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
Rota virus diarrhea
E. coli diarrhea
Cholera
Watery diarrhea
Shigellosis
Amebiasis
Dysentery
Causes are mostly unknown
Persistent diarrhea
Diarrhea
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,
thirsty
irritable,
very
thirsty
lethargy,
coma, or
unconscious
Anterior
Fontanelle
normal depressed markedly
depressed
Eyes normal sunken sunken
ASSESSMENT OF
DEHYDRATION (contd.)
Dehydration
Mild Moderate Severe
Tongue normal dry very dry,
furred
Skin normal slow
retraction
very slow
retraction
Breathing normal rapid very rapid
ASSESSMENT OF
DEHYDRATION (contd.)
Dehydration
Mild Moderate Severe
Pulse normal rapid and
low
volume
feeble or
imperceptible
Urine normal 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 Amount (g/liter)
Sodium chloride 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
Salt (mmol/L)

Diarrhea
Na K Cl HCO
3
Cholera
(child)
88 30 86 32
Cholera
(adult)
135 15 100 45
E. coli 53 37 24 18
Rota
virus
37 38 22 6


ANTIMICROBIAL AGENTS
Type of diarrhea Antimicrobial agent
Cholera Tetracycline,
Doxycycline,
Ciprofloxacine
Shigellosis Pivmecillinam
(Selexid), Nalidixic
acid, Ciprofloxacin,
Ceftriaxone
Amebiasis Metronidazole
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