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Amal Mitra, MD, MPH, DrPH

Professor

University of Southern Mississippi

Diarrheal Disease ManagementEvidence of Some Successful

Programs

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Learning O!ectives

At the end of this session, students "ill learn#

$ommon causes of diarrhea

Mode of transmission of diarrhea

Sign and symptoms of common diarrhealillnesses

Simple management tools for diarrhea

E%amples of some success stories tocomat the prolem

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&ypes of Diarrhea

'atery Diarrhea# ( or more li)uid or "aterystools in *+ h

Dysentery# Presence of lood andor mucus

in stoolsPersistent Diarrhea# Diarrhea lasting for -+

days or more

Mother.s definition/

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$auses

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$ommon Diarrheas

Age 0* years# 1otavirus

Age *23 years# $holera4 E5 coli4 Shigellosis

All ages# E5 coli4 $ampyloacter

6mmunocompromi7ed# Ameiasis4$ryptosporidium

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$OMMO8 $AUSES O9D6A11HEA2 :A$&E16A

Vibrio choleraShigellaEscherichia coliSalmonella

Campylobacter jejuni

Yersinia enterocolitica

StaphylococcusVibrio parahemolyticusClostridium difficile

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$OMMO8 $AUSES O9D6A11HEA2 ;61US

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$OMMO8 $AUSES O9D6A11HEA2 PA1AS6&E

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$OMMO8 $AUSES O9D6A11HEA2O&HE1S

< Metaolic disease

Hyperthyroidism

Diaetes mellitusPancreatic insufficiency

< 9ood allergy

Lactose intolerance

< Antiiotics< 6rritale o"el syndrome

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&1A8SM6SS6O8

Most of the diarrheal agents aretransmitted y the fecal2oral route

$holera# "ater2orne disease4 transmittedthrough "ater contaminated "ith feces

Some viruses >such as rotavirus? can etransmitted through air

8osocommial transmission is possile

Shigellosis >lood dysentery? is mainlytransmitted person2to2person

Shigellosis is a "ater2"ashed disease4transmitted more "hen there is scarcity of

"ater

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SEASO8AL6&@Disease Common season

Cholera Winter

Rotavirus diarrhea Winter

Shigellosis Dry summer

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$holera

&"o iotypes$lassical or Asiatic type

El&or more prevalent

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Vibrio choleraeO-(B

Vibrio choleraein O2group -(B "as firstisolated in -BB* and y -BB( had een foundthroughout the 6ndian sucontinent5 &hisepidemic e%pansion proaly resulted from asingle source after a lateral gene transfer >LC&?event that changed the serotype of anepidemic V choleraeO- El &or strain to O-(B5

More information#

http#"""5cdc5govncidodE6DvolBno*2F5ht

http://www.cdc.gov/ncidod/EID/vol9no7/02-0760.htmhttp://www.cdc.gov/ncidod/EID/vol9no7/02-0760.htm

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Vibrio vulnificus&he organism Vibrio vulnificuscauses

"ound infections, gastroenteritis or aserious syndrome =no"n as Gprimarysepticema5G

V vulnificusinfections are eithertransmitted to humans through open"ounds in contact "ith sea"ater orthrough consumption of certainimproperly coo=ed or ra" shellfish5

&his acterium has een isolated from

"ater, sediment, plan=ton and shellfish>oysters, clams and cras? located in theCulf of Me%ico, the Atlantic $oast as farnorth as $ape $od and the entire U5S5'est $oast5

$ases of illness have also een

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Shigella

Several serotypes

Shigella dysenteriae type - mostdangerous and more drug2resistant

Shigella fle!neri is the most prevalent typeOther ma!or serotypesSh5 Sonnei

Sh5 oydii

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&@PES O9 E C"#I

Si% ma!or types of Escherichia colicausediarrhea#Enteroto%igenic E coli >E&E$?

Enteroinvasive E coli >E6E$?Enteropathogenic E coli>EPE$?Enterohemorrhagic E coli >E coliO-3#H?Enteroaggregative E coli>EAggE$?Diffuse adherent E coli>DAE$?

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6nfluence of $limate

$holera in the South

Dysentery in the 8orth

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SignSymptoms of $holera

1ice2"atery stool

Mar=ed dehydration

Pro!ectile vomiting

8o fever

Shoc=, unconsciousness

Scanty urine

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Sign Symptoms of E coliDiarrhea

@ello" "atery stools

;omiting

Dehydration moderate to severe

9ever often of moderate grade

Mild adominal pain

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Sign Symptoms of 1otavirusDiarrhea

Prodromal symptoms# fever, cough, andvomiting preceding diarrhea

Stools are "atery or semi2li)uid4 the color is

greenish or yello"ish typically loo=s li=eyoghurt mi%ed in "aterMild to moderate dehydration

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Sign Symptoms of Shigellosis

9re)uent passage of scanty amount ofstools, mostly mi%ed "ith lood and somemucus

Moderate to high grade feverSevere adominal cramps

&enesmus pain around anus duringdefecation

Usually no dehydration

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Sign Symptoms of Ameiasis

Offensive and ul=y stools containingmostly mucus and sometimes lood

Lo"er adominal cramp

Mild grade fever8o dehydration

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LA:O1A&O1@ D6AC8OS6S

Stool microscopy

Dar= field microscopy of stool for cholera

Stool cultures

EL6SA for rotavirus

6mmunoassays, ioassays or D8A proetests to identify E colistrains

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ASSESSME8& O9DEH@D1A&6O8

Dehydration

Mild Moderate Severe

Appearance irritable,thirsty

irritable,very

thirsty

lethargy,coma, or

unconscious

AnteriorFontanelle

normal depressed markedlydepressed

Eyes normal sunken sunken

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ASSESSME8& O9DEH@D1A&6O8 >contd5?

Dehydration

Mild Moderate Severe

$ulse normal rapid and

lo"

volume

!eeble or

imperceptible

%rine normal dark scanty

Weight

loss

& '( ) * +( -( or more

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&1EA&ME8 ( Ds

Dehydration correction replace the loss offluid and electrolytes

Diet# Start food as soon as possile

Drug#&etracycline ciproflo%acin for choleraSele%id for shigellosis

Metronida7ole for ameiasis

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$OMPL6$A&6O8S#'A&E1@ D6A11HEA

Dehydration

Electrolyte imalances

&etany$onvulsions

Hypoglycemia

1enal failure

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$OMPL6$A&6O8S#D@SE8&E1@

Electrolyte imalances

$onvulsions

Hemolytic uremic syndrome >HUS?Leu=emoid reaction

&o%ic megacolon

Protein losing enteropathy

ArthritisPerforation

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Some Successful Programs

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O1&

O1& >oral rehydration therapy?

&he leading $ritish %edical &ournal calledO1& Gpotentially the most important

medical advance of the centuryG

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$OMPOS6&6O8 O9 O1S

.ngredient Amount /g0liter1

Sodium chloride 23'

risodium citrate or

Sodium bicarbonate

43+ or

43'

$otassium chloride 3'

5lucose 4-3-

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AMOU8& O9 SAL& LOSSDU168C D6A11HEA

Salt /mmol061Diarrhea

7a 8 Cl 9C:2

Cholera

/child1

;; 2- ;) 24

Cholera

/adult1

2' ' --

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Home2Made O1S

Home2made O1S# Sugar or molasses >+ g?can e used as a sustitute for glucose toprepare home2made O1S5 $ommon salt >3

g? "ill e added to it and dissolved in oneliter of clean "ater5

1ice2O1S# 1ice po"der >3 g? can replacethe sugar or glucose5 &he amount of the

other salts "ill remain the same5 &hese "ille dissolved in one liter of clean "ater toprepare rice2ased O1S5 Studies sho"edthat rice2ased O1S can reduce vomiting

and diarrhea more in some cases compared

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$ it H lth ' =

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$ommunity Health 'or=ers>$H's?

'ell2trained and highly motivatedcommunity health "or=ers >$H's? areproven critical for the success of many

community2ased programs5$H's act as catalysts et"een healthcare

providers and the community people5

&hese $H's are either paid or voluntary

"or=ers5&hey are recruited from the same

community so that they have an intimateinteraction "ith the community people and

an already estalished trust "ith the

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:angladesh E%perience

:1A$ community health "or=ers calledShastho Shei=as5 &hey teach every"oman ho" to prepare oral rehydration

solution to treat diarrhea&he :1A$ health program addresses the

health and nutritional status of "omen andchildren in :angladesh and covers (3

million people "ith appro%imately *3,-+Shastho Shei=as

6$DD1,: to empo"er the communities tota=e full control of their health "ith the

help of community health "or=ers5

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6ndian E%perience

9ollo"ing reports of successful e%perimentsin the non2governmental sector "ith thecommunity health "or=ers >$H's?, the6ndian government introduced a $H'Scheme across the country in -B

Aim# Gprovision of health services at thedoorsteps of villagerG >$hatter!ee -BB(,Maru -BJ(?5

&he scheme included training of onecommunity health volunteer for everyvillage community comprising of -

population5

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6ndian E%perience

&he $H's are e%pected to =no" the healthneeds of the community and provide asichealth services# minor treatments,

preventive measures, including educationand liaison "ith speciali7ed healthinstitutions >Maru -BJ(, Koert -BJ3?5

Evidence sho"s that $H's can e

e%tremely effective to "or= as acomplimentary force promoting utili7ationof availale health services and the lin=et"een the community and the health

system5

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S ill d i i

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Surveillance and &rainingProgram

Covernment of :angladesh providescontinuous surveillance of diarrhealdiseases, among other infectious diseases

in the country6n collaoration "ith the 6nternational

$enter for Diarrhoeal Disease 1esearch,:angladesh >6$DD1,:?, CO: provides

services for#Epidemic Management and $ontrol

&rainingEducational materials

Epidemic $ontrol Preparedness Pro!ect

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;A$$68ES

$holera

1otavirus diarrhea

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$holera ;accines

Du=oral >'$2r:S?# a monovalent oralvaccine ased on =illed "hole2cells >'$? ofV cholerae "' plus recombinant cholera

to!in $ subunitDose# * oral doses days >ut 0F "ee=s?apart for all aged F years5

Shanchol and mO1$;A# ivalent oral

vaccines ased on serogroups O- andO-(B5Dose# * oral doses -+ days apart for all aged

- year5

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1otavirus ;accines

&"o different rotavirus vaccines arecurrently licensed for use in infants in theUnited States5 &he vaccines are 1ota&e)

>1;3? and 1otari% >1;-?5:efore eing licensed, oth vaccines "ere

tested in clinical trials and sho"n to e safeand effective5

6n these studies, during appro%imately thefirst year of an infant.s life, rotavirusvaccine "as found to prevent almost all>J3N2BJN? rotavirus illness episodes that

"ere severe and to prevent +N2JN of all

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P1E;E8&6O8

Safe drin=ing "ater and food:oil it, coo= it, peel it, or forget it5 G

Hand "ashing

Proper sanitation

H d ' hi P ti i

http://www.cdc.gov/travel/foodwatr.htmhttp://www.cdc.gov/travel/foodwatr.htm

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Hand 'ashing Practice in:angladesh

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'ater and Sanitation Pro!ect

U86$E9.s activities on "ater, environmentand sanitation >'ES? support :angladesh.snational plan to achieve a safe "atersupply and sanitary facilities for JN of thepopulation and to improve the personalhygiene practices of FN of the population5

Access to an improved source of "atersupply increased only slightly from *N in-BB to +N in *+, "hereas coverage ofimproved sanitation nearly douled from*N to (BN during the same period5

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'ater Supplies

Uran Areas >*3N of the population?*(N piped inside d"elling

JN piped outside d"ellingFJN tue"ells

1ural Areas >3N of the population?Less than ,FN piped inside and outside

d"elling

BFN tue"ells

-N dug "ellsMore than *N ponds, la=es and rivers

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Lo" $ost Pit Latrine

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Coal

Covernment of :angladesh has set a goalfor -N sanitation y *-(5

:ut, recurrent floods, cyclone andprolonged "ater logging ma=e it harder toadapt appropriate sanitation for thedisplaced and those "ho are living "ithflood and "ater logging conditions5

8atural Disaster

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8atural Disaster

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