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 a disaster situation 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

Viral causes

`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

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

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.

Oral rehydration therapy

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.

Improvising ORS

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

 

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