Diarrheal Disease Edited by Dalit Gulak and Meg Meyer 2011 Vignette Basma is a 19-year-old woman living in Sulaimaniyah,

a small rural village in Northern Iraq. She has a three-month old son named Ahmed. Basma breastfeeds Ahmed but also gives him water from the well like all the other village women do. They think babies get thirsty if they only have breast milk. Ahmed has recently developed a bad case of diarrhea, but Basma does not worry and thinks that it is something that all babies get. The nearest health clinic is about two hours walk away on a dangerous road. Basma does not go there because she does not perceive diarrhea as dangerous. Also, she has too much work and not enough time to visit the clinic. Although Basma has sugar and salt at home that she uses for cooking, no one has ever taught her to make oral rehydration salts (ORS) with it. Eventually the diarrhea stops, and Basma is happy, not realizing it is because Ahmed is severely dehydrated. She does notice that every time she breastfeeds Ahmed or gives him water, the diarrhea seems to start again, so she thinks it is best not to give him too much liquid. Within two weeks Ahmeds health deteriorates losing more than 10 percent of his body weight. Ahmed suffers from severe dehydration and eventually dies. Basma is confused and hopeless as this is her second child to die under these circumstances. Introduction Diarrheal disease is a major cause of morbidity and mortality worldwide. Each year, 2.2 million people die from diarrhea; most are children in developing countries (Boschi-Pinto, 2008). It is the second leading cause of death in children under 5 years, accounting for approximately 15% (~1.36 million) of the 8.7 million deaths worldwide (Lancet, 2010). In developing countries, children average three rounds of diarrhea a year (Boschi-Pinto, 2009). There are several factors that contribute to high mortality and morbidity from childhood diarrhea including poverty, socioeconomic status, maternal education, overcrowding, and access to clean water and sanitation (Boschi-Pinto, 2009). Shown in the graph below, interventions in the area of water, sanitation and hygiene can reduce diarrhea by up to 39% (Lancet, 2005).

Percent reduction of diarrhea through water, sanitation, and hygiene interventions

* WASH = Water and Sanitation, Hygiene

In order to achieve the millennium development goal (MDG) of, reducing childhood deaths by two-thirds combating diarrhea in developing countries is critical because diarrhea disproportionately affects children (UNICEF/WHO, 2008). Children are more susceptible to dehydration from diarrhea, as water constitutes a larger proportion of childrens body weight then adults. Their kidneys are also unable to conserve as much water (UNICEF/WHO, 2009). Young children are especially vulnerable during the weaning phase, since they no longer receive passive immunity from their mothers. Children at this age are also at risk of being introduced to foods that may be contaminated with pathogens. Global Distribution of Deaths Due to Diarrheal Disease Among Children Under 5

Fig. 1: Deaths in the year 2004. Each dot represents 1,000 deaths (Boschi-Pinto, 2008).

What is Diarrhea? According to the United Nations Children Fund (UNICEF) and the World Health Organization (WHO), diarrhea is defined as having loose or watery stools at least three times per day, or more frequently than normal for an individual (UNICEF/WHO, 2009). Diarrhea is caused by pathogens that include bacteria, protozoa, and viruses. It kills by rapidly draining water and electrolytes out of the body. There are three main types of acute diarrhea that can easily turn life-threatening acute watery diarrhea, bloody diarrhea, and persistent diarrhea (UNICEF/WHO, 2009). Morbidity and mortality increase when recurrent diarrhea is coupled with immune compromising conditions such as inadequate feeding, weaning, recent/current measles, malaria, and AIDS (UNICEF/WHO, 2004). Children with frequent bouts of diarrhea enter into a cycle of malnutrition, anemia and decreased immune function. This results in severe loss of energy and protein and ultimately leads to death (UNICEF/WHO, 2004). Epidemiology The majority of the time, diarrheal disease is seen only as a short-term illness. This is because early warning signs of dehydration are difficult to identify and often present little to no signs or symptoms (Boschi-Pinto, 2009). In 2004, there were 5000 child deaths per day from diarrhea

(WHO, 2005). The incidence of diarrheal disease is two to three times higher in developing countries (WHO, 2005). While the mortality rate from diarrhea has decreased slightly in recent years, the incidence has remained relatively stable (Boschi-Pinto, 2009). This implies that while treatment interventions such as oral rehydration salts (ORS) and other therapies have been successful, preventative health interventions are not being implemented with the same degree of success. Diarrhea is especially a challenge in low-income countries that are overcrowded and lack access to safe drinking water (WHO, 2005). In 2004, about 21 percent of children in developing countries did not have access to safe drinking water. Currently, 88 percent of diarrheal deaths worldwide can be attributed to unsafe water and inadequate hygiene and sanitation practices (UNICEF/WHO, 2009). Unlike other endemic diseases, diarrhea can be prevented and treated by simple behavioral and sanitary practices, as well as water treatment interventions. This requires strong leadership, effective public health interventions, and program management. When researchers look at diarrhea from the perspective of morbidity, they find long-term effects that contribute not only to the impaired growth of a child with early diarrhea in the first two years, but also impaired fitness, cognitive function, and school performance between 6-12 years of age (Guerrant, 1999). Not all of these cases reach an end point of mortality. Therefore, the examination of non-fatal cases is essential to assess the true burden of illness in children with diarrheal disease. Etiology Infectious agents linked with diarrhea include bacterial, viral, and parasitic organisms. Cryptosporidia, rotavirus, and cholera are the pathogens primarily associated with acute watery diarrhea (Naficy, 2000). Pathogens that cause dysentery or bloody diarrhea include astrovirus, enterotoxigenic escherichia coli (ETEC), shigella and salmonella. Though persistent diarrhea does not have a single microbial cause, E. coli and cryptosporidia are often implicated (WHO/ UNICEF, 2008). Rotavirus is the most common cause of life-threatening diarrhea in children under 5 worldwide. The World Health Organization estimated that in 2004, rotavirus was responsible for 527,000 children deaths (Ahmed, 2009). In that same year, six countries were responsible for more than half of the rotavirus deaths: India, Nigeria, the Democratic Republic of the Congo, Ethiopia, China, and Pakistan (Ahmed, 2009). The UNICEF/WHO report on diarrhea found that of all hospital admissions caused by diarrhea, rotavirus was responsible for 40 percent of them (UNICEF/WHO, 2009). Transmission The primary routes of transmission for diarrheal diseases are fecal-oral, person-to-person and direct contact with pathogen-infected feces. Fecal-oral transmission is the ingestion of water or food contaminated with infected feces. Person-to-person transmission may occur when one prepares food or handles children with unclean hands. Direct contact with infected feces usually occurs when children play in an area that is contaminated with feces (WHO, 2005).

Case Management Integrated Management of Childhood Illness (IMCI) WHO defines IMCI is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age (WHO, 2010). IMCI implementation includes an 11-day training for health professionals and managers. IMCI has currently been introduced in over 75 countries worldwide. IMCIs strategy is divided into three main components: 1) Improving case management skills of health-care staff 2) Improving overall health systems 3) Improving family and community health practices. One of the main tools of IMCI that is used in the management of diarrhea in children is the algorithm shown below. This algorithm is given to health care providers at all levels in the delivery system, including Community Health Workers.

Treatment of Acute Watery Diarrhea Acute watery diarrhea is often associated with rapid fluid loss and dehydration (UNICEF/WHO, 2009). The pathogens causing this type of diarrhea may include cholera, rotavirus, and E. coli (UNICEF/WHO, 2009). Evidence-based guidelines for the treatment of diarrhea were updated in 2005, to reflect recent advances in care. Most cases of acute onset, non-dysentery diarrhea are self-limited and resolve without the use of antimicrobials. Diarrheal treatment guidelines have four supportive focuses: 1) prevent dehydration if it is not yet present 2) treat dehydration if it is present 3) prevent malnutrition through continued feeding during and after a diarrheal episode 4) reduce the severity of the episode as well as prevent future episodes using zinc supplementation (WHO, 2005). Antimicrobials are not routinely indicated in the treatment of acute, non-dysentery diarrhea. Unnecessary antibiotic therapy upsets the normal bacterial balance of the gut, promotes antibiotic resistance, and when used inappropriately, can lead to adverse outcomes (WHO, 2005). Preventing and Treating Dehydration Diarrheal stool contains large quantities of water and electrolytes such as sodium, potassium, chloride, and bicarbonate. An individual may be at risk of dehydration and metabolic imbalance after large losses and may even suffer from hypoglycemic shock, cardiovascular collapse, or cardiac arrest (Rehydration Project (a), 2009). An integral aspect of managing diarrheal illness is replacing rehydration in order to replace water and electrolyte losses. Oral Rehydration Therapy Oral Rehydration Therapy (ORT) using oral rehydration salts (ORS) is an effective method for preventing dehydration and treating mild to moderate dehydration in children and adults with diarrhea (WHO, 2005). ORT is non-invasive and may be used at home to prevent dehydration or in a hospital setting to treat individuals with signs of dehydration. Oral rehydration therapy relies on the following physiological principle: the absorption of salt through the intestinal lining is enhanced in the presence of glucose. Therefore, when one drinks an appropriately concentrated solution of salt and glucose, absorption of salt through the intestinal wall occurs. Water and other essential electrolytes then move through the intestinal lining in response to the movement of sodium, as water "follows" salt into the body (Goodall, 2009). The use of ORT was pioneered by WHO and UNICEF in the 1970s. Since then, there have been new and improved oral rehydration solutions. In 2005, WHO and UNICEF endorsed the "Reduced Osmolarity ORS". This new formula has a lower concentration of glucose and sodium and has been shown to more effectively and immediately reduce the severity of vomiting and diarrhea (UNICEF, 2004). In addition to standard glucose-based ORS, rice-based formulations are now available commercially, and can be found in health centers and pharmacies. Rice-based ORS is preferred for the treatment of diarrhea that is caused by cholera (WHO/UNICEF, 2002).

Fig. 2: Examples of ORS packets (Rehydration Project (a), 2009; Naveh Pharma, 2010).

In settings where ORS is not available commercially a simple Sugar-Salt Solution (SSS) may be prepared using specified amounts of sugar, salt, and clean water (Rehydration Project (d), 2009). The amount of ORS a sick individual requires for rehydration is dependent on a person's age, weight, stage of dehydration, and whether they continue to pass watery stool throughout the rehydration treatment (WHO, 2005). Those with signs of dehydration will generally require ~75 milliliters of ORS per kilogram of body weight to rehydrate sufficiently (Rehydration Project (d), 2009). ORS is given in small sips every one to two minutes, spooned to infants or given from a cup to children and adults. It should be given slowly and continued even if vomiting occurs (Rehydration Project (d), 2009).

Fig. 3: Directions for a homemade ORS mixture (Rehydration Project (d), 2009).

Intravenous Fluid Resuscitation Intravenous fluid resuscitation is required in cases of severe dehydration when a child is too sick to drink ORS (WHO, 2005). A trained medical professional should administer IV fluids to prevent progression to hypoglycemic shock or unconsciousness. Once severe dehydration has been adequately corrected by IV fluid resuscitation, ORT should commence and continue until diarrhea stops (WHO, 2005).

Preventing Malnutrition The pattern of repeated diarrheal illness in children is often described as a cycle that is perpetuated by malnutrition. Malnutrition makes children more vulnerable to diarrheal illness and is an underlying cause of death in up to 61 percent of childhood diarrheal deaths (Fischer Walker, Black, 2007). Maintaining a steady diet of nutritional, staple foods is therefore extremely important in decreasing the global burden of childhood diarrhea. Micronutrient deficiencies contribute to childhood illnesses by impairing the immune system's ability to ward off and fight infection (Fischer Walker, Black, 2007). Preventing Malnutrition During Diarrhea Continued feeding throughout diarrheal illness speeds recovery, improves intestinal function, and allows for continued growth and weight gain in children. Acute diarrhea can often lead to malnutrition if proper feeding practices are not maintained or increased during an illness episode (WHO, 2005). Recurring diarrheal disease can cause chronic malnutrition, leading to stunted growth, wasting, and increased susceptibility to future diarrheal infection (WHO, 2005). Promoting the intake of appropriate, nutritious food throughout diarrheal episodes is therefore an important aspect of treatment. If possible, calories may be added to a child's meal by adding one to two teaspoons of vegetable or red palm oil (WHO, 2005; Rehydration Project (e), 2009). Foods high in simple sugars, salt, and fat should be avoided as these may exacerbate diarrhea and dehydration. These include commercially prepared soups, soft drinks, and fruit juices. Children should receive an additional meal each day for two weeks following recovery from any diarrheal illness (WHO, 2005). Additionally, vitamin A supplementation may also be applied in instances of severe diarrhea with suspected vitamin A deficiency or other signs of malnutrition (PATH, 2009). Vitamin A, along with zinc, and folate supplementation, are recommended in specific global regions to enhance children's overall immune function (Fischer Walker, Black, 2007). Zinc Supplementation Zinc is critical to growth and development, and specifically supports the functions of the immune system. Depleted levels of zinc are associated with increased rates of infectious disease, including diarrhea, and increased mortality rates from these diseases (UNCIEF/WHO, 2009). Therefore, treating diarrhea with zinc supplementation helps the child recover, specifically by aiding ORS uptake and decreasing misuse of antibiotics. Zinc supplementation during diarrheal illness decreases both the severity and duration of the illness episode. Zinc supplementation substantially decreases the number of diarrheal episodes for two to three months following treatment. Research has shown that it is a highly effective intervention for decreasing under-five mortality due to diarrheal disease (Gilroy, Kuszmerski & Winch, 2005). All children with diarrhea should receive 10-14 days of zinc supplementation starting at the onset of illness (WHO, 2005). Breastfeeding One of the most effective means of protecting infants from diarrheal disease is through exclusive

breastfeeding. Breast milk provides passive immunity through maternally acquired antibodies and prevents the ingestion of contaminated foods or fluids during the infant's most vulnerable stage (Rehydration Project (b), 2009). Promotion of exclusive breastfeeding for the first 4-6 months of life is often a pillar of program curriculums aimed at combating diarrheal morbidity and mortality (WHO, 2005; UNICEF/WHO, 2010). Breastfed infants should continue to breastfeed without interruption during diarrheal illness (Rehydration Project (b), 2009). Children who continue to breastfeed throughout an illness episode experience a shorter duration of illness and lighter stool volume than those who are not breastfed (Rehydration Project (b), 2009). Some infants may feed more than usual but this is normal and should be encouraged (WHO, 2005). Older children receiving semi-solid or solid foods should continue to receive their normal, staple diet during diarrheal illness. They should be offered small, frequent meals (six per day). Recommended foods are those that are readily available, culturally acceptable, have high energy content and provide essential micronutrients (WHO, 2005). Foods that have been well cooked and are mashed or ground are particularly easy to digest (WHO, 2005). Rice, potatoes, noodles, milk, homemade soups, banana, cooked vegetables, and cereal grains with milk are examples of acceptable foods. Culturally acceptable eggs, meat, and fish dishes that contain ample energy are highly beneficial (WHO, 2005; Rehydration Project (e), 2009). Treatment of Complex Diarrheas The treatment of complex diarrheas require additional interventions and management than acute onset or watery diarrhea require. Complex diarrheas include dysentery (acute bloody diarrhea), suspected cholera with severe dehydration, persistent diarrhea (>14 days), and diarrhea in a child with signs of severe malnutrition (kwashiorkor or marasmus) (WHO, 2005). In these instances children may require hospitalization, careful fluid management, antimicrobial drug therapy, laboratory assessments, specific nutritional management, and additional multivitamin/mineral supplementation. For specific clinical treatment guidelines refer to the above IMCI algorithm and IMCI complete training manual. Clinical practice algorithms, such as the one below, are intended to guide practitioners through appropriate standardized treatment protocols. Community health workers, nurses, and physicians working outside the hospital setting should familiarize themselves with the appropriate treatment of diarrheal illness based on the child's unique presentation. Most importantly, providers should familiarize themselves with those factors that warrant referral to a more skilled provider or equipped care setting. Diarrhea Prevention Prevention is the most effective means of combating deaths due to diarrheal disease. The majority of global diarrheal cases can be prevented by improving access to clean water and implementing simple sanitary/hygienic practices. An estimated 88 percent of diarrheal disease is related to poor water, sanitation, and hygiene (WHO, 2004). Other effective prevention methods include the promotion of appropriate feeding practices, vitamin supplementation, and vaccination against illnesses like rotavirus and measles.

Clean Water and Sanitation Two and one half billion people lack access to clean water and 38 percent of the global population lacks access to appropriate sanitation facilities. Worldwide, 8 percent of people use shared facilities, 12 percent use inadequate facilities, and 18 percent practice open defecation. Those living in areas where inadequate facilities and open defecation are common are at particular risk of contracting diarrheal disease through fecal contamination of water supplies or by direct contact with fecal matter. Refugees and displaced populations are also in danger of contracting diarrheal diseases due to unsafe water supplies. Access to an improved water supply reduces diarrhea morbidity by up to 25 percent and improved sanitation by up to 32 percent (WHO, 2004). Therefore, providing adequate supplies of clean water and appropriate waste disposal technologies are vital components of programs aimed at improving general health, which in turn prevent child deaths due to diarrhea. Until broad coverage with clean, piped-in water can be achieved for those that do not yet have it, global health organizations are promoting the use of effective household water treatment and safe storage (Clasen, 2009). Educating families about point-of-use water disinfection practices as well as safe storage of water may represent the most realistic means for meeting the Millennium Development Goals related to water and protecting children from contaminated water sources (Clasen, 2009). Proper Hygiene Proper hygiene and sanitary practices, particularly hand washing, may reduce the risk for diarrheal disease by as much as 47 percent (Curtis, Cairncross, 2003). The importance of washing hands with soap and water or ash and water after defecating, changing diapers, and before preparing food should be stressed in any program curriculum (Rehydration Project (c), 2009). Water and food should be covered for storage, and families should avoid difficult to clean infant bottles and rely on spoon feeding instead (WHO, 2005; UNICEF/WHO, 2010). Vaccination Diarrhea prevention programming may include broadening immunization coverage for illnesses like rotavirus and measles, both of which contribute significantly to diarrheal mortality (Valencia-Mendoza et al., 2008; WHO/UNICEF, 2006). With the recent rollout of safe, effective rotavirus vaccines, the WHO now recommends rotavirus vaccination be included in all national immunization programs (GAVI, 2009). Vaccines for rotavirus have been developed by Merck, RotaTeq, Galaxo-Smith-Kline, and Rotarix, which are 98 percent effective in preventing severe cases of rotavirus (Parashar, 2003). Full coverage with rotavirus vaccine would reduce child deaths from rotavirus by 85 percent of (Parashar, 2003). Likewise, measles-associated diarrhea contributes significantly to global diarrheal morbidity and mortality (WHO/UNICEF, 2006). In fact, worldwide, diarrhea is one of the most common causes of death associated with measles (UNCIEF/WHO, 2009). Measles vaccination is highly effective and reduces the incidence and severity of diarrheal illness in children. The vaccination should continue to be promoted in all settings because of its success (WHO, 2009; WHO/UNICEF, 2006).

Education A rapid response to diarrheal disease is the key to recovery. Educating mothers, teachers, community health workers, and mass media about diarrhea identification and prompt, appropriate treatment is therefore vital. Those populations that are often most susceptible to diarrheal disease may be in hard to reach rural areas, or in areas with poor access to health care. Education campaigns should include key messages for parents, such as the importance of increasing fluid intake during diarrheal illness, the importance of continued feeding throughout and following illness, and when to see a healthcare provider. In Bangladesh, a wide-scale and culturally sensitive campaign to educate women about the use of ORT is a well-known success story. Over a 10-year period more than 12 million mothers were taught how to prepare ORS solution at home. Upon follow up, ORS solution was used in 60 percent of all diarrheal episodes and in 80 percent of acute watery diarrhea episodes, up from a baseline of 30 percent use (Chowdhury, A., et al., 1997). Technical Issues and Access Access to treatment and sustainable community management of care are two major barriers in reducing childhood mortality related to diarrhea. The Environmental Health Project (sponsored by UNICEF and USAID) published a basic framework to direct access of care and sustainability programs (EHP, 2004).

Fig. 4: Framework to direct access to care and sustainability (EHP, 2004).

Access to ORS ORS is an effective and inexpensive treatment for diarrhea, but it does not reach everyone who needs it. While some of the reasons behind this might be cultural and related to lack of education, ORS also faces the same issues any drug faces that is trying to reach the remote and rural populations of the world: distribution logistics. The logistics of transportation and distribution to such areas can be very challenging, and supplies are therefore often inconsistent or non-existent. This highlights the importance of teaching people to prepare their own ORS from sugar and salt rather than letting them become dependent on ORS packets. ORS faces yet another challenge. As has been discussed previously in this chapter, obtaining a clean and adequate supply of drinking water can be difficult in certain parts of the world. Not only does this create a greater risk of contracting a diarrheal disease, but it also becomes a problem when the standard treatment for diarrhea with ORS requires access to clean water. Access to Zinc In 2004, WHO and UNICEF added zinc supplementation to their recommendations for diarrhea treatment (WHO/UNICEF, 2004). However, six years after the WHO/UNICEF recommendation, zinc is still not widely available (UNCIEF/WHO, 2009). There have been many challenges in trying to scale up the zinc regimen, including: difficulties importing a new product to countries, start-up funds, hesitation in acceptance, and delay in purchase because local organizations are unclear on demand. Between increased zinc production locally and by UNICEF, and zinc education campaigns, the availability and acceptance of zinc as a treatment for diarrhea should improve. Program Strategies Due to the inadequate supply of both ORS and IV therapy, several proposed programs aimed at prevention of diarrhea have been directed towards mitigating known causes. Developing such programs requires detailed planning, as they need to be sustainable; ultimately, the goal of ORS programs is to reduce childhood mortality related to diarrhea as well as dependence on donor support for treatments. All goals and objectives must be explicit, methods realistic, and indicators informative. Several steps should be taken during the planning and managing process of a community-based diarrheal disease program. Organizations such as USAID promote strategies for control of diarrheal disease (CDD). The following is a description of program strategies for monitoring the implementation and evaluating the success of intervention programs within the context of hygiene (Curtis et. al., 2003). Engage stakeholders Stakeholders are persons or organizations (within the specified community) who have an investment in what will be learned from the program and are affected by how the knowledge gained will be used and applied within the community. It is critical to understand and integrate the perspectives of the stakeholders into program design.

Decide on a specific program objective(s) The objectives should be specific, measurable, agreed upon by all stakeholders, reasonable, and time-framed (SMART). It is essential that the objective(s) mirror concerns voiced within the community. For example, does the program aim to reduce mortality from diarrheal diseases or to decrease the number of children requiring IV treatment? Once clear objective(s) are decided upon, resources can be evaluated and distributed in an efficient manner. Designing the program The program should be designed based on the stakeholders input and agreed-upon objectives. Other important factors to consider in designing a program include developing a targeted educational campaign, creating a case management system, addressing the issue of sustainability, and adapting the intervention as much as possible to local resources and cultural behaviors. Design a methodology for program evaluation Programmatic issues must be prioritized and evaluated according to priority level with respect to available time and resources. Some issues of particular concern in diarrheal disease programs may be duration of illness, method of treatment (ORS versus IV fluids), and morbidity and mortality. Data collection involves time and resource costs and must be considered when designing the evaluation process. Data collection Information collection should convey a well-rounded picture of the program and will also present a credible image to the primary users of the community (Milstein & Wetterhall, 1999). Data collection is extremely important in the evaluation and improvement of a program. Even with resource constraints an effort should be made to collect a minimal amount of data at the start of a new program to ensure that the objectives are being met. Evaluate data and provide feedback to community Once data is collected, evaluate its efficacy and relevance to the primary objectives and make programmatic changes accordingly. This data should then be widely disseminated throughout the community and accompanied with appropriate explanation so that the community members understand the results. Furthermore, feedback from the community must be evaluated and incorporated into future program designs. Monitoring and Evaluation (M&E) The success of community-based diarrhea programs depends on several factors. Involvement in program development, especially by mothers, is crucial to program participation. Education messages must also be relevant and appropriate for the program setting. Families must be taught attainable skills, provided with easily understandable knowledge and continuous motivation and support in order to achieve program success. Additionally, communities should receive support from the existing health system. Accessible clinics, appropriate medical services, and educated health care workers are all crucial factors to success (WHO, 2006; WHO/UNICEF, 2004). Examples of indicators often used in the monitoring and evaluation of community-based diarrheal disease programs include (WHO, 1999):

 Duration of illness Treatment method (ORS versus IV therapy) Morbidity and mortality rates Training coverage rates (e.g., delivery of care, education methods in breastfeeding and hygiene practices, etc.) ORS access rates ORS use rate ORT use rate Zinc supplementation use Increased fluid intake rate Continued feeding rate Households knowledgeable of when to seek treatment outside the home Households knowledgeable in preparing a safe and effective ORS The data for these indicators can be obtained through household surveys and health facility surveys. The results of these surveys can then be used in focused program reviews to analyze how well the program has achieved its goals and identify any changes that need to be made. The evaluation process and program findings must be shared and disseminated appropriately, especially among the community members (Milstein & Wetterhall, 1999) Example Intervention: Hygiene

Fig. 5: Potential transmission routes for diarrhea causing pathogens (Eisenberg, 2007).

Above is a diagram mapping disease pathogens related to hygiene. An estimated 88 percent of diarrheal deaths are attributed to poor hygiene (UNCIEF/WHO, 2009). The diagram is a useful tool in understanding where program interventions can play a large role. Innovations and Technology Progress has been made over the past decade in the technology available for household water treatment and safe storage. Many technologies are available for varying costs ranging from very inexpensive (chlorine tabs such as AquaTabs) to expensive (PUR, a disinfection/flocculation technology available from Proctor and Gamble). Below is a chart of several technologies that are available and their varying effectiveness in reducing diarrhea. A great degree of behavior change is inevitably necessary in order to implement these technologies, which means that it is difficult to measure the rate at which these changes are adapted.

Clasen T, Roberts (2006)

In addition to the above techniques currently being promoted throughout the world, there is a focus by the donor community on improving sanitation to reduce burden of illnesses such as childhood diarrhea. In a list of new investments announced in July, 2011 the Gates Foundation committed $42 million in grants for the promotion of safe sanitary practices in the developing countries. Since flush toilets are not feasible in much of the developing countries, they requesting proposals to reinvent the toilet (Gates Foundation, 2010).

Under the same theme of improving water and sanitation, yet through a different approach, UNESCO-IHE Institute for Water Education has committed $8 million to higher education through their support efforts to change the postgraduate water and sanitation education system through an increased focus on solutions that work for the poor and a robust online curriculum to reduce costs and increase accessibility to higher education (Gates Foundation, 2010). It is through new technologies and innovations, like the water purification systems shown above, and dedicated donors and researchers, that we achieve progress in our continued fight to reduce the incredible burden of morbidity and mortality that comes from childhood illnesses such as chronic diarrhea and dehydration. Conclusion Dysentery, persistent diarrhea, and diarrhea in a child with malnutrition require skilled care including appropriate antibiotic administration. Therefore, practitioners need to be familiar with diarrhea's various presentations and practice guidelines in order to effectively treat children to reduce the under-5 mortality rate. Likewise, they must also engage in teaching families how to appropriately care for their children so that families can take appropriate action to save their children. Diarrhea's impact on children's health will continue to be seen for years to come. Short-term and long-term consequences from diarrhea yield a decrease in quality of life. Focusing on only one aspect of the disease, however, will not suffice. The monitoring of other diseases such as malnutrition and immuno-compromising illnesses is essential as they contribute greatly to the disease's onset and reoccurrence. As demonstrated, there are concrete and immediate interventions that can reduce the number of children suffering from diarrhea. That said, the underlying concerns with regard to prevention are those that can be addressed in order to achieve long-term impact. If devised and implemented at the community level, with a strong plan of action and achievable indicators, health care workers and families will not only be able to treat children with diarrhea, but also jumpstart long-term reduction in diarrhea, and ultimately, childhood mortality. Perhaps, one day this disease, and others, will be conquered as countries continue their efforts to fulfill MDG4.

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