DIARRHOEA
A threat to child health and survival
Diarrhoea is one of the leading causes of death and illness among children
under five years of age in the world. It results in billions of cases per year.[1, 2]
In 2013, over 570,000 children under five years of age died from diarrhoea.[2, 3]
In India, diarrhoea caused more than 130,000 child deaths in 2013.[3] This
accounts for roughly one-fourth of all global diarrhoea deaths among children
under five years of age.[4]
What is > According to the World Health Organization (WHO), diarrhoea is
passage of three or more loose or liquid stools per day, or more
diarrhoea? “the
frequently than is normal for the individual.”[1] If left untreated,
diarrhoea can lead to severe dehydration, which can result in
hospitalisation or even death.
What causes > Most cases of diarrhoea in children result from infection caused
viruses, bacteria, or parasites, which disrupt the normal fluid and
diarrhoea? by
nutrient absorption of the intestines. These pathogens commonly
spread through unsafe drinking water, poor hygiene and sanitation,
unclean feeding practices, or person-to-person contact.
Children who suffer from underlying malnutrition, poor health, and
lack of access to medical care are more vulnerable to diarrhoea.
Diarrhoea in turn perpetuates their malnutrition and susceptibility
to illness and death.
Rotavirus is the leading cause of moderate-to-severe diarrhoea
Rotavirus >
in India, accounting for approximately 40% of all diarrhoea cases
diarrhoea requiring treatment.[5, 6, 7] Symptoms of rotavirus infection include
rapidly progressing profuse diarrhoea, vomiting, and fever. Recent
studies have estimated that rotavirus led to more than 78,000
deaths in India in 2011 among children under five years of age.
In the same year, the virus accounted for more than 870,000
hospitalisations, over 3 million outpatient visits, and over 11 million
diarrhoea episodes.[8]
Rotavirus diarrhoea also poses a significant economic burden to
India. One study estimated that India spends Rs. 4.9 billion and
Rs. 5.4 billion each year on hospitalisation and outpatient visits—
each of which is more than the estimated Rs. 4.5 billion it would
cost to fund a rotavirus immunisation program.[8]
The average cost of a hospitalisation for rotavirus diarrhoea ranges
between Rs. 2000 and Rs. 8400, depending on the hospital facility.
[8, 9] This equates to one or two months of income for an average
Indian family – a cost that could easily push a family into poverty.[9]
1 WHO. Diarrhoeal disease. 2013.
Available from:http://www.who.int/
mediacentre/factsheets/fs330/en/
index.html
2 Fischer Walker, C., Rudan, I., Liu,
L. et al. Global burden of childhood
pneumonia and diarrhoea, Lancet,
2013.
3 Committing to Child Survival: A
Promise Renewed Progress Report
2014, UNICEF (2014). Accessed 4
November, 2014: http://files.unicef.
org/publications/files/APR_2014_
web_15Sept14.pdf
4 Liu, L., et al., Global, regional, and
national causes of child mortality: in
2000—13, with projections to inform
post-2015 priorities: an updated
systematic analysis. Lancet (2014).
Access 21 November 2014: http://
www.thelancet.com/journals/lancet/
article/PIIS0140-6736(14)61698-6/
fulltext
5 Kang G, Arora R, Chitambar SD, et
al. Multicenter, Hospital-Based Surveillance of Rotavirus Disease and
Strains Among Indian Children Aged
<5 Years. Journal of Infectious Diseases. 2009;200(Supplement1):S147S53
6 Tate JE, Chitambar S, Esposito DH,
Sarkar R, Gladstone B, Ramani S, et
al. Disease and economic burden of
rotavirus diarrhoea in India. Vaccine.
2009; 27 Suppl 5: F18-24
7 Kang G, et al. Diversity of circulating rotavirus strains in children
hospitalized with diarrhea in India,
2005–2009. Vaccine, 2013. 31: p.
2879–2883.
8 John J, Sarkar R, Muliyil J, Bhandari
N, Bhan MK, Kang G. Rotavirus
gastroenteritis in India, 2011-2013:
Revised estimates of disease burden
and potential impact of vaccines.
Vaccine. 2014; 32 Suppl 1: A5-9.
9 Sowmyanarayanan TV, Patel T,
Sarkar R, Broor S, Chitambar SD,
Krishnan T, et al. Direct costs of
hospitalization for rotavirus gastroenteritis in different health facilities
in India. Indian J Med Res. 2012;
136(1): 68-73
How can
diarrhoea be
addressed?
Strategies for
preventing and
treating diarrhoea
A set of comprehensive interventions that includes protection, prevention, and treatment,
and which is supported by robust health systems, is essential to address death and suffering
arising from this disease. A key component of prevention is vaccination.
Protection
Prevention
Treatment
• Exclusive breastfeeding
for 6 months
• Vaccination:
- rotavirus, hep A/B,
typhoid, cholera, measles
(shown to indirectly reduce
risk of diarrhoea)
• Community case
management
• Vitamin A and zinc
supplementation
• Adequate nutrition
• Health facility case
management
• HIV Prevention
• Improvement of
care-seeking behaviour
• Promotion of hand
washing and hygiene
• Oral Rehydration
Therapy (ORT)
• Safe water and sanitation
ORT, most often in the form of Oral Rehydration Salts (ORS), is
Vaccination: >
effective in treating mild rotavirus infections. However, when this
The best treatment is unavailable, or received too late, rotavirus can be
protection deadly. Rotavirus cannot be treated with antibiotics or other drugs
against and is highly contagious. Interventions that prevent other forms
diarrhoea — such as improvements in hygiene, sanitation, and
Rotavirus ofdrinking
water — do not adequately prevent the spread of rotavirus.
Prior to vaccination, rotavirus infected children everywhere – even
in countries with excellent sanitation and water supply. For these
reasons, vaccination offers the best hope for protecting children.
Today, rotavirus vaccines are saving lives, reducing disease and
suffering, and improving health worldwide.
Rotavirus > Rotavirus vaccines are currently being used in more than 70
countries.[10] Reductions in diarrhoea hospitalisations have been
vaccines demonstrated
in more than 10 countries, including low - and
middle-income countries.[11, 12, 13, 14] Additionally, several countries
have also documented a steady decline in diarrhoea deaths.[15, 16, 17, 18]
Studies show that the vaccine significantly reduces rotavirus
INDIRECT EFFECT >
hospitalisations among older children who are not vaccine-eligible.
OF ROTAVIRUS This phenomenon is called “indirect effect” or “herd protection.”
VACCINES This is likely because of reduced circulation. For instance, in the
US, the number of hospitalisations caused by rotavirus fell by 80%
among children who were vaccinated and by 74% among those not
vaccinated.[11]
Recommended > Rotavirus vaccines have been recommended by the WHO for
in national immunisation programs worldwide and have been
By experts use
listed as necessary components of WHO and UNICEF’s Integrated
Global Action Plan for the Prevention and Control of Pneumonia and
Diarrhoea (GAPPD). They are also key elements of the WHO Global
Vaccine Action Plan, which is endorsed by 194 member states,
including India. In India, the Indian Academy of Pediatrics has
recommended the use of these vaccines for all Indian children.[19, 20]
Rotavirus > In July 2014, the Prime Minister’s Office announced the inclusion
vaccine in India’s Universal Immunisation Programme.
vaccines in ofIn rotavirus
addition to Rotarix and RotaTeq, which are currently licenced and
India available in the private market, India’s first indigenous rotavirus
vaccine, Rotavac, was licensed in 2013.
Impact of
rotavirus
vaccines
> According to one study, introduction of a rotavirus vaccine in the
national immunization program would prevent over 25,000 deaths,
nearly 300,000 hospitalisations, and more than 600,000 outpatient
visits each year in India.[8]
10Johns Hopkins Bloomberg School of
Public Health. Vaccine Information
Management System (VIMS). 2014
[cited September 2014]; Available
from: http://www.jhsph.edu/research/centers-and-institutes/ivac/
vims/
11 Patel MM, Glass R, Desai R, Tate JE,
Parashar UD. Fulfilling the promise
of rotavirus vaccines: how far have
we come since licensure? Lancet
Infect Dis. 2012; 12(7): 561-70.
12Patel MM, Steele D, Gentsch JR,
Wecker J, Glass RI, Parashar UD.
Real-world impact of rotavirus vaccination. Pediatr Infect Dis J. 2011;
30(1 Suppl): S1-5.
13 Yen C, Tate JE, Patel MM, Cortese
MM, Lopman B, Fleming J, et al.
Rotavirus vaccines: update on global
impact and future priorities. HumVaccin. 2011; 7(12): 1282-90.
14Patel MM, Patzi M, Pastor D, Nina A,
Roca Y, Alvarez L, et al. Effectiveness
of monovalent rotavirus vaccine in
Bolivia: case-control study. BMJ.
2013; 346: f3726.
15 Bayard V, DeAntonio R, Contreras R,
et al. Impact of rotavirus vaccination
on childhood gastroenteritis-related
mortality and hospital discharges
in Panama. International Journal of
Infectious Diseases 2012;16:e94-e98.
16De Oliveira LH, Giglio N, Ciapponi A,
et al. Temporal trends in diarrhearelated hospitalizations and deaths
in children under age 5 before and
after the introduction of the rotavirus
vaccine in four Latin American countries. Vaccine 2013;31:C99-C108.
17 do Carmo GM, Yen C, Cortes
J, Siqueira AA, de Oliveira WK,
Cortez-Escalante JJ, et al. Decline in
diarrhoea mortality and admissions
after routine childhood rotavirus
immunization in Brazil: a timeseries analysis. PLoS Med. 2011;
8(4):e1001024.
18Gastanaduy PA, Sanchez-Uribe
E, Esparza-Aguilar M, Desai R,
Parashar UD, Patel M, et al. Effect
of rotavirus vaccine on diarrhoea
mortality in different socioeconomic
regions of Mexico. Pediatrics. 2013;
131(4): e1115-20.
19 WHO, UNICEF. The Integrated Global
Action Plan for Pneumonia and Diarrhoea (GAPPD)2013. http://defeatdd.
org/sites/default/files/node-images/
gappd-full-report.pdf (accessed 1
Aug 2013).
20WHO, Strategic Advisory Group of Experts on Immunisation (SAGE). 2014
Assessment Report of the Global
Vaccine Action Plan. http://www.
who.int/immunization/sage/meetings/2014/october/1_GVAP_Assessment_Report_2014_draft_SAGE_discussion.pdf (accessed 24 Nov 2014).