
• The causes of refusal to take ORS
the child may refuse to accept ORS for following reasons-
1. If there is no fluid or salt loss and dehydration is
corrected.
2. If salt loss is corrected but fluid loss continues, the child
will accept only plain water.
3. If preparation is not correct.
4. If the child is drowsy and unable to drink.
 Treatment plan C: rehydration therapy for
children with physical signs of severe
dehydration.
• All cases with signs of severe dehydration should be treated with
rapid Intravenous Rehydration for correction of existing water and
electrolyte deficits. However, while the i.v. drip is setup, the child
should be started on ORS.
The steps of I.V. Rehydration are as follows-
1. Amount of fluid : 100ml /kg body wt to be infused in 4 hours.
2. Nature of fluids: Ringer’s lactate with 5% dextrose is the best.
0.9% sodium chloride can be used if Ringer’s lactate is not
available. Ringer’s lactate is preferred because it contains
potassium and lactate which helps to correct hypokalemia and
acidosis in addition to sodium and chloride. Severe dehydration
usually has hypokalemia and acidosis
3. Amount and rate of therapy
age 30 ml /kg body wt 70 ml/ kg body wt
Less than 12 months 1 hour 5 hours
More than 12 months ½ hour 2 ½ hours
 Evaluation and Action
1. The should be assessed every 15 to 30 mins until a normal radial
pulse is present. If there is no improvement, the rate of i.v. fluid
infusion should be given more rapidly.
2. All children should be started on ORS solution 5ml/kg body
wt/hour when they are able to drink properly during the time
they are getting i.v. fluids.
3. If i.v. infusion is not possible, rehydration therapy can be started
with ORS using a nasogastric tube at the rate 30ml/kg/hrs ( total
of 120ml/kg body wt) in 4 hrs. if there is repeated vomiting,
thevrate should be slowed down. If there is no improvement after
3 hrs, i.v. fluid should be started. This method may be used in
children with severe dehydration during transport to a higher
facility for mangement.
4. If the signs of severe dehydration are still present after 4 hrs of
deficit therapy, the treatment plan c is repeated.
5. If the child shows signs of some dehydration
after 4 hrs, i.v. fluid administration should be
discontinued and ORS solution should be
given for 4 hrs as in Plan B .
6. If there are no signs of dehydration after
4hrs,ORS should be given as in Plan A. the
child should be observed in the hospital for 6
hrs and if the hydration is maintained, child
can be discharged.
 2. Drug Therapy
• Unnecessary prescription of antibiotics and other drugs will do more harm
than good in the treatment of diarrhoea . antibiotics should be considered
where the cause of diarrhoea has been clearly identified as Shigella,
typhoid or cholera. The symptomatic differential diagnosis of shigella and
cholera are as shown in the table -

symptoms Cholera Shigella

Diarrhoea Acute watery diarrhoea Acute bloody diarrhoea

Fever No Yes
Abdominal cramps Yes Yes
Vomiting Yes No
Rectal pain No Yes
Stool More than 3 More than 3 stool/day
loosestools/day, watery with blood or pus
like rice water
• Diarrhoea due to Cholera
in India , cholera still accounts for 5-10% cases of acute
diarrhoea. drug of choice are-
antibiotics dose Duration of treatment

1. Trimethoprim + 5mg/kg 12 hourly x 3 days

Sulfamethoxazole 25mg/kg

2. Tetracycline 12.5mg/kg 6 hourly x 3 days

3. Erythromycin 12.5mg/kg 6 hourly x 3 days

4. cholamphenicol 20mg/kg 6 hourly x 3 days

• Diarrhoea due to shigella
the drug of choice is ciprofloxacin as shigella is usually
resistant to ampicillin and TMP-SMX.

Drugs Dose Duration of treatment

First line
1. Trimethoprim + 5mg/kg 12 hourly x 5 days
sulfamethoxazole 25mg/kg
Second line
2. Nalidixic acid 15mg/kg/dose 6 hourly x 5days
Third line
3. Ciprofloxacin 125mg (< 20kg) 12 hourly x 5days
250mg (>20kg)
4.Ceftriaxone inj 40mg/kg/day (i.m./ i.v.) Daily/12 hourly x 5 days
• Amoebic dysentery – metronidazole is the drug of choice in the dose of 10
mg/kg/dose 3times daily for 5 days (10 days for severe disease).
• The medicines that should not be used in the treatment of diarrhoea are
as follows-
 Neomycin ( damages the intestinal mucosa and can cause malabsorption)
 Purgatives ( worsen diarrhoea and dehydration)
 Tincture of opium or atropine ( dangerous for children and dysentery
patient because of decreased intestinal transit time)
 Cardiotonics such as coramine ; shock in diarrhoea must be corrected by
i.v. fluid and not by drugs.
 Steroids ( expensive, useless and may cause adverse effects )
 Oxygen (expensive and unnecessary)
 Charcoal , kaolin , pectin , bismuth( no value)
 Mexaform (no value and can be dangerous )
• Zinc supplimentation: when a zinc suppliment
is given during an episode of acute diarrhoea,
it reduces the episode’s duration and severity.
In addition, zinc suppliments given for 10-14
days lower the incidence of diarrhoea in the
following 2-3 months. WHO and UNICEF
therfore recommend daily 10mg of zinc for
infants under 6months of age and 20 mg for
children older than 6months for 10-14 days.
 b. Better MCH Care practices
• Maternal nutrition- improving prenatal
nutrition will reduce the LBW problem. Pre &
post natal nutrition will improve the quality of
breastmilk.
• Child nutrition- i) promotion of breast
feeding. ii) appropriate weaning practices .
iii) supplementary feeding. iv) Vit A
supplementation.
 c. Preventive strategies
• Sanitation.
• Health education
• Immunization – immunization against measles is a potential intervention
for control. When administered at the recommended age, the measles
vaccine can prevent upto 25% of diarrhoeal deaths in children under
5years of age.
Rotavirus vaccine – two live, oral attenuated rotavirus vaccines were
licenced in 2006: the monovalent human rotavirus vaccine (Rotarix™) and
the pentavalent bovine – human, reassortant vaccine (Rota Teq ™).
The Rotarix™ vaccine is administered orally in a 2 dose schedule to
infants appoximately 2 and 4 months of age. The first dose can already be
administered at the age of 6 weeks and should be given no later than at
the age of 12weeks. The interval between the two doses should be atleast
4 weeks. The two dose schedule should be completed by age of 16 weeks
and no later than by 24 weeks.
 For Rota Teq ™ , the recommended schedule is three oral
doses at the age of 2, 4 and 6 months. The first dose should
be administered between ages 6 to 12 weeks and
subsequent doses at interval of 4 to 10 weeks .vaccination
should not be initiated for infants aged greater than
12weeks. All three doses should be administered before
the age of 32 weeks.
there is potentially higher risk of intussuception when the
first dose of this vaccines is given to the infants aged > 12
weeks, consequently, the current rotavirus vaccine should
not be used in catch-up campaign, where the exact age of
vaccine may be difficult to ascertain.
iv) Fly Control flies breeding in association with animal feaces
should be controlled.
 d. Control and 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- the integrated Global Action Plan
for the Prevention and Control of Pneumonia
and diarrhoea (GAPPD) proposes cohesive
approach to ending preventable pneumonia
and diarrhoea deaths.
Diarrhoeal Dieases Control Programme
in India
• The Diarrhoeal Diseases Control Programme was
started in 1978 with the objective of reducing the
mortality and morbidity due to Dirrhoeal diseases
since 1985 to 1986, with the inception of the
National Oral Rehydration Therapy Programme,
the focus of activities has been on strengthening
case management of diarrhoea for children under
age of 5 years and improving maternal knowledge
related to use of home available fluids, use of
ORS and continued feeding.