Prevention

Prevention is the most effective means of combating deaths due to diarrheal disease. The majority of global cases of diarrheal diseases can be prevented by improving access to clean water and implementing simple sanitation and hygienic practices. An estimated 88 percent of diarrheal disease is related to poor water, sanitation, and hygiene (WHO, 2009).  As shown in the graph below, interventions in the area of water, sanitation, and hygiene can reduce diarrhea by up to 39% (Lancet, 2005).

 

Fig. 1: Percent reduction of diarrhea through water, sanitation, and hygiene interventions (Lancet, 2005)

 

Other effective prevention methods include the promotion of appropriate feeding practices, vitamin supplementation, and vaccination against illnesses like rotavirus and measles. 

 

Clean Water and Sanitation

Seven hundred and eighty million people live without access to an improved water source and 2.5 billion people are without improved sanitation. Reports suggest that Millennium Development Goal 5 regarding improved sanitation practices will not be met as 1.1 billion people continue to practice open defecation; the majority of those individuals living in rural areas. Eleven percent of individuals use shared sanitation, which is defined as facilities that are shared between two or more households. More than 60 percent of people using shared sanitation facilities live in urban areas (UNICEF and WHO, 2012). Those living in areas where inadequate facilities and open defecation are common are at particular risk of contracting diarrheal disease through fecal contamination of water supplies or by direct contact with fecal matter.  Refugees and displaced populations are also in danger of contracting diarrheal diseases due to unsafe water supplies.

 

Access to an improved water supply reduces diarrhea morbidity by up to 21 percent and improved sanitation by up to 37.5 percent (WHO, 2004).  Therefore, providing adequate supplies of clean water and appropriate waste disposal technologies are vital components of programs aimed at improving general health, which in turn prevent child deaths due to diarrhea.  Until broad 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 practices as well as safe storage of water is an important means for protecting children from contaminated water sources (Clasen, 2009).

 

Fig. 2: Proportion of people using improved sanitation (UNICEF and WHO, 2012)

 

 

To view a larger version of the map:

http://gamapserver.who.int/mapLibrary/Files/Maps/phe_Global_sanitation_2010.png

The graph above indicates that the 2 regions in the world with the highest <5 mortalities due to diarrheal disease (SSA and Southeast Asia) also have the lowest proportion of population with access to sanitation facilities.

 

Proper Hygiene 

Proper hygiene and sanitary practices, particularly hand washing, may reduce the risk for diarrheal disease by as much as 47 percent (Curtis, Cairncross, 2003).  The importance of washing hands with soap and water or ash and water after defecating, changing diapers, and before 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 to clean infant bottles and rely on spoon feeding instead (WHO, 2005; UNICEF/WHO, 2010). Below is a diagram mapping disease pathogens related to hygiene, and is useful in identifying where interventions can play a role. 

 

Fig. 3: Example Intervention on Hygiene: Potential transmission routes for diarrhea causing pathogens (Eisenberg, 2007). 

   

The diagram above shows common methods for children to contract diarrheal diseases and the exponential rates of transmition.  

 

Vaccination

Diarrhea prevention programming may include broadening immunization coverage for illnesses like 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 all national immunization programs (GAVI, 2009). Many countries have evaluated the efficacy of RV1, Rotarix, developed by GlaxoSmithKline and RV5, RotaTeq, developed by Merck.

 

A meta-analysis was conducted to look at vaccine efficacy of RV1 and RV5 in 41 countries. Results indicated that both RV1 and RV5 had higher efficacy in countries that had low-mortality. However, countries with high-mortality have a higher burden of disease, including diarrhea, making the absolute benefit higher (Soares-Weiser, 2012).

 

Table 1. Prevention of Severe Diarrhea cases by Vaccine Type (Soares-Weiser, 2012)

Rotavirus moratality prevelance RV1RV5
Low-mortality countries>80>80
High-mortality countries>4040-57

Likewise, measles-associated diarrhea contributes significantly to global diarrheal morbidity and mortality (WHO/UNICEF, 2006).   In fact, worldwide, diarrhea is one of the most common causes of death associated with measles (UNCIEF/WHO, 2009).  Measles vaccination is highly effective and reduces the incidence and severity of diarrheal illness in children, and its promotion should continue (WHO, 2009; WHO/UNICEF, 2006). 

 

Breastfeeding

One of the most effective means of protecting infants from diarrheal disease is through exclusive breastfeeding. Breast milk provides passive immunity through maternally acquired antibodies and prevents the ingestion of contaminated foods or fluids during the infant's most vulnerable stage (Rehydration Project (b), 2009).  Promotion of exclusive breastfeeding for the first 4-6 months of life is often a pillar of program curriculums aimed at combating diarrheal morbidity and mortality (WHO, 2005; UNICEF/WHO, 2010). 

 

Preventing Malnutrition in Children with Diarrhea

The pattern of repeated diarrheal illness in children is often described as a cycle  perpetuated by malnutrition.  Malnutrition makes children more vulnerable to diarrheal illness and 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 therefore extremely important in decreasing the global burden of childhood diarrhea.  Micronutrient deficiencies contribute to childhood illnesses by impairing the immune system's ability to ward off and fight infection (Fischer Walker, Black, 2007). 

 

Fig. 4: The vicious cycle of childhood malnutrition, deficiencies, and diarrhea (Nourish Fiji Children Project).

 

 

 

 

Continued feeding throughout diarrheal illness speeds recovery, improves intestinal function, and allows for continued growth and weight gain in children. Acute diarrhea can often lead to malnutrition 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 an important aspect of treatment.

 

Breastfed infants should continue to breastfeed without interruption during diarrheal illness (Rehydration Project (b), 2009).  Children who continue to breastfeed throughout an illness episode experience a shorter duration of illness and lighter stool volume than those who are not breastfed (Rehydration Project (b), 2009).  Older children receiving semi-solid or solid foods should continue to receive their normal diet during diarrheal illness.  They should be offered small, frequent meals (six per day) consisting of food with a high energy content and essential nutrients.

 

Foods that have been well cooked and are mashed or ground are particularly easy to digest (WHO, 2005).  Acceptable foods include rice, potatoes, noodles, milk, homemade soups, banana, cooked vegetables, and cereal grains with milk.  Culturally acceptable eggs, meat, and fish dishes that contain ample energy are highly beneficial (WHO, 2005; Rehydration Project (e), 2009). If possible, calories may be added to a child's meal by adding one to two teaspoons of vegetable or 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 include commercially prepared soups, soft drinks, and fruit juices.

 

Children should receive an additional meal 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 diarrhea with 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 to enhance children's overall immune function (Fischer Walker, Black, 2007). 

 

Zinc Supplementation

Zinc is critical to growth and development, and specifically supports the functions of the immune system. Depleted levels of zinc are associated with increased rates of infectious disease, including diarrhea, and increased mortality rates from these diseases (UNCIEF/WHO, 2009).  Research has shown that it is a highly effective intervention for decreasing under-five mortality due to diarrheal disease (Gilroy, Kuszmerski & Winch, 2005).  Therefore, treating diarrhea with zinc supplementation helps the child recover, specifically by aiding ORS uptake and decreasing misuse of antibiotics.  It decreases both the severity and duration of the illness episode and substantially decreases the number of diarrheal episodes for two to three months following treatment. All children with diarrhea should receive 10-14 days of zinc supplementation starting at the onset of illness (WHO, 2005). 

 

Unfortunately, many countries have been slow to adopt zinc into child health policies. However, zinc was added to the WHO Essential Medicines List in 2005. In the past 4 years, 46 countries have successfully changed national child-health policies to include and zinc, yet many countries are hampered by the inability to get Locally produced zinc products, that meet the GMP standards. Currently there are 8 countries with new develoments of local zinc products including: Bangladesh, Egypt, El Salvador, India, Indonesia, Nepal, Pakistan and the United Republic of Tanzania with the potential for more in the future (WHO, 2009). 

 

Treatment

Acute watery diarrhea is often associated with rapid fluid loss and dehydration (UNICEF/WHO, 2009).  Evidence-based guidelines for the treatment of diarrhea were updated in 2005 to reflect recent advances in care.  Diarrheal treatment guidelines have four supportive focuses: 1) prevent dehydration if it is not yet present 2) treat dehydration if it is present 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 designated for the treatment of acute, non-dysentery diarrhea. Unnecessary antibiotic therapy upsets the normal bacterial balance of the gut, promotes antibiotic resistance, and when used inappropriately, can lead to adverse outcomes (WHO, 2005).

  

Oral Rehydration Therapy

Diarrheal 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 imbalance after large losses and may even suffer from hypovolemic shock, cardiovascular collapse, or cardiac arrest (Rehydration Project (a), 2009). An integral aspect of managing diarrheal illness is to replace water and electrolyte losses. Oral Rehydration Therapy (ORT) using oral rehydration salts (ORS) is an effective method for preventing dehydration and treating mild to moderate dehydration in children and adults with diarrhea (WHO, 2005).  ORT is non-invasive and may be used at home to prevent dehydration or in a hospital setting to treat individuals.

 

 

UNICEF: Oral Rehydration Salts (UNICEF, 2012)

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ORT relies on the following physiological principle: the absorption of salt through the intestinal lining is enhanced in the presence of glucose. People suffering from diarrheal diseases not only lose water, but sodium as well. As the intestine is unable to absorb sodium, providing diarrheal disease patients with simple saline solution (water and sodium) is ineffective. Rather, the sodium from the saline in the intestine could lead to excess water loss, worsening the diarrhea. The glucose in an ORS solution helps to mediate the absorption of sodium into the body, and ultimately the reabsorption of water. The glucose is able to "co-transport" sodium on an even ratio. Therefore, when one drinks an appropriately concentrated solution of salt and glucose, absorption of salt through the intestinal wall can occur. As the relative concentration of sodium increases in the body, water diffuses along its concentration gradient, allowing water and other essential electrolytes to then move through the intestinal lining in response to the movement of sodium, as water "follows" salt into the body (Goodall, 2009). 

 

Fig. 5: Physiological method of water re-absorption made possible by sugar/salt solution (Goodall, 2009) 

  

The use of ORT was pioneered by WHO and UNICEF in the 1970s. Since then, there have been new 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 sodium and has been shown to more effectively and immediately reduce the severity of vomiting and diarrhea (UNICEF, 2004). In addition to standard glucose-based ORS, rice-based formulations are now available commercially, and can be found in health centers and pharmacies.  Rice-based ORS is preferred for the treatment of diarrhea that is caused by cholera (WHO/UNICEF, 2002). 

 

Fig. 6: 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 be prepared 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 the rehydration treatment (WHO, 2005).  Those with signs of dehydration will generally require ~75 milliliters of ORS per kilogram of body weight to rehydrate sufficiently (Rehydration Project (d), 2009).  ORS is given in small, slow sips every one to two minutes. It should be spooned to infants or given from a cup to children and adults. If vomiting occurs, it is important to continue giving the treatment. (Rehydration Project (d), 2009).

 

Fig. 7: Directions for a homemade ORS mixture (Rehydration Project (d), 2013).

 

 

 

Intravenous Fluid Resuscitation

Intravenous fluid resuscitation is required in cases of severe dehydration when a child is too sick to drink ORS (WHO, 2005). A trained medical professional should administer IV fluids to prevent progression to hypovolemic shock or unconsciousness. Once severe dehydration has been adequately corrected by IV fluid resuscitation, ORT should commence and continue until diarrhea stops (WHO, 2005).

 

IMCI Guidelines

WHO defines Integrated Management of Childhood Illness (IMCI) as "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 improved growth and development among children under five years of age” (WHO, 2010). Health professions and managers may learn about IMCI implementation in an 11-day training.

 

Figure 8: Estimated coverage of IMCI training as of Dec 2009(WHO 2010)

 

For a larger view of the map: 

http://gamapserver.who.int/mapLibrary/Files/Maps/World_IMCI_trainingcov_Dec2009.png?ua=1

 

IMCI's strategy is divided into three main components:

 

   1) Improving case management skills of health-care staff

   2) Improving overall health systems

   3) Improving family and community health practices.

 

One of the main tools of IMCI that is used to manage diarrhea in children is the algorithm shown below. This algorithm is given to health care providers at all levels in the delivery system, including Community Health Workers (CHWs).

 

 Fig. 9: Diarrheal Disease diagnosis and treatment guidelines, IMCI Handbook (WHO, 2010)

 

 

Treatment of Complex Diarrheas

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

 

Technical Issues and Access

Access to treatment and sustainable community management of care are two major barriers in reducing childhood mortality related to diarrhea. The Environmental Health Project (sponsored by UNICEF and USAID) published a basic framework to direct access of care and sustainability programs (EHP, 2004).

 

Fig. 10: Framework to direct access to care and sustainability (EHP, 2004).  

 

 

Access to ORS

ORS is an effective and inexpensive treatment for diarrhea, but it does not reach everyone who needs it.  In the developing world, only 39 percent of children with diarrhea receive ORT (UNICEF & WHO, 2009). While some of the reasons behind this might be cultural and related to lack of education, 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 and distribution to such areas can be very challenging, and supplies are therefore often inconsistent or non-existent. This highlights the importance of teaching people to prepare their own ORS from sugar and salt rather than letting them become dependent on ORS packets. Another challenge to using ORS is ensuring that the water used in the solution is from a clean and adequate source. Not only does unclean water create a greater risk of contracting a diarrheal disease, but it also becomes a problem 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 diarrhea treatment (WHO/UNICEF, 2004).  There have been many challenges in trying to scale up the zinc regimen, including: difficulties importing a new product to countries, a lack of start-up funds, hesitation in acceptance, and delay in purchase because local organizations are unsure of demand. As of 2008, 46 countries have changed national policies to include zinc for the treatment of diarrhea (Fischer-Walker, Fontaine, Young, Black 2009).  However, few efforts have been made to include robust indicators for monitoring zinc coverage on an individual level (Fischer-Walker, Fontaine, Black, 2013).

 

Management Issues

Due to the inadequate supply of both ORS and IV therapy, efforts have been placed on sustainable programs which mitigate the known cases of diarrhea. The goal of such programs is to reduce childhood mortality related to diarrhea as well as the dependence on donor support for treatments. The success of community-based diarrhea programs depends on several factors. Community involvement in program development, especially by mothers, is crucial to program participation. Education messages must be relevant and appropriate for the program setting. Program facilitators should teach families attainable skills and provide continuous motivation, support, and knowledge. The existing health system within a community is critical to the success of programs through also providing support with accessible clinics, appropriate medical services, and educated health care workers are all crucial factors to success (WHO, 2006; WHO/UNICEF, 2004)

 

Monitoring and Evaluation

 In 2005, USAID developed a comprehensive guide to indicators for monitoring and evaluating child health programs. Drawing from numerous sources, categorical approaches to organizing the indicators emerged (Gage 2005).

 

The following outlines key indicators recommended in A Guide for Monitoring and Evaluating Child Health Programs.

 

Prevention

Home case management

Care seeking 

Morbidity