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Diarrheal Disease Management Evidence of Some Successful Programs

Diarrheal Disease Management Evidence of Some Successful Programs. Amal Mitra, MD, MPH, DrPH Professor University of Southern Mississippi. Learning Objectives. At the end of this session, students will learn: Common causes of diarrhea Mode of transmission of diarrhea

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Diarrheal Disease Management Evidence of Some Successful Programs

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  1. Diarrheal Disease ManagementEvidence of Some Successful Programs Amal Mitra, MD, MPH, DrPH Professor University of Southern Mississippi

  2. 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

  3. 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?

  4. Causes

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

  6. COMMON CAUSES OF DIARRHEA- BACTERIA • Vibrio cholera • Shigella • Escherichia coli • Salmonella • Campylobacter jejuni • Yersinia enterocolitica • Staphylococcus • Vibrio parahemolyticus • Clostridium difficile

  7. COMMON CAUSES OF DIARRHEA- VIRUS • Rotavirus • Adenoviruses • Caliciviruses • Astroviruses • Norwalk agents and Norwalk-like viruses

  8. COMMON CAUSES OF DIARRHEA- PARASITE • Entameba histolytica • Giardia lamblia • Cryptosporidium • Isospora

  9. COMMON CAUSES OF DIARRHEA-OTHERS • Metabolic disease • Hyperthyroidism • Diabetes mellitus • Pancreatic insufficiency • Food allergy • Lactose intolerance • Antibiotics • Irritable bowel syndrome

  10. 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

  11. SEASONALITY

  12. Cholera • Two biotypes • Classical or Asiatic type • ElTor – more prevalent

  13. 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

  14. 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

  15. 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

  16. 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)

  17. Influence of Climate Cholera in the South Dysentery in the North

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

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

  20. 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

  21. 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

  22. Sign Symptoms of Amebiasis • Offensive and bulky stools containing mostly mucus and sometimes blood • Lower abdominal cramp • Mild grade fever • No dehydration

  23. 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

  24. ASSESSMENT OF DEHYDRATION

  25. ASSESSMENT OF DEHYDRATION (contd.)

  26. ASSESSMENT OF DEHYDRATION (contd.)

  27. 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

  28. COMPLICATIONS:WATERY DIARRHEA • Dehydration • Electrolyte imbalances • Tetany • Convulsions • Hypoglycemia • Renal failure

  29. COMPLICATIONS:DYSENTERY • Electrolyte imbalances • Convulsions • Hemolytic uremic syndrome (HUS) • Leukemoid reaction • Toxic megacolon • Protein losing enteropathy • Arthritis • Perforation

  30. Some Successful Programs

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

  32. COMPOSITION OF ORS

  33. AMOUNT OF SALT LOSS DURING DIARRHEA

  34. 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.

  35. 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)

  36. 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.

  37. 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).

  38. 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.

  39. 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.

  40. 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.

  41. 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)

  42. 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

  43. VACCINES • Cholera • Rotavirus diarrhea

  44. 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.

  45. 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.

  46. 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.

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

  48. Hand Washing Practice in Bangladesh

  49. Household Characteristics who Washed Hands with Soap

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