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

Etiologic Agents Toxin-producing bacteria Invasive Bacteria Parasites Viruses

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

Invasive Bacteria EIEC (enteroinvasive E. coli) Salmonella Campbylobacter Yersinia

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

Parasites Giardia lamblia Entamoeba histolytica Cryptosporidium

Giardia Zoonosis, animals contami- nated Water Diarrhea, abdominal pain, gas Treat w/ Flagyl

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

Viruses Rotavirus

Norwalk Agent

Calciviruses

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

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TERIMA KASIH