CDDOnlineChapter_2011

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Diarrheal Disease

Edited by Dalit Gulak and Meg Meyer

2011Vignette

Basma is a 19-year-old woman living in Sulaimaniyah, a small rural village in Northern Iraq.She has a three-month old son named Ahmed. Basma breastfeeds Ahmed but also gives himwater from the well like all the other village women do. They think babies get thirsty if they onlyhave breast milk. Ahmed has recently developed a bad case of diarrhea, but Basma does notworry and thinks that it is something that all babies get. The nearest health clinic is about twohours walk away on a dangerous road. Basma does not go there because she does not perceivediarrhea as dangerous. Also, she has too much work and not enough time to visit the clinic.Although Basma has sugar and salt at home that she uses for cooking, no one has ever taught herto make oral rehydration salts (ORS) with it. Eventually the diarrhea stops, and Basma is happy,not realizing it is because Ahmed is severely dehydrated. She does notice that every time shebreastfeeds Ahmed or gives him water, the diarrhea seems to start again, so she thinks it is best

not to give him too much liquid. Within two weeks Ahmeds health deteriorates losing more than10 percent of his body weight. Ahmed suffers from severe dehydration and eventually dies.Basma is confused and hopeless as this is her second child to die under these circumstances.

Introduction

Diarrheal disease is a major cause of morbidity and mortality worldwide. Each year, 2.2 millionpeople die from diarrhea; most are children in developing countries (Boschi-Pinto, 2008). It isthe second leading cause of death in children under 5 years, accounting for approximately 15%(~1.36 million) of the 8.7 million deaths worldwide (Lancet, 2010). In developing countries,children average three rounds of diarrhea a year (Boschi-Pinto, 2009). There are several factorsthat contribute to high mortality and morbidity from childhood diarrhea including poverty,socioeconomic status, maternal education, overcrowding, and access to clean water andsanitation (Boschi-Pinto, 2009). Shown in the graph below, interventions in the area of water,sanitation and hygiene can reduce diarrhea by up to 39% (Lancet, 2005).

Percent reduction of diarrhea through water, sanitation, and hygiene interventions

* WASH = Water and Sanitation, Hygiene


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In order to achieve the millennium development goal (MDG) of, reducing childhood deaths bytwo-thirds combating diarrhea in developing countries is critical because diarrheadisproportionately affects children (UNICEF/WHO, 2008). Children are more susceptible todehydration from diarrhea, as water constitutes a larger proportion of childrens body weight

then adults. Their kidneys are also unable to conserve as much water (UNICEF/WHO, 2009).Young children are especially vulnerable during the weaning phase, since they no longer receivepassive immunity from their mothers. Children at this age are also at risk of being introduced tofoods that may be contaminated with pathogens.

Global Distribution of Deaths Due to Diarrheal Disease Among Children Under 5

Fig. 1: Deaths in the year 2004. Each dot represents 1,000 deaths (Boschi-Pinto, 2008).

What is Diarrhea?According to the United Nations Children Fund (UNICEF) and the World Health Organization(WHO), diarrhea is defined as having loose or watery stools at least three times per day, ormore frequently than normal for an individual (UNICEF/WHO, 2009). Diarrhea is caused bypathogens that include bacteria, protozoa, and viruses. It kills by rapidly draining water andelectrolytes out of the body.

There are three main types of acute diarrhea that can easily turn life-threatening acute waterydiarrhea, bloody diarrhea, and persistent diarrhea (UNICEF/WHO, 2009). Morbidity andmortality increase when recurrent diarrhea is coupled with immune compromising conditionssuch as inadequate feeding, weaning, recent/current measles, malaria, and AIDS

(UNICEF/WHO, 2004). Children with frequent bouts of diarrhea enter into a cycle ofmalnutrition, anemia and decreased immune function. This results in severe loss of energy andprotein and ultimately leads to death (UNICEF/WHO, 2004).

Epidemiology

The majority of the time, diarrheal disease is seen only as a short-term illness. This is becauseearly warning signs of dehydration are difficult to identify and often present little to no signs orsymptoms (Boschi-Pinto, 2009). In 2004, there were 5000 child deaths per day from diarrhea


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(WHO, 2005). The incidence of diarrheal disease is two to three times higher in developingcountries (WHO, 2005). While the mortality rate from diarrhea has decreased slightly in recentyears, the incidence has remained relatively stable (Boschi-Pinto, 2009). This implies that whiletreatment interventions such as oral rehydration salts (ORS) and other therapies have beensuccessful, preventative health interventions are not being implemented with the same degree of

success.

Diarrhea is especially a challenge in low-income countries that are overcrowded and lack accessto safe drinking water (WHO, 2005). In 2004, about 21 percent of children in developingcountries did not have access to safe drinking water. Currently, 88 percent of diarrheal deathsworldwide can be attributed to unsafe water and inadequate hygiene and sanitation practices(UNICEF/WHO, 2009). Unlike other endemic diseases, diarrhea can be prevented and treatedby simple behavioral and sanitary practices, as well as water treatment interventions. Thisrequires strong leadership, effective public health interventions, and program management.

When researchers look at diarrhea from the perspective of morbidity, they find long-term effects

that contribute not only to the impaired growth of a child with early diarrhea in the first twoyears, but also impaired fitness, cognitive function, and school performance between 6-12 yearsof age (Guerrant, 1999). Not all of these cases reach an end point of mortality. Therefore, theexamination of non-fatal cases is essential to assess the true burden of illness in children withdiarrheal disease.

EtiologyInfectious agents linked with diarrhea include bacterial, viral, and parasitic organisms.Cryptosporidia, rotavirus, and cholera are the pathogens primarily associated with acute waterydiarrhea (Naficy, 2000). Pathogens that cause dysentery or bloody diarrhea include astrovirus,enterotoxigenic escherichia coli (ETEC), shigella and salmonella. Though persistent diarrheadoes not have a single microbial cause, E. coli and cryptosporidia are often implicated (WHO/UNICEF, 2008).

Rotavirus is the most common cause of life-threatening diarrhea in children under 5 worldwide.The World Health Organization estimated that in 2004, rotavirus was responsible for 527,000children deaths (Ahmed, 2009). In that same year, six countries were responsible for more thanhalf of the rotavirus deaths: India, Nigeria, the Democratic Republic of the Congo, Ethiopia,China, and Pakistan (Ahmed, 2009). The UNICEF/WHO report on diarrhea found that of allhospital admissions caused by diarrhea, rotavirus was responsible for 40 percent of them(UNICEF/WHO, 2009).

TransmissionThe primary routes of transmission for diarrheal diseases are fecal-oral, person-to-person anddirect contact with pathogen-infected feces. Fecal-oral transmission is the ingestion of water orfood contaminated with infected feces. Person-to-person transmission may occur when oneprepares food or handles children with unclean hands. Direct contact with infected feces usuallyoccurs when children play in an area that is contaminated with feces (WHO, 2005).


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Case Management

Integrated Management of Childhood Illness (IMCI)

WHO defines IMCI is an integrated approach to child health that focuses on the well-being of

the whole child. IMCI aims to reduce death, illness and disability, and to promote improvedgrowth and development among children under five years of age (WHO, 2010). IMCIimplementation includes an 11-day training for health professionals and managers. IMCI hascurrently been introduced in over 75 countries worldwide.

IMCIs strategy is divided into three main components:

1) Improving case management skills of health-care staff2) Improving overall health systems3) Improving family and community health practices.

One of the main tools of IMCI that is used in the management of diarrhea in children is thealgorithm shown below. This algorithm is given to health care providers at all levels in thedelivery system, including Community Health Workers.


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Treatment of Acute Watery DiarrheaAcute watery diarrhea is often associated with rapid fluid loss and dehydration (UNICEF/WHO,2009). The pathogens causing this type of diarrhea may include cholera, rotavirus, and E. coli(UNICEF/WHO, 2009). Evidence-based guidelines for the treatment of diarrhea were updatedin 2005, to reflect recent advances in care. Most cases of acute onset, non-dysentery diarrhea are

self-limited and resolve without the use of antimicrobials. Diarrheal treatment guidelines havefour supportive focuses: 1) prevent dehydration if it is not yet present 2) treat dehydration if it ispresent 3) prevent malnutrition through continued feeding during and after a diarrheal episode 4)reduce the severity of the episode as well as prevent future episodes using zinc supplementation(WHO, 2005).

Antimicrobials are not routinely indicated in the treatment of acute, non-dysentery diarrhea.Unnecessary antibiotic therapy upsets the normal bacterial balance of the gut, promotesantibiotic resistance, and when used inappropriately, can lead to adverse outcomes (WHO,2005).

Preventing and Treating DehydrationDiarrheal stool contains large quantities of water and electrolytes such as sodium, potassium,chloride, and bicarbonate. An individual may be at risk of dehydration and metabolic imbalanceafter large losses and may even suffer from hypoglycemic shock, cardiovascular collapse, orcardiac arrest (Rehydration Project (a), 2009). An integral aspect of managing diarrheal illness isreplacing rehydration in order to replace water and electrolyte losses.

Oral Rehydration TherapyOral Rehydration Therapy (ORT) using oral rehydration salts (ORS) is an effective method forpreventing dehydration and treating mild to moderate dehydration in children and adults withdiarrhea (WHO, 2005). ORT is non-invasive and may be used at home to prevent dehydration orin a hospital setting to treat individuals with signs of dehydration. Oral rehydration therapyrelies on the following physiological principle: the absorption of salt through the intestinal liningis enhanced in the presence of glucose. Therefore, when one drinks an appropriatelyconcentrated solution of salt and glucose, absorption of salt through the intestinal wall occurs.Water and other essential electrolytes then move through the intestinal lining in response to themovement of sodium, as water "follows" salt into the body (Goodall, 2009).

The use of ORT was pioneered by WHO and UNICEF in the 1970s. Since then, there have beennew and improved oral rehydration solutions. In 2005, WHO and UNICEF endorsed the"Reduced Osmolarity ORS". This new formula has a lower concentration of glucose and sodiumand has been shown to more effectively and immediately reduce the severity of vomiting anddiarrhea (UNICEF, 2004). In addition to standard glucose-based ORS, rice-based formulationsare now available commercially, and can be found in health centers and pharmacies. Rice-basedORS is preferred for the treatment of diarrhea that is caused by cholera (WHO/UNICEF, 2002).


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Fig. 2: Examples of ORS packets (Rehydration Project (a), 2009; Naveh Pharma, 2010).

In settings where ORS is not available commercially a simple Sugar-Salt Solution (SSS) may beprepared using specified amounts of sugar, salt, and clean water (Rehydration Project (d), 2009).

The amount of ORS a sick individual requires for rehydration is dependent on a person's age,weight, stage of dehydration, and whether they continue to pass watery stool throughout therehydration treatment(WHO, 2005). Those with signs of dehydration will generally require ~75milliliters of ORS per kilogram of body weight to rehydrate sufficiently(Rehydration Project (d),2009). ORS is given in small sips every one to two minutes, spooned to infants or given from acup to children and adults. It should be given slowly and continued even if vomiting occurs(Rehydration Project (d), 2009).

Fig. 3: Directions for a homemade ORS mixture (Rehydration Project (d), 2009).

Intravenous Fluid ResuscitationIntravenous fluid resuscitation is required in cases of severe dehydration when a child is too sickto drink ORS (WHO, 2005). A trained medical professional should administer IV fluids toprevent progression to hypoglycemic shock or unconsciousness. Once severe dehydration hasbeen adequately corrected by IV fluid resuscitation, ORT should commence and continue untildiarrhea stops (WHO, 2005).


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Preventing Malnutrition

The pattern of repeated diarrheal illness in children is often described as a cycle that isperpetuated by malnutrition. Malnutrition makes children more vulnerable to diarrheal illnessand is an underlying cause of death in up to 61 percent of childhood diarrheal deaths (Fischer

Walker, Black, 2007). Maintaining a steady diet of nutritional, staple foods is thereforeextremely important in decreasing the global burden of childhood diarrhea. Micronutrientdeficiencies contribute to childhood illnesses by impairing the immune system's ability to wardoff and fight infection(Fischer Walker, Black, 2007).

Preventing Malnutrition During Diarrhea

Continued feeding throughout diarrheal illness speeds recovery, improves intestinal function, andallows for continued growth and weight gain in children. Acute diarrhea can often lead tomalnutrition if proper feeding practices are not maintained or increased during an illness episode(WHO, 2005). Recurring diarrheal disease can cause chronic malnutrition, leading to stunted

growth, wasting, and increased susceptibility to future diarrheal infection(WHO, 2005).Promoting the intake of appropriate, nutritious food throughout diarrheal episodes is therefore animportant aspect of treatment.

If possible, calories may be added to a child's meal by adding one to two teaspoons of vegetableor red palm oil (WHO, 2005; Rehydration Project (e), 2009). Foods high in simple sugars, salt,and fat should be avoided as these may exacerbate diarrhea and dehydration. These includecommercially prepared soups, soft drinks, and fruit juices. Children should receive an additionalmeal each day for two weeks following recovery from any diarrheal illness(WHO, 2005).Additionally, vitamin A supplementation may also be applied in instances of severe diarrheawith suspected vitamin A deficiency or other signs of malnutrition (PATH, 2009). Vitamin A,along with zinc, and folate supplementation, are recommended in specific global regions toenhance children's overall immune function (Fischer Walker, Black, 2007).

Zinc SupplementationZinc is critical to growth and development, and specifically supports the functions of the immunesystem. Depleted levels of zinc are associated with increased rates of infectious disease,including diarrhea, and increased mortality rates from these diseases (UNCIEF/WHO, 2009).Therefore, treating diarrhea with zinc supplementation helps the child recover, specifically byaiding ORS uptake and decreasing misuse of antibiotics. Zinc supplementation during diarrhealillness decreases both the severity and duration of the illness episode.

Zinc supplementation substantially decreases the number of diarrheal episodes for two to threemonths following treatment. Research has shown that it is a highly effective intervention fordecreasing under-five mortality due to diarrheal disease (Gilroy, Kuszmerski & Winch, 2005).All children with diarrhea should receive 10-14 days of zinc supplementation starting at the onsetof illness (WHO, 2005).

BreastfeedingOne of the most effective means of protecting infants from diarrheal disease is through exclusive


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breastfeeding. Breast milk provides passive immunity through maternally acquired antibodiesand prevents the ingestion of contaminated foods or fluids during the infant's most vulnerablestage (Rehydration Project (b), 2009). Promotion of exclusive breastfeeding for the first 4-6months of life is often a pillar of program curriculums aimed at combating diarrheal morbidityand mortality(WHO, 2005; UNICEF/WHO, 2010).

Breastfed infants should continue to breastfeed without interruption during diarrheal illness(Rehydration Project (b), 2009). Children who continue to breastfeed throughout an illnessepisode experience a shorter duration of illness and lighter stool volume than those who are notbreastfed(Rehydration Project (b), 2009). Some infants may feed more than usual but this isnormal and should be encouraged(WHO, 2005). Older children receiving semi-solid or solidfoods should continue to receive their normal, staple diet during diarrheal illness. They shouldbe offered small, frequent meals (six per day). Recommended foods are those that are readilyavailable, culturally acceptable, have high energy content and provide essential micronutrients(WHO, 2005). Foods that have been well cooked and are mashed or ground are particularly easyto digest (WHO, 2005). Rice, potatoes, noodles, milk, homemade soups, banana, cooked

vegetables, and cereal grains with milk are examples of acceptable foods. Culturally acceptableeggs, meat, and fish dishes that contain ample energy are highly beneficial(WHO, 2005;Rehydration Project (e), 2009).

Treatment of Complex Diarrheas

The treatment of complex diarrheas require additional interventions and management than acuteonset or watery diarrhea require. Complex diarrheas include dysentery (acute bloody diarrhea),suspected cholera with severe dehydration, persistent diarrhea (>14 days), and diarrhea in a childwith signs of severe malnutrition (kwashiorkor or marasmus) (WHO, 2005). In these instanceschildren may require hospitalization, careful fluid management, antimicrobial drug therapy,laboratory assessments, specific nutritional management, and additional multivitamin/mineralsupplementation. For specific clinical treatment guidelines refer to the above IMCI algorithmand IMCI complete training manual.

Clinical practice algorithms, such as the one below, are intended to guide practitioners throughappropriate standardized treatment protocols. Community health workers, nurses, and physiciansworking outside the hospital setting should familiarize themselves with the appropriate treatmentof diarrheal illness based on the child's unique presentation. Most importantly, providers shouldfamiliarize themselves with those factors that warrant referral to a more skilled provider orequipped care setting.

Diarrhea Prevention

Prevention is the most effective means of combating deaths due to diarrheal disease. Themajority of global diarrheal cases can be prevented by improving access to clean water andimplementing simple sanitary/hygienic practices. An estimated 88 percent of diarrheal disease isrelated to poor water, sanitation, and hygiene (WHO, 2004). Other effective prevention methodsinclude the promotion of appropriate feeding practices, vitamin supplementation, and vaccinationagainst illnesses like rotavirus and measles.


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Clean Water and Sanitation

Two and one half billion people lack access to clean water and 38 percent of the globalpopulation lacks access to appropriate sanitation facilities. Worldwide, 8 percent of people useshared facilities, 12 percent use inadequate facilities, and 18 percent practice open defecation.

Those living in areas where inadequate facilities and open defecation are common are atparticular risk of contracting diarrheal disease through fecal contamination of water supplies orby direct contact with fecal matter. Refugees and displaced populations are also in danger ofcontracting diarrheal diseases due to unsafe water supplies.

Access to an improved water supply reduces diarrhea morbidity by up to 25 percent andimproved sanitation by up to 32 percent(WHO, 2004). Therefore, providing adequate suppliesof clean water and appropriate waste disposal technologies are vital components of programsaimed at improving general health, which in turn prevent child deaths due to diarrhea. Untilbroad coverage with clean, piped-in water can be achieved for those that do not yet have it,global health organizations are promoting the use of effective household water treatment and

safe storage(Clasen, 2009). Educating families about point-of-use water disinfection practicesas well as safe storage of water may represent the most realistic means for meeting theMillennium Development Goals related to water and protecting children from contaminatedwater sources(Clasen, 2009).

Proper Hygiene

Proper hygiene and sanitary practices, particularly hand washing, may reduce the risk fordiarrheal disease by as much as 47 percent (Curtis, Cairncross, 2003). The importance ofwashing hands with soap and water or ash and water after defecating, changing diapers, andbefore preparing food should be stressed in any program curriculum(Rehydration Project (c),2009). Water and food should be covered for storage, and families should avoid difficult toclean infant bottles and rely on spoon feeding instead(WHO, 2005; UNICEF/WHO, 2010).

Vaccination

Diarrhea prevention programming may include broadening immunization coverage for illnesseslike rotavirus and measles, both of which contribute significantly to diarrheal mortality(Valencia-Mendoza et al., 2008; WHO/UNICEF, 2006). With the recent rollout of safe,effective rotavirus vaccines, the WHO now recommends rotavirus vaccination be included in allnational immunization programs(GAVI, 2009). Vaccines for rotavirus have been developed byMerck, RotaTeq, Galaxo-Smith-Kline, and Rotarix, which are 98 percent effective in preventingsevere cases of rotavirus (Parashar, 2003). Full coverage with rotavirus vaccine would reducechild deaths from rotavirus by 85 percent of (Parashar, 2003).

Likewise, measles-associated diarrhea contributes significantly to global diarrheal morbidity andmortality(WHO/UNICEF, 2006). In fact, worldwide, diarrhea is one of the most commoncauses of death associated with measles (UNCIEF/WHO, 2009). Measles vaccination is highlyeffective and reduces the incidence and severity of diarrheal illness in children. The vaccinationshould continue to be promoted in all settings because of its success (WHO, 2009;WHO/UNICEF, 2006).


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EducationA rapid response to diarrheal disease is the key to recovery. Educating mothers, teachers,community health workers, and mass media about diarrhea identification and prompt,appropriate treatment is therefore vital. Those populations that are often most susceptible todiarrheal disease may be in hard to reach rural areas, or in areas with poor access to health care.

Education campaigns should include key messages for parents, such as the importance ofincreasing fluid intake during diarrheal illness, the importance of continued feeding throughoutand following illness, and when to see a healthcare provider.

In Bangladesh, a wide-scale and culturally sensitive campaign to educate women about the useof ORT is a well-known success story. Over a 10-year period more than 12 million motherswere taught how to prepare ORS solution at home. Upon follow up, ORS solution was used in60 percent of all diarrheal episodes and in 80 percent of acute watery diarrhea episodes, up froma baseline of 30 percent use (Chowdhury, A., et al., 1997).

Technical Issues and Access

Access to treatment and sustainable community management of care are two major barriers inreducing childhood mortality related to diarrhea. The Environmental Health Project (sponsoredby UNICEF and USAID) published a basic framework to direct access of care and sustainabilityprograms (EHP, 2004).

Fig. 4: Framework to direct access to care and sustainability (EHP, 2004).


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Access to ORS

ORS is an effective and inexpensive treatment for diarrhea, but it does not reach everyone whoneeds it. While some of the reasons behind this might be cultural and related to lack ofeducation, ORS also faces the same issues any drug faces that is trying to reach the remote and

rural populations of the world: distribution logistics. The logistics of transportation anddistribution to such areas can be very challenging, and supplies are therefore often inconsistentor non-existent. This highlights the importance of teaching people to prepare their own ORSfrom sugar and salt rather than letting them become dependent on ORS packets.

ORS faces yet another challenge. As has been discussed previously in this chapter, obtaining aclean and adequate supply of drinking water can be difficult in certain parts of the world. Notonly does this create a greater risk of contracting a diarrheal disease, but it also becomes aproblem when the standard treatment for diarrhea with ORS requires access to clean water.

Access to Zinc

In 2004, WHO and UNICEF added zinc supplementation to their recommendations for diarrheatreatment (WHO/UNICEF, 2004). However, six years after the WHO/UNICEFrecommendation, zinc is still not widely available(UNCIEF/WHO, 2009). There have beenmany challenges in trying to scale up the zinc regimen, including: difficulties importing a newproduct to countries, start-up funds, hesitation in acceptance, and delay in purchase because localorganizations are unclear on demand. Between increased zinc production locally and byUNICEF, and zinc education campaigns, the availability and acceptance of zinc as a treatmentfor diarrhea should improve.

Program Strategies

Due to the inadequate supply of both ORS and IV therapy, several proposed programs aimed atprevention of diarrhea have been directed towards mitigating known causes. Developing suchprograms requires detailed planning, as they need to be sustainable; ultimately, the goal of ORSprograms is to reduce childhood mortality related to diarrhea as well as dependence on donorsupport for treatments. All goals and objectives must be explicit, methods realistic, andindicators informative.

Several steps should be taken during the planning and managing process of a community-baseddiarrheal disease program. Organizations such as USAID promote strategies for control ofdiarrheal disease (CDD). The following is a description of program strategies for monitoring theimplementation and evaluating the success of intervention programs within the context ofhygiene (Curtis et. al., 2003).

Engage stakeholdersStakeholders are persons or organizations (within the specified community) who have aninvestment in what will be learned from the program and are affected by how the knowledgegained will be used and applied within the community. It is critical to understand and integratethe perspectives of the stakeholders into program design.


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Decide on a specific program objective(s)The objectives should be specific, measurable, agreed upon by all stakeholders, reasonable, andtime-framed (SMART). It is essential that the objective(s) mirror concerns voiced within thecommunity. For example, does the program aim to reduce mortality from diarrheal diseases orto decrease the number of children requiring IV treatment? Once clear objective(s) are decided

upon, resources can be evaluated and distributed in an efficient manner.

Designing the programThe program should be designed based on the stakeholders input and agreed-upon objectives.Other important factors to consider in designing a program include developing a targetededucational campaign, creating a case management system, addressing the issue of sustainability,and adapting the intervention as much as possible to local resources and cultural behaviors.

Design a methodology for program evaluationProgrammatic issues must be prioritized and evaluated according to priority level with respect toavailable time and resources. Some issues of particular concern in diarrheal disease programs

may be duration of illness, method of treatment (ORS versus IV fluids), and morbidity andmortality. Data collection involves time and resource costs and must be considered whendesigning the evaluation process.

Data collectionInformation collection should convey a well-rounded picture of the program and will alsopresent a credible image to the primary users of the community (Milstein & Wetterhall, 1999).Data collection is extremely important in the evaluation and improvement of a program. Evenwith resource constraints an effort should be made to collect a minimal amount of data at thestart of a new program to ensure that the objectives are being met.

Evaluate data and provide feedback to communityOnce data is collected, evaluate its efficacy and relevance to the primary objectives and makeprogrammatic changes accordingly. This data should then be widely disseminated throughoutthe community and accompanied with appropriate explanation so that the community membersunderstand the results. Furthermore, feedback from the community must be evaluated andincorporated into future program designs.

Monitoring and Evaluation (M&E)

The success of community-based diarrhea programs depends on several factors. Involvement inprogram development, especially by mothers, is crucial to program participation. Educationmessages must also be relevant and appropriate for the program setting. Families must be taughtattainable skills, provided with easily understandable knowledge and continuous motivation andsupport in order to achieve program success. Additionally, communities should receive supportfrom the existing health system. Accessible clinics, appropriate medical services, and educatedhealth care workers are all crucial factors to success (WHO, 2006; WHO/UNICEF, 2004).

Examples of indicators often used in the monitoring and evaluation of community-baseddiarrheal disease programs include (WHO, 1999):


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Duration of illness Treatment method (ORS versus IV therapy) Morbidity and mortality ratesTraining coverage rates (e.g., delivery of care, education methods in breastfeeding and hygienepractices, etc.)

ORS access rates ORS use rate ORT use rate Zinc supplementation use Increased fluid intake rate Continued feeding rate Households knowledgeable of when to seek treatment outside the home Households knowledgeable in preparing a safe and effective ORSThe data for these indicators can be obtained through household surveys and health facilitysurveys. The results of these surveys can then be used in focused program reviews to analyze

how well the program has achieved its goals and identify any changes that need to be made. Theevaluation process and program findings must be shared and disseminated appropriately,especially among the community members (Milstein & Wetterhall, 1999)

Example Intervention: Hygiene

Fig. 5: Potential transmission routes for diarrhea causing pathogens (Eisenberg, 2007).


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Above is a diagram mapping disease pathogens related to hygiene. An estimated 88 percent ofdiarrheal deaths are attributed to poor hygiene (UNCIEF/WHO, 2009). The diagram is a usefultool in understanding where program interventions can play a large role.

Innovations and Technology

Progress has been made over the past decade in the technology available for household watertreatment and safe storage. Many technologies are available for varying costs ranging from veryinexpensive (chlorine tabs such as AquaTabs) to expensive (PUR, a disinfection/flocculationtechnology available from Proctor and Gamble). Below is a chart of several technologies thatare available and their varying effectiveness in reducing diarrhea. A great degree of behaviorchange is inevitably necessary in order to implement these technologies, which means that it isdifficult to measure the rate at which these changes are adapted.

Clasen T, Roberts (2006)

In addition to the above techniques currently being promoted throughout theworld, there is a focus by the donor community on improving sanitation to reduce burden ofillnesses such as childhood diarrhea.InalistofnewinvestmentsannouncedinJuly,2011theGates Foundation committed $42 million in grants for the promotion of safe sanitary practices inthe developing countries. Since flush toilets are not feasible in much of the developing countries,they requesting proposals to reinvent the toilet (Gates Foundation, 2010).


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Under the same theme of improving water and sanitation, yet through a different approach,UNESCO-IHE Institute for Water Education has committed $8 million to higher education

through their support efforts to change the postgraduate water and sanitation education systemthrough an increased focus on solutions that work for the poor and a robust online curriculum toreduce costs and increase accessibility to higher education (Gates Foundation, 2010).

It is through new technologies and innovations, like the water purification systems shown above,and dedicated donors and researchers, that we achieve progress in our continued fight to reducethe incredible burden of morbidity and mortality that comes from childhood illnesses such aschronic diarrhea and dehydration.

Conclusion

Dysentery, persistent diarrhea, and diarrhea in a child with malnutrition require skilled careincluding appropriate antibiotic administration. Therefore, practitioners need to be familiar withdiarrhea's various presentations and practice guidelines in order to effectively treat children toreduce the under-5 mortality rate. Likewise, they must also engage in teaching families how toappropriately care for their children so that families can take appropriate action to save theirchildren.

Diarrhea's impact on children's health will continue to be seen for years to come. Short-term andlong-term consequences from diarrhea yield a decrease in quality of life. Focusing on only oneaspect of the disease, however, will not suffice. The monitoring of other diseases such asmalnutrition and immuno-compromising illnesses is essential as they contribute greatly to thedisease's onset and reoccurrence.

As demonstrated, there are concrete and immediate interventions that can reduce the number ofchildren suffering from diarrhea. That said, the underlying concerns with regard to preventionare those that can be addressed in order to achieve long-term impact. If devised and implementedat the community level, with a strong plan of action and achievable indicators, health careworkers and families will not only be able to treat children with diarrhea, but also jumpstartlong-term reduction in diarrhea, and ultimately, childhood mortality.

Perhaps, one day this disease, and others, will be conquered as countries continue their efforts tofulfill MDG4.


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References

Ahmed, S., et al. Severity of rotavirus in children: One year experience in a children hospital ofBangladesh. Iranian Journal of Pediatrics. 19.2 (2009): 107-116.

Black, Robert MD., et al. Global, regional, and national causes of child mortality in 2008:systemic analysis, The Lancet, Vol. 375, 9730. (2010): 1969-1987.

Boschi-Pinto, C., et al. The Global Burden of Childhood Diarrhea, in: Ehiri, J.E., M.Meremikwu (eds.), International Maternal and Child Health, Part 3, 225-243: 2009.

Boschi-Pinto, C., Velebit, L., & Shibuya, K., "Estimating child mortality due to diarrhoea indeveloping countries", Bull World Health Organ, 86.9 (2008): 710-717.

Chowdhury, A., et al. The Status of ORT in Bangladesh: how widely is it used? Health Policyand Planning 12.1 (1997): 58-66.

Clasen, T.F. Scaling Up Household Water Treatment Among Low-Income Populations. WorldHealth Organization: 2009.

Curtis, V., et. al. The Public Private Partnership for Hand-washing with Soap: Monitoring andEvaluation Framework. Global Hand Washing: 2003.

Curtis, V. & Cairncross, S. "Effect of washing hands with soap on diarrhea risk in thecommunity: A systematic review", The Lancet Infectious Diseases 3.5 (2003): 275.

Eisenberg, Joseph N.S. Integrating Disease Control Strategies: Balancing Water Sanitation andHygiene Interventions to Reduce Diarrheal Disease. Am J Public Health 97.5 (2007):846-852.

Environmental Health Project. Joint Publication 8: The hygiene improvement framework: Acomprehensive approach for preventing childhood diarrhea. EHP, UNICEF/WES,USAID, World Bank/WSP, WSSCC: 2004.

Fewtrell L. et al., Water, sanitation, and hygiene interventions to reduce diarrhoea in lessdeveloped countries: a systematic review and meta-analysis, Lancet Infect. Dis., 2005, 5-42-52.

Fischer Walker, C.L. & Black, R.E. "Micronutrients and Diarrheal Disease. Clinical InfectiousDiseases 45 (2007): S73.

GAVI. WHO recommends global use of Rotavirus vaccines. Press Release: 5 June 2009.

Gilroy, K., Kuszmerski, N. & Winch, P. Lessons learned in a pilot introduction of zinc treatmentfor childhood diarrhea in Bougouni District, Mali. USAID: 2005.


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Goodall, R.M. Oral Rehydration Therapy: How it Works.Rehydration Project. Available:rehydrate.org

Guerrant DI, Moore SR, Lima AAm, Patrick P, Schorling JB, Guerrant RL. Association ofearly childhood diarrhea and cryptosporidosis with impaired physical fitness and

cognitive function four-seven years later in a poor urban community in NortheastBrazil. Am J Trop Med Hyg 61(1999): 707-713.

Milstein, Robert L., M.P.H. and Wetterhall, Scott F., M.D., M.P.H. MMWR Report:Framework for Program Evaluation in Public Health. September 17, 1999. Morbidityand Mortality Weekly Report Vol 48, No. RR-11.

Naficy AB, Rao MR, Holmes JL et al. Astrovirus diarrhea in Egyptian children. J Infect Dis182 (2000): 685-690.

Naveh Pharma.ElectroRice Strawberry and Lemon:Rice-based Electrolyte Rehydration

Solution. Available: http://navehpharma.com/products_superice.php. 2010.

Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deathscaused by rotavirus disease in children. Emerg Infect Dis 9.5 (2003): 565-72.

PATH. Diarrheal Disease: Solutions to Defeat a Global Killer. PATH, Washington, D.C. 2009.Available: www.eddcontrol.org.

Rehydrate Project (a). Acute Diarrhoeal Diseases-Clinical Features and Management. 2009.Available: http://rehydrate.org/shows/acute/diarrhoea-acute-12.htm.

-- (b) Breastfeeding. 2009. Available: http://rehydrate.org/breastfeed/index.html.

-- (c) Hygiene, Hand Washing and Clean Water. 2009. Available:http://rehydrate.org/hygiene/.

-- (d) Oral Rehydration Solutions: Made at Home. 2009. Available:http://rehydrate.org/solutions/homemade.htm#recipes.

-- (e) Unit 7 - Diarrhoea and Nutrition: Medical Education: Teaching Medical Studentsabout Diarrhoeal Diseases. 2009. Available:http://rehydrate.org/diarrhoea/tmsdd/7med.htm.

United Nations Childrens Fund & World Health Organization. Diarrhoea: Why Children AreStill Dying and What Can Be Done. 2009.

United Nations Children's Fund & World Health Organization. Facts for Life: Diarrhoea. 2010.

United Nations Children's Fund & World Health Organization. Progress on Drinking Water andSanitation: Special Focus on Sanitation. 2008.


18/18

United States Agency for International Development. Zinc Supplementation for the Treatment of

Diarrhea: Moving from Research to Practice. MOST: The USAID MicronutrientProgram.

Valencia-Mendoza, A., Bertozzi, S.M., Gutierrez, J.P. & Itzler, R. "Cost-effectiveness ofintroducing a rotavirus vaccine in developing countries: the case of Mexico." BMCInfectious Diseases. 8 (2008): 103.

World Health Organization.Diarrhoeal Disease. 2009.

World Health Organization. Framework for Monitoring and Evaluation of Integrated ChildSurvival Interventions. 2006.

World Health Organization. Health Status: Mortality. World Health Statistics 2006.

World Health Organization, Integrated Management of Childhood Illness (IMCI), 2010Available at link:http://www.who.int/child_adolescent_health/topics/prevention_care/child/imci/en/index.html

World Health Organization. The Evolution of Diarrhoeal and Acute Respiratory Disease Controlat WHO. Achievements 19801995 in Research, Development, andImplementation.1999.

World Health Organization. The Treatment of Diarrhoea: A Manual for Physicians and OtherSenior Health Workers. 2005.

World Health Organization. Water, Sanitation, and Hygiene Links to Health: Facts and Figures.2004.

World Health Organization & United Nations Children's Fund. Integrated Management ofChildhood Illness. 2008.

World Health Organization & United Nations Children's Fund. Integrated Management ofChildhood Illness. 2008.

World Health Organization & United Nations Children's Fund. WHO/UNICEF Joint Statement:Clinical Management of Acute Diarrhoea.2004.

World Health Organization & United Nations Children's Fund. WHO/UNICEF Joint Statement:Global Plan for Reducing Measles Mortality 2006-2010. 2006.

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