CURICULUM VITAE • Name :Suharyo Hadisaputro, Prof.Dr.dr..Sp.PD-KPTI, FINASI• Borne : Juana, March 10 , 1945;• Position : Professor in Medicine Medical Faculty Diponeoro Univ• Education : 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
International Seminar of Food and Water Borne Disease
September 17, 2012 in Semarang, Indonesia
Suharyo Hadisaputro
Outline of Presentation 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.
0.6%
0.7%
1.1%
1.7%
2.1%
3.9%
5.8%
8.5%
Lancet 1997;349:1269Percent0 2 4 6 8
HIV
Pertussis
Tetanus
Malaria
Measles
TB
Diarrhea
Pneumonia
• Infections - 24.4%
• Ischemic Heart Disease - 12.5%
Causes of Death Worldwide
TEN MAIN DISEASES IN INDONESIA URBAN/RURAL AREA
0 5 10 15 20 25
Metabolic D
Respiratory Inf
Other Inf
Trauma- Accident
Diarrhea
Bron-Emp-Asthma
Neoplasma
Digestive S
TBC
Circulatory S
UrbanRural
TEN MAIN DISEASES OF CAUSED OF DEATH IN INDONESIA
0 5 10 15 20
Malaria
Neoplasma
Sist Pencernaan
Trauma- Kerac-Kcl
Bronc-asma-emp
Peny Infeksi lain
Diare
Inf Sal Nafas
TBC
Peny Sist Sirkulasi
Risks in 3rd World Lack of safe water supply Contaminated foods Poor sanitation Overcrowding Malnutrition
Global Risks in the World
Traveller Diarrhoea HIV infection &
immunosuppression Day Care Centers: fomite spread
– Also affects staff, household contacts Nursing Home/Chronic Care
Facilities Antibiotics Achlorhydria/H2 blocker
Factors in Emergencies Lack of safe, clean water
supply Contamination of food supply Poor sanitation Overcrowding Malnutrition HIV infection &
immunosuppression
Overall Significance 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
DIARRHEADiarrhea 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 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 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/dStomach : 2 L
Bile : 1 LPancreas : 2 LBowel : 1 L
Jejunum : 5 L/d
Ileum : 2-3 L
Colon : 1-2 L
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.
Total 9 L Total 8.8 L
ACUTE DIARRHEA 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. Viral - Norwalk virus, Norwalk-like virus, Rotavirus
2. Protozoal - Giardia lamblia, Cryptosporidium
3. 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, ShigellaSalmonella, 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
Toxin-producing bacteria
Cholera Shigella ETEC (enterotoxigenic E. Coli) EHEC (Enterohemorrhagic/EC 0157 Clostridium difficile Bacillus cereus
Vibrio Cholera 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 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)
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) 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
Antibiotics facilitate overgrowth of normal bowel inhabitant
Watery diarrhea +/- blood, cramps, fever
Treatment: oral vancomycin or Flagyl
More info: C. difficile
Enteroinvasive E. coli 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 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 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 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 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
Entamoeba histolytica Diarrhea, often Bloody, fever, abd cramps Onset usually 2-4wks, range days-mos Treat w/ Flagyl More info: Amoeba
Cryptosporidium 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
Rotavirus Epidemiology Most common cause of acute
gastro-enteritis 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 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 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 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 STUDIESIf available, may include: Fecal leukocytes Stool culture Ova and parasites C. difficile titer Amoeba titers
MANAGEMENT OF DIARRHOAE
Treatment often empiric Oral rehydration therapy (ORT) IV hydration Anti-diarrheals: anti-motility,
absorbent, and anti-secretory agents
Antibiotics
Oral Rehydration 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 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
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 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 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 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 Decrease propulsive contractions Increase mucosal absorption Decrease mucosal secretion Enhance electrolyte & H20
reabsorption Most useful in AIDS-associated
diarrhea Ex.: octreotide
Antibiotics in Diarrhoae 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
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
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
(2) Improved on environment health
. 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
(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
(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.
CONTROL OF ENTERIC FEVER
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.
THE WHO GOLDEN RULES FOR SAVE FOOD PREPARATION
NO DISEASE
ASYMPTOMATIC DISEASE
CLINICAL COURSE
ONSETORDINARY DETECTION
LEVEL OF PREVENTION
PRIMARYRemove of risk factors
SECONDARYEarly detec-tion & prompt treatment
TERTIARYReduce complications
PREMORDUnderlying risk factors
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 DIARRHEA CONTROL
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 ??.
SUMMARY OF DIARRHAE CONTROL