'DIARRHOEA CLOCK'

• 2 million children die due to diarrhoea and related diseases every year .
• 80% of them in the first two years of their life;
• 38,000 a week,
• 5,400 a day,
• 225 every hour
• four every minute,
• One every sixteen seconds.

What is Diarrhoea?

Diarrhoea is a common disease affecting the people of all age group, especially young children. Though this disease can be easily prevented, people suffer from the same because of their unawareness of its prevention and control.

Diarrhoea is not itself a disease, but can be a symptom of several diseases. Diarrhoea means there are frequent, loose or liquid stools. There may abdominal pain, which may reduce after a stool is passed. Acute diarrhoea may come on suddenly for a short time. Chronic diarrhoea may affect someone for a long period of time. In Diarrhoea, patient looses water and salt from the body. If this continues, patient suffers from serious shortage of salt and especially water in the body leading to what is known as dehydration. This is a serious condition and if not corrected early, it can lead to death of the patient.

Impact of Diarrhoea on Infants & Young Children:

Nearly 10 million children under five die every year globally. Among them 20% children die due to diarrhea infections. Children are more vulnerable to diarrhoea in early childhood. A child suffers, on an average, 10 to 15 episodes of diarrhoea in the first five years of life. Of these, three to five occur in the first year of life. A child may lose almost as much water and electrolytes from the body during an episode of diarrhoea as an adult. Loss of one liter of fluid from the body of a child weighing 5 Kg is much more hazardous compared with a similar depletion from an adult of 60 Kg weight. Some of these cases may prove fatal, if fluids and electrolytes are not replaced to restore normal circulation and body functions which are impaired in the dehydrated state.

Symptoms of Diarrhoea

The common symptom of diarrhoea includes:

• Frequent, loose, watery stools.
• Loss of appetite.
• Nausea
• Vomiting.
• Stomach pains.
• Abdominal pain &  cramps
• Dehydration.
• Fever
• Pricking sensation.
• Sometimes bacterial or parasitic infections sometimes cause bloody stools.

Causes of Diarrhoea

There are many causes of diarrhoea, including food poisoning, infection, malnutrition. Diarrhoea may also be caused due to a chronic problem like viral stomach flu. Diarrhoea occurs when the lining of the small or large intestine is irritated. It leads to increased water being passed in the stools.

The causes of diarrhoea are many. Out of which the main causes are listed below:

Bacterial Infections: Several types of bacteria which get into our body through contaminated food or water are the main causes of diarrhea.

Viral infections: Many viruses are also responsible for the cause diarrhea, including rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, and viral hepatitis.

Parasitic infections are also a cause for diarrhoea.

Other Causes includes food intolerance, reactions of some medicine, intestinal diseases, inflammatory bowel disorder.

Clinical Types of Diarrhoea

Acute Watery Diarrhoea

This term refers to diarrhoea that begins acutely, lasts less than 14 days (most episodes last less than seven days), and involves the passage of frequent loose or watery stools without visible blood. Vomiting may occur and fever may be present. Acute watery diarrhoea causes dehydration; when food intake is reduced, it also contributes to under nutrition. When death occurs, it is usually by acute dehydration. Example Rotavirus Diarrhoea.

The term dysentery refers to diarrhoea with visible blood in the faeces. Important effects of dysentery include anorexia, rapid weight loss, and damage to the intestinal mucosa by the invasive bacteria. A number of other complications may also occur.

Persistent Diarrhoea

This term refers to diarrhoea that begins acutely but is of unusually long duration (at least 14 days). The episode may begin either as watery diarrhoea or as dysentery. Marked weight loss is frequent. Diarrhoeal stool volume may also be great, with a risk of dehydration. Persistent diarrhoea should not be confused with chronic diarrhoea, which refers to recurrent or long-lasting diarrhoea due to non-infectious causes.

Status of Diarrhoea Management in Madhya Pradesh

Diarrehoea is one of the single most common causes of death among children under age five worldwide, following acute respiratory infection. According to World Health Organization (WHO) nearly two million children die from diarrhoea every year, mostly in developing countries. If childhood diarrhoea is not addressed urgently, the countries will fail to achieve the fourth Millennium Development Goal (MDG4) target of reducing child deaths by two-thirds by 2015.

If we look at the status of child health with regard to the diarrhoea in India, focusing especially on state of Madhya Pradesh, the scenario seems to be divesting the risk associated with life of young children. According to NFHS-3 report, overall 9 percent of all children under five had diarrehoea, with 1 percent having diarrehoea with blood. As per the population census 2001, the child population under 5 years of age in Madhya Pradesh constitutes 17.59 % of total population numbering 1, 06, 18,232.

This means nearly 10 lakhs children in Madhya Pradesh suffers from diarrhoea & out of them around one lakh (106182.30) children reached to stage of acute diarrhoea. If treatment is not given in time, this one percent children suffering from sever diarrhoea may turn dead. The state government on the other hand trying to hide the truth behind the diarrhoea cases in Madhya Pradesh by illustrating the death of only  855 person including adult population in a time span of three & half years from Jan’2004 to Aug’2008.

If the data of Department of Public Health & Family Welfare assumed to be true, that means almost 100% children suffering from Diarrhoea are covered under the Oral Rehydration Therapy & also getting treatment in time. But unfortunately, NFHS-3 again reveals that under the diarrhoea treatment & management practices around 26 percent of children who suffered from diarrhea did not receive any treatment at all in the first two weeks preceding the survey. Advice or treatment was sought from a health provider for 6 in 10 children who had diarrehoea.

In Madhya Pradesh merely 58.1% children with diarrhoea were taken to health providers against the national average of 59.8% children. Again under the oral rehydration therapy less than thirty percent (29.8%) children with diarrhoea received ORS packets & merely 25.0% received gruel in two weeks preceding diarrhoea.44.2 percent received either ORS or gruel. Treatment of acute diarrhoea is a must to prevent child mortality due to diarrhoeal diseases but overlooking it about 22.7% children with diarrhoea is such that do not receives any treatment.

Among children 0-59 months, children 6-11 months are most susceptible to diarrehoea. 26.6% children under the age of 6-11 months in Madhya Pradesh suffer from diarrhea against the national average of 18.1%.  But diarrhoea cases are often ignored during this period of life span in India saying that  loose motion are occurring due to growth of  infant tooth enamel often known as teething diarrhoea. 33.3 percent of children in this age do not receive any treatment at all, which is fatal to the life of infants. Studies have shown no strong relationship between teething and diarrhoea and the children suffering from diarrhoea in this age group should be given immediate medical care.

Use of ORS to treat diarrhea has not increased in urban & rural areas in seven years between NFHS-3 & NFHS-3, which further indicates on the lack of awareness among masses on diarrhoea management.

Prevention is always better than cure. But it seems that lesser attention is paid in the state on preventive measures to prevent the occurrence of diarrhoeal diseases. Hygiene maintenance can prevent diarrhoea to a great extent. Also diarrhoea can be checked from becoming fatal through the increased use of ORS, increased fluid intake, continuing breastfeeding during diarrhoea. Due to lack of appropriate BCC (Behavioral Change Communication) program, still only 8.4 percentage children under five years given increased fluid. More than half (52.2%) of children received neither oral rehydration therapy nor increased fluids when sick with diarrhea.

The knowledge & skills of community health worker & mothers regarding home remedies including the sugar salt solution can be very helpful in treating diarrhoeal dehydration at the initial stage. But in Madhya Pradesh 26% children were given liquids less than usual intake.

Use of other unknown drugs is particularly common in Madhya Pradesh, where 4 in 10 children with diarrhea were given drugs of an unknown type. These figures indicate poor knowledge not only among mothers but also among health providers.

DLHS-3 report shows that a health indicator has not improved to a great extent even now. The indicators of Diarrhoea  in DLHS-3 report of 2007-08 are more or less equivalent to NFHS-3 survey in 2005-06.As per DLHS-3 also only 29.9 percent children with diarrhoea received ORS &  63.9% children were given treatment. In rural areas of the state ORS reached to only 25.8% children with diarrhoea.

Relationship between Diarrhoea & Malnutrition

Malnourishment diminishes resistance to infections leading to further spread of infections among young children which decreases the food absorption capacity & adds further recurrence to diarrhoea and ultimately further enhance the cases of malnutrition deaths. And a vicious cycle of diarrhoea-malnutrition-diarrhoea sets in.

- Seema Jain

¹World Health Organization/March 2009/Childhood Diarrhoea