Control of Diarrheal Disease

Presentation Transcript

http://www-busph.bu.edu

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

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

IH887 - Maternal and Child Health in Developing Countries

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

Diarrhea

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

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

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

Prevention

With good nutrition and good hygiene, diarrhea can be prevented.

Picture from UNICEF

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

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

Etiology

Cholera

Giardia

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

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

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

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

Types

Osmotic

Secretory

Chemical toxins via “second messengers”

Bacterial enterotoxin

Cholera toxin

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

Pathophysiology

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

Case Management of Acute Diarrhea

Case Management

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

Case Management

Focus on

RECOGNITION of clinical signs and symptoms
ASSESSMENT of severity
APPROPRIATE TREATMENT

of 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.

Overview of Case Management

1. ORT = Oral Rehydration Therapy

2. DIETARY MANAGEMENT

3. ANTIMICROBIALS - used only in special circumstances

4. ANTIDIARRHEAL DRUGS - generally avoided

1. ORT = oral rehydration therapy

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

2. DIETARY MANAGEMENT

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

3. ANTIMICROBIAL

Used only in special circumstances

4. ANTIDIARRHEAL DRUGS

Should be generally avoided.

Case Management

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

Recognition of Dehydration

From class text

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

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

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%.

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

Mechanism of ORS

Glucose

Sodium

Water

Fluid absorbed better with glucose and sodium

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.

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.

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.

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

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

Vicious Circle

Malnutration causes diarrhea.
Diarrhea causes malnutrition

From When There Is No Doctor

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.

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