Control of Diarrheal Disease

1. 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/

2. 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

3. 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

4. Diarrhea • Characterized as loose or watery stools. • Can be mild or serious, acute or chronic IH887 - Maternal and Child Health in Developing Countries

5. 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

6. 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

7. Prevention • With good nutrition and good hygiene, diarrhea can be prevented. Picture from UNICEF IH887 - Maternal and Child Health in Developing Countries

8. 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

9. 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

10. 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

11. http://www.lfc.edu/~timocjm/Page1.html IH887 - Maternal and Child Health in Developing Countries

12. 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

13. 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

14. 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

15. Case Management of Acute Diarrhea IH887 - Maternal and Child Health in Developing Countries

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Overview of Case Management 3. ANTIMICROBIAL • Used only in special circumstances IH887 - Maternal and Child Health in Developing Countries

23. Overview of Case Management 4. ANTIDIARRHEAL DRUGS • Should be generally avoided. IH887 - Maternal and Child Health in Developing Countries

24. 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

25. Recognition of Dehydration From class text IH887 - Maternal and Child Health in Developing Countries

26. 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

27. 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

28. 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

29. 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

30. Mechanism of ORS Glucose Sodium Water Fluid absorbed better with glucose and sodium IH887 - Maternal and Child Health in Developing Countries

31. 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

32. 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

33. 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

34. 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

35. Dangers of ORS IH887 - Maternal and Child Health in Developing Countries

36. Home Treatment IH887 - Maternal and Child Health in Developing Countries

37. Barriers to Home Use IH887 - Maternal and Child Health in Developing Countries

38. Cost IH887 - Maternal and Child Health in Developing Countries

39. Nutrition • It’s more common and dangerous in young children, especially those who are poorly nourished. IH887 - Maternal and Child Health in Developing Countries

40. Vicious Circle • Malnutration causes diarrhea. • Diarrhea causes malnutrition From When There Is No Doctor IH887 - Maternal and Child Health in Developing Countries

41. 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

42. 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

43. Claudia will supply IH887 - Maternal and Child Health in Developing Countries

44. Advances in Technology IH887 - Maternal and Child Health in Developing Countries

45. New developments in ORT technology IH887 - Maternal and Child Health in Developing Countries

46. Conclusion IH887 - Maternal and Child Health in Developing Countries

47. IH887 - Maternal and Child Health in Developing Countries