Diarrhea Due to Bad Sanitation

Inappropriate sewage disposal leads to contamination of drinking water with human or animal stools; this is the main cause of diarrhea in poor countries. Besides which, inadequate food storing and bad hygiene during food preparation result in food poisoning.

Prevention Of Diarhea in Poor Countries:

Latrines

Using latrines can help to keep the sources of drinking water clean.

Image 1. Latrine

Vaccination against Rotavirus

All children under 5 years of age should be vaccinated with oral vaccine. In poor countries, vaccination has greatly reduced mortality from diarrhea in last years.

Point-of-Use (POU) Water Treatment

1. Boiling

Boiling of water kills all microbes in a minute.

2. Chlorination

Sodium hypochlorite solution (household bleach) or calcium hypochlorite tablets are put in a container with water. Released chlorine kills most microorganisms in 30 minutes (it doesn’t kill cryptosporidium); disinfected water is safe to use for the next 24 hours. There are conflicting opinions about cancerogenic effect of chlorination byproducts, such as chloroform, but current scientific data shows that the benefit of chlorinating is much greater than any health risk (1).

3. Solar Disinfection (SODIS)

Water is put in plastic (or glass) bottles and placed on a sunny place. Ultraviolet radiation kills most microorganisms in 6 hours on a bright day. In cloudy weather 2 days of exposure is needed; however, on a rainy day SODIS doesn’t work (9). SODIS disinfect only relatively clear water (Image 2).

Image 2. Solar disinfection of water (SODIS)

4. Ceramic Filters

Ceramic filters can remove most of bacteria and parasites, but usually not viruses; many types of ceramic filters exist, so specifications should be checked. Disadvantage of ceramic filters is a slow filtration rate (0.5-4 L/day) (10).

 5. Biosand Filters

Biosand filter is made of layers of sand put in a concrete container (Image 3). When water is poured through the sand, organic substances build a biological layer on the surface of the sand. In 1-3 weeks, microorganisms colonize this layer and may destroy harmful microorganisms. Additional filtering is provided by attachment of microbes to the sand grains. 

 Image 3. Biosand filter

6. Rainwater Harvesting

Rainwater harvesting is possible in areas with enough rain. Water is usually caught from the roofs and stored in tanks. Main problems are microbes (rainwater has to be chlorinated), heavy metals (roofs, tanks) and chemicals from the environment (12).

Treatment of Diarrhea in Poor Countries

• Oral rehydration solutions, provided by the World Health Organization (WHO-ORS), as a prepared powder mixture of electrolytes should be used with boiled water in all children under 5 years of age with acute diarrhea.
• Zinc, 10-20mg/day, for 10-14 days, shortens the duration of acute and chronic diarrhea, reduces stool amount, and reduces further episodes of diarrhea in next 2-3 months (2).
• Vitamin and mineral supplements should be given, according to their levels in the blood.
• Enough calories and proteins have to be provided.

All these measures have greatly reduced diarrheal diseases in poor countries recently, however 2.2 million children worldwide still die each year.

Diarrhea in Flood

In a disaster, like an earthquake or flood, outbreaks of diarrheal disease (usually bacterial or parasitic) are mostly due to interrupted supply of drinking water, and contaminated flood water. Flood water may be contaminated with sewage content, soil, pesticides and animal stool from fields, chemicals from factories, and garbage.

Prevention of Diarrhea During the Flood

Flood water and tap water are both likely to be contaminated during the flood, so only bottled water should be used for drinking, cooking and teeth washing. People from flooded houses should move to a dry place if possible. Infections are not likely to spread through the air, or with direct contact to an infected person, but anything what got in contact with flood water is likely to be contagious and should be touched with gloved hands only, or hands have to be washed after each contact. After moving through floodwater, a thorough shower with soap is a must.

After floodwater is pumped from buildings, rooms should be aired and heated if necessary so the walls can dry off. Anything (furniture, carpets, couches, bedding, toys) what came into touch with a flood water should be thrown away; valuable things should be cleaned by professional cleaners. All wet food, including packaged food should be thrown away; cans may be kept, but labels should be removed and cans disinfected with chlorine bleach (sodium hypochlorite). Cosmetics, medicines, kitchenware, and cardboard should be discarded. Dish washer and washing machine should be checked by electrician and disinfected with bleach. Clothes may be washed in washing machine, using detergent and bleach, but the latter may react with chemicals from the floodwater, so it is safer to use a professional cleaning service.

Yards should be disinfected with lime after waste has been removed. Grass could be left to decontaminate naturally.

Wells should be disinfected with 10 liters of 3-6% commercial bleach. All faucets should be opened until chlorine smell is detected, then closed for 10 hours, then opened again and water allowed to run until chlorine smell disappears. Water shouldn’t be drunk if it has a chlorine smell or taste. 24 hours after disinfection, water should be tested by a registered laboratory.

Caution: chlorine bleach may cause skin burns. Released chlorine may irritate respiratory mucosa and eyes.

Medical Help During the Flood

The validity of anti-tetanus vaccine should be checked and renewed if necessary. Having other vaccines right after the flood does not help. Diarrhea mostly heals on its own, antibiotics are used only in prolonged or heavy diarrhea.

Traveler’s Diarrhea

Travelers are at risk of diarrhea when they move from a high hygiene area into low hygiene areas. For western visitors, high risk areas are: Africa, South America, South Asia, Caribbean and the Pacific islands.

Prevention of Traveler’s Diarrhea

Children should be vaccinated against Rotavirus. Information about most often infections in planned destinations should be obtained. Preventive taking of antibiotics in general is not recommended because of possible side effects. If someone really wants to be protected as much as possible, antibiotics, prescribed by a doctor, may be started 2-3 days before travel; this prevents diarrhea in most cases. Bismuth subsalicylate (Pepto-Bismol) reduces intestinal secretion and it has a slight antimicrobial effect, so it may be effective in prevention of diarrhea (3). It’s use should be limited to 3 weeks, and should be not taken by children under the age of 3 or pregnant women. Pepto-Bismol may color the tongue and stool black.

SAFE drinks and food during the travel: bottled water, bottled carbonated drinks, alcohol beverages, hot tea, canned food, fruits which can be peeled by the user, cooked foods which are served hot. Boiling disinfects water in less than a minute, food should be cooked as long as necessary (meat shouldn’t stay red in the middle). Chemical disinfection of water with chlorine is effective in the time provided on the product label (minutes). Disinfection with iodine doesn’t kill Cryptosporidium. Filtering with special filters holds bacteria and parasites but not viruses so additional chemical disinfection is needed.

NOT SAFE to ingest: tap water (not even for washing food or teeth), ice cubs made from tap water, unpasteurized fruit juices or milk (even if bottled), any raw, non-packed food, bought on the open market (meat, vegetables).

Medications in Traveler’s Diarrhea

In most cases, traveler’s diarrhea is caused by bacteria, it starts suddenly, lasts for 2-3 days, and heals on its own, so no antibiotic is needed. In heavy or prolonged diarrhea, adults may take norfloxacin or ciprofloxacin; children and pregnant women should take azithromycin. These antibiotics are effective against most bacteria which cause traveler’s diarrhea so no stool test is needed. In bloody diarrhea, a stool test should be done to identify the causing microorganism. Bismuth subsalicylate (Pepto Bismol) alone may sometimes shorten the course of bacterial diarrhea. Parasites Giardia, Entamoeba, Cryptosporidium and Cyclospora usually cause mild diarrhea, but it may last up to a month or longer. Antibiotic metronidazole is recommended for parasites (mild, prolonged, relapsing course of diarrhea is a sufficient sign for self-diagnosis of parasite infection). A combination of antibiotic Rifaximin and loperamide brought immediate relief of diarrhea in some American students in a study conducted in the Gulf of Mexico in 2005 (4).

A person with diarrhea should drink enough fluid to prevent dehydration, and eat as he/she feels comfortable.

Sometimes diarrhea may appear weeks or months after the end of the travel, like in infection with shigella or parasites, or in tropical sprue. Travelers who repeatedly visit the same country, may gradually develop some (not complete) immunity against particular microorganisms within a few years, so usually they have less problems with diarrhea. Some travelers may develop post-infectious IBS, months after their travel.

Typhoid Fever

Salmonella typhi causes typhoid fever (enteric fever); infection occurs only in human, and is now present mainly in Africa, Latin America and South Asia. First symptoms are slowly progressing fever, up to 40°C (104°F), abdominal pain, and relatively slow heart beat. After a week, diarrhea, enlarged liver and spleen, and rose spots (3-4 mm) on the chest appear. Despite successful antibiotic treatment, some people may become Salmonella carriers - bacteria remains trapped in the gallbladder, and is released with the stool which is contagious. Removal of gallbladder in combination with antibiotics treats the condition (5). Vaccine, which is not effective in all cases, is available; it is usually reserved for travelers. Preventive use of antibiotics doesn’t help. The only thing which typhoid fever has in common with typhus is the rose skin rash.

Tropical Sprue

Tropical sprue is an intestinal malabsorption disorder of unknown origin (possibly infection), which affects mostly adult residents or visitors of Caribbean area or South Asia. The main symptom is chronic diarrhea. Due to malabsorption of iron, folate, and vitamin B12, anemia may develop. Diagnosis is made by biopsy (characteristic changes in small intestinal mucosa) and history of long (more than 1 month) visits to the tropics; symptoms may appear months or years after travel (6). Treatment with antibiotics usually results in full recovery in a few weeks, but sometimes disease recurs (7).

Cholera

Cholera, caused by bacterium Vibrio cholerae, which in last decade occurs mainly in India and sub-Saharan Africa, is mostly caught by drinking water contaminated with human stool. Profuse, painless, watery, mucous diarrhea, and vomiting, may result into severe dehydration within a day; without treatment, it may kill an adult in few hours. Oral rehydration solution, or intravenous Ringer lactate, is effective in most cases; additional antibiotic may shorten the course of diarrhea. Oral cholera vaccine (OCV) provides protection in over 80% of cases (8).

Intestinal Worms (Helminths)

Intestinal worms may cause severe infection (infestation), predominantly in children in areas with hot climates, bad hygiene and poor sewage disposal: in rural parts of Africa, Middle East, South Asia, Indonesia, and Central and South America. In Europe and North America, infestations are more sporadic.

Sources of Worm Infection

Eggs, shed with the stool of human (or animal), infected with adult worms, contaminate soil or water. Eggs, once outside the body, need several days or weeks to develop into the infective stage - cysts or immature worms (larvae) - and these may be ingested via soil-contaminated hands, or with raw vegetables, or they may penetrate a person’s skin during swimming or walking barefoot. When they reach the small or large intestine, they grow into adult worms. Another source is undercooked infected meat of domestic pig, freshwater fish, or wild animals (bear, walrus etc). One can also be infected from ingesting dog’s fleas, which have in turn ingested parasitic eggs. Children may contract infection from sandboxes contaminated with pet’s stool.

Pathology of Intestinal Worms

Adult worms (from 1 millimeter to several meters long), invade the bowel wall, and suck the blood from it, or live freely in the intestine, and utilize nutrients from the bowel content. The result are small intestinal or colonic inflammation and ulcers, anemia, protein, iron and vitamin (A, C, B12) deficiency. Intestinal obstruction may occur in severe cases. Larvae may migrate to other organs (liver, spleen, bladder, muscles, lungs, brain), where they form cysts and trigger allergic inflammation.

Image 4. Roundworm

Symptoms of Infection with Intestinal Worms

In most infestations there are no symptoms, but a few days after acute infection, mild diarrhea or bloating may appear. Parts of parasites may sometimes be found in the stool. Swollen itchy spot on the skin (usually foot) denotes parasite entry. Itchy anus, swelling around the eyes, and skin rash are also common. Intestinal worm may find its way out through the mouth or nostrils during the sleep.

Diagnosis

• stool: ova and parasites (O&P) exam,
• blood: specific antibodies, larvae, raised eosinophils,
• CT or biopsy to determine involvement of other organs.

Treatment of Worm Infection

Anti-worm drugs: mebendazole (safe for pregnant women), albendazole, diethylcarbamazine, ivermectin or praziquantel cure parasites in most cases. Affected organs, other than intestine, can be treated only with operation or organ transplantation. For some days after the healing, a stool-to-mouth autoinfection with eggs is still possible. Untreated infestations may last for years.

Prevention of Worm Infection

Cooking kills all worms, but smoking or freezing doesn’t.

Worms which Commonly Cause Diarrhea in Human: 

A. Roundworms:

• The large roundworm (Ascaris lumbricoides), ~ 30 cm long, worldwide distribution;
• hookworms (Necator americanus, Ancylostoma duodenale), ~ 1 cm long, sucks blood from intestinal wall;
• whipworm (Trichuris trichiura);
• threadworms (Strongyloides stercoralis);
• Trichinella spiralis.

 B. Flukes:

• Schistosoma mansoni. Symptoms after invasion in other organs: enlarged liver and spleen, jaundice, abdominal swelling (ascites), urinary bleeding, coughing blood, muscular aches, seizures.

C. Tapeworms:

• fish (broad) tapeworm (Diphyllobothrium latum), contracted by infected freshwater fish, may exceede 10 m, occur in Europe, Russia, US;
• beef tapeworm (Taenia saginata) and pork tapeworm (Taenia solium) are contracted by undercooked beef or pork in rural areas, worldwide; adult worms may be over 20 m long.

References:

•  
  1. http://www.americanchemistry.com/s_chlorine/sec_content.asp?CID=1133&DID=4491&CTYPEID=109 WATER CHLORINATION
  2. http://www.eddcontrol.org/files/Zinc_research_to_practice_USAID.pdf ZINC IN DIARRHEA
  3. http://www.cptips.com/travdia.htm BSS (PEPTO-BISMOL)
  4. http://www.docguide.com/dg.nsf/PrintPrint/6820F2D9D649D1BC8525717800538D71 RIFAXIMIN + LOPERAMIDE
  5.  http://www.emedicine.com/ped/topic2033.htm TYPHOID FEVER.
  6. http://web.gideononline.com/abstract.php?module=epidemiology&disease=12449&view=General
     TROPICAL SPRUE, INCUBATION PERIOD
  7. http://merck.com/mmhe/sec09/ch125/ch125d.html TROPICAL SPRUE
  8. http://www.who.int/mediacentre/factsheets/fs107/en/index.html CHOLERA

This article is the property of http://www.AllHealthSite.com
Copying and publishing any article from our site is strictly NOT allowed