Diarrhoea was the third leading cause of childhood mortality in India, and is responsible for 13% of all annual deaths in children under 5 years of age killing an estimated 300,000 children in India each year. According to a report by the World Health Organization (WHO), India has the highest burden of diarrheal disease in the world, with an estimated 340,000 deaths per year due to this condition. The epidemiological transition from communicable diseases to non-communicable diseases has shifted the attention of public health researchers accordingly in recent years. Yet, the morbidity, mortality, and disability associated with communicable diseases, or so-called primitive diseases, and are still significant, but things have been changing and changing fast! Usually, the incidence of diarrheal diseases is high during the summer months, when drinking water becomes a major scarcity. That makes people below poverty line (BPL) consume whatever is available; Prime Minister Narendra Modi therefore addressed this subject on Mann ki Baat on several occasions. On 22 March 2015, the PM said, “Some farmers have to drink contaminated water in their villages” that lead to a systemic path towards safe potable water. While taking the stock of the situation, in the 31 January 2021 episode of “Mann Ki Baat” he applauded the feat achieved by the Badaut village Panchayat of Panchkula in Haryana. He said, “This Panchayat faced the problem of water drainage. Because of this dirty water was spilling around, spreading disease, but, people of Badaut decided that they would create wealth even from this water waste. The village Panchayat started filtering the dirty water coming from the village after collecting it at a place, and this filtered water is now being used for irrigation by the farmers of the village, thereby, liberating them from pollution, filth and disease and irrigating the fields too.” In the 28 February 2021 episode of Mann ki Baat, he said “Bin paani sab soon—without water, everything comes to a naught. And that just as there is a collective gift, there is a collective accountability too. River, lake, pond or groundwater—all of these are for everyone.”
India has made steady progress in reducing deaths in children younger than 5 years, with total deaths declining from 2.5 million in 2001 to 1.5 million in 2012 thanks to the success of many universal programs like expanded program on immunization, program for the control of diarrhoeal diseases and acute respiratory infection. India’s child mortality rate has improved further, bringing the country closer to achieving the UN sustainable development goal on child health, with a new official report showing under-5 mortality rate of 32 in 2020, from 47 in 2014. Even then, the proportional mortality accounted by diarrhoeal diseases still remains high. In addition to the direct effects of the disease, diarrhoea can also have significant long-term consequences, including malnutrition, stunted growth, and cognitive impairment.
Diarrhoea is a condition characterized by loose, watery stools that occur more frequently than usual. The most common cause of diarrhoea is infection either because of viruses, bacteria or parasites. Spread of infectious agents through contaminated food, water, or surfaces due to poor sanitation and unhygienic conditions are the important risk factors for diarrhoea in our country. Despite the progress we are making, mode of water transportation, and poor handling of water at the household level, poor wastewater management, refuse storage, collection and disposal, domestic water reservoir conditions, faeces disposal and presence of vectors predispose us to diarrhoea.
Prevention and control of diarrhoeal diseases in India has been a very complex challenge, requiring a multifaceted approach that addresses the underlying social and environmental determinants of the disease. The government has launched several initiatives to address these issues, including the Swachh Bharat Abhiyaan and the National Health Mission, which includes a focus on maternal and child health. Some of the key strategies to target diarrhoeal diseases are:
Improve access to safe drinking water: According to a report by the National Sample Survey Organization (2018), only about 51.4% of the households in the rural and about 72.0% in the urban areas used improved source of drinking water, sufficiently available throughout the year located in the premises. For all the water being supplied to become potable may take over a decade. Diarrhoea cases were seen in greater proportion of houses not practising water purification methods. Therefore, people need to be educated about these—like boiling of water, candle based filters, ultraviolet purification etc. An NGO in Maharashtra studied a simple strategy for sterilization: filter the water to remove particulate matter, then raise the temperature to about 45 degrees and maintain for at least three hours. For this a unique low-cost solar water purifier using discarded sari, a few glass pipes and freely available sunlight was used. Such sustainable strategies need to be encouraged and scaled up.
Improving sanitation: Lack of toilets remains one of the leading causes of illness and death among children. According to UNICEF, 626 million people in India practised open defecation, which is now fast declining. About 71.3% of the households in the rural and about 96.2% in the urban areas had access to latrine. Sulabh International, an NGO launched an excellent initiative starting public toilets in slums and crowded localities; which has been replicated across the country by different NGOs. Concept of mobile toilets has also come to the rescue. Government also provided cash incentives for construction of domestic toilets.
Promoting good hygiene practices: Hand-washing before preparing food is a particularly important opportunity to prevent diarrhoea and it works best when it is part of a package of behaviour change interventions. Washing hands with soap can reduce the risk of diarrheal diseases by 42-47%. Hand-washing with soap before eating and after defecation, is being promoted among children in India through the school hygiene program and mass media campaign on “the hand-washing day”. Similar catchy campaigns need to be ongoing to ensure that hand washing becomes part of the behaviour change communication. Washing hands after defecating or handling children’s feces and before handling food entails an average of 32 hand washes a day and consumes 20 litres of water. Although the interventions promoting hand-washing and other hygiene measures clearly show a reduction in diarrheal diseases risk in the short term, sustainability of hand-washing behaviour in the communities and the benefits of upscaling interventions need to be studied, as India-specific data are scarce. The Covid-19 pandemic did provide a major push towards hand hygiene.
Immunization: Increasing access to vaccines against common diarrhoeal pathogens. Rota virus was the commonest cause of childhood diarrhoea and fortunately is vaccine-preventable. India has played a great role not only providing affordable and accessible Rota Vaccine to Indian children but globally. More than 80% children immunized globally with Rota virus vaccine and other childhood vaccines are made in India.
Management of diarrhoea: Current guidelines for management of diarrhoea by the Ministry of Health, recommend low osmolarity oral rehydration salt solution (ORS), zinc and continued feeding of energy dense feeds. Knowledge of ORS among mothers of under-five children in India is good (73%), but there is a big gap between knowledge and practice as reflected in poor ORS usage rates (43%). Though zinc is distributed under the National Rural Health Mission (NRHM), very low coverage of zinc prescription has been documented, due to lack of knowledge and awareness among the care providers. In addition to improving this, compliance with the use of zinc and scaling up of zinc use in communities will have a major impact in decreasing morbidity and mortality. Reportedly, harmful practices such as restrictions of fluid or breast milk during diarrhoea are still rampant with negative health outcomes.
There is also an indiscriminate use of antibiotics that is unnecessary in most patients. Antibiotics are needed in diarrhoeal diseases only for bloody motions, or those associated with fever or severe malnutrition. However, many of us have been guilty of having consuming these often without prescriptions. This further contributes to the development of antibiotic-resistant strains of bacteria, which can further complicate treatment and increase mortality.
Access to healthcare when sick: Lack of access to affordable healthcare for those who need the most remains a challenge especially for people in hilly terrains, tribal, rural or low-income areas. There is a need for increased investment in primary healthcare. This includes not only the provision of healthcare facilities and trained healthcare professionals but also the development of robust surveillance systems to monitor the spread of infectious agents and track interventions.
Public awareness: One of the main barriers to prevention and control of diseases is lack of awareness and understanding of the causes and consequences of the disease, the importance of preventive measures and proper health-science communications. This highlights the need for greater public education and awareness campaigns. Having celebrities to deliver catchy messages often drives home the prevention in the best way.
*Dr Trupti Gilada is a Physician in Infectious Diseases at Unison Medicare and Research Centre, Saifee, Masina and Bhatia Hospitals in Mumbai. trupti_gilada@yahoo.com, www.unisonmedicare.com