Acute Diarrhea:2nd killer Disease In India

By 1 2 1 News Reporter

Chandigarh 12^th June:- Acute diarrhea is a great public health problem world over but more so in the underprivileged countries. 2-5 (3.2) episodes of diarrhea occur in children in tropical countries annually. This is leading cause of high morbidity and mortality globally responsible for 2 million deaths under 5 year of age. This is having the great impact to health cost of the families and health organizations. Over all diarrhea related deaths are 15% of 10.5 million deaths under 5 year in developing countries. In India it is 2nd killer disease responsible for 20% deaths where as deaths due to respiratory problem are 30%. In India one child dies per minute due to diarrhea. 70% deaths are due to dehydration and these deaths are preventable with timely administration of fluids.

Acute diarrhea is important water borne disease and the main causal factors are unsafe (contaminated) drinking water, bad sanitation and poor hygiene. The contamination of food, eating outside, fly menance,  water supply and unhygienic practices by food handlers are also very important determinants of acute diarrhea.  2.5 billion people lacks improved sanitation and 1.1 billion people have no access to safe drinking water and many have to drink contaminated water worldwide. 4 billion episodes of diarrhea are occurring annually over worldwide and 88% are attributable to unsafe drinking water and poor standards of sanitation and hygiene. Overall 94% are preventable out of 2 millions dying under five annually.

Acute diarrhea is caused by viruses, bacteria and protozoal infections. Rotavirus is important cause of watery diarrhea in children below 2 years of age. This is responsible for mild to severe disease and results in dehydration. Rotavirus is responsible for 20-60% of diarrheal episodes in our country. In 20% cases rotavirus is responsible for diarrhea as reported from our center. This is responsible for 40% hospital admissions due to diarrhea in India due to severe dehydration and prolonged diarrhea. Out of bacterial infections E.coli is responsible for watery diarrhea in 50% cases. Vibrio cholerae causes severe diarrhea resulting in severe dehydration and shock state with high mortality. Shigella is important cause of bloody diarrhea called dysentery. This is due to invasive nature involving colon. Irrational use of antibiotics result in antibiotic associated diarrhea. The protozoal infections include giardiasis and amebiasis. Watery diarrhea without complications does not require work up. Whereas stool culture should be done in case of bloody diarrhea, neonatal period, outbreak of diarrhea, individual coming from non endemic to endemic area, immune compromised and severely malnourished children. Stool toxin assay should be done to diagnose antibiotic associated diarrhea.

The treatment of acute diarrhea is aimed at 1) to prevent and treat dehydration with oral rehydration solution(ORS). 2) Zinc and 3) continuous calorie dense diet. According to WHO the dehydration can be classified as, no dehydration, some and severe dehydration.

No dehydration is the state when diarrhea starts at home and the child is not dehydrated. Aim is to prevent dehydration to occur. Step A treatment protocol is followed like recommended homemade fluids; the lemon water, rice water, lassi(butter water), dal water, kanji, coconut water, salt and sugar solution prepared by adding 2 finger pinch salt and 1 tea spoonful of sugar added to 200ml of water. To make 1 liter of solution add 3 finger pinch salt and hand scoopful of sugar (20g of sugar). It should not be saltier than taste of the tears. Give homemade fluids as in 1 year old 50-100ml of fluid, 1-2 year 100-200 ml and beyond 2 year 200ml after every stool. This will avoid the occurrence of dehydration.

The some dehydration is characterized by signs of dehydration like thirst, tachycardia, depressed anterior fontanel, shrunken eyes, loss of skin turgor, dry buccal mucosa and skin in maxillae. Plan B protocol is followed to give deficit fluids. The deficit fluids like low osmolality ORS is given to correct dehydration over 4 hours. The maintenance fluid and concomitant loses should be supplemented.

Severe dehydration (shock state, hypotension, and acidosis) plan C protocol with intravenous deficit fluids in form of ringer lactate/normal saline till child passes urine. Zinc is important and should be given in dose of  of 20mg/day above 6 month of age. Whereas 10mg/day under 6 month of age. This is helpful to control diarrhea and can prevent diarrhea occurrence. Calorie dense diet (khichri, rice and curd) is helpful for absorption of fluids and electrolyte and maintain health of the child.