Amal Mitra, MD, MPH, DrPH Professor University of Southern Mississippi Diarrheal Disease Management Evidence of Some Successful Programs

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

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 Mother’s definition?

Causes DiarrhoeaPersistent Multiple cause DysenteryBacillaryAmoebicWateryCholeraE. coliRotavirus

Common Diarrheas Age <2 years: Rotavirus Age 2-5 years: Cholera; E. coli; Shigellosis All ages: E. coli; Campylobacter Immunocompromized: Amebiasis; Cryptosporidium

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 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

SEASONALITY

Cholera Two biotypes Classical or Asiatic type ElTor – more prevalent

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:

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:

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

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)

Influence of Climate Cholera in the South Dysentery in the North

Sign/Symptoms of Cholera Rice-watery stool Marked dehydration Projectile vomiting No fever Shock, unconsciousness Scanty urine

Sign Symptoms of E. coli Diarrhea Yellow watery stools Vomiting Dehydration moderate to severe Fever– often of moderate grade Mild abdominal pain

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

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

Sign Symptoms of 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

ASSESSMENT OF DEHYDRATION (contd.)

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

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

Some Successful Programs

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

COMPOSITION OF ORS

AMOUNT OF SALT LOSS DURING DIARRHEA

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.

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)

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.

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).

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.

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.

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.

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)

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

VACCINES Cholera Rotavirus diarrhea

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 <6 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.

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.

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 infant’s 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.

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

Hand Washing Practice in Bangladesh

Household Characteristics who Washed Hands with Soap CharacteristicHad this characteristic Did not have this characteristic P-value Mother’s education Some education40 (17)25 (10)0.04 Above primary69 (26)25 (10)<0.001 Wealth index 2 nd quintile21 (14)17 (11) rd quintile23 (16)17 (11) th quintile32 (20)17 (11)0.03 Availability at place of handwashing Water116 (21)18 (9)<0.001 Soap93 (24)41 (11)<0.001 Both water and soap79 (24)55 (13)<0.001

Water and Sanitation Project UNICEF’s activities on water, environment and sanitation (WES) support Bangladesh’s 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.

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

Low Cost Pit Latrine

Goal Government of Bangladesh has set a goal for 100% sanitation by 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.

Natural Disaster