Diarrheal Disease Management Evidence of Some Successful Programs

Amal Mitra, MD, MPH, DrPH Professor University of Southern Mississippi

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 diarrheal illnesses Simple management tools for diarrhea E%amples of some success stories to com at the pro lem

&ypes of Diarrhea
'atery Diarrhea# ( or more li)uid or "atery

stools in *+ h Dysentery# Presence of lood and,or mucus in stools Persistent Diarrhea# Diarrhea lasting for -+ days or more Mother.s definition/

$auses

$ommon Diarrheas
Age 0* years# 1otavirus Age *23 years# $holera4 E5 coli4 Shigellosis All ages# E5 coli4 $ampylo acter 6mmunocompromi7ed# Ame iasis4

$ryptosporidium

$OMMO8 $AUSES O9 D6A11HEA2 :A$&E16A

Vibrio cholera Shigella Escherichia coli Salmonella Campylobacter jejuni Yersinia enterocolitica Staphylococcus Vibrio parahemolyticus Clostridium difficile

$OMMO8 $AUSES O9 D6A11HEA2 ;61US

< Rotavirus < Adenoviruses < Caliciviruses < Astroviruses < 8or"al= agents and 8or"al=2li=e

viruses

$OMMO8 $AUSES O9 D6A11HEA2 PA1AS6&E

< Entameba histolytica < Giardia lamblia < Cryptosporidium < Isospora

$OMMO8 $AUSES O9 D6A11HEA2O&HE1S

< Meta olic disease

Hyperthyroidism Dia etes mellitus Pancreatic insufficiency

< 9ood allergy

Lactose intolerance < Anti iotics < 6rrita le o"el syndrome

&1A8SM6SS6O8
Most of the diarrheal agents are

transmitted y the fecal2oral route $holera# "ater2 orne disease4 transmitted through "ater contaminated "ith feces Some viruses >such as rotavirus? can e transmitted through air 8osocommial transmission is possi le Shigellosis > lood dysentery? is mainly transmitted person2to2person Shigellosis is a "ater2"ashed disease4 transmitted more "hen there is scarcity of "ater

SEASO8AL6&@
Disease Cholera Shigellosis Common season Winter Dry summer

Rotavirus diarrhea Winter

$holera
&"o

iotypes

$lassical or Asiatic type El&or A more prevalent

Vibrio cholerae O-(B

Vibrio cholerae in O2group -(B "as first

isolated in -BB* and y -BB( had een found throughout the 6ndian su continent5 &his epidemic e%pansion pro a ly resulted from a single source after a lateral gene transfer >LC&? event that changed the serotype of an epidemic V cholerae O- El &or strain to O-(B5 More information# http#,,"""5cdc5gov,ncidod,E6D,volBnoD,E*2EDFE5htm

Vibrio vulnificus
&he organism Vibrio vulnificus causes

"ound infections, gastroenteritis or a serious syndrome =no"n as Gprimary septicema5GH V vulnificus infections are either transmitted to humans through open "ounds in contact "ith sea"ater or through consumption of certain improperly coo=ed or ra" shellfish5 &his acterium has een isolated from "ater, sediment, plan=ton and shellfish >oysters, clams and cra s? located in the Culf of Me%ico, the Atlantic $oast as far north as $ape $od and the entire U5S5 'est $oast5H $ases of illness have also een

Shigella
Several serotypes Shigella dysenteriae type - most

dangerous and more drug2resistant Shigella fle!neri is the most prevalent type Other ma!or serotypes
Sh5 Sonnei Sh5 oydii

&@PES O9 E C"#I
Si% ma!or types of Escherichia coli cause

diarrhea#

Enteroto%igenic E coli >E&E$? Enteroinvasive E coli >E6E$? Enteropathogenic E coli >EPE$? Enterohemorrhagic E coli >E coli O-3D#HD? Enteroaggregative E coli >EAggE$? Diffuse adherent E coli >DAE$?

6nfluence of $limate

$holera in the South Dysentery in the 8orth

Sign,Symptoms of $holera
1ice2"atery stool Mar=ed dehydration Pro!ectile vomiting 8o fever Shoc=, unconsciousness Scanty urine

Sign Symptoms of E coli Diarrhea

@ello" "atery stools ;omiting Dehydration moderate to severe 9everA often of moderate grade Mild a dominal pain

Sign Symptoms of 1otavirus Diarrhea

Prodromal symptoms# fever, cough, and

vomiting preceding diarrhea Stools are "atery or semi2li)uid4 the color is greenish or yello"ishA typically loo=s li=e yoghurt mi%ed in "ater Mild to moderate dehydration

Sign Symptoms of Shigellosis

9re)uent passage of scanty amount of

stools, mostly mi%ed "ith lood and some mucus Moderate to high grade fever Severe a dominal cramps &enesmusA pain around anus during defecation Usually no dehydration

Sign Symptoms of Ame iasis

Offensive and

ul=y stools containing mostly mucus and sometimes lood Lo"er a dominal cramp Mild grade fever 8o dehydration

LA:O1A&O1@ D6AC8OS6S
Stool microscopy Dar= field microscopy of stool for cholera Stool cultures EL6SA for rotavirus 6mmunoassays, ioassays or D8A pro e

tests to identify E coli strains

ASSESSME8& O9 DEH@D1A&6O8
Dehydration Mild Moderate Severe Appearance irritable, irritable, lethargy, thirsty very coma, or thirsty unconscious Anterior normal depressed markedly Fontanelle depressed Eyes normal sunken sunken

ASSESSME8& O9 DEH@D1A&6O8 >contd5?

Mild normal normal Dehydration Moderate Severe dry very dry, !urred slo" very slo" retraction retraction rapid very rapid

ongue Skin

#reathing normal

ASSESSME8& O9 DEH@D1A&6O8 >contd5?

Mild normal Dehydration Moderate Severe rapid and !eeble or lo" imperceptible volume dark scanty ) * +( ,-( or more

$ulse

%rine Weight loss

normal & '(

&1EA&ME8&# ( Ds
Dehydration correctionA replace the loss of

fluid and electrolytes Diet# Start food as soon as possi le Drug#

&etracycline, ciproflo%acin for cholera Sele%id for shigellosis Metronida7ole for ame iasis

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

Dehydration Electrolyte im alances &etany $onvulsions Hypoglycemia 1enal failure

$OMPL6$A&6O8S# D@SE8&E1@
Electrolyte im alances $onvulsions Hemolytic uremic syndrome >HUS? Leu=emoid reaction &o%ic megacolon Protein losing enteropathy Arthritis Perforation

Some Successful Programs

O1&
O1& >oral rehydration therapy? &he leading $ritish %edical &ournal called

O1& Gpotentially the most important medical advance of the centuryG

$OMPOS6&6O8 O9 O1S
.ngredient Sodium chloride risodium citrate or Sodium bicarbonate $otassium chloride 5lucose Amount /g0liter1 23' 43+ or 43' ,3' 4-3-

AMOU8& O9 SAL& LOSS DU168C D6A11HEA

Diarrhea Cholera /child1 Cholera /adult1 E. coli Rota virus Salt /mmol061 7a 8 Cl 9C:2 ;; 2- ;) 24 ,2' ,' ,-- <' '2 2= 2= 4< 2; 44 ,; )

Home2Made O1S
Home2made O1S# Sugar or molasses >+E g?

can e used as a su stitute for glucose to prepare home2made O1S5 $ommon salt >3 g? "ill e added to it and dissolved in one liter of clean "ater5 1ice2O1S# 1ice po"der >3E g? can replace the sugar or glucose5 &he amount of the other salts "ill remain the same5 &hese "ill e dissolved in one liter of clean "ater to prepare rice2 ased O1S5 Studies sho"ed that rice2 ased O1S can reduce vomiting and diarrhea more in some cases compared

$oncept of Depot Holder

Depot holders >Depot Mothers? in rural

:angladesh Diarrhea control in :angladesh# a social movement y :angladesh 1ural Advancement $ommittee >:1A$? Other Pro!ects,$enters
6nternational $enter for Diarrhoeal Disease

1esearch, :angladesh >6$DD1,:? Applied Diarrheal Disease 1esearch Pro!ect >ADD1?

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

'ell2trained and highly motivated

community health "or=ers >$H's? are proven critical for the success of many community2 ased 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 intimate interaction "ith the community people and an already esta lished trust "ith the

$H's
According to 'HO, G$H's are men and

"omen chosen y the community, and trained to deal "ith the health pro lems of individuals and the community, and to "or= in close relationship "ith the health ServicesI >'HO -BBE?5

:angladesh E%perience
:1A$ community health "or=ers called

Shastho She i=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 and children in :angladesh and covers (3 million people "ith appro%imately *3,-+E Shastho She i=as 6$DD1,: to empo"er the communities to ta=e full control of their health "ith the help of community health "or=ers5

6ndian E%perience
9ollo"ing reports of successful e%periments

in the non2governmental sector "ith the community health "or=ers >$H's?, the 6ndian government introduced a $H' Scheme across the country in -BDD Aim# Gprovision of health services at the doorsteps of villagerG >$hatter!ee -BB(, Maru -BJ(?5 &he scheme included training of one community health volunteer for every village community comprising of -EEE population5

6ndian E%perience
&he $H's are e%pected to =no" the health

needs of the community and provide asic health services# minor treatments, preventive measures, including education and liaison "ith speciali7ed health institutions >Maru -BJ(, Ko ert -BJ3?5 Evidence sho"s that $H's can e e%tremely effective to "or= as a complimentary force promoting utili7ation of availa le health services and the lin= et"een the community and the health system5

$ommunity2Operated &reatment $enters

&ransportation of patients to the health

center in a timely manner is a pro lem in some parts of :angladesh Some diarrheal diseases, such as cholera is a deadly disease if not treated in time $O&1s are used as satellite treatment centers $O&$s are uilt on donated lands in the community Operated y trained "or=ers recruited from the community Supervised y locally2recruited people

Diarrheal Disease Surveillance and &raining Program

Covernment of :angladesh provides

continuous surveillance of diarrheal diseases, among other infectious diseases in the country 6n colla oration "ith the 6nternational $enter for Diarrhoeal Disease 1esearch, :angladesh >6$DD1,:?, CO: provides services for#
Epidemic Management and $ontrol &raining Educational materials

Epidemic $ontrol Preparedness Pro!ect

;A$$68ES
$holera 1otavirus diarrhea

$holera ;accines
Du=oral >'$2r:S?# a monovalent oral

vaccine ased on =illed "hole2cells >'$? of V cholerae "' plus recombinant cholera to!in $ subunit
Dose# * oral doses LD days > ut 0F "ee=s?

apart for all aged LF years5

Shanchol and mO1$;AM#

ivalent oral vaccines ased on serogroups O- and O-(B5

Dose# * oral doses -+ days apart for all aged

L- year5

Efficacy
Du=oral and Shanchol,mO1$;AM offer

significant protection against cholera during the first t"o years after vaccination &he ranges of protective efficacy at +2F months, - year, and * years after vaccination are JFN2FFN, F*N2+3N, and DDN23JN, respectively5

1otavirus ;accines
&"o different rotavirus vaccines are

currently licensed for use in infants in the United States5 &he vaccines are 1ota&e)O >1;3? and 1otari%O >1;-?5 :efore eing licensed, oth vaccines "ere tested in clinical trials and sho"n to e safe and effective5 6n these studies, during appro%imately the first year of an infant.s life, rotavirus vaccine "as found to prevent almost all >J3N2BJN? rotavirus illness episodes that "ere severe and to prevent D+N2JDN of all

P1E;E8&6O8
Safe drin=ing "ater and food

P:oil it, coo= it, peel it, or forget it5 G Hand "ashing Proper sanitation

Hand 'ashing Practice in :angladesh

"ho 'ashed Hands "ith Soap

Characteristi c Had this characteristi c Did not have this characteristi c P-value

Mother.s education Some education A ove primary 'ealth inde% *nd )uintile (rd )uintile +th )uintile Availa ility at place of hand"ashing *- >-+? *( >-F? (* >*E? -D >--? -D >--? -D >--? E5+D E5(E E5E( +E >-D? FB >*F? *3 >-E? *3 >-E? E5E+ 0E5EE-

'ater and Sanitation Pro!ect

U86$E9.s activities on "ater, environment

and sanitation >'ES? support :angladesh.s national plan to achieve a safe "ater supply and sanitary facilities for JEN of the population and to improve the personal hygiene practices of FEN of the population5 Access to an improved source of "ater supply increased only slightly from D*N in -BBE to D+N in *EE+, "hereas coverage of improved sanitation nearly dou led from *EN to (BN during the same period5

'ater Supplies
Ur an Areas >*3N of the population?
*(N piped inside d"elling JN piped outside d"elling FJN tu e"ells

1ural Areas >D3N of the population?

Less than E,FN piped inside and outside

d"elling BFN tu e"ells -N dug "ells More than *N ponds, la=es and rivers

Lo" $ost Pit Latrine

Coal
Covernment of :angladesh has set a goal

for -EEN sanitation y *E-(5 :ut, recurrent floods, cyclone and prolonged "ater logging ma=e it harder to adapt appropriate sanitation for the displaced and those "ho are living "ith flood and "ater logging conditions5

8atural Disaster