1. CURICULUM VITAE Job Description (History) :
Name :Suharyo Hadisaputro, Prof.Dr.dr..Sp.PD-KPTI, FINASI
Borne : Juana, March 10 , 1945;
Position : Professor in Medicine Medical Faculty Diponeoro Univ
Education : Doctoral in Medical (Public Helath),1990;
Cosultan of Tropical Infectious Disease, 1986;
Internal Medicine Spesialist, 1981;
Medical Doctor, 1972;
Job Description (History) :
Chief I of Researcher Tropical Infectious Disease Jkt;
Chief of Researcher Tropical Infectious Disease Semg
Chief of Program of Doctoral Medical & Health Undip.
Chief Program of Magister Epidemiologiy Undip.
Director of Postgraduate Program Diponegoro Univ;
Interest of Science :
Field and Clinical Epidemiology
Tropical I nfectious Disease;
Epidemiology of Communicable Disease;
Epidemiologiy of Non Communicable Disease;
Epidemiology of Iodine Disorder Deficiency

2. (Food & Water Borne Disease)
INFECTIOUS DIARRHEA
(Food & Water Borne Disease)
Suharyo Hadisaputro
International Seminar of Food and Water Borne Disease
September 17, in Semarang, Indonesia

4. Outline of Presentation
Introduction
Significance & prevalence
High Risk Circumstances & Populations
Pathogenesis
Etiologic Agents
Diagnostic Approach & Differential
Management

5. FACTORS INFLUENCED TO INCREASED OF INFECTIOUS DISEASES IN INDONESIA
(1) Economic Development, Changed of Demografic and Life Style in Community;
(2) Development of Transportation  Increased of Traveller inter-region, island, and city in Indonesia.
(3) Environmental changed  Disaster in many areas in Indonesia, and many projects irigations ?
(4) Limitation of manpower and health sevices in community;
Non hygiene of foodhandling  transmission of bacteriae (Salmonella typhi);
Mutation and Evolution of organism  new strain emerge and antibiotics resistancy.

6. EMERGING INFECTIOUS DISEASES IN INDONESIA
Vector borne Disease : (1) DF/DHF (2) Chikungunya (3) Japanese Encephalitis (4) Malaria (5) Filariasis (6) Leptospirosis (7) Toxoplasmosis;
Sexual Transmitted Disease (STD);
Airborne Disease : (1) Tuberculosis (2) Influenza.
Food and Water borne Disease : (1) Typhoid Fever (2) Diarrhoae.

7. FOOD AND WATER BORNE DISEASES.
(1) TYPHOID DAN SALMONELLOSIS : The sanitary factor and hygienic food and water take was responsibility on the increase of the morbidity of typhoid fever.
DIARRHOEA : Many causes of diarrhoea, and the strain of Cholera Vibrio O 139 from Bangladesh was a potentially factor to increase the case of diarrhoea in Indonesia.

8. Causes of Death Worldwide
Pneumonia
8.5%
Diarrhea
5.8% TB
3.9%
Measles
2.1%
• Infections %
• Ischemic Heart Disease %
Malaria
1.7%
Tetanus
1.1%
Pertussis
0.7%
HIV
0.6% 2 4 6 8
Percent
Lancet 1997;349:1269

9. TEN MAIN DISEASES IN INDONESIA URBAN/RURAL AREA

10. TEN MAIN DISEASES OF CAUSED OF DEATH IN INDONESIA

11. Risks in 3rd World Lack of safe water supply Contaminated foods
Poor sanitation
Overcrowding
Malnutrition

12. Global Risks in the World
Traveller Diarrhoea
HIV infection & immunosuppression
Day Care Centers: fomite spread
Also affects staff, household contacts
Nursing Home/Chronic Care Facilities
Antibiotics
Achlorhydria/H2 blocker

13. Factors in Emergencies
Lack of safe, clean water supply
Contamination of food supply
Poor sanitation
Overcrowding
Malnutrition
HIV infection & immunosuppression

14. Overall Significance One of most common diseases in world
3-5 billion cases of acute infectious diarrhea annually
Kills 5-10 million people/year
In the U.S., more than 8 million seek medical attention for diarrhea; costs $23 billion in medical expenses & lost wages

15. DIARRHEA
Diarrhea is a common symptom that can range in severity from an acute, self-limited annoyance to a severe, life-threatening illness. Patients may use the term "diarrhea" to refer to increased frequency of bowel movements, increased stool liquidity, a sense of fecal urgency, or fecal incontinence

17. Definition διάρροια; literally meaning "through-flowing"
Stool looses its normal consistence
Weight usually increases: >235g/d (♂), >175g/d (♀)‏
Frequency increases: >2/d
Often associated with imperative urge to defecate
Can contain blood, pus and mucous

18. Definition
In the normal state, approximately 10 L of fluid enter the duodenum daily, of which all but 1.5 L are absorbed by the small intestine. The colon absorbs most of the remaining fluid, with only 100 mL lost in the stool. From a medical standpoint, diarrhea is defined as a stool weight of more than 250 g/24 h

19. Input Absorption Fecal Water 100-200 mL/d Diet/Saliva : 3 L/d
Stomach : 2 L
Jejunum : 5 L/d
Bile : 1 L
Pancreas : 2 L
Bowel : 1 L
Ileum : 2-3 L
Colon : 1-2 L
Total L
Total L
Fecal Water mL/d
Thus, diarrhea is defined as >200 mL liquid excretion per day. In extremus,
the gastrointestinal tract can both absorb and secrete 20 L of water per day.

20. ACUTE DIARRHEA
Diarrhea that is acute in onset and persists for less than 3 weeks is most commonly caused by infectious agents, bacterial toxins (either ingested preformed in food or produced in the gut), or drugs

21. Causes of acute infectious diarrhea
Viral - Norwalk virus, Norwalk-like virus, Rotavirus
Protozoal - Giardia lamblia, Cryptosporidium
Bacterial - Preformed enterotoxin production
Staphylococcus aureus, Bacillus
cereus, Clostridium perfringens
Enterotoxin production;
Enterotoxigenic E coli
(ETEC), Vibrio cholerae

22. Toxicogenic/Secretory
Other classifacation
Viral
Protozoan
CMV, Rota, adeno, enterovirus, Norwalk
Giardia, Amy the Ameba, Cryptosporidium
“Invasive”
Toxicogenic/Secretory
E. Coli 0157:H7, Shigella
Salmonella, Vibrios, Campy Low-Backed Her,
Staph, noninvasive E. Coli, Be Serious, C. Difficile, Cholera
*lumps together invasive, inflammatory, non-amebic dysenteries, etc.

23. Pathogenesis Stimulation of net fluid secretion
Mucosal destruction with increased permeability
Nutrient malabsorption
Increased propulsive contraction

24. Etiologic Agents Toxin-producing bacteria Invasive Bacteria Parasites
Viruses

25. Toxin-producing bacteria
Cholera
Shigella
ETEC (enterotoxigenic E. Coli)
EHEC (Enterohemorrhagic/EC 0157
Clostridium difficile
Bacillus cereus

26. Vibrio Cholera Spread in water, undercooked seafood
Secretion of fluid in small intestine
Malabsorption of fluid in large intestine
Rice water stools—large volume, high electrolyte content
More info: Cholera

27. Shigella Spread by contaminated food, water
Bloody diarrhea characteristic
Fever common
Some carriers asmptomatic; symptoms usually occur in 2-3 days
More info: Shigella

28. ETEC (Enterotoxigenic EC)
Major cause of diarrhea in developing countries & travelers
Two toxins, one cholera-like
Causes watery diarrhea, nausea, cramps, low-grade fever
Rx: TMP-SMX or Bismuth salicylate
More info: ETEC

29. EHEC (Enterohaemorrhagic EC)
Toxin from undercooked food, especially beef
May be mild or asx, but fever, severe cramps & bloody diarrhea common
Cause of hemolytic uremic syndrome
More info: EHEC-O157

30. C. difficile
Antibiotics facilitate overgrowth of normal bowel inhabitant
Watery diarrhea +/- blood, cramps, fever
Treatment: oral vancomycin or Flagyl
More info: C. difficile

31. Invasive Bacteria EIEC (enteroinvasive E. coli) Salmonella
Campbylobacter
Yersinia

32. Enteroinvasive E. coli
Symptoms mimic Shigella: bloody diarrhea, fever, cramps
Thought to be spread by food contamination
Therapy supportive, usually self-limited without requiring antibiotics
More info: EIEC

33. Salmonella Contaminates raw eggs, dairy products, poultry, other meats
Fever, diarrhea, +/- vomiting, can enter bloodstream
More common in children, in summer
More info: Salmonella

34. Enteric Fever
A severe systemic illness manifested initially by prolonged high fevers, prostration, confusion, respiratory symptoms followed by abdominal tenderness, diarrhea, and a rash is due to infection with Salmonella typhi or Salmonella paratyphi, which causes bacteremia and multiorgan dysfunction

35. Campylobacter Spread by contaminated water or raw milk
Causes patchy destruction of walls of small and large intestines
Diarrhea +/- blood, fever, vomiting, HA, abd pain
More info: Campylobacter

36. Yersinia Contaminates dairy products, poultry, & other meat
Multiple syndromes, including sepsis in immunosuppressed; appendicitis-like; fever/diarrhea/abd pain in children; & extra-intestinal infections
More info: Yersinia

37. Parasites
Giardia lamblia
Entamoeba histolytica
Cryptosporidium

38. Giardia Zoonosis, animals contami- nated Water
Diarrhea, abdominal pain,
gas
Treat w/ Flagyl

39. Entamoeba histolytica
Diarrhea, often
Bloody, fever, abd
cramps
Onset usually 2-4
wks, range days-mos
Treat w/ Flagyl
More info: Amoeba

40. Cryptosporidium Watery diarrhea, emesis, cramps, fever
Transmitted in water or fecal-oral
More pathogenic in immunosupressed, especially AIDS
Best treatment is restoring immune fn, (e.g., several drugs for HIV), azithromycin shows some efficacy
More info: Cryptosporidium

41. Viruses
Rotavirus
Norwalk Agent
Calciviruses

42. Rotavirus Epidemiology
Most common cause of acute gastro-enteritis in children worldwide
Infects almost all children by age 4
Kills nearly one million annually
Fecal-oral transmission, lasts for days on toys & countertops
More common in winter

43. Rotavirus features Ranges from asymptomatic to severe
3-9 days’ fever, abd. pain, diarrhea
Wheel-shaped RNA virus, seen in stool on EM, or diagnosed by ELISA
Prevent w/ handwashing & hygiene
Rx severe cases w/ ORS or IV fluids
More info: Rotavirus

44. Calciviruses
Known as Norwalk-like viruses—small, single-stranded RNA viruses
Associated with ingestion of raw shellfish, fecal-oral transmission
Cause diarrhea, vomiting, fever, headache

45. DIAGNOSTIC APPROACH Often based on clinical grounds alone
Diagnostic studies often unavailable
Symptoms often resolve, or require prompt treatment, before results can be obtained
Clinical features that may be helpful include exposure/risk factors; stool volume, presence of blood, associated symptoms

46. DIAGNOSTIC STUDIES If available, may include: Fecal leukocytes
Stool culture
Ova and parasites
C. difficile titer
Amoeba titers

47. MANAGEMENT OF DIARRHOAE
Treatment often empiric
Oral rehydration therapy (ORT)
IV hydration
Anti-diarrheals: anti-motility, absorbent, and anti-secretory agents
Antibiotics

48. Oral Rehydration Safe, simple, cheap
1st use: Bangladesh, 1971—dramatic reduction in mortality
Premix, or use H2O, salt, sugar
Treats and prevents diarrhea
Sodium-glucose co-transport
Mothers can administer ORT

49. Oral Rehydration
Glucose-based ORT may paradoxically increase fecal fluid loss
Rice-based ORT may more quickly relieve symptoms, ? More available
High amylose maize (amylase-resistant) based ORT shortens diarrhea duration and reduces stool volume

50. Indications for IV hydration
Severe dehydration (hypotension, shock, stupor, coma)
Ileus—abd distention a/o absent BS
Persistent severe vomiting
Excessive stool output (10cc/kg/hr)
Severe glucose malabsorption

51. More on IV hydration
Replace fluid deficit as well as continuing losses
Transition to ORT as soon as dehydration improves and/or gut seems to be working again

52. Antimotility Agents
Increase segmental & decrease propulsive contractions
Prolong transit time
Loperamide better than diphenoxylate in clinical trials
Opiates have similar effect on motility
Limit to 48 hours; may prolong illness & can cause ileus or toxic megacolon

53. Absorbent agents Nonabsorbable resins, e.g. cholestyramine
Bind C. difficile toxin
Speed toxin clearance, promote mucosal recovery—for multiple pathogens
Stop 5 days after symptoms resolve

54. Antisecretory agents Decrease propulsive contractions
Increase mucosal absorption
Decrease mucosal secretion
Enhance electrolyte & H20 reabsorption
Most useful in AIDS-associated diarrhea
Ex.: octreotide

55. Antibiotics in Diarrhoae
Not indicated for most cases of simple, watery diarrhea
Most helpful for:
Shigella, ETEC, ameobiasis, giardia, cholera, S. typhi
May help for cryptosporidium, other salmonella
Not useful for viral, EIEC

56. Special treatment of cholera
Oral Rehydration Therapy
Antibiotics
Limit spread of disease by reducing volume & duration of diarrhea
Adults: Doxycycline, 300 mg once
Children: 6 mg/kg once
Alternatives: TTC, Chloramphenicol, Septra, quinolones, erythromycin

57. CONTROL OF ENTERIC FEVER
Applying the principle of hygiene
Depend of the improvement of income
Cultural changes of personal hygiene
Many effort for control of TF, are :
(1) Treatment and control of sources infection : Adequate antibiotic treatment for active patients and carriers, special isolation in the hospital ?, desinfections of the excreta, sterilization of the patient’s linen etc.

58. CONTROL OF ENTERIC FEVER
(2) Improved on environment health
. To trace the source infection
. To investigate of routes transmis
. Water purification/chlorination
. Control of all exposed foods for
sale in the market and store.
. Reduction the house-flies density
. To avoid of having open garbage
pail etc.

59. CONTROL OF ENTERIC FEVER
(3) Supervision on food industries and restaurant
. Supervision on sanitation of places work and
food processin, equipment etc.
. Prohibition to employ people who infected
. Routine examination of stool culture
. To trace of food, if as medium suspected
. All milk and milk products should be
pasteurized or boiled.

60. CONTROL OF ENTERIC FEVER
(4) Control of healthy population
. Supervision on hygiene of food and
drink
. Serving the food in hot condition
. Health education for community
. Providing the places for washing hand
. Conducting vaccination of EF in endemic
area, however, improvement of
sanitation and health system is very
important role.

61. THE WHO GOLDEN RULES FOR SAVE FOOD PREPARATION
Choose foods processing for safety.
Cook food thoroughly.
Eat cooked food immediately.
Store cooked food thoroughly.
Reheat cooked food thoroughly.
Avoid contact between raw and cooked foods.
Wash hands repeately.
Keep all kitchen surfaces meticolously clean.
Protect foods from insects, rodents & animals.
Use pure water.

62. LEVEL OF PREVENTION NO DISEASE ASYMPTOMATIC DISEASE CLINICAL COURSE
ORDINARY DETECTION
ONSET
NO DISEASE
ASYMPTOMATIC DISEASE
CLINICAL COURSE
PREMORD
Underlying risk factors
PRIMARY
Remove of risk factors
SECONDARY
Early detec-tion & prompt treatment
TERTIARY
Reduce complications

63. SUMMARY OF DIARRHEA CONTROL
Diarrheal disease most prevalent in developing countries, and costly.
In Indonesia incidence still high.
Transmission most of direct route.
Empiric treatment with ORT most often effective
The strategies of Diarrhea Control

64. SUMMARY OF DIARRHAE CONTROL
The strategies of Diarrhea Control are :
. Detection and control of source,
. Disease surveillance,
. Health education in community,
. Improvement of hygiene sanitation,
. Promotion of water and food borne disease,
. Prevention contamination in food/water production,
. Conducting vaccination ??.

65. TERIMA KASIH