ACUTE DIARRHOEAL DISEASES AMONG PRESCHOOL CHILDREN IN WESTERN MAHARASHTRA, INDIA

Open Access Journal │www.njcmindia.org pISSN 0976 3325│eISSN 2229 6816 Original Article ACUTE DIARRHOEAL DISEASES AMONG PRESCHOOL CHILDREN IN WESTERN MAHARASHTRA, INDIA Mahesh B Tondare1 , Vaishali V Raje2, Satish V Kakade3 , Madhavi V Rayate4 Financial Support: None declared ABSTRACT Conflict of interest: None declared Background: Malnutrition and infectious diseases both occur in the same unfortunate children and together they play a major role in causing the high morbidity and mortality in them. Acute Diarrhoeal diseases (ADD’s) are reported to be the 2nd leading cause of child morbidity and mortality. Copy right: The Journal retains the copyrights of this article. However, reproduction of this article in the part or total in any form is permissible with due acknowledgement of the source. How to cite this article: Tondare MB, Raje VV, Kakade SV, Rayate MV. Acute Diarrhoeal Diseases Among Preschool Children in Western Maharashtra, India. Natl J Community Med 2014: 5(4);383-6. Author’s Affiliation: 1Assistant Professor; 2Associate Professor; 3Statistician , 4Professor, Department of Community Medicine, Ashwini Rural Medical College, Kumbhari, Solapur, Maharashtra Correspondence: Dr. Mahesh B.Tondare E-mail:maheshtondare1@gmail.com Date of Submission: 23-07-14 Date of Acceptance: 02-12-14 Date of Publication: 31-12-14 Objectives: To study the attack rate of Acute Diarrhoeal Disease among pre-school children and to study the socio-demographic variables of pre-school children suffering from Acute Diarrhoeal Disease. Methods: A Longitudinal study was conducted among preschool children (3-5years) of Private pre-primary school of urban area and followed for the period of one year. Mother/ guardian/ teacher was interviewed by using pre-tested proforma. Results: About 56% of children found suffering from ADD with 0.6 episodes per children per year among private pre-primary school. Higher proportions of ADD affected children were residing in nuclear type of family, belonging to middle socio-economic class, mothers were literate & housewives, born with order >2 compared to non ADD affected children. Conclusion: More than half of children from private pre-primary schools suffered with nearly one attack of Acute Diarrhoeal Disease. Maternal illiteracy and working mothers found favorable factors. Immunization coverage, EBF and proper weaning play a very important role in prevention of infections. Keywords: Anganwadi, ADD, Incidence, Literacy, Pre-primary school children INTRODUCTION Malnutrition and infectious diseases both occur in the same unfortunate children and together they play a major role in causing the high morbidity and mortality in them.1 The period below 5 years among the children is the most crucial period and if any infection occurs during this period, will affect the growth and development of child because maximum growth and development occur in this period. Among the infectious diseases, acute respiratory infections (ARI) and acute diarrhoeal disease (ADD) are leading cause for childhood mortality and morbidity.2 acute Diarrhoeal Disease is defined as ‘passage of loose/liquid/watery stools 3 or more than 3 times a day. Recent change in consistency of the stool which is important rather than frequency.3 In India Diarrhoeal disease is a major health problem among children under the age of 5 years. During 2005 about 1.07 million cases of acute diarrhoea were reported in India with 2040 deaths. Diarrhoeal diseases cause a heavy economic burden on health services.4 Most of diarrhoeal diseases (88%) are attributed to unsafe water Supply, inadequate sanitation and hy- National Journal of Community Medicine│Volume 5│Issue 4│Oct – Dec 2014 Page 383 Open Access Journal │www.njcmindia.org giene. Measures like improvement in water supply and sanitation helps in reducing diarrhoeal disease morbidity.5 A major determinant of child health is the health and knowledge of the Child’s mother. It has been seen that the mother is the main caregiver for the child in almost all societies. So, the knowledge, attitude and health practices of the mothers directly reflect on the health and vitality of the child. Most of morbidity due to diarrhoea can adequately managed at home. Health education on the aetiology, prevention and management of the diarrhoea has the potential to establish productive contact between the health services and the community, to increase the capability of the families to recognize the danger signs of diarrhoea in children and to encourage appropriate and early care seeking behaviours.6 MATERIAL & METHODS: A community based longitudinal study was carried out among the pre-primary school children (3-5years) to find out the attack rate of Acute Diarrhoeal Diseases & also study the sociodemographic factors associated with it. Sample size was calculated by taking the incidence of acute diarrhoeal diseases from the past study i.e. 11%, 7 and considering 5% error which comes around 151. The formula applied was sample size = (1.96)2 x pq/E2. Considering the chances of drop outs during the Course of the study, extra 10% samples were added it. So the final sample size was 166. This sample was taken from private pre-primary school of urban area. Three Private pre-primary schools from karad city were selected randomly & required number of children’s & their mother/guardian/teacher were enrolled for the study by using prestructured & pretested proforma. The proforma included the baseline data i.e. general particulars of the parents and children and also on birth and immunization history (cross checked from records), breastfeeding history and anthropometric measurements of the child; general and systemic examination of each subject was carried out. The information was collected from mother/father/guardian and class teacher/anganwadi worker. During this period, parents were told about the signs and symptoms of acute diarrhoeal diseases so that they can deliver proper history. Subsequent three follow up visits were carried out at the interval of every 4 months i.e. in the pISSN 0976 3325│eISSN 2229 6816 month of April, August & December. During the follow up visits, episodes were counted if they appeared freshly after completion of visit & during the visit. This procedure was repeated for all the follow ups. During these visits, history of any illnesses including episodes of ADD till the follow up visit was collected from the mother, guardian or class teacher/ anganwadi worker followed by General and systemic examination of the child. Ethical clearance was obtained from Institutional Ethical Committee & informed verbal consent from principals of schools and guardians were also obtained prior to the study. Frequency percentage, chi-square test & odds ratio calculations were applied for analysis. RESULTS Among private pre-primary children followed for one year 88 out of 155 had attack of ADD one or more time giving an incidence rate of 0.632 episodes/child/year (attack rate 56.77%) Table 1: Magnitude of ADD among preprimary school children Group No. Children affected in a year Episodes in a year Incidence= Episodes/Child/year Annual attack Rate (%) Total 155 88 98 0.632 56.7 Boys 83 48 55 0.662 57.8 Girls 72 40 43 0.597 55.5 Table 2: ADD Episodes according to follow-up visits Particulars Total Episodes Mean Episodes/child Standard Deviation Period Prevalence Baseline 14 0.090 0.287 9% Visit I 27 0.174 0.380 17% Visit II 43 0.277 0.449 27.7% Visit III 14 0.090 0.287 9% The incidence of ADD was observed higher among the boys of private pre-primary school children compared to girls (table 1). Table 2 shows the period prevalence of ADD was 9% during baseline data collection which was increased to 17% & 27.7% during 1st & 2nd follow up and then decreased to 9% during last visit. This shows seasonal change in prevalence of ADD, i.e. 1st & 2nd visits were done during summer & rainy seasons respectively whereas baseline data collection & last 3rd visit was undertaken during winter seasons. Other variable like total number of episodes & mean episodes/child also support the seasonal variation. National Journal of Community Medicine│Volume 5│Issue 4│Oct – Dec 2014 Page 384 Open Access Journal │www.njcmindia.org pISSN 0976 3325│eISSN 2229 6816 Table 3: Distribution of Pre-Primary School Children Particulars ADD present n=88 (%) Sex of the child Boys Girls Age group(mn) 36-47 48-60 Type of Family Nuclear Joint Socio Economic Status Upper class Middle class Lower class Maternal Education Illiterate Literate Maternal Occupation Working Mothers Non-Working Mothers Birth Order ≤2 >2 Birth Weight < 2.5Kgs ≥2.5Kgs ADD absent N=67 (%) Total N=155 (%) χ2 (p value ) OR 95%CI 48(54.5) 40(45.5) 35 (56.4) 32 (43.6) 83 (53.5) 72 (46.5) 0.01 (0.90) 1.09 0.58-2.07 24(27.3) 64(72.7) 24 (36) 43 (64) 48 (31) 107 (69) 0.93 (0.33) 0.67 0.33-1.33 54(61.4) 34(38.6) 28 (42) 39 (58) 82 (53) 73 (47) 5.08 (0.02)* 2.21 1.15-4.22 20 (22.8) 48(54.5) 20(22.7) 09 (13.6) 30 (44.7) 28 (41.7) 29 (19) 78 (50) 48 (31) 6.92 (0.03)* - - 00(00) 88(56.7) 00 (00) 67 (43.3) 00 (00) 155 (100) - - - 43(48.9) 45(51.1) 16 (23.9) 51 (76.1) 59 (38.1) 96 (61.9) 9.03 (0.002)* 3.04 1.51-6.13 40(45.4) 48(54.6) 31 (46.3) 36 (53.7) 71 (46) 84 (54) 0.01 (0.001)* 0.96 0.51-1.83 28 (32) 60 (68) 11 (16.5) 56 (83.5) 39 (25) 116 (75) 4.00 (0.04)* 2.37 1.08-5.21 OR 95% CI Table 4: ADD affected children and Feeding Practices Particulars ADD present N=88 (%) ADD absent N=67 (%) Total N=155 (%) χ2 (p value ) Exclusive Breast Feeding Present 36 (41) Absent 52 (59) 39 (58.2) 28 (41.8) 75 (48) 80 (52) 3.89 (0.04)* 0.49 0.26-0.94 Total Breast Feeding Up to 2yrs 43 (48.9) >2 yrs 45 (51.1) 45 (67.1) 22 (32.9) 88 (56.7) 67 (43.3) 4.47 (0.03)* 0.46 0.24-0.90 4.84 (0.02)* 2.19 1.13-4.22 Weaning ≤6months >6months 47 (46.6) 41 (53.4) 23 (34.4) 44 (65.6) The above table no. III showed that, higher proportions of ADD affected children were boys & in the age group of 48-69months but the difference was not found statistically significant. Whereas significantly higher proportions of ADD affected children were residing in nuclear type of family, belonging to middle socioeconomic class, whose mothers were literate & housewives, born with order >2 and with birth weight ≥2.5Kgs compared to non ADD affected children. The above table IV depicts significantly higher proportion of children affected by ADD had not 70 (45) 85 (55) got Exclusive breast feeding and proper start of weaning compared to non ADD affected children whereas total breast feeding was done for up to 2yrs. On application of odds ratio to weaning showed ADD 2.1times more among children in whom weaning was started before 6months. DISCUSSION In the current study it is observed that the incidence of ADD’s in private pre-primary school children (0.6 episodes/child/year), Gupta N et al8 observed almost similar findings (1.6 epi- National Journal of Community Medicine│Volume 5│Issue 4│Oct – Dec 2014 Page 385 Open Access Journal │www.njcmindia.org sodes/child/year) of DD’s in their study conducted in slum area, where as the incidence of diarrhoea was reported higher from Africa, Asia and Latin America.9 pISSN 0976 3325│eISSN 2229 6816 REFERENCES 1. J. Walter James. Longitudinal study of the morbidity of diarrhoeal and respiratory infections in malnourished children. The American journal of Clinical nutrition July 1972; Volume 25:690-694. 2. Health situation in South East Asia region 1998-2000, WHO, Regional office for South East Asia, New Delhi 2002 : 113-116. 3. K.Park. Park’s Textbook of Preventive and Social Medicine, 21st ed. Jabalpur: Bhanot Publishers; 2011. p 199. 4. Govt of India (2006), Health Information of India 2005, Ministry of health and family Welfare, New Delhi. 5. WHO, Facts and Figures, water, sanitation and hygiene links to health, World Health Organization, updated Nov. 2004. 6. Reshan S, Gautam K, Gurung K. mothers needs to know more regarding management of childhood acute diarrhea. Indian Journal of Prventive & Scocial Medicine 2003: Vol.34 (1&2):41-5. 7. Significantly higher proportion of ADD affected children belonged to nuclear family, similar finding (54.7%) was reported by Bhattacharya et al11. WHO, Millennium Development Goals: Progress towards the health-related Millennium Development Goals, Fact Sheet No.290, May 2011. 8. In the current study more than 50% of mothers of DD’s affected children were working which might have contributed for poor nutrition and poor health status of children thus, similar findings was reported by Mulugeta Teklu14. Gupta N, Jain SK, Ratnesh, Chawla U, Hossain S, S.Venkatesh. An Evaluation of Diarrhoeal diseases and Acute Respiratory infections control Programmes in a Delhi Slum. Indian Journal of Paediatrics May 2007; Volume 74:471-476. 9. Snyder & Merson M., The magnitude of the global problem of acute diarrhoeal diseases: a review of active surveillance data. Bulletin of the World Health Organization 1982; 60 (4): 605-613. In the study of Molbak et al10, Bhattacharya et al11 and Shally Awasthi and Vinod Pande12 it was observed that among the diarrhoea affected children boys were most commonly affected, where as in the current study whereas there is no difference observed in girls and boys suffering with ADD’s in private pre-primary school children. As in the current study proportionately large number of children belong to age group 48-60 months, the higher number of affected children also belong to same group than 36-47 months, similarly of EI-Gilany A.H. et al13 also reported higher proportion of ADD affected children belong to age group (48- 60 months). Higher proportion of ADD affected children were of birth order more than 2 similarly EIGilany A.H. et al13 in his study found that 66% of ADD affected children were of birth order more than 2, it means as birth order increases the risk of DD’s also increases. The period prevalence of ADD was 9% during the baseline data collection period which increased in 1st & 2nd visits, with mean episodes/child of (0.09, 0.17, 0.27 and 0.09), similarly prevalence was reported by Snyder and Merson8, Bhanderi D et al14 and Gupta N et al8 (2.2 episodes/child/year, 2 episodes/child/year and 1.69 episodes /child /year respectively). CONCLUSION Maximum number of children from private preprimary schools suffered with at least one attack of Acute Diarrhoeal Disease. Maternal illiteracy and working mothers found favorable factors in causing ADD. Immunization coverage, EBF and proper weaning play a very important role in prevention of infections in early life as well as repeated attacks in future. 10. Molbak K, Jensen H,Ingholt L, Aaby P. Risk factors of diarrhoeal disease incidence in Early childhood :A Community Cohort Study from Guinea-Bissau. American Journal of Epidemiology 1997; Volume 146, No 3: 273-282. 11. Bhattacharya R, Kaur P. Epidemiological correlates of diarrhoea in a rural area of Varanasi. Indian Journal of Community Medicine 1989; Vol XIV, No 2:79-82 12. Awasthi Shally and Pande Vinod Kumar. Seasonal pattern of morbidities in preschool slum children in Lucknow, North India. Indian Paediatrics November 1997; volume 34. 13. El-Gilany A.H. And Hammad S. Epidemiology of diarrhoeal diseases among children under age 5 years in Dakahlia, Egypt. La Revue de Santé de la Méditerranée orientale 2005; Vol. 11, No 4. 14. Mulugeta Teklu. Socio- Economic, environmental and Behavioural factors Associated with the occurance of Diarrhoeal Disease among under five children, Meskanena Marekoworeda, South Ethiopia. Thesis of MPH submitted to the school of graduates’ studies of Addis Ababa University, 27-35. 15. Bhanderi D, Choudary SK. An epidemiological study of health and nutritional status of under five children in semi-urban community of Gujarat. Indian Journal of Public Health Oct-Dec 2006;50(4). . National Journal of Community Medicine│Volume 5│Issue 4│Oct – Dec 2014 Page 386