Diarrhoea cluster in a coastal hamlet with stored water and few toilets
In a coastal hamlet of about 400 people you are posted as a health worker for one month. In the last 6 days the sub-centre has recorded 23 cases of loose stools, 14 of them in children under 5, and two children are moderately dehydrated. The hamlet has no piped water; families store water in open-mouthed plastic pots and drums, and there are only 6 household toilets for 70 houses, so many people use the beach. A mother brings a 14-month-old girl who is still breastfeeding. The child has had 5 watery stools today, has sunken eyes, and a skin pinch on the abdomen goes back slowly, in about 3 seconds. She is alert and drinks eagerly from a cup.
1. Classify this child's dehydration and write the treatment plan with quantities and timing.
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Classification: some dehydration (moderate), not severe.
Reasoning from the WHO criteria:
- Sunken eyes - one sign
- Skin pinch returning in about 3 seconds - slow, one sign
- Alert and drinking eagerly - this rules out severe dehydration, where the child is lethargic or unconscious and unable to drink
Two or more signs including a slow skin pinch place her in the "some dehydration" group, which needs Plan B, not Plan C (IV fluids) and not Plan A alone.
Plan B:
- ORS 75 mL per kg over 4 hours. A 14-month-old girl weighs about 9–10 kg, so 75 × 9.5 ≈ 700 mL over 4 hours, given by cup and spoon in small frequent sips.
- Continue breastfeeding between sips; do not stop feeds.
- If she vomits, wait 10 minutes and resume more slowly.
- Zinc: 20 mg once daily for 14 days (10 mg if under 6 months).
- Reassess at 4 hours: if the eyes are normal, the skin pinch is fast and she is passing urine, switch to Plan A - ORS after every loose stool and normal feeding. If she is worse, refer for IV fluids.
- Do not give anti-diarrhoeal drugs or antibiotics routinely; antibiotics are only for confirmed dysentery or cholera.
2. List four community-level actions in priority order, with the reason for each.
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1. Treat and follow up every current case (immediate). Set up an ORS and zinc corner at the sub-centre and the anganwadi, teach mothers to mix ORS in 1 litre of safe water, and follow up the moderately dehydrated children daily. Deaths in this outbreak will come from dehydration, not from the organism.
2. Make water safe (next 48 hours). With no piped supply, the stored water is the likeliest vehicle. Advise chlorination of wells and pots (bleaching powder at the correct dose, calculated with the standard formula), boiling or filtering, and storing in narrow-mouthed covered containers with a ladle - never dipping hands or a dirty mug. Open-mouthed pots with a hand dipped in are a direct faecal-oral route.
3. Sanitation and handwashing. Six toilets for 70 houses cannot work; push safe disposal, keep the existing toilets functional with water, and promote handwashing with soap at the five critical times, especially after defecation and before feeding a child. Beach defecation contaminates the shore, the feet and the water source.
4. Surveillance and health education. Notify the PHC and the medical officer; keep a line list by house and date to see whether the outbreak is falling. Check for blood in stool or rice-watery stool, which would change the response to dysentery or cholera. Educate through the anganwadi, the school and house visits, using demonstration, not lecturing.
Reason for this order: treatment first prevents deaths; water and sanitation stop new cases; surveillance tells you whether your actions are working.
3. What would you teach this mother about feeding and about danger signs before she goes home?
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Feeding - food is treatment, not a rest for the gut.
- Continue breastfeeding on demand throughout; breast milk is clean and provides fluid and antibodies.
- Give ORS after every loose stool, about 50–100 mL for a child of this age, in small sips from a cup and spoon.
- Continue her usual soft diet - rice, dal, mashed vegetables, curd - small amounts 5–6 times a day. Do not stop food and do not dilute feeds.
- One extra meal a day for two weeks after recovery, to regain weight.
- Zinc for 14 days, even after the stools stop.
Danger signs - return at once if any appear:
- Sunken eyes, no urine for 6 hours, or a skin pinch that stays up
- Repeated vomiting and inability to drink
- Blood in the stool
- High fever, drowsiness, fits, or the child becoming limp
- Dry mouth, no tears, or the soft spot on the head looking sunken
Also teach: handwashing with soap before feeding and after cleaning the child; boiling or filtering drinking water; keeping the water pot covered; using the toilet or a safe place, not the beach. Ask her to repeat the danger signs back to you, because teaching that is not repeated back is teaching that was not heard.