Epidemiology and Management

of Diarrheal Diseases
Amal Mitra, MD, MPH, DrPH
Professor
University of Southern Mississippi
Readings: Diarrhoeal Diseases
 DEFINITION
• Watery Diarrhea: 3 or more liquid or watery
stools in 24 h
• Dysentery: Presence of blood and/or mucus
in stools
• Persistent Diarrhea: Diarrhea lasting for 14
days or more
 TYPES OF DIARRHEA

D ia rrh e a

W a te ry d ia rrh e a D y s e n te ry P e rs is te n t d ia rrh e a

R o ta v iru s d ia rrh e a S h ig e llo s is C a u s e s a re m o s tly u n k n o w n

E . c o li d ia rrh e a A m e b ia s is
C h o le ra
 COMMON CAUSES OF
DIARRHEA- BACTERIA
– Vibrio cholera
– Shigella
– Escherichia coli
– Salmonella
– Campylobacter jejuni
– Yersinia enterocolitica
– Staphylococcus
– Vibrio parahemolyticus
– Clostridium difficile
 COMMON CAUSES OF
DIARRHEA- VIRUS
• Rotavirus
• Adenoviruses
• Caliciviruses
• Astroviruses
• Norwalk agents and Norwalk-like viruses
 COMMON CAUSES OF
DIARRHEA- PARASITE
• Entameba histolytica
• Giardia lamblia
• Cryptosporidium
• Isospora
 COMMON CAUSES OF
DIARRHEA-OTHERS
• Metabolic disease
Hyperthyroidism
Diabetes mellitus
Pancreatic insufficiency
• Food allergy
Lactose intolerance
• Antibiotics
• Irritable bowel syndrome
 TRANSMISSION
• Most of the diarrheal agents are transmitted
by the fecal-oral route
• Some viruses (such as rotavirus) can be
transmitted through air
• Nosocommial transmission is possible
• Shigella (the bacteria causing dysentery) is
mainly transmitted person-to-person
 SEASONALITY
Disease Common season
Cholera Winter
Rotavirus diarrhea Winter
Shigellosis Dry summer
 PERSON-AT-RISK
• Cholera: 2 years and above, uncommon in
very young infants
• Shigellosis: more common in young
children aged below 5 years
• Rotavirus diarrhea: more common in young
infants and children aged 1-2 years
• E. coli diarrhea: can occur at any age
• Amebiasis: more common among adults
 TYPES OF VIBRIO CHOLERA
• Two major biotypes of Vibrio cholera that
cause diarrhea are:
Classical
ElTor
• Two common serotypes of Vibrio cholera
that cause diarrhea are:
Inaba
Ogawa
 Vibrio cholerae O139
• Vibrio cholerae in O-group 139 was first isolated
in 1992 and by 1993 had been found throughout
the Indian subcontinent. This epidemic expansion
probably resulted from a single source after a
lateral gene transfer (LGT) event that changed the
serotype of an epidemic V. cholerae O1 El Tor
strain to O139.
• More information:
http://www.cdc.gov/ncidod/EID/vol9no7/02-0760.
htm
 Vibrio vulnificus
• The organism Vibrio vulnificus causes wound infections,
gastroenteritis or a serious syndrome known as "primary septicema." 
• V. vulnificus infections are either transmitted to humans through open
wounds in contact with seawater or through consumption of certain
improperly cooked or raw shellfish.
• This bacterium has been isolated from water, sediment, plankton and
shellfish (oysters, clams and crabs) located in the Gulf of Mexico, the
Atlantic Coast as far north as Cape Cod and the entire U.S. West
Coast. 
• Cases of illness have also been associated with brackish lakes in New
Mexico and Oklahoma.
• For more information:
http://hgic.clemson.edu/factsheets/HGIC3663.htm
 TYPES OF SHIGELLA
• The major serotypes of Shigella that cause
diarrhea are:
Dysenteriae type 1 or Shigella shiga
Shigella flexneri
Shigella sonnei
Shigella boydii
 TYPES OF E. COLI
• Six major types of Escherichia coli cause
diarrhea:
Enterotoxigenic E. coli (ETEC)
Enteroinvasive E. coli (EIEC)
Enteropathogenic E. coli (EPEC)
Enterohemorrhagic E. coli (E. coli O157:H7)
Enteroaggregative E. coli (EAggEC)
Diffuse adherent E. coli (DAEC)
 CLINICAL FEATURE:
CHOLERA
• Rice-watery stool
• Marked dehydration
• Projectile vomiting
• No fever or abdominal pain
• Muscle cramps
• Hypovolemic shock
• Scanty urine
 CLINICAL FEATURE:
E. COLI DIARRHEA
• Watery stools
• Vomiting is common
• Dehydration moderate to severe
• Fever– often of moderate grade
• Mild abdominal pain
 CLINICAL FEATURE:
ROTAVIRUS DIARRHEA
• Insidious onset
• Prodromal symptoms, including fever,
cough, and vomiting precede diarrhea
• Stools are watery or semi-liquid; the color
is greenish or yellowish– typically looks
like yoghurt mixed in water
• Mild to moderate dehydration
• Fever– moderate grade
 CLINICAL FEATURE:
SHIGELLOSIS
• Frequent passage of scanty amount of
stools, mostly mixed with blood and mucus
• Moderate to high grade fever
• Severe abdominal cramps
• Tenesmus– pain around anus during
defecation
• Usually no dehydration
 CLINICAL FEATURE:
AMEBIASIS
• Offensive and bulky stools containing
mostly mucus and sometimes blood
• Lower abdominal cramp
• Mild grade fever
• No dehydration
 LABORATORY DIAGNOSIS
• Stool microscopy
• Dark field microscopy of stool for cholera
• Stool cultures
• ELISA for rotavirus
• Immunoassays, bioassays or DNA probe
tests to identify E. coli strains
 ASSESSMENT OF
DEHYDRATION
Dehydration
Mild Moderate Severe
Appearance irritable, irritable, lethargy,
thirsty very coma, or
thirsty unconscious
Anterior normal depressed markedly
Fontanelle depressed
Eyes normal sunken sunken
 ASSESSMENT OF
DEHYDRATION (contd.)
Dehydration
Mild Moderate Severe
Tongue normal dry very dry,
furred
Skin normal slow very slow
retraction retraction
Breathing normal rapid very rapid
 ASSESSMENT OF
DEHYDRATION (contd.)
Dehydration
Mild Moderate Severe
Pulse normal rapid and feeble or
low imperceptible
volume
Urine normal dark scanty
Weight < 5% 6 - 9% 10% or more
loss
 TREATMENT
• Rehydration– replace the loss of fluid and
electrolytes
• Antibiotics– according to the type of
pathogens
• Start food as soon as possible
COMPOSITION OF ORS

Ingredient Amount (g/liter)

Sodium chloride 3.5
Trisodium citrate or 2.9 or
Sodium bicarbonate 2.5
Potassium chloride 1.5
Glucose 20.0
AMOUNT OF SALT LOSS
DURING DIARRHEA
Diarrhea Salt (mmol/L)
Na K Cl HCO3
Cholera 88 30 86 32
(child)
Cholera 135 15 100 45
(adult)
E. coli 53 37 24 18
Rota 37 38 22 6
virus
 ANTIMICROBIAL AGENTS
Type of diarrhea Antimicrobial agent
Cholera Tetracycline,
Doxycycline,
Ciprofloxacine
Shigellosis Pivmecillinam
(Selexid), Nalidixic
acid, Ciprofloxacin,
Ceftriaxone
Amebiasis Metronidazole
 COMPLICATIONS:
WATERY DIARRHEA
• Dehydration
• Electrolyte imbalances
• Tetany
• Convulsions
• Hypoglycemia
• Renal failure
 COMPLICATIONS:
DYSENTERY
• Electrolyte imbalances
• Convulsions
• Hemolytic uremic syndrome (HUS)
• Leukemoid reaction
• Toxic megacolon
• Protein losing enteropathy
• Arthritis
• Perforation
 VACCINES
• An oral cholera vaccine is available, which
gives immunity to 50-60% of those who take
the vaccine, and this immunity lasts only a
few months.
• No vaccines are available against shigellosis
• A vaccine against rotavirus diarrhea has been
withdrawn recently from the market.
 PREVENTION
• Safe drinking water and food
“Boil it, cook it, peel it, or forget it. "
• Hand washing
• Proper sanitation