Epidemiology and Management

of Diarrheal Diseases
Amal Mitra, MD, MPH, DrPH
Professor
University of Southern Mississippi
Readings: Diarrhoeal Diseases

DEFINITION
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

TYPES OF DIARRHEA

D ia rrh e a
W a te ry d ia rrh e a

D y s e n te ry

P e rs is te n t d ia rrh e a

R o ta v iru s d ia rrh e a
E . c o li d ia rrh e a
C h o le ra

S h ig e llo s is
A m e b ia s is

C a u s e s a re m o s tly u n k n o w n

COMMON CAUSES OF
DIARRHEA- BACTERIA

Vibrio cholera
Shigella
Escherichia coli
Salmonella
Campylobacter jejuni
Yersinia enterocolitica
Staphylococcus
Vibrio parahemolyticus
Clostridium difficile

COMMON CAUSES OF
DIARRHEA- VIRUS

Rotavirus
Adenoviruses
Caliciviruses
Astroviruses
Norwalk agents and Norwalk-like viruses

COMMON CAUSES OF
DIARRHEA- PARASITE

Entameba histolytica
Giardia lamblia
Cryptosporidium
Isospora

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

TRANSMISSION
Most of the diarrheal agents are transmitted
by the fecal-oral route
Some viruses (such as rotavirus) can be
transmitted through air
Nosocommial transmission is possible
Shigella (the bacteria causing dysentery) is
mainly transmitted person-to-person

SEASONALITY
Disease

Common season

Cholera

Winter

Rotavirus diarrhea Winter

Shigellosis

Dry summer

PERSON-AT-RISK
Cholera: 2 years and above, uncommon in
very young infants
Shigellosis: more common in young
children aged below 5 years
Rotavirus diarrhea: more common in young
infants and children aged 1-2 years
E. coli diarrhea: can occur at any age
Amebiasis: more common among adults

TYPES OF VIBRIO CHOLERA

Two major biotypes of Vibrio cholera that
cause diarrhea are:
Classical
ElTor
Two common serotypes of Vibrio cholera
that cause diarrhea are:
Inaba
Ogawa

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

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

TYPES OF SHIGELLA
The major serotypes of Shigella that cause
diarrhea are:
Dysenteriae type 1 or Shigella shiga
Shigella flexneri
Shigella sonnei
Shigella boydii

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)

CLINICAL FEATURE:
CHOLERA

Rice-watery stool
Marked dehydration
Projectile vomiting
No fever or abdominal pain
Muscle cramps
Hypovolemic shock
Scanty urine

CLINICAL FEATURE:
E. COLI DIARRHEA

Watery stools
Vomiting is common
Dehydration moderate to severe
Fever often of moderate grade
Mild abdominal pain

CLINICAL FEATURE:
ROTAVIRUS DIARRHEA
Insidious onset
Prodromal symptoms, including fever,
cough, and vomiting precede diarrhea
Stools are watery or semi-liquid; the color
is greenish or yellowish typically looks
like yoghurt mixed in water
Mild to moderate dehydration
Fever moderate grade

CLINICAL FEATURE:
SHIGELLOSIS
Frequent passage of scanty amount of
stools, mostly mixed with blood and mucus
Moderate to high grade fever
Severe abdominal cramps
Tenesmus pain around anus during
defecation
Usually no dehydration

CLINICAL FEATURE:
AMEBIASIS
Offensive and bulky stools containing
mostly mucus and sometimes blood
Lower abdominal cramp
Mild grade fever
No dehydration

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

ASSESSMENT OF
DEHYDRATION
Dehydration
Mild
Moderate Severe
Appearance irritable, irritable, lethargy,
thirsty
very
coma, or
thirsty
unconscious
Anterior
normal
depressed markedly
Fontanelle
depressed
Eyes

normal

sunken

sunken

ASSESSMENT OF
DEHYDRATION (contd.)
Tongue

Mild
normal

Skin

normal

Breathing normal

Dehydration
Moderate Severe
dry
very dry,
furred
slow
very slow
retraction retraction
rapid

very rapid

ASSESSMENT OF
DEHYDRATION (contd.)

Pulse

Mild
normal

Urine

normal

Dehydration
Moderate Severe
rapid and feeble or
low
imperceptible
volume
dark
scanty

Weight
loss

< 5%

6 - 9%

10% or more

TREATMENT
Rehydration replace the loss of fluid and
electrolytes
Antibiotics according to the type of
pathogens
Start food as soon as possible

COMPOSITION OF ORS
Ingredient
Sodium chloride

Amount (g/liter)
3.5

Trisodium citrate or
Sodium bicarbonate

2.9 or
2.5

Potassium chloride

1.5

Glucose

20.0

AMOUNT OF SALT LOSS

DURING DIARRHEA
Diarrhea
Cholera
(child)

Salt (mmol/L)
Na K Cl HCO3
88 30 86 32

Cholera
(adult)

135 15 100 45

E. coli
Rota
virus

53
37

37 24
38 22

18
6

ANTIMICROBIAL AGENTS
Type of diarrhea
Cholera

Antimicrobial agent
Tetracycline,
Doxycycline,
Ciprofloxacine

Shigellosis

Pivmecillinam
(Selexid), Nalidixic
acid, Ciprofloxacin,
Ceftriaxone
Metronidazole

Amebiasis

COMPLICATIONS:
WATERY DIARRHEA

Dehydration
Electrolyte imbalances
Tetany
Convulsions
Hypoglycemia
Renal failure

COMPLICATIONS:
DYSENTERY

Electrolyte imbalances
Convulsions
Hemolytic uremic syndrome (HUS)
Leukemoid reaction
Toxic megacolon
Protein losing enteropathy
Arthritis
Perforation

VACCINES
An oral cholera vaccine is available, which
gives immunity to 50-60% of those who take
the vaccine, and this immunity lasts only a
few months.
No vaccines are available against shigellosis
A vaccine against rotavirus diarrhea has
been withdrawn recently from the market.

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