Post # 4 – The squirts. A General Overview of Diarrhea Causes, Prevention and Treatment for Disaster Preparedness.

Infectious diarrhea can be caused by bacteria, viruses or parasites. Diarrheal illnesses are extremely common throughout the world, but in developing countries these illnesses continue to be a matter of life and death. We are very fortunate to live in the developed world where due to our public health system, good healthcare and infrastructure facilitating access to clean water, sanitation services and education, we largely have not had to think much about the types of issues that often mean life or death in other parts of the world. In an event where those protective measures are disrupted even if only regionally, the problems typical of the developing world can quickly have new precedence. Despite all the efforts to fight these type of illnesses worldwide, diarrhea is still the second leading cause of death in children less than five. It has been the point of much research and effort to ease its effects have long been an important part of aid efforts involving organizations such as the United Nations Children’s Fund (UNICEF) as well as the World Health Organization (WHO). While pediatric illnesses have been focused on by the WHO, these illnesses of course have an impact on people of any age and can have a greater impact on the elderly as well as those with other medical issues in addition to infants and children. Infectious diarrhea can be caused by bacteria, viruses or parasites.

 

“An ounce of prevention is worth a pound of cure” – Benjamin Franklin

Like most maladies, the best initial approach is that of prevention. Some factors that can have a great impact on these types of illnesses are things like hygiene, access to clean water, food preparation and storage practices including clean cookware and utensils, storing and preparing perishable foods properly and adequately managing sanitation to include garbage and sewer disposal. The single best thing one can do for prevention is good hand washing after using the latrine and before eating or preparing food. Thought should be given to these topics and the basic supplies needed to implement it can easily be gathered for a small amount of money ahead of time. Basics such as bleach for sterilization of utensils, cleaning, and even water purification if needed, are a no brainer for disaster preparedness. Other basic considerations which are equally important and easy to address before a crisis are: having the tools to dig a pit toilet, means to properly cook food, separation of food prep areas from bathing and latrine sites, buckets and other vessels for storing clean water, basins for cleaning utensils and laundry, drying rack or clothes lines, pest abatement, detergents and disinfectants, soap for hand washing and bathing, a good stock of toilet paper, baby wipes, diapers, etc.

Types of diarrheal illness

 

`As previously noted infectious diarrhea can be caused by different type of bacteria, viruses or parasites. One of the most common forms of diarrheal illness is attributed to viruses. They are sometime referred to as “the stomach flu” or viral gastroenteritis. This type of illness is spread from person to person and tend to spread quickly in crowded environments such as cruise ships, healthcare facilities and schools. You may have heard of norovirus which is the most common type of viral illness and is very contagious. Besides needing very little of the virus to get sick, it is particularly easy to spread largely due to its ability to remain viable outside of the body on surfaces such as counter tops, door handles etc. where an unwitting person makes contact with it. These viruses can last over a week on surfaces and are often either passed through contact or contaminated food. The symptoms associated with this type of illness typically involve: nausea, vomiting, muscle aches low-grade fever, frequent loose and typically watery stools, and abdominal cramping. These tend to be self limiting, meaning it tends to resolve on it’s own typically within 24-48 hours.Treatment usually involves treating the symptoms and preventing dehydration. If there is blood in the stool, high fever, or severe dehydration, these may be signs of a bacterial cause instead of a virus and can be a more significant issue requiring medical evaluation and treatment providing the resources are available.

 

Bacterial causes can be attributed to any number of bacteria. These bacteria are often times related to poor food handling practices and preparation. Bacteria such as salmonella, E. coli or vibrio cholerae can be passed through contaminated food or water. These infections can have many of the same symptoms as viral gastroenteritis such as: nausea, vomiting, fever or chills, dehydration, abdominal cramping. Again, these illnesses tend to be more severe and can involve bloody stools. You may have heard of travelers diarrhea which is typically attributed to E. coli (up to 80% by CDC estimates). It can be transmitted by contaminated water and poor food handling practices. Despite popular belief that it is attributed to contaminated water, it is just as likely to be passed via a food source. Although it is a bacterial cause, milder forms of the infection can resolve on it’s own but when in doubt, and resource permitting, medical evaluation is worth consideration. Avoiding traveler’s Diarrhea involve only eating thoroughly cooked foods, eating only fruits that need to be peeled, drinking only bottled water and avoiding ice. Of course good hand washing practices are important, but you likely won’t be able to tell if the person preparing your food is as vigilant. It is not uncommon for people to ask their primary care provider for a prescription for an antibiotic such as ciprofloxacin in case of an outbreak while vacationing in an area prone to travelers diarrhea.

 

Parasitic causes for diarrhea as the name implies are due to parasites that live in the intestines of an infected host. They can be transmitted by contact and food, but are more typically associated with contaminated water. One of the most common forms of parasitic illness in the US is giardiasis a.k.a “beaver fever”. This parasite is typically transmitted through contaminated water and can be carried by mammals other than beavers. Consideration for purifying water from questionable sources as well as storing water in vessels that will keep rodents, and other vectors for parasites are essential. These types of parasitic infections share similar symptoms with other form of diarrhea, but can also cause decreased appetite, foul smelling and greasy stools. Medical treatment is effective against these infections however they will typically resolve on their own in an otherwise healthy person but may take weeks without medication.

Approach to treatment

 

Despite your best efforts you may still become ill and need to know some basics of how to deal with it. There are varied opinions regarding treatment of diarrhea when it comes to symptomatic treatment, or how soon to reintroduce solid foods back into the diet as well as which types of foods to reintroduce. It is a relatively common belief that if you have diarrhea it’s best to let it run it’s course with the thought that your body need to rid itself of toxins, bacteria, etc. There is no literature I have found to support this theory and it is not typically recommended. There are several over the counter medications listed below that may be suitable for symptomatic relief in the right setting.

 

Avoiding dehydration

The most important thing you can do in treating diarrhea is replenishing the fluids you are losing and preventing dehydration. Drinking only water to replace fluids is often not enough as you are losing vital electrolytes such as sodium and potassium, and replacing the fluids with large amounts of water and no nutrients can make matters worse. Water is suitable for rehydration if you are also eating enough to replace the electrolytes as well, but at least in the early stages of the illness this is not typical.

 

The world health organization has recommended use of oral rehydration through a specific concentration of electrolytes to water and as a consequence deaths due to diarrhea worldwide have declined sharply.  Oral Rehydration Salts (ORS) can be purchased in a powder form and reconstituted with a prescribed amount of clean water. Another consideration when purchasing ORS solutions is making sure it is the updated and current WHO “low osmolarity formula”, which can help in absorption by the gut. I have seen the older versions for sale on the internet for much less than the newer formulation, so if you’re shopping around it’s something to look for.

 

While ORS solution packets are ideal in providing the best concentration of ingredients, the solution can also be approximated using: 6 tsp of sugar, ½ level tsp of salt and a Liter (~5 cups) of clean water. ORS should be provided in small amounts to prevent triggering vomiting and some absorption is likely even with ongoing diarrhea. Children should be encouraged to drink as much as tolerated but the recommendations for volume by age are: Children <2 years old should be given ¼-½ of a large cup (250 ml) after each watery stool. For ages over 2 years old: at least ½ to 1 cup per each watery stool. Children being breastfed should continue to be breastfed and receive supplemental hydration with ORS.

Simple solution graphic courtesy of: rehydrate.org

 

Dietary concerns regarding treatment

Regarding diet and return to solid foods, it used to be widely recommended to reintroduce foods using the B.R.A.T. diet which is an acronym that stands for: bananas, rice, apples and toast. This too is no longer widely recommended as some have felt it is too restrictive and has no scientific basis proving it is better than other solid foods. In general returning to a solid diet as tolerated is recommended in small amounts, and avoiding foods that are:  acidic, high in sugar or fat content,dairy products, contain synthetic sweeteners, alcohol and caffeine. One notable exception is that some routinely use yogurt in the treatment of diarrhea presumably for the benefits of its probiotic content and ability to help replace beneficial bacteria in the gut lost due to the course of diarrhea. Non-dairy probiotics are also available and may be helpful in a similar fashion.

 

Over the counter (OTC) medication


 Loperamide  (also known by the brand name Imodium) is an OTC medication which helps slow how fast the the gut moves and decreases the amount of liquid in the stool. It can give symptomatic relief for diarrhea, but should never be used in cases where there are bloody stools. The main side effect of course is constipation, but it may also cause some drowsiness, dry mouth and dizziness. Another medication that can help with symptomatic relief is Simethicone which helps reduce bloating and pain related to gas. It works by decreasing the surface tension in the gut to prevent gas bubbles from forming. There are no common side effects noted with the small doses used for treatment of diarrhea and preparations containing both Loperamide and Simethicone (Imodium Multi-Symptom Relief) are available and tend to have the best results for relief. Again, if there is blood present in the stool, use of loperamide should be avoided.

 

Bismuth subsalicylate is another OTC drug that can be helpful in treating the symptoms of diarrhea and is the active ingredient in the brand Pepto– bismol. Bismuth is indicated for treating symptoms of nausea, indigestion and diarrhea. It works as an acid reducer and an anti-inflammatory, but how it effects diarrhea is not clearly understood. It’s anti-inflammatory properties are attributed to it being similar to aspirin, and as a consequence it should never be given to children to avoid the rare but serious condition known as Reye syndrome. There are no common side effects other than some people noting a black coating on there tongue or in their stool due to the interaction of bismuth with sulfur in saliva. This finding is temporary and resolves on it’s own without further issues.

 

Zinc supplementation

While not fully understood recent research has shown a relationship with taking supplemental zinc and a reduction in the duration and severity of diarrheal illness in children. While some critics point out that these studies were conducted in places where malnutrition and zinc deficiency were an issue before the illness, supplementation is still seen as possibly beneficial and at the low doses recommended should be well tolerated. The WHO now recommends children suffering from diarrhea be given 20 mg by mouth per day for 10-14 days (10 mg per day for infants under 6 months of age). Research has only been completed in it’s use in children and is currently ongoing in adults, but given the low risk of side effects and the likelihood that the effect would be the same in adults, it’s certainly seems reasonable to consider.

 

Conclusion

Given how common diarrhea is and understanding that in a grid down or similar reduced infrastructure state your chances for encountering this type of illness will be increased and potentially a bigger issue, it is certainly prudent to know the basics of how to deal with it and have the supplies needed. It can’t be emphasized enough that the primary goal in treatment at any age is maintaining hydration and electrolytes. Having premade oral rehydration packets or the supplies and knowledge to make a substitute may be the most important thing you can do. Symptomatic relief may be useful through OTC medications, and while they are generally safe always use the drug facts label to help guide you through how to safely utilize the medication and discuss it with your primary care provider particularly if you have drug allergies, take prescription medications, and/or how chronic medical issues. While this information is provided to convey basic information regarding diarrheal illness, it of course does not substitute seeking medical advice when possible. Please feel free to add any thoughts regarding this information, any or any questions you may have.

 

For further information regarding this topic:

 

http://www.who.int/mediacentre/factsheets/fs330/en/

 

http://rehydrate.org/

 

http://emedicine.medscape.com/article/928598-treatment

 

Post # 3 – Field sanitation and Hygiene, It ain’t sexy, but it’s important.

Out of all the topics one can research regarding disaster preparedness this isn’t likely to be the most interesting, but it is realistically one of the most important. Of course having food, water, shelter, warmth and being able to defend it all is important, but in prolonged survival situation if you don’t give attention to hygiene and sanitation, all your other preparations may be for nothing.

All you have to do is look closely at natural disasters where there either is no infrastructure, or it has been disrupted to see the ill effects that follow with often dire consequences. Take for example the cholera outbreaks after the earthquake in Haiti in 2010 or more recently after hurricane Matthew. Consider insect borne illnesses that we don’t think about much currently like malaria or West Nile virus. Malaria was not effectively controlled in the southern United States until the 1940’s and despite a late appearance to the US in 1999 has now been found in every state in the lower 48 with exception to Maine. These are just a few names of illnesses that can and do kill. There are many more that would certainly proliferate in disaster conditions where normal infrastructure is impacted.

The many basic things that we take for granted when they are not an issue are what need to be considered here. Clean water is the most obvious of course. I am sure many people have water filters, but I doubt many have thought about how to maintain clean water in a prolonged situation and for a number of people. Other things we often take for granted are sanitation, personal hygiene and pest control. What to do with your trash when the garbage truck isn’t showing up. How to deal with sewage when a flush isn’t available. How to keep clean when you don’t have running water for a sustained period of time. How to control insects such as flies and mosquitoes in your area to help prevent spread of disease.

Of course none of these are novel concepts. They are things that have been considered in depth and have solutions. All I’m saying is they are also things worth giving consideration to before you are in a situation where you really have to. Some basic education and supplies can go a long way if the need ever arises. One resource for covering all these topics and more is the Army field manual for field sanitation and hygiene.This manual gives basic information for topics such as: heat and cold injuries, prevention of insect borne disease, constructing and maintaining field latrines and disposal of waste water and materials. While it is geared towards military units during field operations, much of the information and principles carry over to a disaster type situation. The manual is accessible online in PDF format at: http://olive-drab.com/archive/fm21-10.pdf or can also be purchased in book form from Amazon for $8.99 here: Field Hygiene and Sanitation FM 21-10: MCRP 4-11.1d

Having the necessary equipment to deal with latrine building, maintaining good hygiene, pest control, and purifying and storing water are essential, but far less glamorous compared to tactical gear of course. In a scenario where normal infrastructure such as running water, sanitation services and electricity are lacking these items may be of greater utility than your firearms, and considering these things are a fraction of the price to amass there is no real good excuse not too.

Post # 2- Over the Counter (OTC) Medications

Courtesy of: FDA.gov

What exactly does OTC mean?

Over the counter medications, more commonly referred to as OTC medications, are medications that do not require a prescription from a medical provider to obtain. The specifics of which medications require prescriptions vary depending on country, and in some instances by state government for specific medications. In the United States the task of determining which medications require a prescription falls under the auspices of the Federal Drug Administration (FDA). One particular exception to that has to do with the sales of pseudoephedrine which has been implicated in methamphetamine production, and as a consequence in some states has additional regulations to it’s sale over the counter.

Drug Facts Labeling

In general OTC medications can be bought freely by the consumer without prescription or even consulting with a medical provider. Over the years the FDA has taken steps to aid the consumer in knowing the actual ingredients and how to use various medications. Probably one of the most useful to the consumer, was the mandate creating the drug facts label. This is now a standardized format in the U.S. and has all the important information a consumer would need on one label. While much of this information has been on drug use labels over the years, the latest OTC label requirements go through great effort to make it all concise, easy to read and most importantly, easy to understand. This does of course rely on you the consumer actually picking it up and reading it. Not only is it in the best interest of you or your loved ones health to do so but it can also make more efficient use of how you use these medications and actually save you money in the process.

Why are we talking about the Drug Facts label so much?

An integral part of your first aid kit are the OTC medications that it contains. Many of the things people present to urgent care settings are often treated in some part by OTC medications. By familiarizing yourself with these labels you may be able to save yourself a trip and/or a copay with medications you already stock at home. More importantly if you find yourself in a situation where a trip to your medical provider isn’t possible or practical it’s good to know what you have, how it can help and what it’s limitations are. It is also important to actually heed the warnings on these labels which may advise you to seek care if there is lack of improvement over a given period of time or signs or symptoms that may be more important than you think, thus necessitating further medical evaluation.

The Drug Facts label also allows you to use your medication more efficiently. There are many OTC medications that have multiple active ingredients, in other words multiple drugs. While these can be helpful they can also be harmful or misleading. These “drug cocktails” are common in cold and flu relief medications. An example of this is where one product gives you a medicine to relieve a fever (anti-pyretic), deal with aches and pains (analgesic), help with congestion (decongestant), and help with a cough (cough suppressant). that’s great you think it may be, but what about if you only have a cough and you don’t want the side effects of that particular decongestant that’s going to keep you awake all night. It pays to to know the difference so you can use your medications to treat what you want and not feel out of it due to all the extra medications in that product you didn’t need in the first place.

What’s the big difference between generic and trade name medication?

The most basic way to explain the difference between generic and non-generic medications is that both classes of a given medication must contain the same active ingredients. The FDA regulates both classes to the same standards and mandates that a generic form of a medication not only contain the same active ingredients, but must also be the same concentration of the medication as well as be in the same dosage form i.e. pill versus spray. The medication must also have similar rates of absorption meaning if it is immediate or extended release, the generic must perform similarly to the trade name medication. The inactive ingredients can vary between the generic and trade name medication so if specific allergies are a concern it would make sense to review those ingredients closely. Generic medications may be different colors or shapes than the trade name medication due to different inactive ingredients.

It’s important to remember that trade name medications and their generic equivalents can either be prescription or OTC. In either case generic medicines are far less expensive and as a consequence, used frequently. According to the FDA, almost 80% of drug sales in the US are for generic medications. The reason trade name medications tend to be so much more expensive is that pharmaceutical companies have often spent decades in research and development, as well as clinical trials before they can receive FDA approval to bring a new drug to the marketplace and have to recoup their losses before they can start to make a profit. For this reason the government will award the pharmaceutical company a limited time patent during which time other companies are not allowed to produce generic equivalents of the medication. These patent lengths can vary, and once they expire a generic equivalent on the marketplace is fair game.
OTC medications have either been around for decades or were previously prescription medications. Interestingly, even medications that have been around for over a century in pill form such as aspirin still have trade name and generic versions. For the purposes of building a thorough medical kit you should review your options, but it is this author’s opinion that generic medications are more than suitable and far more cost effective.

Great, so OTC medications are very safe since I don’t need a prescription right?

If only it were that simple…For the most part OTC medications are safe to use if you use them as directed, however your individual medical history and other drugs and/or supplements you take must be considered. Certain OTC medications may not be safe depending on your specific medical problems, possible allergies and in particular, what other medications you’re on especially if you are on prescription medications. The possibilities of adverse reactions counting on all of these variables would be too numerous to outline in specific fashion which is why close attention must be given to the drug facts. It is also advisable to discuss medications you may be considering with your doctor and/or your pharmacist to ensure it is still safe for you to use.

Post # 1- Finally beginning…

This is a project that has been in the back of my mind for almost two years. After all the excuses and reasons not to proceed, I have finally ascended from my own laziness and complacency to  move forward. My aspirations for this project are to discuss subjects pertaining to medical preparedness and treatment. There are countless resources in terms of preparedness in general including how it pertains to medical care. Much of theses resources cover trauma and emergency care which is extremely important, but what seems to be lacking is coverage of more common topics such as over the counter medications, oral re-hydration, field hygiene as it pertains to disaster situations, etc. These are topics that while not being as exciting as trauma, are of equal importance in an austere setting or in our everyday lives if the power goes off. I will approach this topic with what I currently know, as well as ongoing exploration into the subject matter, and look forward to any insight that can be shared by others to help us all be better prepared.

The reasons for such preparations are numerous. You don’t have to subscribe to an apocalyptic school of thought to understand that the infrastructure that rely on to provide us with our relatively comfortable daily lives are tenuous to any number of possible interruptions.  Those interruptions have over the past few decades been infrequent and typically temporary, with power or other resources restored in a timely manner. All it takes is inclement weather or a wayward back hoe on a power line to knock out power for days. In these cases, some minor preparations will help you be comfortable and make the otherwise minor inconvenience a novelty.  Extend the time frame to a week or more and it begins to be of far more critical importance.

I don’t believe this line of thinking is new, in fact until the last few decades simple home preparations were considered a matter of civil defense and the purview of not just the federal government, but the the average citizen as well. This general mindset has seemed to have fallen by the wayside to the vast majority of the population. If we all make simple preparations we will better be able to help our family, friends and neighbors in a time of need. I think it’s worth consideration. Chance favors the prepared mind.