ACUTE DIRRHOEAL 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

Global Problem
4.6 million children
less than 5 years of
age die of diarrheal
diseases.
Diarrhea accounts
for 19% of all deaths
among children
ages 0-4.
Eighty-five percent
of diarrheal deaths
occur in the first

TYPES OF DIARRHEA

D ia rrh ea
W a tery d ia rrh ea

D y sen tery

P ersisten t d ia rrh ea

R o ta v iru s d ia rrh ea
E . c o li d ia rrh ea
C h o lera

S h ig ello sis
A m eb ia sis

C a u ses a re m o stly 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

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

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

Etiological Agents

Bacterial, Viral, and

Parasitic Agents

Protozoans

Giardia

Rotavirus

Rotavirus

Enterotoxigenic E.
Coli
Shigellae
Salmonellae
Vibrio Cholerae
Campylobacter jejuni

Giardia

E.Coli

Entamoeba

World Health Organization. 1997.

http://www.who.int/chd/pub/imci/fs_180.html

Transmission

Diarrheal agents are mostly spread

via the fecal-oral route.
physical contact with infected feces
eating or drinking contaminated food
or water
person to person relay

World Health Organization. 1998. The Epidemiology and Etiology of Diarrhea. http://www.who.int/chd/pub/cdd/meded/1med.htm

Pathophysiology
Intestinal wall becomes damaged
Impaired absorption
Body expels large amounts of
fluids
Shock, blood pressure drops,
kidneys shut down
Death

Socioeconomic factors

Poverty
Overcrowding
Poor sanitation
Contamination of
water
Inadequate food
hygiene
UNICEF. 1998. The State of the Worlds Children, 1998. Oxford and New York: Oxford University Press.

Risk Factors
Household crowding
Low maternal education
Low birth weight

aeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9: 345-35

Behavioral Factors

Failure to breastfeed exclusively

for the first 4-6
months of life
Failure to
continue breastfeeding until one
year of age
Using infant
bottles

Storing food at
room temperature

Contaminated
drinking water

Failure to wash
hands

Failure to dispose
of feces
hygienically

aeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Diseases Journal, 9: 345-3

Host Factors
Immunosuppression
Measles
Malnutrition

Malnutrition and Diarrhea

The Vicious Cycle

(Please see handout.)

Clinical Signs and

Symptoms

Figure 15.1, Lankinen et.

al
Table 15.3, Lankinen et. al.

Prevention Strategies

Breast Feeding
Improved
weaning practices
Proper use of
water
Hand washing
Disposing feces
properly
Effectiveness of
measles

3 main types of diarrhea

Type of
diarrhea

% of cases of
diarrhea

% of deaths
% of deaths
due to diarrhea preventable by
standard case
management

Acute
Watery
Dysentery

80

50

100

10

15

80

Persistent

10

35

80

Total

100

100

90

World Health Organization. 1997. WHO Fact Sheet: Reducing Mortality from Major Childhood Killer Diseases. Fact Sheet
Number 180. http://www.who.int/chd/pub/imci/fs_180.html

Case Management
Oral Rehydration Therapy
Nutritional Management
Drug Therapy

Oral Rehydration Therapy

(video)

Nutritional Management

Appropriate feeding during

diarrhea is encouraged
Decrease in stool output
Shortened duration of illness
Significant weight gain
Improved nutritional status

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea.
Journal of Pediatrics, 131(6): 801-808.

Nutritional Management

Recommendations for nutritional

therapy depend on the age and
diet of the child.
Breast-fed infants
Bottle-fed infants
Weaned Children

Nutritional Management

Breast-fed infants
Continue nursing on demand
ORS

http://www.rehydrate.org/html/dia020.html

Nutritional Management

Bottle-fed infants
Formula
Mixed diet
ORS

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea.
Journal of Pediatrics, 131(6): 801-808.
http://www.rehydrate.org/html/dia020.html

Nutritional Management

Weaned Children
Continuation of regular diet
Easily digested diet
Complex carbohydrates (rice,
potatoes, bread)
Lean meats (e.g. chicken)
Yogurts, fruits, and vegetables

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea. Journal
of Pediatrics, 131(6): 801-808.

Nutritional Management

Micronutrient supplementation
Zinc
Vitamin A
Folic Acid

Duggan, C., & Nurko, S. Feeding the gut: Scientific basis for continued enteral nutrition during acute diarrhea. Journal
of Pediatrics, 131(6): 801-808.

Drug Therapy

Avoid
Adverse reactions
Antibiotic resistance
Unnecessary costs

laeson, M., & Merson, M. 1990. Global progress in the control of diarrheal diseases. Pediatric Infectious Disease Journal, 9: 345-35

Cost Effectiveness

ORT is less than one-tenth as expensive

as intravenous fluid and it is as
effective.
One packet of ORS costs about 8 cents.
An estimated 1 billion dollars per year
could be saved worldwide by
appropriate treatment of diarrhea and
elimination of drug therapy for diarrhea.
USAID. 1999. Http://www.info.usaid.gov/pop_health/cs/csddc.htm

New Developments

Super-ORS
Rotavirus vaccine

Controversies

Underuse of ORT and overuse of

drugs
Boil the water

nt scheme used for children with bloo

Thank you

Super ORS
fortified ORS with the amino acid glycine decreases stool volume
by 49-70% and duration of diarrhea 28-30%, other studies
indicate that it induces excess sodium concentrations in the blood
ORS fortified with the amino acid L-alanine reduced the severity of
symptoms and the need for fluid in patients afflicted with cholera
and enterotoxigenic Escherichia coli. Further studies reveal that
rice powder based ORS (50-80 g/l) reduces stool volume 24-49%
and duration of duration 30%.
The advantage of using rice is that when it hydrolyzes glucose,
amino acids, and oligopeptides emerge. Each 1 of these chemicals
facilitate sodium absorption through separate pathways.
Disadvantages include the fuel must be used to cook the rice, rice
based ORS ferments within 8-24 hours making it useless, and the
rice or pop rice needs to be ground.

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