Amal Mitra, MD, MPH, DrPH

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Diarrheal Disease ManagementEvidence of Some
Successful Programs

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

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Learning Objectives

• At the end of this session, students will learn
• Common causes of diarrhea
• Mode of transmission of diarrhea
• Sign and symptoms of common diarrheal illnesses
• Simple management tools for diarrhea
• Examples of some success stories to combat the
  problem

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Types of Diarrhea

• 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
• Mothers definition?

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Causes
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Common Diarrheas

• Age lt2 years Rotavirus
• Age 2-5 years Cholera E. coli Shigellosis
• All ages E. coli Campylobacter
• Immunocompromized Amebiasis Cryptosporidium

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COMMON CAUSES OF DIARRHEA- BACTERIA

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

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COMMON CAUSES OF DIARRHEA- VIRUS

• Rotavirus
• Adenoviruses
• Caliciviruses
• Astroviruses
• Norwalk agents and Norwalk-like viruses

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COMMON CAUSES OF DIARRHEA- PARASITE

• Entameba histolytica
• Giardia lamblia
• Cryptosporidium
• Isospora

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COMMON CAUSES OF DIARRHEA-OTHERS

• Metabolic disease
• Hyperthyroidism
• Diabetes mellitus
• Pancreatic insufficiency
• Food allergy
• Lactose intolerance
• Antibiotics
• Irritable bowel syndrome

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TRANSMISSION

• Most of the diarrheal agents are transmitted by
  the fecal-oral route
• Cholera water-borne disease transmitted through
  water contaminated with feces
• Some viruses (such as rotavirus) can be
  transmitted through air
• Nosocommial transmission is possible
• Shigellosis (blood dysentery) is mainly
  transmitted person-to-person
• Shigellosis is a water-washed disease
  transmitted more when there is scarcity of water

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SEASONALITY
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Cholera

• Two biotypes
• Classical or Asiatic type
• ElTor more prevalent

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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/vo
  l9no7/02-0760.htm

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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/fact
  sheets/HGIC3663.htm

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Shigella

• Several serotypes
• Shigella dysenteriae type 1 most dangerous and
  more drug-resistant
• Shigella flexneri is the most prevalent type
• Other major serotypes
• Sh. Sonnei
• Sh. boydii

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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 O157H7)
• Enteroaggregative E. coli (EAggEC)
• Diffuse adherent E. coli (DAEC)

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Influence of Climate

• Cholera in the South
• Dysentery in the North

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Sign/Symptoms of Cholera

• Rice-watery stool
• Marked dehydration
• Projectile vomiting
• No fever
• Shock, unconsciousness
• Scanty urine

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Sign Symptoms of E. coli Diarrhea

• Yellow watery stools
• Vomiting
• Dehydration moderate to severe
• Fever often of moderate grade
• Mild abdominal pain

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Sign Symptoms of Rotavirus Diarrhea

• Prodromal symptoms fever, cough, and vomiting
  preceding diarrhea
• Stools are watery or semi-liquid the color is
  greenish or yellowish typically looks like
  yoghurt mixed in water
• Mild to moderate dehydration

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Sign Symptoms of Shigellosis

• Frequent passage of scanty amount of stools,
  mostly mixed with blood and some mucus
• Moderate to high grade fever
• Severe abdominal cramps
• Tenesmus pain around anus during defecation
• Usually no dehydration

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Sign Symptoms of Amebiasis

• Offensive and bulky stools containing mostly
  mucus and sometimes blood
• Lower abdominal cramp
• Mild grade fever
• No dehydration

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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

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ASSESSMENT OF DEHYDRATION
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ASSESSMENT OF DEHYDRATION (contd.)
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ASSESSMENT OF DEHYDRATION (contd.)
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TREATMENT 3 Ds

• Dehydration correction replace the loss of fluid
  and electrolytes
• Diet Start food as soon as possible
• Drug
• Tetracycline/ ciprofloxacin for cholera
• Selexid for shigellosis
• Metronidazole for amebiasis

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COMPLICATIONSWATERY DIARRHEA

• Dehydration
• Electrolyte imbalances
• Tetany
• Convulsions
• Hypoglycemia
• Renal failure

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COMPLICATIONSDYSENTERY

• Electrolyte imbalances
• Convulsions
• Hemolytic uremic syndrome (HUS)
• Leukemoid reaction
• Toxic megacolon
• Protein losing enteropathy
• Arthritis
• Perforation

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Some Successful Programs
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ORT

• ORT (oral rehydration therapy)
• The leading British Medical Journal called ORT
  "potentially the most important medical advance
  of the century"

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COMPOSITION OF ORS
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AMOUNT OF SALT LOSS DURING DIARRHEA
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Home-Made ORS

• Home-made ORS Sugar or molasses (40 g) can be
  used as a substitute for glucose to prepare
  home-made ORS. Common salt (5 g) will be added to
  it and dissolved in one liter of clean water.
• Rice-ORS Rice powder (50 g) can replace the
  sugar or glucose. The amount of the other salts
  will remain the same. These will be dissolved in
  one liter of clean water to prepare rice-based
  ORS. Studies showed that rice-based ORS can
  reduce vomiting and diarrhea more in some cases
  compared to the conventional ORS prepared with
  glucose.

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Concept of Depot Holder

• Depot holders (Depot Mothers) in rural Bangladesh
• Diarrhea control in Bangladesh a social movement
  by Bangladesh Rural Advancement Committee (BRAC)
• Other Projects/Centers
• International Center for Diarrhoeal Disease
  Research, Bangladesh (ICDDR,B)
• Applied Diarrheal Disease Research Project (ADDR)
  

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Community Health Workers (CHWs)

• Well-trained and highly motivated community
  health workers (CHWs) are proven critical for the
  success of many community-based programs.
• CHWs act as catalysts between healthcare
  providers and the community people.
• These CHWs are either paid or voluntary workers.
• They are recruited from the same community so
  that they have an intimate interaction with the
  community people and an already established trust
  with the people.

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CHWs

• According to WHO, "CHWs are men and women chosen
  by the community, and trained to deal with the
  health problems of individuals and the community,
  and to work in close relationship with the health
  Services (WHO 1990).

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Bangladesh Experience

• BRAC community health workers called Shastho
  Shebikas. They teach every woman how to prepare
  oral rehydration solution to treat diarrhea
• The BRAC health program addresses the health and
  nutritional status of women and children in
  Bangladesh and covers 35 million people with
  approximately 25,140 Shastho Shebikas
• ICDDR,B to empower the communities to take full
  control of their health with the help of
  community health workers.

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Indian Experience

• Following reports of successful experiments in
  the non-governmental sector with the community
  health workers (CHWs), the Indian government
  introduced a CHW Scheme across the country in
  1977
• Aim "provision of health services at the
  doorsteps of villager" (Chatterjee 1993, Maru
  1983).
• The scheme included training of one community
  health volunteer for every village community
  comprising of 1000 population.

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Indian Experience

• The CHWs are expected to know the health needs of
  the community and provide basic health services
  minor treatments, preventive measures, including
  education and liaison with specialized health
  institutions (Maru 1983, Jobert 1985).
• Evidence shows that CHWs can be extremely
  effective to work as a complimentary force
  promoting utilization of available health
  services and the link between the community and
  the health system.

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Community-Operated Treatment Centers

• Transportation of patients to the health center
  in a timely manner is a problem in some parts of
  Bangladesh
• Some diarrheal diseases, such as cholera is a
  deadly disease if not treated in time
• COTRs are used as satellite treatment centers
• COTCs are built on donated lands in the community
• Operated by trained workers recruited from the
  community
• Supervised by locally-recruited people
• Supply from the main hospital
• COTCs can prevent deaths due to diarrheal
  diseases (Baqui et al., 1984)

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Diarrheal Disease Surveillance and Training
Program

• Government of Bangladesh provides continuous
  surveillance of diarrheal diseases, among other
  infectious diseases in the country
• In collaboration with the International Center
  for Diarrhoeal Disease Research, Bangladesh
  (ICDDR,B), GOB provides services for
• Epidemic Management and Control
• Training
• Educational materials
• Epidemic Control Preparedness Project (ECPP) is
  funded by Ford Foundation

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VACCINES

• Cholera
• Rotavirus diarrhea

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Cholera Vaccines

• Dukoral (WC-rBS) a monovalent oral vaccine based
  on killed whole-cells (WC) of V. cholerae O1 plus
  recombinant cholera toxin B subunit.
• Dose 2 oral doses 7 days (but lt6 weeks) apart
  for all aged 6 years.
• Shanchol and mORCVAX bivalent oral vaccines
  based on serogroups O1 and O139.
• Dose 2 oral doses 14 days apart for all aged 1
  year.

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Efficacy

• Dukoral and Shanchol/mORCVAX offer significant
  protection against cholera during the first two
  years after vaccination
• The ranges of protective efficacy at 4-6 months,
  1 year, and 2 years after vaccination are
  86-66, 62-45, and 77-58, respectively.

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Rotavirus Vaccines

• Two different rotavirus vaccines are currently
  licensed for use in infants in the United States.
  The vaccines are RotaTeq (RV5) and Rotarix
  (RV1).
• Before being licensed, both vaccines were tested
  in clinical trials and shown to be safe and
  effective.
• In these studies, during approximately the first
  year of an infants life, rotavirus vaccine was
  found to prevent almost all (85-98) rotavirus
  illness episodes that were severe and to prevent
  74-87 of all rotavirus illness episodes.

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PREVENTION

• Safe drinking water and food
• Boil it, cook it, peel it, or forget it. "
• Hand washing
• Proper sanitation

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Hand Washing Practice in Bangladesh
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Household Characteristics who Washed Hands with
Soap
Characteristic Had this characteristic Did not have this characteristic P-value
Mothers education
Some education 40 (17) 25 (10) 0.04
Above primary 69 (26) 25 (10) lt0.001
Wealth index
2nd quintile 21 (14) 17 (11) 0.47
3rd quintile 23 (16) 17 (11) 0.30
4th quintile 32 (20) 17 (11) 0.03
Availability at place of handwashing
Water 116 (21) 18 (9) lt0.001
Soap 93 (24) 41 (11) lt0.001
Both water and soap 79 (24) 55 (13) lt0.001
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Water and Sanitation Project

• UNICEFs activities on water, environment and
  sanitation (WES) support Bangladeshs national
  plan to achieve a safe water supply and sanitary
  facilities for 80 of the population and to
  improve the personal hygiene practices of 60 of
  the population.
• Access to an improved source of water supply
  increased only slightly from 72 in 1990 to 74
  in 2004, whereas coverage of improved sanitation
  nearly doubled from 20 to 39 during the same
  period.

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Water Supplies

• Urban Areas (25 of the population)
• 23 piped inside dwelling
• 8 piped outside dwelling
• 68 tubewells
• Rural Areas (75 of the population)
• Less than 0,6 piped inside and outside dwelling
• 96 tubewells
• 1 dug wells
• More than 2 ponds, lakes and rivers

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Low Cost Pit Latrine
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Goal

• Government of Bangladesh has set a goal for 100
  sanitation by 2013.
• But, recurrent floods, cyclone and prolonged
  water logging make it harder to adapt appropriate
  sanitation for the displaced and those who are
  living with flood and water logging conditions.

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Natural Disaster
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