Investigation of an epidemic with relevant

to Diarrhoeal diseases

Presented by:Dhanpal SinghAishwarya Thakur

1)Dr Q.H Khan(Prof and Head of the Dept)

2)Dr K P Brahmapurkar3)Dr V K Brahmapurkar4)Dr Teeku Sinha5)Dr P.K Srivastava6)Dr VKS Chauhan8)Dr Durgesh Naidu9)Dr Vandana Zargar10)Dr Akhilesh badge

Main motives of investigationTo define the magnitude of the

epidemic outbreak or involvement in terms of time, place and person.

To determine the particuar condition and factors responsible for the occurrence of the epidemic

To identify the cause source of infection and mode of transmission to determine measures necessary to control the epidemic.

To make recommendation to prevent reoccurrence

What do you mean by epidemiology?

Epi = upon, amongDemos= peopleOlogy= science, study ofEpidemiology=the science or the study of what is upon the people.

Definition of epidemiology:

Epidemiology has been defined by John M. Last in 1988 as- “The study of the distribution and determinants of health related states or events in specified population and the application of this study to the control of health problems.”

Occurrence of more cases of disease than expected

- in a given area - among a specific group of people - over a particular period of time

What is an Outbreak?

l. To stop the current outbreak from spreading.ll. Prevent future similar outbreaks.

lll. Provide scientific explanation of the event.

lV. Provide knowledge for the understanding of the disease process which includes:

the cause , source(s) of infection and modes of transmission.

V. React to and calm public and political concerns

Vl. Train epidemiologists

Importance of outbreak investigation

:If the local health officials request assistance, the regional

epidemiologist should try to acquire as much information about the

disease and the population at risk as possible.

: As soon as the initial information on an outbreak reaches, the regional health coordinator must determine whether the information is correct.

: The plan should be based on situational analysis & taking

technical, economical & political factors into account.

Recognition & response

Check initial information

Formulate a plan of action

Initial steps :-

Report:-

Information to be included in the final report on an epidemic

Report1.Background Geographical location

Climatic conditionsDemographic statusSocio economic situationOrganization of health servicessurveillanceNormal disease prevalence

REPORT2.Historical data Previous occurrence of

epidemics-Of the same disease-Locally or elsewhereOccurrence of related diseases , if any-In the same area-In other areas

3.Methodology of investigations

Case definition

Questionnaire used in epidemiological investigationSurvey teams household survey retrospective survey collection of lab specimens lab techniques

Continued….

Report4.Analysis of data Clinical data:

-frequency of signs and symptoms -course of disease -differential diagnosis -death ratesEpidemiological data: -mode of occurrence -time ,place , population groupsModes of transmission: -sources of infection -routes of excretion and portal of entry Lab data: -isolation of agents -serological confirmation -significance of resultsInterpretation of data

Report5.Control measures Definition of strategies &

methodology of implementation -constraints -resultsEvaluation: -significance of results -cost/effectivenessPreventive measures.

The written report should be submitted, in a standardized format, to the public health authorities including the ministry of health & remain confidential until it has been given official permission.

Report contd…

Steps of an outbreak investigation1. Prepare for field work2. Verify diagnosis 3. Confirmation of an existence of an

epidemic 4. Case definition5. Data analysis6. Formulate and testing of hypothesis 7. Evaluation of ecological factors8. Further investigation9. Implement control measures10.Writing the report

Consider your self as an investigator…..

BEFORE LEAVING FOR THE FIELD, WE SHOULD:1.Research the disease and gather the supplies and equipment we will need.

Step 1:- Prepare for field work ..

2. Identify the team members &assign responsibilities.

Composition of typical field team:

Specialists Auxillaries1. Epidemiologist 1. Nurses2.Physician 2. Specialist assistants

3. Microbiologist 3. Secretary/Interpreter4. Veterinarian 4. Driver5. Entomologist

6. Mammalogist

7. Sanitary engineer

8. Toxicologist

9. Information Specialist

10. Laboratory technician

IMPORTANCE OF VERIFICATION OF DIAGNOSIS:-

first- we must ensure that the problem has been properly diagnosed—that it really is what it has been reported to be.

second- for outbreaks involving infectious or toxic-chemical agents, we must be certain that the increase in diagnosed cases is not the result of a mistake in the laboratory.

Step 2 :-Verify the diagnosis..

Verifying the diagnosis requires review of:

-the clinical findings (the signs and symptoms)

- laboratory results for the people who are affected. laboratory investigation whenever applicable are most

useful to confirm diagnosis But in Epidemiological investigation should not be

delayed until the laboratory results are available and

diagnosis should be made based on clinical examination.

For e.g., in case of diarrhoea verification of the diagnosis should be made whether it is a acute watery diarrhoea or acute bloody diarrhoea• Acute watery

diarrhoea• Pathogen- V.cholerae or

E.coli• Characterstics of stool-

Liquid or watery stool of normal colour.

• Complication-dehydration, weight loss

• Treatment- antibiotic

Acute bloody diarrhoea• Pathogen-shigella• Characterstics of stool-

Blood tinged loose stool mixed with mucous.

• Complication-intestinal mucosal damage, sepsis,malnutrition

• Treatment- metronidazole

step 3:- confirmation of existence of epidemic.. First step , is to verify that a suspected epidemic is indeed a real epidemic . For this

Analyze expected frequency based on

past experience

If the number of cases exceed the expected frequency , then it is

an epidemic.

How, then, do we determine what is expected?

Usually we can compare the current number of cases with the number from the previous few weeks or months, or from a comparable period during the previous few years.

- The sources of these data vary:1.For a notifiable disease (one that, by law, must be reported), we can use health department surveillance records.2.For other diseases , we can usually find data from local sources such as hospital discharge records, death records, and cancer or birth defect registries.

Continued…

If local data are not available:-we can make estimates using data from neighboring states or national data.- or we might consider conducting a telephone survey of physicians to determine whether they have seen more cases of the disease than usual-or we could even conduct a survey of people in the community to establish the background level of disease..

Continued….Even if the current number of reported cases exceeds the expected number, the excess may not necessarily indicate an epidemic. Reporting may rise due to

-changes in local reporting procedures,- changes in the case definition- increased interest because of local or national awareness, -improvements in diagnostic procedures.

Finally, particularly in areas with sudden changes in population size, such as resort areas, college towns, and migrant farming areas, changes in the number of reported cases may simply reflect changes in the size of the population.

Step 4:- Case definition

Our next task as an investigator is to establish a case definition. Case definition- standard set of criteria for deciding whether, in this investigation, a person should be classified as having the disease or health condition under study. A case definition usually includes four components:1. clinical information about the disease. Eg:-

as defined y WHO diarrhoea is defined as passage of 3 or more liquid or loose stools per day ( or more frequent passage then is normal for individual). Frequent passing of formed stool is not diarrhoea nor is the passing of loose pasty stool by breastfeed baby.

2. characteristics about the people who are affected- eg- during the first 6 month infants may keep on passing 8-10 loose motion per day and still gain weight. If the child is active and normal on examination he should not be labeled as having diarrhoea. Passage of motion immediately after a meal due to gastro colic reflex should not be taken as diarrhoea.

3. Information about the location or place-eg : reports of diarrhoea are high in areas having high percent of malnourishment or natural calamities.

4.Specification of time during which the outbreak occurred- eg :cases of diarrhoea increase during the rainy season.

Identification of caseA. Medical survey A medical survey should be carried

out in the defined area to identify all cases including those who have not sought medical care and those possibly exposed to risk

Lay health workers may be trained to administer the epidemiological case sheet or questionnaire to collect relevant data

B. Epidemiological Case Sheet:Epidemiological case sheet is made for

collecting the data from the cases and from person apparently exposed but unaffected.

Relevant information to be collected in a case sheet are:-

Name Age Sex Occupation Address Socioeconomic status

Other relevant data:-personals contacts at home,work ,school and other places-Travel-Special events such as parties attended,foods eaten and exposure to common vehicles such as water ,food and milk -Attendance at large gatherings

Relevance of the information collected:-To avoid duplication of cases.To ensure completeness and consistency

of data collection.Address is helpful to contact patient for

additional information.To notify about laboratory resuts.Address also allow to map the

geographical extent of problem.

C. Searching for more cases

Ask the patient if he knew of other cases in the home, family, neighborhood, workplace.

Cases admitted to the local hospital should also be taken into consideration.

This may reveal not only additional cases but also person to person spread.

Recognizing the uncertainty of some diagnoses, investigators often classify cases as "confirmed," " probable," or "possible."

Confirmed cases -must have laboratory verification. Probable cases -have the typical clinical features of the disease without laboratory confirmation. Possible cases- have fewer of the typical clinical features

Case classification :

The data collected should be analyzed on ongoing basis, using

the classical parameters – time, place and person.

Identify when patients became ill (time), where patients

became ill (place) & what characteristics the patients possess

(person). Characterizing an outbreak by these variables is called

descriptive epidemiology -The number of cases is plotted on the y-axis of an epi curve;

the unit of time, on the x-axis.

Step 5:- DATA ANALYSIS..

1. Time The pattern of disease may be described by

the time of its occurrence.A graph of the time distribution of epidemic

cases is called the “epidemic curve”. Epidemic curve may suggest (a) magnitude of epidemic (b) mode of spread

(point source or person to person or both) (c) possible duration of epidemic Epidemic show short term fluctuation in

epidemic curve

The epidemic curve rises and falls rapidly, with no secondary curve.

All cases develop within one incubation period.

Eg – food poisoning

Secondary waves are formed in these case.

Exposure from the same source may be prolonged.

Eg- well of contaminated water

Secondary wave is formed after a brief pause.

Gradual rise and forms a plateau which tails off after a long period of time.

The origin is of infectious agent.Epidemic is initiated from a

common source.

2. PlaceIt provides major clues regarding the source of agent

and/or nature of exposure. Spot maps show a pattern of

distribution of cases .

1. Spot map show at glance area of high or low frequency,

the boundaries and pattern of disease distribution.

2. if the map shows clustering of cases, it may suggest a

common source of infection or common risk factor shared

by all.

Place distribution tells about international variation, national variation , urban –rural variation and local distribution of the disease.

Geographic distribution provides evidence about the source of disease and its mode of spread. By relating events the variations to agent, host and environment, we can device the source of disease.

3. PersonPerson distribution of the epidemic is characterized by

determining –Age

Sex

Ethnicity

Marital status

Occupation

Social status

Behaviour

Importance of person distribution in epidemiology:-Variation in distribution of

disease can be a starting point for an epidemiological enquiry

Formulation of etiological hypothesis.

It also helps in determining “high risk groups”.

High risk groups of diarrhoea are children of age 6month to 2 years i.e. children of weaning period.

Undernourished children suffer from long lasting diarrhoea and are at 15-20 times greater risk of dying compare to well nourished children with diarrhoea.

1. Hypothesis : it is a supposition arrived at by data analysis. Hypothesis should specify:- the population the specific causeoutcome relationship with time

Step 6:- Formulation and testing of hypotheses:

disease

Risk factor

s

Agent’s reservoi

rVehicles

Transm-

ission

The next step is to evaluate the credibility of the hypotheses. There are two approaches that can be used, depending on the nature of the data: 1) Comparison of the hypotheses with the established facts and2) Analytic epidemiology, which allows to test the hypotheses. first method is used when evidence is so strong that the hypothesis

does not need to be tested. For e.g. - investigation of an outbreak of vitamin D intoxication of a

place xyz.

Step Evaluation of hypotheses :

Milk of a dairy of place xyz

People drank that milk people affected

Investigators hypothesized

Source-dairy of excess vit D

Vehicle-milk of excess vit D

Investigators visited dairy

Found more than the recommended

dose of vit D added for no

purpose

No further analysis required

The second method, analytic epidemiology, is used when the cause is less clear.With this method, hypotheses is tested by using a comparison group to quantify relationships between various exposures and the disease. ANALYTIC STUDIES:

COHORT:Consists of two groups:1.Exposed to risk factor2.Not exposed

CASE –CONTROL STUDIES:Compares:1.People with disease(case patients)2.People without disease(control)

Cohort studies A cohort study is the best technique for analyzing an outbreak in a small, well-defined population.

For eg, we would use a cohort study if an outbreak of gastroenteritis occurred among people in a wedding, and a complete list of wedding guests was available. In this situation, question asked to each attendee: potential exposures ( foods and beverages consumed at the wedding)

whether become ill with gastroenteritis.

Ate that item (mushroom)

exposed

+

Didn’t ate that item

Not exposed

no of people didn’t ate that item got ill Total no of people didn’t ate that item

Identification of source of outbreak – look for an item

High incidence-exposed

Low incidence -not exposed

After collecting this information from each guests, calculate the incidence of disease

Relative risk=incidence exposed/incidence not exposed

association between exposure

&illness for that item

incidence=

No. of people ate that item and got ill

Total no of people ate that item

Incidence=

Attributable risk:Difference in incidence rate among

exposed and not exposed.

Incidence of disease rate among exposed –incidence of disease among non-exposed X100

incidence rate among exposed

CASE -CONTROL STUDIES:USED FOR ANALYSING OUTBREAK IN A POORLY DEFINED POPULATION . This study does not prove that a particular exposure caused the disease but effective in obtaining possible cause of disease . In this odd ratio is calculatedIN THESE STUDY QUESTIONS ARE ASKED ABOUT EXPOSURE TO BOTH:

CASE PATIENTS CONTROL

The controls must not have the disease, but should be from the same population as the case-patients. Commonly it consists of neighbors and friends of case-patients and people from the same physician practice or hospital as case-patients.

For e.g. ,suppose we are investigating an outbreak of diarrhoea in a small town, and we suspects that the source is a favorite restaurant A of the townspeople. After questioning case-patients and controls about whether they had eaten at that restaurant, our data might look like this:

Odds ratio = ad = 30 × 70 = 5.8. bc 36 × 10Conclusion-This means that people who ate at Restaurant A were 5.8 times more likely to develop diarrhoea than were people who did not eat there. -

Ate at restaurant A

Case patients

control total

yes a=30 b=36 66no c=10 d=70 80total 40 106 146

Continued…

Step 7 :Evaluation of ecological factors

A study of environmental conditions & the dynamics of its interaction with the population & etiologic agents will help to formulate the hypothesis on the genesis of the epidemic. Ecological factors that should be investigated are:-Sanitary status of eating establishments , -water and milk supply ,- movement of human population -atmospheric changes like temperature, humidity and air pollution population dynamics of insects and animal reservoirs..etc

It is done to study population at risk.

1.It consists of collecting & testing appropriate specimens.

2. To identify the etiologic agent, the collection need to be

properly timed.

3.Examples of specimens include:–

- food & water,

-other environmental samples (air settling plates), and

-clinical (blood or stool) samples from cases & controls.

Step 8 : further investigation

This is done by- medical examinationScreening testExamination of suspected food,

faeces, blood and water.Biochemical studiesAssessment of immunity status

Implementation of control measures, should be aimed at specific links

in the chain of infection, the agent, the source, or the reservoir.

for eg, an epidemic might be controlled by destroying contaminated

foods, sterilizing contaminated water, destroying mosquito breeding

sites, or requiring an infectious food handler to stay away from work

until he or she is well.

-In other situations, we might direct control measures at interrupting

transmission or exposure.

for eg, to limit the airborne spread of an infectious agent among

residents of a nursing home, we could use the method of "cohorting" by

putting infected people together in a separate area to prevent

exposure to others.

-

Step 9: Implement Control Measures:

Continued…Finally, in some outbreaks, we would direct control measures at reducing susceptibility. for eg, immunization against rubella and malaria chemoprophylaxis (prevention by taking antimalarial medications) for travelers.

The epidemiologists may want to perform more detailed & carefully executed studies as there may be a need to find more patients:

-To define better the extent of the epidemic .

- Because a new lab method may need to be evaluated.

-Or case finding method may need to be evaluated.

Conduct additional studies:

The final task in an investigation is to communicate your findings to others who need to know. This communication usually takes two forms: 1) an oral briefing for local health authorities & 2) a written report.ORAL BRIEFING:-The oral briefing should be attended by the local health authorities and people responsible for implementing control and prevention measure.

Report &communicate the findings:

- This presentation is an opportunity for us to describe what we did, what we found, and what we think should be done about it.-We should present our findings in scientifically objective fashion, and we should be able to defend our conclusions and recommendations.

1. Data sources are often incomplete & less

accurate.

2. Decreased statistical power due to analysis of

small numbers.

3. Publicity surrounding the investigation –

community members may have preconceived

ideas.

4. There is a pressure & urgency to conclude the

investigations quickly which may lead to hasty

decisions

Unique aspect of epidemic investigation:

DIARRHOEA

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 & character of stools rather than the number that is more important.

Duration:Acute < 14 daysPersistent > 14 daysChronic > 30 days

Frequent loose, watery stools Abdominal cramps Abdominal pain Fever Bleeding Lightheadedness or dizziness dehydration

Sign and symptoms

SIGNS OF DEHYDRATION

CLINICAL TYPES OF DIARRHOEAL DISEASE

Acute watery diarrhoea- lasts several hours to days the main danger is dehydration.

Start suddenly Most episodes recover or self

limiting within 3-7 days. These may last up to 14 days

>75% of all episodes are of acute

watery diarrhoea. Caused by V.cholerae, E.coli and rotavirus

Acute bloody diarrhoea- also called dysentry the main dangers are damage of the intestinal mucosa and sepsis.

Most commonly caused by shigella.

Diarrhoea with visible blood & mucus in the faeces.

Also abdominal cramps, fever, anorexia and rapid weight loss.

Persistent diarrhoea- lasts for 14 days or longer. The main danger is malnutrition.

AIDS persons are more likely to develop persistent diarrhoea.Incidence is around 5% i.e. 5% of acute diarrhoea may persist beyond 2 weeks

Epidemiological determinantsAgent –

COMMON CAUSES OF DIARRHOEA- BACTERIA

–Vibrio cholera–Shigella–Escherichia coli–Salmonella–Campylobacter jejuni–Yersinia enterocolitica–Staphylococcus–Vibrio parahemolyticus–Clostridium difficile–Neisseria gonorrhoea–Chlamydia–Aeromasa

• Rotavirus• Adenoviruses• Caliciviruses• Astroviruses• Norwalk group viruses• Cytomegalovirus• Coronavirus

COMMON CAUSES OF DIARRHOEA- VIRUS

COMMON CAUSES OF DIARRHEA- PARASITE•Entameba histolytica•Giardia intestinalis•Cryptosporidium •Cyclospora•Trichuriasis• Intestinal Worms

Pathogens % casesViruses Rotavirus 15-25Bacteria Enterotoxige

nic E.ColiShigella Campylobacter jejuniVibrio cholerae 01Salmonella(non-typhoid)Enteropathogenic E.coli

10-20 5-15 10-15 5-101-5

1-5

Protozoans No pathogen found

Cryptosporidium -

5-15 20-30

Pathogens frequently identified in children with

acute diarrhoea in treatment centre's in developing

countries

Host- More common in children of age group 6mnths-2yrs.

Also there is exposure to contaminated food and direct contact with infected faeces.

In adults it is common in persons living in unhygeinic conditions ,malnourished and immunocompromised individuals.

In young adults due to their food habits.

Environmental factors-

Shows a particular geographic pattern.

In temperate climates, bacterial diarrhoea occur more frequently during the warm season, whereas viral in peak during winter.

In tropical areas, rotavirus diarrhoea occur throughout the year increasing in frequency during the drier, cool months whereas bacterial is in peak during the warmer, rainy seasons.

Mode of transmission-

Through the faeco-oral route.

Faeco-oral transmission may be water-borne ,food-borne or via fingers,fomites and dust if ingested.

Diarrhoeal disease is the 2nd leading cause of death in children under 5 yrs of age.

Globally, there are about 2 Bn cases of diarrhoeal disease every yr.

Diarrhoeal disease kills 1.5 Mn children every yr.

African and South-East Asian regions together account for nearly 78% of them.

India alone contributes about 20% of all global under-5yrs diarrhoeal deaths.

It is both preventable and treatable.

MAGNITUDE OF THE PROBLEM: WORLD

COMPONENT OF A DIARRHOEAL DISEASES CONTROL PROGRAMME

• Short Term • Appropriate clinical management• Long Term . Better MCH care practices .preventive strategies .preventing diarrhoeal epidemics

A.Appropriate clinical management1. ORAL REHYDRATION THERAPY • The main aim of oral fluid therapy is to

prevent dehydration and reduce mortality.

• 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.

• At 1st the composition of ORS ( oral rehydration salt ) recommended by WHO was sodium bicarbonate based

INCLUSION OF TRISODIUM

CITRATE IN PLACE OF SODIUM BICARBONATE

• made product more stable • reduces stool output • increase intestinal absorption of

sodium & water .

This ORS formulation focuses on reducing osmolarity of ORS solution;

To avoid adverse effects of hypertonicity on net fluid absorption by reducing concentration of glucose and sodium chloride in solution.

INDIA was 1st country in world to launch ORS formulation since JUNE 2004

REDUCED OSMOLALITY ORS

GRAM/ LITRE

SOD.CHLORIDE 2.6 GLUCOSE, ANHYDROUS

13.5

POTASSIUM CHLORIDE

1.5

TRISODIUM CITRATE , DIHYDRATE

2.9

TOTAL WEIGHT 20.5

REDUCED OSMOLARITY ORS

Mmol/L

SODIUM 75CHLORIDE 65GLUCOSE , ANHYDROUS

75

POTASSIUM 20CITRATE 10TOTAL OSMOLARITY

245

Composition of reduced osmolarity

ORS

MILD SEVERE PATIENT APPEARANCE THIRSTY, ALERT ,

RESTLESSDROWSY, LIMP, COLD ,SWEATY, MAY BE COMATOSE .

RADIAL PULSE NORMAL RATE & VOLUME

RAPID , FEEBLE ,SOMETIMES IMPALPABLE

BLOOD PRESSURE NORMAL <80mm Hg SKIN ELASTICITY PINCH RETRACTS

IMMEDIATELY PINCH RETRACTS VERY SLOWLY

TONGUE MOIST VERY DRY URINE FLOW NORMAL LITTLE/ NONE ANTERIOR FONTANELLE

NORMAL VERY SHRUKEN

% BODY WEIGHT LOSS 4-5% 10% Or MORE

• How to access the dehydration

Look at Eyes for Dehydration

Shrunken Eyes

• Normal eyes

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

Cases with No Signs of Dehydration Plan A In early stages, when fluid loss is <5% of the

body weight, children may not show any clinical signs of dehydration

Plan A involves counselling the child's mother about the 3 Rules of Home treatment.

GIVE EXTRA FLUID (as much as the child will take)

CONTINUE FEEDING

WHEN TO RETURN TO DOCTER

GUIDELINES FOR ORAL REHYDRATION THERAPY (FOR ALL AGES /DURING FIRST FOUR HOURS )

AGE Under 4 months

4-11 months

1-2 yrs.

2-4 yrs. 5-14 yrs. 15 yrs. or over

WEIGHT (KG)

UNDER 5

5-7.9 2-10.9 11-15.9 16-29.9 30 OR OVER

ORS SOLUTION ( IN ml)

200-400

400-600

600-800

800-1200

1200-2200

2200- 4000

Amt. of ORS sol.= wt. of child X 75 ml / kg

Plan-B

After 4 hours Reassess and classify the child for dehydration

Select the appropriate plan to continue treatment

Begin feeding

Plan-C 1% diarrhoea may develop severe

dehydration. Children with severe dehydration

must be admitted. Child is rehydrated quickly by using

I/V infusion.

I/V infusions recommended : R/L solution N/S when R/L is not available 1/2 N/S with 5% dextrose is

acceptable

Plain glucose is unsuitable solution

Cases with signs of severe dehydration

Rate & Quantities of I/V infusion for severe

dehydrationAge First give 30ml/kg

Then give 70ml/kg

InfantUnder(12month)

1 hour 5 hours

Older 30 minutes 2.5hours

Reassess the infant every 1-2 hrs. until a strong radial pulse is present.If hydration status is not improving,givethe IV drip more rapidly.

Also give ORS (about 5 ml/kg/hour) as soon as the infant can drink: usually after 3-4 hours

Reassess the infant after 6 hours & classify dehydration then choose the appropriate plan (A,B, or C) to continue treatment

2. INTRAVENOUS REHYDRATION Intravenous infusion is usually required only for initial rehydration of severely dehydration pt. who is in shock or unable to drink . Such patients are best transferred to nearest hospital or treatment Centre . Solution recommended by WHO for intravenous infusion are……. 1.RINGER LACTATION SOLUTION Its also known as Hartmamm’s solution for injection. It is the best commercially available solution . It supplies adequate concentration of sodium and potassium and the lactate yields bicarbonate for correction of the acidosis.

2.DIARRHOEAL TREATMENT SOLUTION ( DTS )

Recommended by WHO as ideal polyelectrolyte solution for intravenous infusion . It contains in one litre Sodium Acetate- 6.5g, Sodium Chloride- 4g,Potassium Chloride- 1g Glucose- 10g.

Normal saline can also be given but its poorest fluid because it will not correct the acidosis and will not replace the potassium losses..

3.MAINTENANCE THERAPY • After the sign of dehydration

has been corrected, Oral fluid should be used for maintenance therapy .

AMOUNT OF DIARRHOEA

AMOUNT OF ORAL FLUID

Mild diarrhoea (not more than one stool every 2hrs or longer, or less than 5ml stool per kg)

100 ml /kg body weight per day until diarrhoea stops

Severe diarrhoea (more than one stool every 2 hours, or more than 5 ml of stool per kg per hour)

Replace stool losses volume for volume , if not measurable give 10-15 ml/kg body weight per hour

4 . APPROPRIATE FEEDING

• Especially relevant for the exclusively breast-fed infants.

• Rice water ,unsalted soup ,yoghurt drinks , green coconut water should be given.

• Drug of choice for diarrhoea due to cholera

DOXICYCLINE TETRACYCLINE, TMP-SMX ERYTHROMYCIN Drug of choice For diarrhoea due to shigella CIPROFLOXACIN

As shigella resistant to ampicillin & TMP-SMX.

5 . Chemotherapy

Symtoms Cholera Shigella

Diarrhoea Acute watery diarrhoea

Acute bloody diarrhoea

Fever No Yes

Abdominal pain Yes Yes

Vomiting Yes No

Rectal pain No Yes

Stool >3 loose stoolper day,watery like rice

water

>3 loose stoolper day,with blood or

pus

Symptomatic differential diagnosis of shigella and

cholera

6 . ZINC SUPPLEMENT

B. BETTER MCH CARE PRACTICES .

A . Maternal Nutrition B. Child nutrition . Promotion of Breast feeding . Appropriate weaning practices .Supplementary Feeding .vitamin A supplementation

C. PREVENTIVE STRATEGIES

1 . SANITATION 2 .HEALTH EDUCATION 3 . IMMUNISATION

• It emphasis on personal & domestics hygiene like hand washing with soap before preparing food

• before eating ,• before feeding a child, • after defecation ,• after cleaning a child who has

defecated and • after disposing off a child’s stool .

Sanitation

Health Education • An important job of health

worker is to prevent diarrhoea by convincing and helping community members to adopt and maintain preventive measures like breast feeding,

• improved weaning ,• clean drinking, • Use of plenty of water for

hygiene,• use of latrine,• proper disposal of stools of

young children etc.

• Immunization against measles is a potential intervention for diarrhoea control.

• Measles vaccine can prevent 25% of diarrhoeal deaths in children under 5 yrs. of age

IMMUNISATION

There are two vaccines ROTARIX –TM ( monovalent human rotavirus vaccine)ROTA Teq-TM ( pentavelent bovine-human vaccine) Rotarix-TM …… 2 -dose schedule to 2 -4 months aged child 1 . DOSE – upto 6 weeks & no later than 12 weeks 2 . DOSE - upto 16 weeks & no later than 24 weeks. Rota Teq-TM……3 oral dose at ages 2,4,6 months.

ROTAVIRUS VACCINE

NATIONAL DIARRHOEAL DISEASE CONTROL PROGRAMME

Goals were: Reduce diarrhoeal associated mortality in

children <5 years by 30% by 1995 and by 70% by 2000 A.D.

Improvement in water and sanitation facilities was the long term goal of NDDCP

National ORT Programme was incepted in 1980

From 1992-93 the programme has become a part of CSSM Programme.

CSSM programme become a part of RCH programme in 1997

In RCH Programme, policy of IMCI was adopted

Strategy of IMCI was to address all children and not only sick children

IMCI focused on life threatening illnesses-diarrhoea, Pneumonia, Measles, Malaria etc.

Indian version of IMCI guidelines renamed as IMNCI.

Since 2003 - DDCP included in IMNCI which includes

- Neonates of 0-7 days - Incorporating national guidelines on diarrhoea, ARI ,Malaria, Anaemia, Vit. A supplementation & Immunizations.

Contd.

THE INTEGRATED GLOBAL ACTION PLAN FOR

THE PREVENTION AND CONTROL OF

PNEUMONIA AND DIARRHOEA Reduce mortality from diarrhoea in children less than 5 years of age to fewer Than 1 per 1000live birthsReduce the incidence of severe diarrhoea by 75% in children less than 5 years of age compared to 2010 levelReduce by 40% the global number of children less than 5 years of age

GOAL- UPTO 2025

Thus in this seminar we have learnt how to investigate an epidemic and have then learnt about diarrhoeal diseases which is a very common .

So by applying knowledge of these both topics we will be able to study an epidemic and reduce its severity and also to prevent any further diarrhoeal epidemic.

CONCLUSION

MODULES of IMNCI 2003 K.PARK , TEXTBOOK OF COMMUNITY MEDICINE SUNDER LAL, TEXTBOOK OF COMMUNITY

MEDICINE. HARRISONS PRINCIPLES OF INTERNAL MEDICINE

17th edition IAP GUIDELINES FOR MANAGEMENT OF DIARRHEA WORLD HEALTH ORGANIZATION (WHO) GUIDELINES

ON TREATMENT OF DIARRHEA (2005) IDSP PNEMONIA AND DIARRHOEA (UNICEF)

REFERENCES

THANKYOU