Control of diarrheal diseases (CCD)

Definition of diarrhoea
Diarrhoea is the passage of unusually loose or watery stools, usually at
least three times in a 24 hour period. The consistency of the stools more
important than frequency. Frequent passing of formed stools is not
diarrhoea. Babies fed only breast milk often pass loose, "pasty" stools;
this also is not diarrhoea.Mothers usually know when their children have
diarrhoea and may provide useful working definitions in local situations.

Dehydration
During diarrhoea there is an increased loss of water and electrolytes
(sodium, chloride, potassium and bicarbonate) in the liquid stool. Water
and electrolytes are also lost through vomit, sweat, urine and breathing.
Dehydration occurs when these losses are not replaced adequately and a
deficit of water and electrolytes develops.The most common causes of
dehydration are rotavirus, enterotoxigenic Escherichia coli (ETEC) and
Vibrio cholerae O1 or O139.The degree of dehydration is determined
according to signs and symptoms that reflect the amount of fluid lost.

Malnutrition
Diarrhoea is, in reality, as much a nutritional disease as one of fluid and
electrolyte loss. Children who die from diarrhoea, despite good
management of dehydration, are usually severely malnourished.
During diarrhoea, decreased food intake, decreased nutrient absorption,
and increased nutrient requirements often combine to cause weight loss
and failure to grow: the child's nutritional status declines and any pre-
existing malnutrition is made worse. In turn, malnutrition contributes to
diarrhoea which is more severe, prolonged, and possibly more frequent in
malnourished children. This vicious circle can be broken by:
1. Continuing to give nutrient rich foods during and after diarrhea.
2. Giving a nutritious diet, appropriate for the child's age, when the child
is well.
 ASSESSMENT OF THE CHILD WITH DIARRHOEA
A child with diarrhoea should be assessed for dehydration, bloody
diarrhoea, persistent diarrhoea, malnutrition and serious non-intestinal
infections.
1. History:
Ask the mother or other caretaker about:
1. Presence of blood in the stool.
2. Duration of diarrhea.
3. Number of watery stools per day.
4. Number of episodes of vomiting.
5. Presence of fever, cough, or other important problems (e.g.
convulsions, recent measles).
6. Pre-illness feeding practices, type and amount of fluids (including
breast milk) and food taken during the illness.
7. Drugs or other remedies taken.
8. Immunization history.
2 . Physical examination
1. Check for signs and symptoms of dehydration.
• General condition: is the child alert; restless or irritable; lethargic or
unconscious.
• Are the eyes normal or sunken?
• When water or ORS solution is offered to drink, is it taken normally
or refused, taken eagerly, or is the child unable to drink owing to
lethargy or coma?
• Skin turgor. When the skin over the abdomen is pinched and
released, does it flatten immediately, slowly, or very slowly (more
than 2 seconds).
2. Look for these signs:
• Does the child's stool contain red blood?
• Is the child malnourished? Remove all upper body clothing to
observe the shoulders, arms, buttocks and thighs for evidence of
marked muscle wasting (marasmus). Look also for oedema of the
 feet; if this is present with muscle wasting, the child is severely
malnourished.
• Is the child coughing? If so, count the respiratory rate to determine
whether breathing is abnormally rapid and look for chest indrawing.
3. Take the child's temperature:
• Fever may be caused by severe dehydration, or by a non-intestinal
infection such as malaria or pneumonia.

Determine the degree of dehydration

Treatment Plan A:
Home therapy to prevent dehydration and malnutrition:
1. Give extra fluid including (ORS, plain clean water and rice water).
2. Continue feeding (breast or other).
3. Give supplemental zinc (10 - 20 mg) to the child, every day for 10 to
14 days.
4. Take the child to a health worker if there are signs of dehydration or
other problems.
How much fluid to give:
The general rule is: give as much fluid as the child wants until diarrhoea
stops. As a guide, after each loose stool, give ORS as follow::
1) Children under 2 years of age: 50-100 ml (a quarter to half a large
cup) of fluid.
2) Children aged 2 up to 10 years: 100-200 ml (a half to one large
cup).
3) Older children: as much fluid as they want.

Treatment Plan B:
Oral rehydration therapy for children with some dehydration
Children with some dehydration should receive oral rehydration therapy
(ORT) with ORS solution in a health facility. Children with some
.dehydration should also receive zinc supplementation
1. The amount of ORS solution needed for rehydration estimated by
multiplying the child's weight in kg by 75 ml given over first 4
hours. If the patient wants more ORS than shown, give more.
2. Encourage mother to continue breast feeding for her child.
3. Oedematous (puffy) eyelids are a sign of over-hydration. If this
occurs, stop giving ORS solution, but give breast milk or plain
water, and food. Do not give a diuretic. When the oedema has
gone, resume giving ORS solution or home fluids according to
Treatment Plan A.
4. Reassess after four hours and classify according to degree of
hydration and choose appropriate plan.
Treatment Plan C:
For patients with severe dehydration
The preferred treatment for children with severe dehydration is rapid
intravenous rehydration. If possible, the child should be admitted to
hospital.

Questions:
1. Enumerate clinical types of diarrhea?
2.Write short notes about role of Zinc in management of child with
diarrhoea?

3. Two months male child visited the primary health care center in Hilla
city complain from diarrhea and vomiting since 1 days, on examination
the child was well and alert, eyes was normal, drink normally and skin
pinch go back quickly. What degree of dehydration that the child had and
who you treat?
4. 2 years old female weighted 13 kg visited the primary health care
center with history of diarrhea and vomiting since 2 days on examination
she looked irritable, eye sunken and thirsty. Who you treat that child?

5. Antimicrobials should not be used routinely in child with diarrhea.

Why?
6. Fifteen months old child weighted 10 kg visited the primary health care
center with history of diarrhea and vomiting since 4 days, on examination
the child was lethargic, not able to drink and skin pinch return slowly.
What degree of dehydration that the child had and who you treat?
 Control of Acute Respiratory Infections (ARI) Program
Acute respiratory tract infection (ARI) is considered as one of the major
public health problems and it is recognized as the leading cause of
mortality and morbidity in many developing countries. The greatest
problem for developing countries is the mortality from ARI in children
less than five year of age. In most countries, ARI occurs more frequently
than any other acute illness, including diarrhea and other tropical
diseases.In developing countries 30% of all patients' consultation and
25% of all pediatric admission are of ARI. Most infections are limited to
the upper respiratory tract and 5% involve the lower respiratory tract.
Incidence of ARI is almost the same all over the world: 5-7 episodes per
child per years in urban areas and 3-5 episodes in rural area.
ARI is mostly caused by both viruses and bacteria. Viral agents account
for 90% of upper respiratory tract infection (URIs), however most of
these infections do not result in fatal sever disease; they are mild and self-
limited illnesses. While bacterial pulmonary infections are common in
developing countries associated with a greater risk of death.

Standard Case Management of ARI

History taken ask about:
a. Age of the patient.
b. Duration of cough.
c. If the child able to drink (2 month to 5 years), or if infant stop feeding
well (< 2 months).
d. If child had fever and was difficult to be awake (for how long).
e. If child had convulsion, difficult breathing and history of cyanosis.
f. History of associated disease like measles and history of treatment.
Physical examination:
a. Count breaths per one minute : Fast breathing is present when
respiratory rate is:
1. 60 or more per one minute for (age <2 months).
2. 50 or more per one minute for (age 2 months up to one year).
3. 40 or more per one minute for (age 1 up to 5 year).
b. Look for chest indrawing :
The child has chest indrawing when lower chest wall goes in when child
breath in. This occur when effort need for breathing more than normal.
c. Look and listen for strider:
Strider is harsh sound when child breathing in. This occurs as a result of
narrowing of upper respiratory passages including (trachea, larynx and
epiglottis).
d. Look and listen for wheeze:
Wheeze is soft musical sound when child breathing out. This occurs as a
result of narrowing of lower respiratory passages.
e. See: if child abnormally sleep or difficult to be a wake.
f. Feel for fever or low body temperature.
g. Check for malnutrition.
H. Check for cyanosis.

Case Classification:
1. Child age less than 2 months: classify into
a. Very severe disease: when any of the following danger signs is
detected:
1. Stop feeding well.
2. Convulsions.
3. Abnormally sleep or difficult to be awake.
4. Strider in previously calm child.
5. Wheezing.
6. Fever or low body temperature.
Treatment: Refer urgently to hospital, keep the infant warm and give
first dose of antibiotic.
b. Severe pneumonia: When the child presented with severe chest
indrawing or fast breathing (≥ 60 / minute).
Treatment: Refer urgently to hospital, keep the infant warm and
give first dose of antibiotic.

c. No pneumonia (cough and cold): when there was no chest

indrawing and no fast breathing.
Treatment: advise the mother about home care including (keep
warm, continue breast feeding, clear nose).Return back to health
 center if breathing become difficult or faster or occurrence of any
danger signs.

2. Child age 2 months to 5 years : classify into

a. Very severe disease: when any of the following danger signs is
detected:
1. Not able to drink.
2. Convulsions.
3. Abnormally sleep or difficult to be awake.
4. Strider in previously calm child.
5. Severe malnutrition.
Treatment: Refer urgently to hospital, keep the child warm and
give first dose of antibiotic. Treat fever or wheeze if present.
b. Severe pneumonia: When the child presented with chest indrawing.
Treatment: Refer urgently to hospital, keep the child warm and
give first dose of antibiotic. Treat fever or wheeze if present.
c. Pneumonia: When the child presented with only fast breathing (≥
50 / minute for child age from 2months up to 1 year , ≥ 40 / minute
for child age 1year up to 5 year ) , no chest indrawing.
Treatment: advise the mother about home care including (keep warm,
continue breast feeding, clear nose).Give antibiotic, treat fever and
wheeze if present. Reassess in 2 days (if child improve continue with
treatment for 5 days, if child present with same condition change
antibiotic, if worse refer to hospital).
d. No pneumonia (cough and cold): when there was no chest
indrawing and no fast breathing.
Treatment: advise the mother about home care including (keep warm,
continue breast feeding, clear nose). Treat fever or wheeze if present.
Assess and treat ear or throat problems when present.
Questions:
1. 2 years old female child was brought to PHC with history of cough
and fever for 4 days and not able to drink. On examination the
baby had fever and RR=45/minute. From above data how you
diagnose and treat that patient?

2. 3 years old male child was brought to PHC with history of cough
and fever for 2 days. On examination the baby had fever and
RR=38 /minute and baby had chest indrawing. From above data
how you diagnose and treat that patient?
3. 30 months old male child was brought to PHC with history of
cough and difficulty of breathing for 3 days. On examination
RR=55 /minute and no chest indrawing. From above data how you
diagnose and treat that patient?

4. 10 days old neonate complains from sneezing. On examination the

RR=40/minute, no chest indrawing . Enumerate lines of treatment.
 Tuberculosis
TB is an infectious disease caused by the bacillus Mycobacterium
tuberculosis. It typically affects the lungs (pulmonary TB) but can affect
other sites as well (extra pulmonary TB). The disease is spread in the air
when people who are sick with pulmonary TB expel bacteria for example
by coughing.

Infectious agents:
Mycobacterium tuberculosis complex which include: M. Tuberculosis.
M. Bovis .M. Africanum . M. Microti .M. Canetti.

TB Transmission:
1. Inhalation: TB spread from person to person through the air via
droplet nuclei. M. tuberculosis may be expelled when an infectious
person (Cough, Sneeze, Speaks, Sings).Transmission occurs when
another person inhales droplet nuclei.
2. Ingestion: Ingestion of contaminated milk (M. bovis).
3. Extra-pulmonary TB other than laryngeal TB was non infective.

TB Pathogenesis:
Pathogenesis is defined as how an infection or disease develops in the
body.
a. Latent TB Infection (LTBI): Occurs when tubercle bacilli are in the
body, but the immune system is keeping them under control. This
infection usually detected by the Mantoux skin test.
b. TB Disease: Develops when immune system cannot keep tubercle
bacilli under control . It may develop very soon after infection or many
years after infection. About 10% of all people with normal immune
systems who have LTBI will develop TB disease at some point in their
lives.

Clinical features:
General Symptoms of TB Disease:
Fever, Chills, Night sweats, Weight loss, Appetite loss, Fatigue and
Malaise.
Symptoms of Pulmonary TB Disease:
Cough lasting 3 or more weeks, Chest pain and Coughing up sputum or
blood.
Symptoms of extra pulmonary TB disease depend on part of body that is
affected.

Case definition:
A case of TB is defined as a patient in whom tuberculosis has been
confirmed by bacteriological or clinical diagnosis.

Case definition depends on:

1. Site of disease:
TB affect the lung → pulmonary TB.
TB in other organs → Extra pulmonary TB.
2. Severity of disease:
Depend on bacteriological load, extent of disease and anatomical
site.
3. Bacteriological results of sputum examination:
a. Smear positive pulmonary TB which represent either:
1. At least 2 sputum smears positive for AFB by
microscopically diagnosis.
2. One sputum smears positive for AFB plus X-ray findings
consistent with TB and clinical decision.
3. One sputum smears positive for AFB plus culture positive
for AFB.

b. Smear negative pulmonary TB : Patient should full all the

following criteria:
1. At least 3 sputum smears negative (one of them at early
morning).
2. Radiological findings consistent with TB.
3. Lack of response for antibiotics.
* Extra-pulmonary TB: TB of organs other than the lung.
4. Case classification according to previous treatment:
1. New case (Positive, Negative& Extra-pulmonary).
2. Defaulter.
3. Relapse.
 4. Treatment failure.
5. Chronic Case (drug resistances MDR-TB).
New case: A patient who has never had treatment for TB or who has
taken anti-tuberculosis drugs for Less than four weeks.
Relapse: A patient who has been declared cured of any form of TB
in the past by a physician after one full course of chemotherapy and
has become sputum smear-positive.
Defaulter: A patient who interrupts treatment for two months or
more, and returns to the health service with smear-positive sputum
consider as treatment failure or sputum negative continue his
treatment but from the start.
Chronic case: A patient, who remains or becomes again smear-
positive, after completing a fully supervised retreatment regimen.
Treatment failure: A patient who remains or becomes again smear-
positive after five months or later during treatment or change from
negative to positive after second month of treatment.

Diagnosis
.Medical history .1
.Physical examination .2
.Tuberculin test .3
.Chest x-ray .4
5. Bacteriological examination

DOTS Strategy:
DOTS (directly observed therapy, short-course) is a strategy which
primary health services are using to detect and cure TB patients. Health
workers counsel and observe their patients swallowing each dose of
medicine and monitor the patient’s progress until cured.

Anti-TB drugs:
Isoniazid (H), Rifampin (R( , Pyrazinamide (Z), Ethambutol (E) and
Streptomycin (S).
Treatment category:
CATEGORY - I TREATMENT:
TYPE OF Patients
1. New sputum positive.
2. New sputum negative and seriously ill (Extensive parenchyma
damage).
3. New extra pulmonary seriously ill (Severe form).
CATEGORY - II TREATMENT:
TYPE OF PATIENTS
1. Sputum smear positive relapse.
2. Sputum smear positive treatment after default.
3. Sputum smear positive failure.
4. Other previously treated.
CATEGORY III TREATMENT
TYPE OF PATIENTS
1. New sputum negative and not seriously ill.
2. New extra pulmonary and not seriously ill.

Classification of extra-pulmonary TB
Standard Short course regimen of Anti-TB drugs (WHO)
Treatment divided into 2 phases including (intensive phase and
continuation phase).
Category I : 2HRZE(S)/4HR
Category II : 2HRZES/HRZE/5HRE
Category III : 2HRZ/4HR
Category IV: Chronic case with MDR-TB.
MDR-TB: multi drug-resistant tuberculosis defined as resistance to at
least isoniazid and rifampin which emerged as a threat to TB control.
MDR-TB treatment requires the use of second-line drugs that are less
effective, more toxic, and costlier than first-line isoniazid- and rifampin-
based regimens.

Questions:
1. 25 years old male presented to chest clinic with history of
productive cough, fever and loss of appetite. On examination chest
clear, sputum smear was positive for Mycobacterium tuberculosis,
the patient had no history of taking anti TB drugs. What we call
that patient? In which category we put him? How you treat?
2. 22 years old female presented with history of regular treatment for
smear positive pulmonary TB since 5 months. The patient still had
sputum smear positive for Mycobacterium tuberculosis. How you
treat that patient?

3. 33 years old female has been newly diagnosed to be suffering from

TB skin. In which category we put him? How you treat?
4. Adult male patient presented to health center with history of cough
and fever since 4 months. His sputum was positive for AFB. The
patient had history of receiving treatment (RHZE) for 2 weeks
from nearby hospital. What we call that patient? In which category
we put him?

5. How you treat pregnant women with sputum smear positive TB

detected at the first trimester of pregnancy?
 Immunization
Immunization: It is process which aim to provide protection against
occurrence of disease and its complications.
Vaccine: it is substance that given to individual to stimulate the immune
system to resist and destroy the pathogen or its toxins when enter the
human body.
Vaccines may be bacteria, virus, genetic recombinant and reassortement.

Major constituents of vaccine:

1. Active immunization antigens for example (live or killed virus, live
or killed bacteria).
2. Suspending fluid either (sterile water, saline and complex tissue
culture fluid).
3. Preservatives, stabilizers and antibiotics (eg: neomycin to prevent
bacterial overgrowth).
4. Adjuvants eg: aluminum salts which frequently used to increase
immunogenicity and to prolong stimulatory effect.

Types of vaccines:
1. Live attenuated vaccine.
2. Inactivated vaccine.
3. Polysaccharide vaccine.
4. Conjugated vaccine.
5. Recombinant vaccine.
6. Reassortment vaccine.

1. Live attenuated vaccines: Derived from wild or disease causing

virus or bacteria attenuated in laboratory usually by repeated
culturing by serial passage using tissue culture media eg (MMR
vaccine, Rota vaccine, OPV and BCG).
2. Inactivated vaccine : produced by growing of the bacteria or virus
in culture media then inactivated it with heat and or chemicals like
formalin including
A. Whole cell vaccine eg (Rabies vaccine and typhoid vaccine).
B. Fractional vaccine eg (toxoid like tetanus toxoid and subunit
like a cellular pertussis).
3. Polysaccharide vaccine: A unique type of inactivate subunit
vaccine composed of long chains of sugar molecules that make up
 the surface capsule of certain bacteria (pneumococcal vaccine and
meningococcal vaccine).
4. Conjugate vaccine: it is polysaccharide chemically bound with
protein molecule eg (Heamophilus influenza and pneumococcal
vaccines).
5. Recombinant vaccine: vaccine Ag produced by genetic engineering
technology by insertion of a segment of the respective viral gene
into the gene of yeast cell (eg: HB vaccine and live flu vaccine).
6. Reassortment vaccine: Tissue culture cells were infected with two
ROTA virus strains (a nonhuman and human parent strains),
offspring contain human and nonhuman, this process called genetic
reassortment.

Routine immunization schedule in Iraq since 2011

Age Type of vaccine

After OPV0 , BCG and HepB (should be given as soon
delivery as after delivery within first 24 hours)
OPV1, Penta vaccine (DTP vaccine, HepB vaccine
2 months and Hemophilus influenze type B vaccine) and
Rota vaccine1.
OPV2, Quadrivalent vaccine (DTP vaccine and
4 months Hemophilus influenze type B vaccine) and Rota
vaccine2.
OPV3, Penta vaccine (DTP vaccine, HepB vaccine
6 months and Hemophilus influenze type B vaccine) and
Rota vaccine3.
9 months Measles vaccine + VIT A-100000 IU.
15 months (Measles , Mumps , Rubella) MMR vaccine.
Quadrivalent vaccine, OPV 1st Booster dose + Vit.
18 months
A-200000-IU.
MMR 2 and DTP 2nd Booster dose, OPV 2nd
4-6 years
Booster dose.

Polio vaccine:
It has 2 types:
a. Inactivated polio vaccine (Salk): consist of killed virus contain 3
serotypes (1, 2, 3) given via IM or subcutaneously in four doses. In
Iraq it use in certain situations eg: malignancy, use of steroid for
long period.
b. Live attenuated polio vaccine (Sabin): It is consisting of live
attenuated virus contain 3 serotypes given orally in 2 drops. The
vaccine used in Iraq routinely and in campaigns.

BCG (Bacillus Calmette Guirine)

It is consisting of live attenuated tuberculus bacilli of bovine strain
(freeze dried).The aim of BCG vaccination is not prevent occurrence of
TB but prevent serious complications that occur during infancy including
miliary TB and TB meningitis. BCG is given routinely after birth in dose
of 0.05cc intradermally in left upper arm.

Hepatitis B vaccine
Consist of HbsAg. Vaccine given in dose (10 microgram) in right thigh
(IM) routinely for infants in 3 doses (after birth, 2 nd and 6th months of
age). For adults the vaccine (20 microgram) given for high risk group in 3
doses 0,1,6 ( 0 at first contact, 1 after one month from first dose and 6
after 6 months from first dose).

DTP (diphtheria, tetanus and pertussis vaccine):

Given in 3 main doses and 2 booster doses in dose of 0.5cc IM in left
thigh.
Diphtheria vaccine:
It is diphtheria toxoid (diphtheria toxin chemically treated to remove
toxic effect and remain antigenicity effect to stimulate the immunity).
Tetanus vaccine:
Consist of tetanus toxoid (chemically treated toxin).
Pertussis vaccine:
Either killed bacteria or a cellular vaccine (which cause fewer side
effects). Pertussis vaccine not recommended after age of 6 years because
the risk of whooping cough decrease with age.
Tetanus toxoid given for pregnant women and for women at
child bearing age as the following:
For pregnant women:

Period of
Dose time
protection
First dose 4th month of pregnancy No protection
Second dose 5th month of pregnancy 3 years
Third dose After 6 months of second dose 5 years

Fourth dose After 1 year from the third

10 years
dose

Fifth dose After 1 year from the fourth

15 years
dose

For women at child bearing age:

Period of
Dose time
protection
First dose At first contact No protection
Second dose After 1 month from first dose 3 years
Third dose After 6 months of second dose 5 years

Fourth dose After 1 year from the third

10 years
dose

Fifth dose After 1 year from the fourth

15 years
dose

Measles vaccine:
Consist of live attenuated virus (freeze dried) given subcutaneously or IM
in left arm. Dose 0.5 cc. it is given routinely as measles vaccine at 9
months of age and its efficacy was 85% and give at 15 months of age as
MMR and its efficacy was 95%.

MMR (Mumps,Measles and Rubella vaccine)

Consist of live attenuated viruses (freeze dried) given subcutaneously or
IM in left arm. Dose 0.5 cc. it is given at 15 months of age as first dose
and second at 4-6 years.
Rota vaccine
Live attenuated vaccine, liquid in consistency, given orally, dose 2 cc at
2nd,4th and 6th months of age.

Haemophilus-influenze type B vaccine:

It is either polysaccharide or conjugate vaccine. It is given routinely in
form of quadrivalent or penta vaccine.

DT vaccine:
It consists of diphtheria and tetanus toxoid given for children developed
serious side effect for previous dose of DTP. Diphtheria toxoid in that
vaccine may exceed 20 IU.

Td vaccine
Similar to DT vaccine but with reduced dose of diphtheria toxoid which
not more than 10 IU. It given to children 7 years or more which develop
serious side effect for DT vaccine.

Meningococcal vaccine:
It has two types:
a. Polysaccharide vaccine: given in dose of 0.5cc subcutaneously,
immunity will develop 7-10 days after vaccination.
b. Conjugate vaccine: it use in Iraq since 2011.it conjugate with
diphtheria or tetanus toxoid. Dose 0.5 cc IM from 2 years of age.

Questions:

1. Enumerate the differences between Sabin and Salk vaccine.

2. 6 years old child presented to health center with cough and fever.
Regarding immunization history the child not take BCG vaccine.
As doctor what's your decision regarding BCG vaccination to that
child and why?

3. Enumerate the indications of Hepatitis B vaccine at adulthood.

4. Enumerate the indications of meningococcal vaccine.