Food and Waterborne Diseases

Prevention and Control Program

Profile:

Food and Waterborne Diseases (FWBDs) are among the most common causes of
diarrhea. In the Philippines, diarrheal diseases for the past 20 years is the number one
cause of morbidity and mortality incidence rate is as high as 1,997 per 100,000
population while mortality rate is 6.7 per 100,000 population. From 1993 to 2002,
FWBDs such as cholera, typhoid fever, hepatitis A and other food poisoning/foodborne
diseases were the most common outbreaks investigated by the Department of Health.
Also, outbreaks from FWBDs can be very passive and catastrophic. Since most of these
diseases have no specific treatment modalities, the best approach to limit economic losses
due to FWBDs is prevention through health education and strict food and water
sanitation.

The Food and Waterborne Disease Prevention and Control Program (FWBDPCP)
established in 1997 but became fully operational in year 2000 with the provision of a
budget amounting to PHP551,000.00. The program focuses on cholera, typhoid fever,
hepatitis A and other foodborne emerging diseases (e.g. Paragonimiasis). Other diseases
acquired through contaminated food and water not addressesd by other services fall under
the program.

National program planning and implementation: Eighteen countries formulated plans of

operation for national CDD programs in 1983, bringing the total to 72. Of these, 52
(72%) now have operational CDD programs, 14 having been implemented in 1983
Research areas: The broad biomedical research areas receiving support from the three
global SWGs continued to be: (1) development of more stable and more effective ORS
and homemade solutions and appropriate feeding regimens during diarrhea; (2) etiology
and epidemiology of acute diarrhea; (3) development and evaluation of improved
diagnostic tests (in particular, to detect rotavirus and enterotoxigenic Escherichia coli);
(4) development and testing of new vaccines (e.g., against typhoid fever, rotavirus
diarrhea, and cholera); and (5) development and testing of new and existing antidiarrheal
drugs. The majority of operational research projects were concerned with
etiology/epidemiology and case management of acute diarrhea, especially the delivery of
ORT in local settings. Research was also in progress on community attitudes and
practices in relation to diarrheal disease and on the development of local educational
materials.
The aim of the program is to conduct studies that help reduce mortality and morbidity due to
diarrhea. Since formation in 1982, the program continues to provide relevant data for the National
Control Program (CDD) through its community- and laboratory-based researches. The
community-based studies focused on interventions on infant feeding specifically the promotion of
breastfeeding, improved weaning practices; foods and fluids taken during diarrhea; factors
affecting food intake during diarrhea; and, the acceptability of rice-based and flavored glucose-
based oral rehydration solutions.
With the promotion of breastfeeding as a preventive measure against diarrhea, its effect on
growth beyond 12 months was explored including analysis of growth of bacteria of stored
breastmilk. Other breastfeeding projects include among its target groups the working mothers in
the community and workplace (establishment of RITM as a mother- and baby-friendly workplace).

Moreover, in 1996, the research program group was part of the team, which conducted the last
Third Country Training Program in the Laboratory Diagnosis of Diarrheal Diseases and HIV
Infection funded by the Japan International Cooperation Agency (JICA). Aside from conducting
studies addressing the issues on: epidemiology and etiology; diagnosis; case management in the
home and health facility; prevention program; and, evaluation, the group also conducted other
non-diarrhea projects on community assessment of natural food sources of vitamin A and
focused ethnographic study (FES).

To date, the investigators are working on a study to evaluate the impact of the Baby-friendly
Hospital Initiative program on the exclusivity and duration of breastfeeding; and, development of
an intervention to promote breastfeeding among working mothers in an urban Philippine setting.
Other research plans include: 1) a qualitative study on street vendors and their behaviors that
contribute to danger or safety of street foods; 2) design and testing of an intervention study on
dietary management of acute diarrhea in home; 3) assessment of the impact of the National CDD
Programme on the country's diarrheal morbidity; and, 4) further studies on the laboratory
detection of important enteric pathogens.

Diarrheal diseases are one of the leading causes of childhood morbidity and mortality in
developing countrie s. An estimated 1,000 million episodes occur each year in children under
5
years of age. Diarrhea causes an estimated 5 million deaths in children under 5 years of age
per
year.
About 80% of these deaths occur in children in the first 2 years of life. Approximately
one third of deaths among children under five are caused by diarrhea.1 In the Philippines,
diarrheal disease is the second leading cause of morbidity and 6th leading cause of mortality
for
all ages. It is the third leading cause of infant deaths.2 Surveys done in La Union, Bohol, and
Bukidnon in 1985 showed that every Filipino child suffered an average of 2.8 episodes
annually.3
Most diarrheal illnesses are acute, usually lasting no more than 3-5 days and are secondary to
infectious causes (bacterial, viral, and parasitic). Infectious agents that cause diarrheal disease
are
usually spread by the fecal-oral route, specifically by a) ingestion of contaminated food or
water
and b) contact with contaminated hands.
The usual pathogenic mechanisms for infectious diarrhea include toxin production, tissue
invasion, or invasion of intestinal cells with consequent alteration of their function and
reproduction. Today, with newer techniques available, laboratories capable of comprehensive
laboratory studies can identify potential pathogens in up to 70% of acute diarrheas presenting
to
hospital or treatment facilities and in about half of cases occuring in the community. Mixed
infections with two or more enteropathogens occur in 15% to 20% of cases, but their clinical
significance is difficult to interpret; one or more of the organisms recovered may be
responsible
for the diarrhea.
In general, the same pathogens are responsible for diarrhea in infants and young children
worldwide; however, the frequency and proportion of the specific diarrheal pathogens
identified
may be different in different places and laboratories. The most common organisms
responsible
for most cases of diarrhea obtained from pooled data worldwide include rotavirus, ETEC,
shigella, campylobacter, Vibrio cholerae, and non-typhoidal salmonella, Table 1.4 Hospital-
and
community-based etiology studies done in the Philippines showed the predominance of
rotavirus
and enterotoxigenic E. coli as causes of diarrhea,5,6 Table 2. Serologic surveys conducted in
Metro Manila showed early acquisition of antibodies to rotavirus. Whereas rotavirus
accounted
for only 7% of sporadic diarrhea in the community, it was detected in 35% of hospitalized
cases
suggesting that rotavirus causes a more severe and dehydrating diarrhea. In addition to
rotavirus,
it appears that infection due to Norwalk virus is also not uncommon.
Studies on the prevalence of antibodies to Norwalk virus in Manila showed that 43% of
individuals would have detectable levels by age 12 years.7 Isolation rates for salmonella,
shigella,
EPEC, V. cholerae 01 and other vibrios, Campylobacter jejuni, and Aeromonas sp. differed
from
study to study. No local studies have been done to determine the prevalence of the newer
bacterial agents, namely, enterohemorrhagic and enteroadherent E. coli, and Clostridium
difficile.
Contrary to popular belief, Entamoeba histolytica was detected in less than 5% of
cases.6,8 This data proves the relatively low prevalence of E. histolytica cysts and trophozoites
in
the general population. The most extensive prevalence survey done in the Philippines showed
that
only 5% of 14,205 stool specimens were positive for the parasite and 6% of 19,771 sera had
antibody titers ~ 1:128 by indirect hemagglutination.9 The percentage isolation of Giardia
intestinalis was likewise low.
In addition to the etiologic agents mentioned above, other conditions causing or are
associated with diarrhea include drugs, surgical conditions, other diseases (e.g. malaria,
schistosomiasis, measles), systemic infections, and food intolerance (e.g. lactase deficiency).
A number of pathogens have also been associated with persistent diarrhea (diarrhea
episode lasting for at least 14 days) and dysentery {diarrhea associated with blood and pus
cells
in the stools). These "types" of diarrhea are important in that they are more likely to have
severe
consequences. Studies have shown that one-third to one half of all diarrhea-associated deaths
among children occurred following episodes of persistent diarrhea10 where dysentery
accounts for
10% to 15% of diarrheal episodes in children under the age of 5, but up to 25% of diarrheal
deaths.4
Less than half of all children with persistent diarrhea have a recognized enteric pathogen
in their feces. Enteropathogens that are isolated with greater frequency from episodes of
persistent diarrhea include enteroadherent E. coli {EAEC), enteropathogenic E. coli {EPEC)
and
cryptosporidium.10 The mechanisms by which these agents cause persistent diarrhea is
probably
related to their capacity to adhere to or invade the bowel mucosa.
Dysentery is caused primarily by bacteria, which invade the epithelial cells of the small
intestine and colon, produce, a variety of toxins, disrupt the cell and cause an inflammatory
response. A number of organisms have been found in dysentery cases, and more than one
pathogenic organism is found in many cases. However, shigella is the most common (from
33%
to 62% of cases in 3 studies).4 The second most common cause of dysentery, particularly in
children younger than 1 year, is campylobacter. Other organisms which may cause dysentery
include: 1) Invasive E. coli, 2) P. shigelloides, 3) salmonella, and Aeromonas spp.

http://www.ritm.gov.ph/program/diarrhea.htm
http://portal.doh.gov.ph/programs/fwbd.html
http://www.cdc.gov/mmwr/preview/mmwrhtml/00000402.htm
http://www.psmid.org.ph/vol19/vol19num2topic3.pdf