Download CONTROL OF ENTERIC FEVER

CURICULUM VITAE
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Name
Borne
Position
Education
:Suharyo Hadisaputro, Prof.Dr.dr..Sp.PD-KPTI, FINASI
: Juana, March 10 , 1945;
: Professor in Medicine Medical Faculty Diponeoro Univ
: Doctoral in Medical (Public Helath),1990;
Cosultan of Tropical Infectious Disease, 1986;
Internal Medicine Spesialist, 1981;
Medical Doctor, 1972;
Job Description (History) :
Chief I of Researcher Tropical Infectious Disease Jkt;
Chief of Researcher Tropical Infectious Disease Semg
Chief of Program of Doctoral Medical & Health Undip.
Chief Program of Magister Epidemiologiy Undip.
Director of Postgraduate Program Diponegoro Univ;
Interest of Science :
Field and Clinical Epidemiology
Tropical I nfectious Disease;
Epidemiology of Communicable Disease;
Epidemiologiy of Non Communicable Disease;
Epidemiology of Iodine Disorder Deficiency
Suharyo Hadisaputro
International Seminar of Food and Water Borne Disease
Outline of Presentation
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Introduction
Significance & prevalence
High Risk Circumstances & Populations
Pathogenesis
Etiologic Agents
Diagnostic Approach & Differential
Management
FACTORS INFLUENCED TO INCREASED OF
INFECTIOUS DISEASES IN INDONESIA
(1) Economic Development, Changed of Demografic and Life
Style in Community;
(2) Development of Transportation  Increased of Traveller
inter-region, island, and city in Indonesia.
(3) Environmental changed  Disaster in many areas in
Indonesia, and many projects irigations ?
(4) Limitation of manpower and health sevices in community;
(5) Non hygiene of foodhandling  transmission of bacteriae
(Salmonella typhi);
(6) Mutation and Evolution of organism  new strain emerge
and antibiotics resistancy.
EMERGING INFECTIOUS DISEASES IN
INDONESIA
(A) Vector borne Disease : (1) DF/DHF (2)
Chikungunya (3) Japanese
Encephalitis (4) Malaria (5) Filariasis
(6) Leptospirosis (7) Toxoplasmosis;
(B) Sexual Transmitted Disease (STD);
(C) Airborne Disease : (1) Tuberculosis (2)
Influenza.
(D) Food and Water borne Disease : (1)
Typhoid Fever (2) Diarrhoae.
FOOD AND WATER BORNE
DISEASES.
(1) TYPHOID DAN SALMONELLOSIS : The
sanitary factor and hygienic food and water
take was responsibility on the increase of the
morbidity of typhoid fever.
(2) DIARRHOEA : Many causes of diarrhoea, and
the strain of Cholera Vibrio O 139 from
Bangladesh was a potentially factor to increase
the case of diarrhoea in Indonesia.
Causes of Death Worldwide
Pneumonia
8.5%
Diarrhea
5.8%
TB
3.9%
Measles
2.1%
Malaria
• Infections - 24.4%
1.7%
Tetanus
• Ischemic Heart Disease -
1.1%
Pertussis
HIV
12.5%
0.7%
0.6%
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2
4
Percent
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8
Lancet 1997;349:1269
TEN MAIN DISEASES IN INDONESIA
URBAN/RURAL AREA
Circulatory S
TBC
Digestive S
Neoplasma
Bron-Emp-Asthma
Urban
Rural
Diarrhea
Trauma- Accident
Other Inf
Respiratory Inf
Metabolic D
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5
10
15
20
25
TEN MAIN DISEASES OF CAUSED OF
DEATH IN INDONESIA
Peny Sist Sirkulasi
TBC
Inf Sal Nafas
Diare
Peny Infeksi lain
Bronc-asma-emp
Trauma- Kerac-Kcl
Sist Pencernaan
Neoplasma
Malaria
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5
10
15
20
Risks in 3rd World
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Lack of safe water supply
Contaminated foods
Poor sanitation
Overcrowding
Malnutrition
Global Risks in the World
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Traveller Diarrhoea
HIV infection & immunosuppression
Day Care Centers: fomite spread
– Also affects staff, household contacts
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Nursing Home/Chronic Care Facilities
Antibiotics
Achlorhydria/H2 blocker
Factors in Emergencies
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Lack of safe, clean water supply
Contamination of food supply
Poor sanitation
Overcrowding
Malnutrition
HIV infection & immunosuppression
Overall Significance
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One of most common diseases in world
3-5 billion cases of acute infectious
diarrhea annually
Kills 5-10 million people/year
In the U.S., more than 8 million seek
medical attention for diarrhea; costs
$23 billion in medical expenses & lost
wages
DIARRHEA
Diarrhea is a common symptom
that can range in severity from an
acute, self-limited annoyance to a
severe, life-threatening illness.
Patients may use the term
"diarrhea" to refer to increased
frequency of bowel movements,
increased stool liquidity, a sense of
fecal urgency, or fecal incontinence
Definition
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διάρροια; literally meaning "through-flowing"
Stool looses its normal consistence
Weight usually increases: >235g/d (♂), >175g/d
(♀)
Frequency increases: >2/d
Often associated with imperative urge to
defecate
Can contain blood, pus and mucous
Definition
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In the normal state, approximately 10 L
of fluid enter the duodenum daily, of
which all but 1.5 L are absorbed by the
small intestine. The colon absorbs most
of the remaining fluid, with only 100 mL
lost in the stool. From a medical
standpoint, diarrhea is defined as a
stool weight of more than 250 g/24 h
Input
Absorption
Diet/Saliva : 3 L/d
Stomach
:2L
Jejunum : 5 L/d
Bile
:1L
Pancreas
:2L
Bowel
Total
:1L
Ileum
: 2-3 L
Colon
: 1-2 L
Total
8.8 L
9L
Fecal Water 100-200 mL/d
Thus, diarrhea is defined as >200 mL liquid excretion per day. In extremus,
the gastrointestinal tract can both absorb and secrete 20 L of water per day.
ACUTE DIARRHEA
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Diarrhea that is acute in onset and
persists for less than 3 weeks is
most commonly caused by
infectious agents, bacterial toxins
(either ingested preformed in food
or produced in the gut), or drugs
Causes of acute infectious
diarrhea
1.
2.
3.
Viral - Norwalk virus, Norwalk-like virus,
Rotavirus
Protozoal - Giardia lamblia, Cryptosporidium
Bacterial - Preformed enterotoxin production
Staphylococcus aureus, Bacillus
cereus, Clostridium perfringens
Enterotoxin production;
Enterotoxigenic E coli
(ETEC), Vibrio cholerae
Other classifacation
Viral
Protozoan
CMV, Rota, adeno,
enterovirus, Norwalk
Giardia, Amy the
Ameba, Cryptosporidium
“Invasive”
Toxicogenic/Secretory
E. Coli 0157:H7, Shigella
Salmonella, Vibrios,
Campy Low-Backed Her,
Staph, noninvasive E.
Coli, Be Serious, C.
Difficile, Cholera
*lumps together invasive, inflammatory, non-amebic dysenteries, etc.
Pathogenesis
• Stimulation of net fluid secretion
• Mucosal destruction with increased
permeability
• Nutrient malabsorption
• Increased propulsive contraction
Etiologic Agents
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Toxin-producing bacteria
Invasive Bacteria
Parasites
Viruses
Toxin-producing bacteria
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Cholera
Shigella
ETEC (enterotoxigenic E. Coli)
EHEC (Enterohemorrhagic/EC 0157
Clostridium difficile
Bacillus cereus
Vibrio Cholera
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Spread in water, undercooked seafood
Secretion of fluid in small intestine
Malabsorption of fluid in large intestine
Rice water stools—large volume, high
electrolyte content
More info: Cholera
Shigella
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Spread by contaminated food, water
Bloody diarrhea characteristic
Fever common
Some carriers asmptomatic; symptoms
usually occur in 2-3 days
More info: Shigella
ETEC (Enterotoxigenic EC)
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Major cause of diarrhea in developing
countries & travelers
Two toxins, one cholera-like
Causes watery diarrhea, nausea,
cramps, low-grade fever
Rx: TMP-SMX or Bismuth salicylate
More info: ETEC
EHEC
(Enterohaemorrhagic EC)
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Toxin from undercooked food,
especially beef
May be mild or asx, but fever, severe
cramps & bloody diarrhea common
Cause of hemolytic uremic syndrome
More info: EHEC-O157
C. difficile
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Antibiotics facilitate overgrowth of
normal bowel inhabitant
Watery diarrhea +/- blood, cramps,
fever
Treatment: oral vancomycin or Flagyl
More info: C. difficile
Invasive Bacteria
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EIEC (enteroinvasive E. coli)
Salmonella
Campbylobacter
Yersinia
Enteroinvasive E. coli
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Symptoms mimic Shigella: bloody
diarrhea, fever, cramps
Thought to be spread by food
contamination
Therapy supportive, usually self-limited
without requiring antibiotics
More info: EIEC
Salmonella
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Contaminates raw eggs, dairy products,
poultry, other meats
Fever, diarrhea, +/- vomiting, can enter
bloodstream
More common in children, in summer
More info: Salmonella
Enteric Fever
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A severe systemic illness manifested
initially by prolonged high fevers,
prostration, confusion, respiratory
symptoms followed by abdominal
tenderness, diarrhea, and a rash is due
to infection with Salmonella typhi or
Salmonella paratyphi, which causes
bacteremia and multiorgan dysfunction
Campylobacter
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Spread by contaminated water or raw
milk
Causes patchy destruction of walls of
small and large intestines
Diarrhea +/- blood, fever, vomiting, HA,
abd pain
More info: Campylobacter
Yersinia
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Contaminates dairy products, poultry, &
other meat
Multiple syndromes, including sepsis in
immunosuppressed; appendicitis-like;
fever/diarrhea/abd pain in children; &
extra-intestinal infections
More info: Yersinia
Parasites
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Giardia lamblia
Entamoeba histolytica
Cryptosporidium
Giardia
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Zoonosis, animals contaminated Water
Diarrhea, abdominal pain,
gas
Treat w/ Flagyl
Entamoeba histolytica
Diarrhea, often
Bloody, fever, abd
cramps
n Onset usually 2-4
wks, range days-mos
n Treat w/ Flagyl
n More info: Amoeba
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Cryptosporidium
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Watery diarrhea, emesis, cramps, fever
Transmitted in water or fecal-oral
More pathogenic in immunosupressed,
especially AIDS
Best treatment is restoring immune fn,
(e.g., several drugs for HIV),
azithromycin shows some efficacy
More info: Cryptosporidium
Viruses
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Rotavirus
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Norwalk Agent
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Calciviruses
Rotavirus Epidemiology
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Most common cause of acute gastroenteritis in children worldwide
Infects almost all children by age 4
Kills nearly one million annually
Fecal-oral transmission, lasts for days
on toys & countertops
More common in winter
Rotavirus features
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Ranges from asymptomatic to severe
3-9 days’ fever, abd. pain, diarrhea
Wheel-shaped RNA virus, seen in stool
on EM, or diagnosed by ELISA
Prevent w/ handwashing & hygiene
Rx severe cases w/ ORS or IV fluids
More info: Rotavirus
Calciviruses
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Known as Norwalk-like viruses—small,
single-stranded RNA viruses
Associated with ingestion of raw
shellfish, fecal-oral transmission
Cause diarrhea, vomiting, fever,
headache
DIAGNOSTIC APPROACH
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Often based on clinical grounds
alone
– Diagnostic studies often unavailable
– Symptoms often resolve, or require prompt
treatment, before results can be obtained
– Clinical features that may be helpful
include exposure/risk factors; stool volume,
presence of blood, associated symptoms
DIAGNOSTIC STUDIES
If available, may include:
n Fecal leukocytes
n Stool culture
n Ova and parasites
n C. difficile titer
n Amoeba titers
MANAGEMENT OF DIARRHOAE
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Treatment often empiric
Oral rehydration therapy (ORT)
IV hydration
Anti-diarrheals: anti-motility, absorbent,
and anti-secretory agents
Antibiotics
Oral Rehydration
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Safe, simple, cheap
1st use: Bangladesh, 1971—dramatic
reduction in mortality
Premix, or use H2O, salt, sugar
Treats and prevents diarrhea
Sodium-glucose co-transport
Mothers can administer ORT
Oral Rehydration
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Glucose-based ORT may paradoxically
increase fecal fluid loss
Rice-based ORT may more quickly
relieve symptoms, ? More available
High amylose maize (amylase-resistant)
based ORT shortens diarrhea duration
and reduces stool volume
Indications for IV hydration
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Severe dehydration (hypotension,
shock, stupor, coma)
Ileus—abd distention a/o absent BS
Persistent severe vomiting
Excessive stool output (10cc/kg/hr)
Severe glucose malabsorption
More on IV hydration
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Replace fluid deficit as well as
continuing losses
Transition to ORT as soon as
dehydration improves and/or gut seems
to be working again
Antimotility Agents
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Increase segmental & decrease
propulsive contractions
Prolong transit time
Loperamide better than diphenoxylate
in clinical trials
Opiates have similar effect on motility
Limit to 48 hours; may prolong illness &
can cause ileus or toxic megacolon
Absorbent agents
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Nonabsorbable resins, e.g.
cholestyramine
Bind C. difficile toxin
Speed toxin clearance, promote
mucosal recovery—for multiple
pathogens
Stop 5 days after symptoms resolve
Antisecretory agents
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Decrease propulsive contractions
Increase mucosal absorption
Decrease mucosal secretion
Enhance electrolyte & H20 reabsorption
Most useful in AIDS-associated diarrhea
Ex.: octreotide
Antibiotics in Diarrhoae
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Not indicated for most cases of simple,
watery diarrhea
Most helpful for:
– Shigella, ETEC, ameobiasis, giardia,
cholera, S. typhi
– May help for cryptosporidium, other
salmonella
– Not useful for viral, EIEC
Special treatment of cholera
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Oral Rehydration Therapy
Antibiotics
– Limit spread of disease by reducing volume
& duration of diarrhea
– Adults: Doxycycline, 300 mg once
– Children: 6 mg/kg once
– Alternatives: TTC, Chloramphenicol,
Septra, quinolones, erythromycin
CONTROL OF ENTERIC FEVER
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Applying the principle of hygiene
Depend of the improvement of income
Cultural changes of personal hygiene
Many effort for control of TF, are :
(1) Treatment and control of
sources infection : Adequate
antibiotic treatment for active patients
and carriers, special isolation in the
hospital ?, desinfections of the excreta,
sterilization of the patient’s linen etc.
CONTROL OF ENTERIC FEVER
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(2) Improved on environment health
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To trace the source infection
To investigate of routes transmis
Water purification/chlorination
Control of all exposed foods for
sale in the market and store.
. Reduction the house-flies density
. To avoid of having open garbage
pail etc.
CONTROL OF ENTERIC FEVER
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(3) Supervision on food industries and
restaurant
. Supervision on sanitation of places work and
food processin, equipment etc.
. Prohibition to employ people who infected
. Routine examination of stool culture
. To trace of food, if as medium suspected
. All milk and milk products should be
pasteurized or boiled.
CONTROL OF ENTERIC FEVER
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(4) Control of healthy population
. Supervision on hygiene of food and
drink
. Serving the food in hot condition
. Health education for community
. Providing the places for washing hand
. Conducting vaccination of EF in endemic
area, however, improvement of
sanitation and health system is very
important role.
THE WHO GOLDEN RULES FOR
SAVE FOOD PREPARATION
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Choose foods processing for safety.
Cook food thoroughly.
Eat cooked food immediately.
Store cooked food thoroughly.
Reheat cooked food thoroughly.
Avoid contact between raw and cooked foods.
Wash hands repeately.
Keep all kitchen surfaces meticolously clean.
Protect foods from insects, rodents & animals.
Use pure water.
LEVEL OF PREVENTION
ONSET
ORDINARY
DETECTION
NO
ASYMPTOMA
DISEASE TIC DISEASE
PREMORD
PRIMARY
SECONDARY
Underlying Remove of Early detecrisk factors risk factors tion & prompt
treatment
CLINICAL COURSE
TERTIARY
Reduce
complications
SUMMARY OF DIARRHEA CONTROL
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Diarrheal disease most prevalent in
developing countries, and costly.
In Indonesia incidence still high.
Transmission most of direct route.
Empiric treatment with ORT most
often effective
The strategies of Diarrhea Control
SUMMARY OF DIARRHAE CONTROL
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The strategies of Diarrhea Control are :
. Detection and control of source,
. Disease surveillance,
. Health education in community,
. Improvement of hygiene sanitation,
. Promotion of water and food borne
disease,
. Prevention contamination in
food/water production,
. Conducting vaccination ??.
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