‫بسم ال الرحمن الرحيم‬

DIARRHOEAL DISEASE
Definition of Diarrhea:

According to [WHO], Diarrhea is

defined as passage of three or more
abnormal loose stools with or
without [fever, vomiting, blood,
mucous,.]
According to the etiology
diarrhea can be divided into:

Non infective diarrhea Infective diarrhea

I.Non-infective Diarrheal Disease

 A-Acute Non-infective Diarrhea:

 Chemical Food Poisoning e.g,insecticides,drugs,
metals
 Naturally Poisonous Foods:
 Dietetic Diarrhea: e.g, laxatives, overfeeding, high
dietary fibers, spicy f.,
 Food Allergy : e.g certain proteins (inherited or
aquired)
I.Non-infective Diarrheal Disease

 B- Chronic Non-infective Diarrhea:

 a. Systemic Infection
 e. Lactose or fructose intolerance.
 d. Emotional upset and anxiety neurosis,
causing" irritable colon“
 c. Chronic diseases of small and large
intestine as tumors and inflammatory bowel
disease.
Clinical presentations of diarrhea
according to WHO classification.

 1- Simple diarrhea: the etiology is not important

. It is managed by rehydration therapy.
 2- Bloody diarrhea: [dysentry]
 Ex. Shigellosis, bilharzia, amoeba.
 3- Severe purging diarrhea: as in cholera.
 4- Minimal diarrhea: associated with vomiting,
as in staphylococcus.infection, bacillus cereus, in
some viral gastroenteritis due to toxins.
 5- Persistant diarrhea: lasting > 14 days.
II.Infective Diarrheal Diseases

 Dysenteries(bacterial, parasitic)
 Food poisoning
 Gastroenteritis in children.
 Cholera
Dysentries

 It is a clinical syndrome due to inflammation of large

inestine.
 Classically, It is represented with frequent stool (with
blood and mucous), tenesmus, & abdominal pain.
 Causative agents:
 Bacterial: Shigella
 Protozoal: balantidium coli & ameba
 Helminthic: Bilharziasis
Food poisoning

1- Salmonellosis
2- Staph.Aureus food p.
3- Botulism
1- causative organisms

1-Salmonella food  2-Staphylococcal food

poisoning poisoning.
Non-typhoidal  Caused by enterotoxins
Salmonella , (a gram – secreted by staph.
ve bacilli) with its many Aureus .
serotypes[
s.typhimurium &
s.enteritidis, s.infantis]
They possess O & H
antigens.
Continue, Causative organisms

 3- Botulism
 The Exotoxin of clostridium
botulinum (a gram +ve,
anaerobic, spore forming
rod bacilli).
 It has 7 known types , A, B,
C, D, E, f,G.
 A, B, E most common in
Human.
 C, D, in animals.
Reservoirs of infection (source)

In salmonella Infection, In staph. Infection,

1- Man (cases & 1- Man: in the nasopharynx.
carriers,all types 2-Cattle: in staph. Mastitis
including chronic) which may
2-cattle excreta Contamination of milk.
contaminating milk &
meat.
3-Rodents,
4-Swines, paultry (eggs,
tissues).
5-shell fish, mussels,
6- In sewage effluents.
Continue reservoirs

In botulism,
1- The soil that
contaminate the
vegetables.
2-Animals (cattle, sheep,
pigs, horses,…) in their
excreta and reach the
soil.
Modes of transmission
In salmonellosis,
1-Hand–to-mouth infection .
2-ingestion of infected meat,
eggs, paultry.
3-Contamination of food occur
by excreta of man (as in
food handlers), animals,
rodents either directly or
indirect by a vehicle[, flies,
insects, polluted water].
In Staph.(no direct transmission)
1- Ingestion of contaminated
food or milk [by food
handlers].
2- Type of contaminated food
especially( pastries, cookies,
coscosi, and contaminated
milk). The Toxins are
liberated in carbohydrate
and prorein media.
Continue modes of transmission
 In botulism
 1- ingestion of canned food
+home preserved
vegetables, with improper
sterilization
 Ingestion of smoked beef
and fish contamintaed with
spores.
 Put under anaerobic
conditions (suitable for
vegetation and toxin
liberation).
Type of toxicity

In salmonellosis, In staph., infection occur

poisoning by the organism by the enterotoxins
itself. secreted by the
organism in vitro.
On ingestion of
contaminated food or The toxin is thermostable,
drink, the organism is it resists boiling for 30
multiplied in large minutes.
numbers in vitro then, Acts locally at
complete its neuroreceptors of the
multiplication inside the gut and Vomiting center
gut. in brain
Continue type of toxicity
 In Botulism,
By the neurotoxin secreted
by the spores on
germination.
Heat:
The toxin is thermo-labile
disintegrated by heat.
PH:
The vegetative form can’t stand Germination and toxin
the HCL but the neurotoxin production is inhibited at PH
can stand HCL but can be <4.5
destroyed by alkalinity. In achlorohydria or infants, the
swallowed spores can
germinate in the stomach.
Incubation period

 1- Salmonellosis: from 12- 36 hours.

 2- Staph. : from 2-4 hours
 3- Botulism: from 12- 36 hours.

 Discuss the differences in time between the

three organisms?
Clinical picture

1- in Salmonellosis 2- In Staph. Infection

a- mild inapparent cases Acute gastroenteritis with
slight or no fever,
b- Acute gastroenteritis, mild fever, mainly nausea,
diarrhea mainly, cramps, nausea, vomiting and minimal
vomiting lasting few days. diarrhea.
c- Bacteremia with arthritis and or
cholecyctitis.
Incidence of bacteremia
increased with: Schistosomiasis
leading to chronic carriers and or
bacteraemia; with hemolytic
diseases as sickle cell anaemia,
with malaria.
 Continue clinical picture

In Botulism
• Neurotoxicity: toxins work
at neuromuscular
junctions inhibiting
acetylcholine.
• Weakness, dry mouth,
fissured tongue, 3rd nerve
paralysis with dilated
fixed pupils, + ptosis.
Continue clinical picture

• Squint due to 6th nerve

paralysis.
• Dysphonia, dysphagia,
descending weakness
of respiratory muscles,
then paralysis of repir.
Ms. And death.
• Rarely, GIT
manifestations: nausea,
vomiting, constipation.
Diagnosis

 In Salmonellosis:  In Staph. Infection:

1-Isolation from stool or  1----
vomitus by culture.  2---
2-Culture of suspected food
 3-----
remains.  4- Nose & throat swabs for
suspected food handlers.
3-Serological tests
In Botulism:
1- Animal inoculation for
toxin domonstration.
[flaccid paralysis].
2- ------
3- ------
Prevention

In salmonellosis: In Staph.
1- Environmental 1- Environmental sanitation:
including, Mainly Food
sanitation: including, sanitation
Water, waste, A: food handlers:
sewage, rodents *clinical examination
and insect control. * Lab. Investigation: [skin +swab
examination]
Food & milk *Supervision & H.E
sanitation. B: Inspection of food establishments.
C: Food utensils.
D: Food stuff & products.
Milk sanitation: veterinary care,
mechanical milking process
Prevention

In Salmonellosis In Staph
2- Health education: 2- H.E.,
the target is the public, The target is the same. [mainly food
housewives, food handlers. handlers]

The message: The message:

*The 5 keys of WHO:
clean preparation
*boiling of food, milk,cooking of
meat., Refrigeration, food
protection, heating before
serving. Proper storage
The 5 keys of WHO:
(Avoid handling food too much and
washing hands, wearing gloves).
.
Prevention

In Botulism:
1-Food sanitation:
Proper canning&
preservation [cooked in
steam pressure pots at
120°c[kill spores].
Germination can be
prevented by
refrigeration, salt,
venegar 2% [kill spores]
Continue prevention

In Botulism: The message:

2-Health education: proper cleaning, boiling for 3
consecutive days before
The target is mainly
preservation (Tyndallization
housewives, + those in
process].
fesick buiseness.
Boiling before serving to disintegrate
the toxin.Or adding of sodium
bicarbonate (alkali) if possible.
Never to taste any canned food
showing spoilage by gases.It must
be discarded
 Control
In Salmonellosis In Staph.
Early case finding Early case finding
Control measures for the cases, Control measures for the cases
including notification, disinfection,
and Treatment :resistance is high to
Treatment (with ampicillin or majority of antibi.
trimethoprim) Sensetive to Vanomycin and
Rifampin

Investigation of the outbreak.

N.B search for the suspected N.B search for the suspected
food handler food handler
N.B

 Multidrug-resistant(MDR) strains of
Salmonella are now encountered frequently
and the rates of multidrug-resistance have
increased considerably in recent years
 Drug-resistant Salmonella emerge in
response to antimicrobial usage in food of
animals
Human health consequences of drug-
resistant Salmonella following non-
human use of antimicrobial agents
 These consequences can be divided into two
categories:
 (1) increase the rate of salmonella infections,
(ex. in the United States, it was estimated
that antimicrobial resistance in Salmonella
may result in about 30 000 additional
Salmonella infections over the average rate.
 (2) increased frequency of treatment failures
and increased severity of infections.
Control

In Botulism Cases treated by:

(Destroy food remains). 1- stomach wash by 2-5%
For cases: notification, bicarbonate [alkali] to make
treatment by IV dose the toxin unstable.
[100,000] units polyvalent 2- Soap &oil Enema:
antitoxin [A, B, E]. The soap to inactivate the toxin.
For exposed individuals, The oil to prevent its rapid
seroprophylaxis. absorption.