Diarrhoeal control programme

1. Diarrheal control programme and ort Purnima chaudhary Roll no.-77 MBBS 2011

2. INTRODUCTION Its now obvious that some known and unknown organism probably causes diarrhoea . Regardless of the causative agents or age of patient; the sheet anchor of treatment is oral rehydration therapy such as the one advocated by WHO/ UNICEF.

3. DIARRHOEAL DISEASE CONTROL PROGRAMME The diarrhoel disease control programme was started in 1978 with the objective of reducing the mortality & morbidity due to diarrohoeal diseases. from 1992-1993 , the programme has become a part of child survival & safe motherhood programme. At present, it is a part of NRHM

4. COMPONENT OF A DIARRHOEAL DISEASES CONTROL PROGRAMME Short Term Appropriate clinical management Long Term . Better MCH care practices .preventive strategies .preventing diarrhoeal epidemics

5. Appropriate clinical management 1. 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 .

6. At 1 st 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 .

7. 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.

8. Reduce the sodium concentration of ORS solution to 75 mOsmol/ L ,improved the efficacy of ORS regimen for children with acute non-cholera diarhoea. Since January 2004 new ORS formulation is the only 1 procured by UNICEF . INDIA was 1 st country in world to launch ORS formulation since JUNE 2004

9. Composition of reduced osmolarity ORS 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 75 CHLORIDE 65 GLUCOSE , ANHYDROUS 75 POTASSIUM 20 CITRATE 10 TOTAL OSMOLARITY 245

10. How to access the dehydration MILD SEVERE PATIENT APPEARANCE THIRSTY, ALERT , RESTLESS DROWSY, 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

11. 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

12. 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 arid the lactate yields bicarbonate for correction of the acidosis.

13. 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. .

14. Plain glucose and dextrose solution should not be used as they provide only water & glucose. The initial rehydration should be fast until an easily palpable pulse is present . Reasses the patient every 1-2 hours. After infusing 1-2 litres of fluid , rehydration should be carried out at a somewhat slower rate until pulse and blood pressure return to normal. It is most helpful to examine skin elasticity and pulse strength ,both of which should be normal.

15. 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 2 hrs or longer, or less than 5 ml 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

16. 4 . APPROPRIATE FEEDING Especially relevant for the exclusively breast-fed infants. If the child is breast-fed , nursing should be pursued during treatment with ORS solution. Non-breast-fed infants under age 6 months should be given an additional 100-200 ml of clean water during the first four hour ,when old ORS containing 90 mmol/L is given. But additional water is not given along with 75 mmol/L.

17. Commercially carbonated beverages , commercial fruits & sweetened tea should not be given as it causes osmotic diarrhoea and hypernatraemia . Rice water ,unsalted soup ,yoghurt drinks , green coconut water should be given.

18. 5 . Chemotherapy D rug of choice for cholera DOXICYCLINE TETRACYCLINE, TMP-SMX Drug of choice For diarrhoea due to shigella ciprofloxacin . As shigella resistant to ampicillin & TMP-SMX .

19. 6 . ZINC SUPPLEMENT It reduces episodes duration and severity so recommended by WHO & UNICEF 10 mg of Zn for infants under 6 months of age 20 mg for children older than 6 months for 10-14 days

20. B. BETTER MCH CARE PRACTICES . a . Maturation nutrition Improving prenatal nutrition will reduce the low birth weight problem Prenatal & postnatal nutrition will improve the quality of beast milk .

21. b. child nutrition . Promotion of Breast feeding . Appropriate weaning practices .Supplementary Feeding .vitamin A supplementation

22. C . PREVENTIVE STRATEGIES 1 . SANITATION 2 .HEALTH EDUCATION 3 . IMMUNISATION 4 . FLY CONTROL

23. Sanitation 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 .

24. 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 .

25. IMMUNISATION 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

26. ROTAVIRUS VACCINE 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 - 6 weeks - 12 weeks 2 . DOSE - upto 16 weeks & no later than 24 weeks. Rota Teq-TM…… 3 oral dose at ages 2,4,6 months.

27. FLY CONTROL Flies breeding in association with human or animal faeces should be controlled.

28. Control and prevention of diarrhoeal epidemics An intersectoral approach centered upon PHC involving activities in fields of water supply & excreta disposal ,communicable disease control, mother & child health , nutrition & health education is regarded as essential for ultimate for ultimate control of diarrhoeal diseases.

29. THANK U