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http://www-busph.bu.edu Control of Diarrheal Disease IH 887 - Maternal and Child Health in Developing Countries http://med-sph.bu.edu/courses/IH887/ Control of Diarrheal Disease Presenters Caren Rosenthal Maya Yasmin Mauch Jeffery Lee Claudia Molina

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control of diarrheal disease

http://www-busph.bu.edu

Control of Diarrheal Disease

IH 887 - Maternal and Child Health in Developing Countries

http://med-sph.bu.edu/courses/IH887/

control of diarrheal disease2
Control of Diarrheal Disease

Presenters

Caren Rosenthal

Maya Yasmin Mauch

Jeffery Lee

Claudia Molina

http://med-sph.bu.edu/courses/IH887/bustugal.htm

IH887 - Maternal and Child Health in Developing Countries

control of diarrheal disease3
Introduction - Epidemiology

Etiology and Pathophysiology

Traditional Medical Treatment

Integrated Case Management

Dehydration

Oral Replacement Therapy / Oral Rehydration Salts

Nutrition

Advances in Technology

Better ORS

Vaccines

Conclusion - How to assess

Control of Diarrheal Disease

IH887 - Maternal and Child Health in Developing Countries

diarrhea
Diarrhea
  • Characterized as loose or watery stools.
  • Can be mild or serious, acute or chronic

IH887 - Maternal and Child Health in Developing Countries

diarrhea5
Diarrhea
  • Major cause of morbidity and mortality in infants and young children.
  • 4.6 million children <5 years of age die annually.

http://cdrwww.who.ch/images/deaths.gif

IH887 - Maternal and Child Health in Developing Countries

main causes

Pictures from UNICEF

Main Causes
  • Poor nutrition
  • Shortage of water and unclean conditions
  • Viral infection
  • Infection of the gut caused by bacteria and amoebas
  • Worm infection
  • Infections outside the gut
  • Malaria
  • Food poisoning

IH887 - Maternal and Child Health in Developing Countries

prevention
Prevention
  • With good nutrition and good hygiene, diarrhea can be prevented.

Picture from UNICEF

IH887 - Maternal and Child Health in Developing Countries

etiology
Etiology

Vibrio cholerae

Giardia

Entamoeba

Rotavirus

E. Coli (ETEC)

Shigellae

Salmonellae

Campylobacter

The etiology of 70 - 80% of diarrhea reaching health facilities in developing countries can be identified.

World Health Organization, Diarrhoeal Diseases Control Programme

Sleisenger - Gastrointestinal disease: pathophysiology, diagnosis, management

IH887 - Maternal and Child Health in Developing Countries

etiology9
Rotavirus

Enterotoxigenic E. coli

Campylobacter jejuni

Cryptosporidium

Etiology

http://ncmi.bcm.tmc.edu/~ay/Branches/rotavirus.html

http://www.mosbych.com/mhc/fullsize/1050.jpg

http://www.mosbych.com/mhc/fullsize/1395.jpg

http://whyfiles.news.wisc.edu/038badbus/images/cover.gif

IH887 - Maternal and Child Health in Developing Countries

etiology10
Etiology

Cholera

Giardia

http://www.lfc.edu/~timocjm/Page1.html

http://www.venturenorth.com/home/livres/images/giardia.gif

IH887 - Maternal and Child Health in Developing Countries

slide11

http://www.lfc.edu/~timocjm/Page1.html

IH887 - Maternal and Child Health in Developing Countries

pathophysiology
The small intestines absorb ~8L water.

The large intestines absorb ~1 L water.

300 cc in feces.

Impaired absorption

Increased secretions

Change in motor function of the gut

Unabsorbable osmotically active molecules

Pathophysiology

IH887 - Maternal and Child Health in Developing Countries

pathophysiology13
Types

Osmotic

Secretory

Chemical toxins via “second messengers”

Bacterial enterotoxin

Cholera toxin

http://www.bmsc.washington.edu/projects/toxins.html

Pathophysiology

IH887 - Maternal and Child Health in Developing Countries

traditional medical treatment
ETEC - trimethoprim-sulfamethoxasole (Septra, Bactrim) or bismuth subsalicylate (Peptol-Bismol)

Shigella - anti-biotics needed - tmp-smx, ciprofloxacin

Salmonella - ampicillin, tmp/smx,

ciprofloxacin

Campylobacter - erythromycin

Cholera - tetracycline for severe cases Giardia - quinacrine; metronidazole

Entamoeba - metronidazole

Traditional Medical Treatment

IH887 - Maternal and Child Health in Developing Countries

case management of acute diarrhea
Case Management of Acute Diarrhea

IH887 - Maternal and Child Health in Developing Countries

case management
Case Management

Approximately 2/3 of diarrheal deaths are attributable to dehydration and, therefore preventable by adequate fluid therapy.

IH887 - Maternal and Child Health in Developing Countries

case management17
Case Management

Focus on

  • RECOGNITION of clinical signs and symptoms
  • ASSESSMENT of severity
  • APPROPRIATE TREATMENT

of dehydration

IH887 - Maternal and Child Health in Developing Countries

dehydration
Dehydration
  • Recognition of dehydration and its correction is first priority in treatment of acute diarrhea.
  • Not all episodes associated with dehydration.
  • HOWEVER, diarrhea and vomiting are likely to result in life-threatening dehydration.

IH887 - Maternal and Child Health in Developing Countries

overview of case management
Overview of Case Management

1. ORT = Oral Rehydration Therapy

2. DIETARY MANAGEMENT

3. ANTIMICROBIALS - used only in special circumstances

4. ANTIDIARRHEAL DRUGS - generally avoided

IH887 - Maternal and Child Health in Developing Countries

overview of case management20
Overview of Case Management

1. ORT = oral rehydration therapy

  • Correction of fluid deficit
  • Replacement of continuous fluid losses: ORS to substitute for stool volume and vomiting.

IH887 - Maternal and Child Health in Developing Countries

overview of case management21
Overview of Case Management

2. DIETARY MANAGEMENT

  • Breast feeding not interrupted
  • Start feeding as s/s of dehydration disappear. Continue feeding even if severe diarrhea persists.

IH887 - Maternal and Child Health in Developing Countries

overview of case management22
Overview of Case Management

3. ANTIMICROBIAL

  • Used only in special circumstances

IH887 - Maternal and Child Health in Developing Countries

overview of case management23
Overview of Case Management

4. ANTIDIARRHEAL DRUGS

  • Should be generally avoided.

IH887 - Maternal and Child Health in Developing Countries

case management24
Case Management

General principles of case management are applicable to most cases of acute diarrhea regardless of etiology and pathogenic mechanisms.

IH887 - Maternal and Child Health in Developing Countries

recognition of dehydration
Recognition of Dehydration

From class text

IH887 - Maternal and Child Health in Developing Countries

oral rehydration therapy
Oral Rehydration Therapy
  • Oral rehydration therapy (ORT) is a solution of sodium and glucose designed to replace water and electrolytes lost during episodes of diarrhea.
  • The majority of cases of diarrhea, regardless of the etiologic agent, can be successfully managed with ORT.

Picture from UNICEF

IH887 - Maternal and Child Health in Developing Countries

oral replacement therapy
Oral Replacement Therapy
  • The World Health Organization estimates that 90% of diarrheal deaths worldwide could be prevented with appropriate treatment with ORT.
  • ORT can be prepared from ready made packages of oral rehydration salts or with home made sugar and salt solutions (SSS) using household salt and sugar or molasses.

From class text

IH887 - Maternal and Child Health in Developing Countries

history
History
  • ORT was developed in the early 1950’s and was formulated to mirror ions lost in stool.
  • The mechanism by which ORT works, the coupled transport of sodium and glucose, was discovered in the early 1960’s.
  • In 1971, the efficacy of ORS was shown during an epidemic of cholera in a refugee camp in Bangladesh. ORS reduced the death rate from more than 50% to only 5%.

IH887 - Maternal and Child Health in Developing Countries

history29
History
  • By the early 1970’s a consensus was reached about the effectiveness of ORT. WHO and UNICEF endorsed a universal, all-purpose, high sodium, ORS formula which has come to be known as ORS-WHO.
  • In 1985, ORT was endorsed by the American Academy of Pediatrics.
  • Despite widespread endorsement, ORT remains underused in this country as well as in many developing countries.

Picture from UNICEF

IH887 - Maternal and Child Health in Developing Countries

mechanism of ors
Mechanism of ORS

Glucose

Sodium

Water

Fluid absorbed better with glucose and sodium

IH887 - Maternal and Child Health in Developing Countries

composition of ors
Composition of ORS
  • The original formula of ORT contained 60 mmol of sodium/liter, 20 mmol of potassium/liter, 54 mmol of chloride/liter, 33 mmol of lactate/liter and 3.3 g glucose per deciliter.
  • The standard ORS recommended by WHO and UNICEF contains 90 mmol of sodium/liter, 20 mmol of potassium/liter, 80 mmol of chloride/liter, 10 mmol of citrate/liter and 111 mmol of glucose/liter.

IH887 - Maternal and Child Health in Developing Countries

composition of ors ii
Composition of ORS II
  • Potassium and chloride in the formula replace those lost in the stool of patients with diarrhea. Citrate, a base precursor, corrects acidosis and enhances the absorption of water and electrolytes.
  • The ORS formula has changed very little in the last decade except that sodium bicarbonate has been replaced by trisodium citrate, a more stable compound which allows for longer storage and cheaper packaging.
  • ORS solutions should include from 75-90 mmol of sodium/liter for rehydration solutions and from 40-60 mmol of sodium/liter for maintenance solutions
  • Maximum uptake of water and electrolytes occurs when the ratio of carbohydrates to sodium approaches one but formulas range from ratios of 1:1 to 2:1.

IH887 - Maternal and Child Health in Developing Countries

efficacy
Efficacy
  • Numerous studies have shown ORT to be extremely effective in reducing mortality from diarrhea induced dehydration in both children and adults.
  • In addition to being less painful, less costly and safer than IV rehydration, studies with significant findings indicate that oral rehydration has a lower failure rate, causes greater weight gain, and leads to a shorter duration of diarrhea than does IV rehydration.

IH887 - Maternal and Child Health in Developing Countries

safety
Safety
  • Overall, ORT appears to be remarkably safe and have few side effects.
  • A number of studies have addressed concerns that ORT can lead to hypernatremia in neonates and infants.
  • These studies show that administration of breast milk or plain water after rehydration prevents this problem.

Picture from World Bank

IH887 - Maternal and Child Health in Developing Countries

dangers of ors
Dangers of ORS

IH887 - Maternal and Child Health in Developing Countries

home treatment
Home Treatment

IH887 - Maternal and Child Health in Developing Countries

barriers to home use
Barriers to Home Use

IH887 - Maternal and Child Health in Developing Countries

slide38
Cost

IH887 - Maternal and Child Health in Developing Countries

nutrition
Nutrition
  • It’s more common and dangerous in young children, especially those who are poorly nourished.

IH887 - Maternal and Child Health in Developing Countries

vicious circle
Vicious Circle
  • Malnutration causes diarrhea.
  • Diarrhea causes malnutrition

From When There Is No Doctor

IH887 - Maternal and Child Health in Developing Countries

nutritional therapy
Nutritional Therapy
  • Reduce or prevent the damage of intestinal function induced by withholding food.
  • Prevent or decrease the nutritional damage caused by the disease.
  • Shorten the duration of disease.
  • Allow catch-up growth and a good return to good nutritional condition during convalescence.

IH887 - Maternal and Child Health in Developing Countries

preventing diarrhea
Preventing Diarrhea
  • Breast feed rather than bottle feed.
  • With new or solid food, give small amounts, mash it and mix it with breast milk.
  • Keep the baby clean.
  • Do not give unnecessary medicine

IH887 - Maternal and Child Health in Developing Countries

slide43

Claudia will supply

IH887 - Maternal and Child Health in Developing Countries

advances in technology
Advances in Technology

IH887 - Maternal and Child Health in Developing Countries

new developments in ort technology
New developments in ORT technology

IH887 - Maternal and Child Health in Developing Countries

conclusion
Conclusion

IH887 - Maternal and Child Health in Developing Countries

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