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Transcript of preventive and social medicine presentation
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
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