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/


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


$OMMO8 $AUSES O9 D6A11HEA2 :A$&E16A Vibrio cholera Shigella Escherichia coli Salmonella Campylobacter jejuni Yersinia enterocolitica Staphylococcus Vibrio parahemolyticus Clostridium difficile .

61US < Rotavirus < Adenoviruses < Caliciviruses < Astroviruses < 8or"al= agents and 8or"al=2li=e viruses .$OMMO8 $AUSES O9 D6A11HEA2 .

$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 .

E6D.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..volBnoD.E*2EDFE5htm ."""5cdc5gov.ncidod.El &or strain to O-(B5  More information# http#.

Vibrio vulnificus &he organism Vibrio vulnificus causes "ound infections. plan=ton and shellfish >oysters. 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. clams and cra s? located in the Culf of Me%ico. sediment. 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. unconsciousness Scanty urine .Symptoms of $holera 1ice2"atery stool Mar=ed dehydration Pro!ectile vomiting 8o fever Shoc=.


omiting Dehydration moderate to severe 9everA often of moderate grade Mild a dominal pain .Sign Symptoms of E coli Diarrhea @ello" "atery stools .

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 . cough.Sign Symptoms of 1otavirus Diarrhea Prodromal symptoms# fever.

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 Shigellosis 9re)uent passage of scanty amount of stools.

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 .

ioassays or D8A pro e tests to identify E coli strains .LA:O1A&O1@ D6AC8OS6S Stool microscopy Dar= field microscopy of stool for cholera Stool cultures EL6SA for rotavirus 6mmunoassays.

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

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 .

-( or more $ulse %rine Weight loss normal & '( .ASSESSME8& O9 DEH@D1A&6O8 >contd5? Mild normal Dehydration Moderate Severe rapid and !eeble or lo" imperceptible volume dark scanty ) * +( .

ciproflo%acin for cholera Sele%id for shigellosis Metronida7ole for ame iasis .&1EA&ME8&# ( Ds Dehydration correctionA replace the loss of fluid and electrolytes Diet# Start food as soon as possi le Drug# &etracycline.

$OMPL6$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- .

) 24 .. coli Rota virus Salt /mmol061 7a 8 Cl 9C:2 ..AMOU8& O9 SAL& LOSS DU168C D6A11HEA Diarrhea Cholera /child1 Cholera /adult1 E. 44 . 2.' .-..<' '2 2= 2= 4< 2. ) .2' .

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 .

$enters 6nternational $enter for Diarrhoeal Disease 1esearch.$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.:? Applied Diarrheal Disease 1esearch Pro!ect >ADD1? . :angladesh >6$DD1.

$ommunity Health 'or=ers >$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 .

G$H's are men and "omen chosen y the community. and to "or= in close relationship "ith the health ServicesI >'HO -BBE?5 .$H's According to 'HO. and trained to deal "ith the health pro lems of individuals and the community.

: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.: to empo"er the communities to ta=e full control of their health "ith the help of community health "or=ers5 .-+E Shastho She i=as 6$DD1.

6ndian E%perience 9ollo"ing reports of successful e%periments in the non2governmental sector "ith the community health "or=ers >$H's?. Maru -BJ(?5 &he scheme included training of one community health volunteer for every village community comprising of -EEE population5 . 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(.

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 .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(.

such as cholera is a deadly disease if not treated in time $O&1s are used as satellite treatment centers $O&$s are uilt on donated lands in the community Operated y trained "or=ers recruited from the community Supervised y locally2recruited people .$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.

:angladesh >6$DD1.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. CO: provides services for# Epidemic Management and $ontrol &raining Educational materials Epidemic $ontrol Preparedness Pro!ect .

.A$$68ES $holera 1otavirus diarrhea .

and O-(B5 Dose# * oral doses -+ days apart for all aged L.AM# ivalent oral vaccines ased on serogroups O.$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$.year5 .

F*N2+3N.year. and DDN23JN. respectively5 .mO1$. and * years after vaccination are JFN2FFN. .AM offer significant protection against cholera during the first t"o years after vaccination &he ranges of protective efficacy at +2F months.Efficacy Du=oral and Shanchol.

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

E8&6O8 Safe drin=ing "ater and food P:oil it. peel it. or forget it5 G Hand "ashing Proper sanitation . coo= it.P1E.

Hand 'ashing Practice in :angladesh .

>-+? *( >-F? (* >*E? -D >--? -D >--? -D >--? E5+D E5(E E5E( +E >-D? FB >*F? *3 >-E? *3 >-E? E5E+ 0E5EE- ."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 *.

"hereas coverage of improved sanitation nearly dou led from *EN to (BN during the same period5 .'ater and Sanitation Pro!ect U86$E9.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+. environment and sanitation >'ES? support :angladesh.s activities on "ater.

FN piped inside and outside d"elling BFN tu e"ells -N dug "ells More than *N ponds. la=es and rivers .'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.

Lo" $ost Pit Latrine .

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 . recurrent floods.Coal Covernment of :angladesh has set a goal for -EEN sanitation y *E-(5 :ut.

8atural Disaster .