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📚 Acute Diarrhoeal Diseases (ADD) - PSM Viva Study Guide

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1. DEFINITION (Most basic question!)

• Consistency (watery/loose stool) + Frequency (>3 times/day)

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2. CLASSIFICATION (4 types)

Viva tip: MCC (Most Common Cause) of dysentery = Shigella

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3. EPIDEMIOLOGY (Remember these numbers!)

• 2nd leading cause of death in children under 5
• 1.7 billion cases of childhood diarrhoea every year
• 525,000 children under 5 die each year from diarrhoea
• 80% of deaths occur in the first 2 years of life
• Main cause of death = Dehydration (other causes: septic shock, peritonitis, malnutrition)
• Diarrhoea is also a leading cause of malnutrition in under-5s

• In 2017, 1193 under-5 children died from diarrhoea

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4. EPIDEMIOLOGICAL DETERMINANTS (Agent, Host, Environment - remember AHE)

A - Agent Factors

• Bacterial: E. coli, Shigella, Vibrio cholerae, Salmonella
• Viral: Rotavirus (MCC of diarrhoea in children), Adenovirus, Calcivirus
• Parasitic: Giardia lamblia

Viva tip: Rotavirus = MCC in children | Shigella = MCC of dysentery

H - Host Factors

• Most common in children 6 months - 2 years
• Malnutrition → weaker immune system → more susceptible
• Lack of exclusive breastfeeding in first 6 months → loses protective antibodies
• Zinc deficiency, Vitamin A deficiency, HIV, lack of rotavirus vaccine → increase severity

E - Environmental Factors

• Bacterial diarrhoea → more common in warm/rainy season
• Viral diarrhoea → more common in winter
• Poor sanitation, no handwashing, unsafe water, contaminated food
• Crowded living, refugee camps, disasters → outbreak risk

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5. RISK FACTORS (Easy list to remember)

1. Children 6 months - 2 years
2. Poor sanitation & personal hygiene
3. Absence of safe drinking water
4. Immunization low rates / Immunodeficiency
5. No breastfeeding (low breastfeeding rates)
6. Crowded living conditions
7. Malnutrition
8. Poverty + Unsafe food preparation

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6. MODE OF TRANSMISSION

1. Water-borne (contaminated water)
2. Food-borne (contaminated food)
3. Direct transmission (person to person, hand to mouth)

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7. ASSESSMENT OF DEHYDRATION (The most important table!)

Viva tip for the case scenario: 8-month-old with sunken eyes + skin pinch >2 sec + drowsy = SEVERE DEHYDRATION → Plan C

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8. TREATMENT PLANS (A, B, C)

Plan A - No Dehydration (Treat at home)

• WHO ORS at home after every loose stool
  • <2 years: 50-100 ml per loose stool
  • 2-10 years: 100-200 ml per loose stool
• Zinc supplementation
• Teach mother danger signs

Plan B - Some Dehydration (Treat at health centre/hospital)

1. IV Fluids (RL or NS) - Normal daily requirement:
   • <10 kg = 100 ml/kg/day
   • 10-20 kg = 50 ml/kg/day

   • 20 kg = 20 ml/kg/day

2. WHO ORS: 75 mL/kg in first 4 hours (deficit replacement)
3. Zinc supplementation
4. Maintenance fluid (Plan A ORS for ongoing losses)

Plan C - Severe Dehydration (Emergency!)

1. IV Bolus: 100 ml/kg of RL/NS (with or without 5% dextrose)
2. WHO ORS if child can drink orally
3. Zinc supplementation
4. Reassess every 2-3 hours → if improved: go to Plan B → then Plan A

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9. ORS COMPOSITION

• Sodium chloride: 2.6 g
• Glucose anhydrous: 13.5 g
• Trisodium citrate: 2.9 g
• Potassium chloride: 1.5 g
• Osmolarity: ~245 mOsmol/L (low-osmolarity ORS)

• 1 litre clean water + 6 level teaspoons sugar + ½ level teaspoon salt
• Should taste like tears (not too salty, not too sweet)
• Use within 24 hours

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10. ZINC SUPPLEMENTATION (Numbers to remember!)

Why zinc? It reduces duration and severity of diarrhoea AND prevents future episodes.

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11. CHEMOTHERAPY (Only specific organisms!)

Note: Antibiotics are NOT given routinely for all diarrhoea - only for specific causative organisms!

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12. PREVENTION & CONTROL (WHO recommended)

Short-term measures (Clinical management):

• ORS (Oral rehydration)
• IV fluids (RL/NS)
• Maintenance ORS
• Chemotherapy (when indicated)
• Zinc supplementation

Long-term measures:

1. Promote breastfeeding (reduces diarrhoeal disease)
2. Appropriate weaning (poor weaning = major risk factor)
3. Supplementary feeding (improve nutritional status)
4. Vitamin A supplementation (prevents diarrhoea)
5. Maternal nutrition

1. Health Education:
   • About diarrhoeal disease
   • Environmental sanitation & personal hygiene
   • Safe drinking water, use of latrine, proper excreta disposal
2. Sanitation:
   • Personal/domestic hygiene
   • Safe water supply
   • Clean toilets, proper excreta disposal (especially young children's)
3. Immunization:
   • Measles vaccine (reduces diarrhoea-related deaths)
   • Rotavirus vaccine (most direct prevention)
4. Fly Control:
   • Control flies that breed in human/animal faeces

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13. ROTAVIRUS VACCINE (likely a specific question!)

• Oral vaccine given to infants
• 2 doses: at 6 weeks and 10 weeks (in Nepal's national immunization schedule)
• Protects against the MCC of diarrhoea in children
• Part of Nepal's national immunization programme

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14. NATIONAL PLANS FOR ADD IN NEPAL

• IMCI (Integrated Management of Childhood Illness) - uses Plan A/B/C framework
• CSSDP (Control of diarrhoeal disease programme)
• Oral Rehydration Corners (ORC) at health facilities
• Community-based ORS distribution
• Health worker training on dehydration assessment

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15. SAMPLE VIVA QUESTION (From your slide - memorize this!)

1. Safe drinking water - chlorine tablets, boil water, repair water supply
2. Sanitation & hygiene - handwashing with soap, safe food handling, proper waste disposal
3. Disease surveillance - activate Rapid Response Teams (RRTs), monitor cases, report outbreaks
4. Health education - use media/volunteers/posters, educate on symptoms and when to seek care
5. Emergency rehydration services - set up ORS corners, ensure ORS/IV fluids/medicines availability

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QUICK RECALL SHEET FOR TOMORROW

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• Color-coded sections - each topic has its own color so your eye jumps straight to it
• Dehydration table - the full Plan A / B / C comparison table in red/yellow/green
• Treatment Plans side by side - all three plans at a glance with exact doses
• Agent-Host-Environment determinants in a 3-column table
• ORS composition + homemade recipe
• Zinc doses and chemotherapy drugs in clean tables
• Prevention & control - short-term and long-term measures from WHO
• Quick recall numbers box - all the stats you need (525,000, 1.7 billion, 75 ml/kg, etc.)
• Sample viva Q&A - the flood scenario with the 5-point answer