©Jhpiego CorporationThe Johns Hopkins University

CDI Module 18: Community Management of Diarrhea

A Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services

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Module 18 Objectives

By the end of this module, learners will: State the burden of diarrheal illnesses Define types of diarrheal diseases Describe steps in recognizing and classifying

diarrhea List causes of diarrhea and ways to prevent diarrhea Describe management of diarrhea

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Why We Cannot Ignore Diarrheain Efforts to Control Malaria

Diarrheal disease: Is a leading cause of death in children under five

years old Is both preventable and treatable Kills 1.5 million children every year

Globally, about two billion cases of diarrheal disease occur every year

Source: WHO Fact sheet N°330, August 2009

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More Reasons We Cannot Ignore Diarrheain Efforts to Control Malaria

Diarrheal disease: Mainly affects children under two years old Is more common in babies under six months of

age who are on infant feeding formula or cow’s milk

Is a leading cause of malnutrition in children under five years old

Any effort to improve overall child survival must make reducing diarrhea’s death toll a priority

Source: WHO Fact sheet N°330, August 2009

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Global Annual Child Deaths

4% 5%

10%

15%

18%

25%

23%

HIV/AIDSMeaslesMalariaDiarrheaARI*OthersPerinatal

Deaths associated

with Malnutrition

= 54%

*Acute respiratory infection

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The Diarrhea Burden

Diarrhea is defined as the passage of three or more loose or watery stools in a 24-hour period

With the use of oral rehydration therapy (ORT), the annual death rate for children under five suffering from acute diarrhea has fallen over the years but: Acute diarrhea continues to exact a high toll of over

one million child deaths annually in developing countries

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Recognizing Diarrhea:Stooling and Dehydration

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Recognizing Diarrhea

Mothers usually know when their children have diarrhea and may use a local word for diarrhea

They may say that the child has loose or watery stools—but frequent passage of normal, formed stools is not diarrhea

Diarrhea is defined as passage of three or more loose or watery stools in a 24-hour period

Diarrhea kills a child through dehydration—the loss of too much fluid

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Three Classifications of Diarrhea

Acute Diarrhea Diarrhea that has lasted less than 14 days Acute diarrhea is a major cause of dehydration and leads

to death among children under five years of agePersistent Diarrhea Diarrhea that lasts 14 days or moreDysentery Blood in the stool, with or without mucus Dysentery is commonly caused by Shigella bacteria in

children under five years of ageAll three forms are dangerous

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Most Important Signs

The child is lethargic or unconscious—general danger sign

The child is restless and irritable all the time, or every time she or he is touched and handled

An infant or child who is calm when breastfeeding but becomes restless and irritable when he or she stops breastfeeding, is classified as "restless and irritable”

Many children are upset just because they are in the clinic Usually these children can be consoled and calmed These children are not classified as "restless and irritable”

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Danger Signs and Symptoms

If the child has two or more of the following signs, he or she is classified as having SOME DEHYDRATION: Is restless and irritable Has sunken eyes Is thirsty (drinks eagerly

and clearly wants to drink) Exhibits a skin pinch that

goes back slowly

Causes and Prevention

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Diarrhea Is Caused by DirtyWater, Food and Hands

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Preventing Diarrhea

Preventing children from developing diarrhea in the first place is essential for reducing child deaths

Key prevention measures include: Promoting adequate nutrition (including breastfeeding and

zinc intake) Raising immunization rates Reducing indoor and outdoor access to oral fecal matter

Recent research also suggests that handwashing plays a role in reducing the incidence of diarrhea

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Preventive Measures: Breastfeeding, Handwashing with Soap and Reduced Access to Oral Fecal Matter

Case Management

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Results of Past Efforts

Diarrhea oral rehydration solution (ORS) and increased fluids have helped but: Only 26% of children <5 years of age with diarrhea

received ORS packets or pre-packaged liquid (Demographic and Health Survey [DHS] 2008)

Only 25% of children <5 years of age with diarrhea received oral rehydration therapy (ORT) or increased fluids with continued feeding, a slight decrease from 28% in 2003 (Millennium Development Goal [MDG] Countdown)

For Common Diarrhea, DrugsAre Generally NOT the Right Choice of Treatment

Generally, if the child continues to receive plenty of fluids and food to replace what is lost through stooling, diarrhea will resolve itself

Unless we really know that the diarrhea is caused by a bacterium like Shigella, treatment with antibiotics can make it worse

Treatment with medicines like kaolin slow down the diarrhea, but also keep the germs in the gut

So, it is better to keep giving fluids, not drugs

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ORS/ORT: Fluids and Food

Tell us some of the local foods and fluids that can help children with diarrhea

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Sources of Zinc

Diarrhea depletes the body’s stores of zinc

Food (and tablets) with zinc

Zinc reduces stooling and is found in foods and tablets.

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Case Management Steps forthe Community-Directed Distributor (CDD) Ask about the frequency and nature of stooling If one of the three types of diarrhea is recognized, commence

case management Mix and begin using ORS Explain the need to continue breastfeeding in a child of appropriate

age Review importance of continued feeding and fluids by asking

caregiver the child’s normal diet and suggesting additional items for increasing zinc and fluids

Explain dangers of drugs and how ORS works Refer any child who is severely dehydrated immediately Explain preventive measures like handwashing and feeding

with clean cups, hands and utensils

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Both ORS and Zinc Are Needed

Facilitators of CDD training should use the following: Role play to help in

recognizing diarrhea Demonstration of ORS

preparation with re-demonstration

Role play of counseling about prevention

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Summary/Discussion

Diarrhea is a major killer of children and also leads to malnutrition, which kills more children

Please tell us how to recognize a child with diarrhea

Please remind us of the major causes of diarrhea

List the different ways to prevent diarrhea Explain the best case management steps for

diarrhea