CURICULUM VITAE

1. CURICULUM VITAE • 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. INFECTIOUS DIARRHEA (Food & Water Borne Disease) Suharyo Hadisaputro International Seminar of Food and Water Borne Disease September 17, 2012 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 morbidityof 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 DeathWorldwide Pneumonia 8.5% Diarrhea 5.8% TB 3.9% Measles 2.1% • Infections- 24.4% • Ischemic Heart Disease - 12.5% Malaria 1.7% Tetanus 1.1% Pertussis 0.7% HIV 0.6% 0 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 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 9 L Total 8.8 L Fecal Water 100-200 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. Other classifacation *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