Diarrhoea remains the second leading cause of death among children under five, globally. Nearly one in five child deaths – about 1.5 million each year – is due to diarrhoea. It kills more young children than AIDS, malaria and measles combined. In India, Diarrhoea is one of the major causes of mortality among under- five population as it contributes for 11 per cent of deaths in the age group, beyond neonatal period. Over 200,000 children lose their lives every year to this easily manageable condition. Despite improving trends, the persistently high mortality and disease burden resulting from diarrhoea, call for urgent implementation of interventions to effectively manage this condition in order to achieve the Sustainable Development Goals, SDG 3.
There are lessons to be learnt from past experience. An international commitment to tackle childhood diarrhoea in the 1970s and 1980s resulted in a major reduction in child deaths. This came about largely through the scaling up of oral rehydration therapy (ORS), coupled with programmes to educate caregivers on its appropriate use. But these efforts lost momentum as the world turned its attention to other global emergencies. Today, in developing countries only 39 per cent of children with diarrhoea, receive the recommended treatment, and limited trend data suggest that there has been little progress since 2000.
To effectively tackle this problem, a 7-point plan for comprehensive diarrhoea control was envisaged, according to which the following are the health interventions:
The treatment package focuses on two main elements, as outlined in a 2004 joint statement from UNICEF and WHO:
Fluid replacement to prevent dehydration and Zinc treatment:
Oral rehydration therapy – which has been heralded as one of the most important medical advances of the 20th century – is the cornerstone of fluid replacement. New aspects of this approach include low-osmolarity oral rehydration salts (ORS), which are more effective at replacing fluids than the original ORS formulation, and zinc treatment, which decreases diarrhoea severity and duration. Important additional components of the package are continued feeding, including breastfeeding, during diarrhoea episodes and the use of appropriate fluids available at home if ORS is not available, along with increased fluids in general. Studies have shown that 100% uptake of Oral Rehydration Salt (ORS) reduces diarrhoea mortality by 93%, whilst Zinc contributes to 23% reduction in deaths from diarrhoea.
Treatment of diarrhoea using both ORS and Zinc is significantly low in India. A UNICEF report in 2009 indicated that only 1.3% children with diarrhoea were treated with Zinc and only 39% of children with diarrhoea in rural areas and 52% in urban areas were treated with ORS. The National Family Health Survey (NFHS) three, showed that more than 60% of mothers are aware of ORS. However, there is a big gap between knowledge and practice which results in poor uptake of ORS. Similarly, lack of adequate training in Oral Rehydration Therapy (ORT) has also been cited as a barrier to the use of ORS and Zinc. As per the GoI guidelines, Accredited Social Health Activists (ASHAs) are not only trained in identification of diarrhoea cases, but also in its treatment using ORS and Zinc supplementation. An assessment showed that very limited numbers of ASHAs knew about Zinc tablet or syrup whilst only a few had ORS in their drug kits and none of them had Zinc.
Rotavirus and Measles vaccinations:
Recent inclusion of rotavirus in UIP is a great step forward by Govt. of india. Rotavirus is estimated to cause about 40 per cent of all hospital admissions due to diarrhoea among children under five years of age worldwide, leading to some 100 million episodes of acute diarrhoea each year that result in 350,000 to 600,000 child deaths (Weekly Epidemiological Record, vol. 83, no. 47, 21 November 2008). Currently Rotavirus vaccinations have been initiated in four States, Himachal Pradesh, Haryana, Andhra Pradesh and Odisha.
Measles is an acute viral infection that is often self-limiting. But some children, particularly those who are undernourished or have compromised immune systems, may experience serious side effects, including diarrhoea. Diarrhoea is one of the most common causes of death associated with measles worldwide. According to WHO about 2-5% of diarrhoeal episodes in the first five years of life are measles-related. This includes both with-measles and post-measles diarrhoea. The Lancet’s child survival series in 2003 and 2013 has validated this association, confirming the efficacy and effectiveness of measles vaccination for diarrhoea prevention and control In India, measles vaccination coverage is 72%. Despite this, more than 50,000 children die every year from measles in the country.