Diarrheal diseases (gastro-enteritis)

Diarrheal diseases (gastro-enteritis)

Epidemiology of Communicable Diseases Childhood Diarrhea (Gastro-enteritis) Prof. Dr. Mohamed A. Khafagy Public Health & Preventive Medicine A clinical syndrome: 1. Affects GIT 2. Has different etiologies: viruses, bacteria, etc. 3. Ch. by diarrhea 4. Usually associated with vomiting & fever Definition of diarrhea: Passage of 3 or more loose or watery stools in 24 hrs. A single loose or watery stool containing blood.

In practice: diarrhea is an in stool frequency or liquidity that is considered abnormal by the mother. Epidemiology of childhood diarrhea (1) Public Health Significance (2) Seasonality (3) Its infectious cycle: 1. Etiology (= Agent) 2. Source of infection: - Type - Portal of Exit - Period of communicability 3- Modes of transmission 4- Susceptible Host - Portal of entry

- Incubation period - Pathogenesis - Diagnosis: Clinical picture + Complications + Lab. diagnosis [1] Public Health Significance Endemic worldwide (1) Its magnitude: (incidence & prevalence) (2) Its severity: (morbidity & mortality) (3) Its socio-economic burden: (individual, family, community, nation) (4) It can be prevented & controlled (1) Its magnitude: (High incidence) Globally: 2 billion cases of diarrhea / year (WHO).

In developing countries In developed countries 3.2 episodes/child/year 1.4 episodes/child/year not changed much since 1990s 211375 million cases/year 900,000 hospital admissions 6000 deaths

In developing countries (Egypt) it is a public Health problem because: 1- Unsanitary environment (unsafe water & food, flies) 2- Faulty traditional beliefs & health habits 3- improper child H. care: artificial feeding & faulty feeding 4- Lack of effective H. services 5- Other H. hazards: (Malnutrition & Systemic infs, ARI). (2) Its severity: (= morbidity & mortality) esp. in children 5 years of age malnutrition & poor growth Global mortality due to diarrheal diseases: Estimated deaths / year Period

4.8 million before 1980 3.3 million 19801990 2.6 million 19902000 1.8 million 2001-2005 1.5 million

2006- 2010 In Egypt: It accounts for 25-30% of mortality among children aged 5 yrs (3) Its economic burden: 1- the use of Health resources (facilities, H. workers time) 2- cost of ttt of diarrhea & malutrition. [2] Seasonality Sporadic cases all over the year. Peak of morbidity & mortality in summer & early fall (summer diarrhea) Small peak during winter: ARI associated with 2ry diarrhea.

[3] The infectious cycle (The natural history of the disease) Etiology: It is multi-factorial (1) 1ry infection of GIT: Protozoal Giardia, Entamebia, B. coli Bacterial E. Coli (ETEC, EHEC, EPEC, EIEC) Shigella, almonella, S. aureus, Others

Viral Rotavirus (70%) Enteroviruses Adenoviruses Hepatitis A & E (2) 2ry diarrhea: as a complication of other diseases: Viral diseases: measles, rubella, mumps, chickenpox Bacterial infections: ARI, tonsillitis, What are the causes of non-infectious diarrhea? Source of infection (reservoir): 1. Human: (main source): cases & carriers. 2. Animals: (in some infection) e.g. salmonella, balantidium coli. Exit:

With stool of infected person vomitus Period of communicability: As long as the organism is excreted in stool usually 2-3 weeks. Modes of transmission: 1. 2. 3. 4. Ingestion infection Water (with human excreta or sewage). Milk & milk products.

Food (handling, flies, dust or polluted water) Bottles, teats & utensils used to prepare baby Contaminated formulas & feeding. Incubation period: From few hrs up to 2-4 days according to causative agent Pathogenesis: invades intestinal mucosa e.g. salmonella, EHEC, EIEC. 1- Invasive diarrhea enterotoxins stimulate secretions of epithelial 2- Secretory diarrhea

cells e.g. ETEC, vibrio cholera, staph aureus. disaccharidase enzymes hydrolysis of disaccharides into monosaccharides in lumen osmotic diarrhea. 3- Osmotic diarrhea motility, interference with absorption (malabsorption) 4- Others Clinical picture:

Mild cases Moderate & severe cases Fever: no or mild. Diarrhea: mild (<5 times/day) Sudden onset, with fever. Irritability or apathy, anorexia. Abdominal cramps & distension Diarrhea: Frequent (up to 20 or more) blood & pus Vomiting usually appears later. usually no vomiting.

Dehydration: no or insignificant systemic manifestation: no or mild Self-limited within few days Clinical types of diarrhea: Acute onset of frequent loose or watery stools without visible bl. Lasts for 14 days Acute watery diarrhea: Last for 14 days with remission & exacerbation Chronic diarrhea:

Acute diarrhea that lasts for 14 days or more without remission & exacerbation. Persistent diarrhea: Diarrhea with visible blood in the stool Dysentery: Complications 1. Dehydration which is the major cause of mortality. 2. Nutritional deficiency: recurrent diarrhea predispose to PEM (interaction bet. Inf. & malnutrition) Vicious circle. 3. susceptibility to systemic infection , esp. ARI. 4. Cardiovascular, nervous & urinary complications. Laboratory diagnosis:

Acute disease is managed without waiting for investigation. Lab. diagnosis is of practical value for persistent or recurrent cases only 1. Microscopic exam. of stools. 2. Stool culture to isolate causative bacteria. 3. Serologic testing for viral infection , esp. rotavirus. Prevention of childhood diarrhea General measures: 1- Sanitary clean environment: - safe water supply, - milk & food sanitation, - sanitary waste disposal & - fly control. 2- H. education of mothers: - BF & proper Weaning, - Food & milk sanitation,

- use of ORS 3- H. promotion: adequate nutrition 4- Prevention & control of systemic infection (general & specific) Specific measures: Rota viruses vaccines & measles vaccine Control measures for cases Aim: Early case finding & proper ttt. Mild cases: outpatient care & continue ttt at home. Severe cases: hospitalization. Components of treatment : 1- Rehydration therapy. 2- Diet therapy.

3- Symptomatic treatment. 4- Supplementary treatment. 5- Treatment of underlying disease. 6- Chemotherapy. Case Assessment (history + clinical exam) How to assess a case of diarrhea for dehydration? (1) History: 1. Personal: name, age, sex, address. 2. Diarrhea: duration, frequency, consistency, blood. 3. Vomiting: duration, frequency, color 4. Urination: last time urine passed. 5. Thirst. 6. Other complaint: fever, cough, skin rash, ear problems. 7. Feeding & fluid intake: time, type, amount. 8. Previous ttt during this episode: ORS, drugs. 9. Vaccination history.

(2) Weight: To assess 1. degree of dehydration 2. amount of fluid required for initial rehydration. (1 gm wt loss = 1 ml water loss) (3) Temperature: Fever may be due to: 3. Infectious diarrhea. 4. Associated infection: otitis media, pneumonia. 5. Dehydration (disappear after rehydration). (4) Examination: to detect: 6. Presence & severity of dehydration 7. Associated conditions: under nutrition, otitis media, pneumonia 8. Complication: ileal paralysis.

Assessment of Dehydration Features Degree of Dehydration Mild Weight loss General Condition Pulse (N=110-120 < 5% Well, alert BP (N=90/60 mm

Normal beat/min) Hg) Resp. rate Urine output Slightly Slightly Normal Moderate Severe

5-9% 10% or more Restless, thirsty, Drowsy, cold irritable extremities, lethargic , weak , sometime impalpable , may be unrecordable Deep, rapid Markedly

Assessment of Dehydration Features Mild Degree of Dehydration Moderate Severe Eyes Normal Sunken Very sunken, dry

Tears Present Absent Absent Anterior fontanelle Normal depressed Very depressed

Mouth + tongue Normal dry Very Dry, furred Skin pinch goes back quickly slowly very slowly Treatment Plan B ttt

Plan C ttt Plan A ttt Treatment Plan A Aim: ttt of diarrhea at home to prevent dehydration & malnutrition Food + Fluids + Follow up (1) Food: Continue Feeding In breast fed child continue breastfeeding. In non-breast fed child give usual milk. If child is 6 months or older: 1.Give starchy food mixed with vegetables, meat or fish.

2.Add 1-2 teaspoonful of vegetable oil to each serving 3.Fresh fruit juice or mashed banana. How often & how much food: During diarrhea: At least 6 meals / day Frequent, small feedings are tolerated better than less frequent, large ones After stoppage of diarrhea: extra-meal for 2 weeks. In malnourished child , extra meals is given until the child regain his normal weight-for-height. (2) Fluids: 1. 2. 3.

4. 5. ORS (oral rehydration solution) Rice water. Soup Orange juice Yoghurt. Unsuitable fluids Fluids which can cause osmotic diarrhea & hypernatraemia, e.g.: soft drinks sweetened fruit drinks sweetened tea. Fluids with stimulant, diuretic or purgative effects, e.g.: coffee some medicinal teas or infusions.

How much fluid to give: Give as much fluid as the child or adult wants until diarrhea stops. General rule As a guide, after each loose stool, give: 50-100 ml of fluid children aged 2 years 100-200 ml. as much fluid as they want children aged 2-10 years older children & adults

(3) Follow up for the following symptoms: 1. 2. 3. 4. 5. 6. 7. Repeated vomiting Persistence of fever Persistence of diarrhea. Severe thirst Poor eating or drinking Blood in the stool; or the child does not get better in 3 days.

ORS: packets, each of 5.5 g, dissolved in 200 ml water WHO formula, each packet contains: Replacement 0.7 g Sodium chloride correct acidosis 0.5 g Na. bicarbonate correct hypokalaemia

0.3 g K. chloride Nutrient 4.0 g Glucose How to give ORS solution: Teach a family member how to prepare & give ORS solution.

Use a clean spoon or cup to give ORS infants & young children (feeding bottles should not be used). For babies, use a dropper or syringe (without the needle). For children aged 2 yrs a teaspoonful every 1-2 mins Older children (& adults) may take sips directly from the cup. Vomiting: 1. usually occurs during the 1st 2 hrs of ttt, esp. if child drink quickly. Rarely prevents successful ORT bed. most of the fluid is absorbed. After that vomiting usually stops.

2. If child vomits: wait 5-10 mins & then give ORS solution again, but more slowly (e.g. a spoonful every 2-3 mins). Treatment Plan B Aim: ttt of dehydration within 4 hours (1) Food: as in plan A. (2) Fluid: As plan A, except: The amount of ORS = 75 ml / kg body weight If child vomit: wait 10 mins, then continue ORS but at slower rate (a spoonful / 2-3 min). If child eye lids becomes puffy: stop ORS & give plain water or breast milk till puffiness is gone give ORS as in plan A. (3) Follow up for reassessment: After 4 hours, reassess the child : No signs of dehydration, consider the child fully rehydrated. - Skin pinch is normal.

- Thirst has subsided. - urine is passed. - Child becomes quiet, no longer irritable & often falls asleep. Child still has signs indicating some dehydration: 1- continue ORT by repeating ttt Plan B. 2- start to offer food, milk & other fluids, in ttt Plan A, 3- continue to reassess the child frequently. If signs of severe dehydration: shift to ttt Plan C. Treatment plan C Aim: ttt of severe dehydration quickly in hospital to avoid death Steps: (1) Give Ringers Lactate Solution: 100 ml / kg (if not available use normal saline). (2) Reassess child every 1-2 hrs, if no improvement, give I.V. drip

more rapidly. (3) Give ORS by mouth (5 ml /kg/hour) as soon as patient can drink. (4) Evaluate patient after 6 hrs in infants (3 hrs in older patients), then continue ttt according to appropriate plan (A, B or C). Indications for I.V. Ringers Lactate therapy: (1) Severe dehydration (plan C) (2) Failure of oral rehydration (3) Paralytic ileum (4) Unable to drink, as in coma. Indications for giving ORS by nasogastric tube: (5) Repeated vomiting. (6) Refusal of ORS or unable to drink. (7) Stool output exceeds ORS input. (8) Exhausted mother.

Chemotherapy: Indications: (1) infective diarrhea: Shigella, vibrio (2) Protozoal: Giardia & entamebia (3) Any existing systemic bacterial infection. Proper dosage, for short time (resistance, side effects). Symptomatic treatment: (1) Fever: No antityretics, ORS is valuable (there is interaction bet. fever & dehydration), cold compresses with light cloths & ttt of any associated systemic inf. (2) Diarrhea: diarrhea helps elimination of infection. It is self-limited & improved by rehydration. Avoid antidiarrheal, adsorbent (kaolin, pectin) & antimotility drugs. (3) Vomiting:

It is due to loss of electrolytes & acidosis. Slow intake of ORS improves vomiting. Avoid antiemetics. (4) Abdominal distension: due to loss of potassium in stools or ileus. National Control of Diarrheal Disease Program (NCDDP), 1991 Aim: (1) Morbidity spread of infection & incidence of diarrhea Incidence of persistent diarrhea Improve nutritional status (2) Mortality (3) Inappropriate use of antibiotics. Components: 1. ORS: production, packaging & distribution. 2. Training on ORT for doctors, pharmacists, nurses & mothers.

3. Research related to ORT: Clinical, social & economic. 4. Promotion of the project nationally: using TV, radio & other public media 5. Integration into PHC network. 6. Evaluation. Key measures to prevent diarrhoea include: (WHO) 1. promotion of breast-feeding; exclusive breastfeeding for the 1st 6 months of life 2. Proper weaning 3. promoting personal & domestic hygiene; 4. Sanitary water supply: access to safe drinking-water 5. Improved sanitation; 6. use of oral rehydration solution (ORS) in the community; 7. vaccination (rotavirus & other vaccines, e.g. measles). Objectives of International

Control Project of Diarrheal illness 1- mortality of diarrheal illness by short policies e.g. ORT, community education. 2- morbidity in developing countries: - Raising standards of environmental - Health education for specific groups e.g. mothers 3-Availability of accessible health services: - High immunization coverage. - Proper infant & child care. - Proper treatment of diseases complicated by diarrhea. - Improving nutritional status of young age group. 4-Detection of source of infection & decrease reservoir. Thank You

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