DISEASES TRANSMITTED BY

FECAL-ORAL ROUTE Kilimnjaro Christian Medical University College (KCMUCo)Emmanuel H. Mtui

Ummi Abdul

Situ Mhunzi

Outline

1. Introduction2. Epidemiology3. Prevention and Control measures 4. Challenges5. References

Introduction

DefinitionDiseases that are transmitted when the pathogens excreted in the stool of an infective human or animal gain access to uninfected individual via the oral route.

(AMREF, 2007)

Fecal-oral Transmission route

(AMREF, 2007)

Introduction cont…

• The Fs involved in fecal-oral route are Feces, fingers, flies, fluids, fomites, fields and food

• Direct pathway: Feces – fingers – food.

• Indirect pathway: Passes through fluids, field and fomites.

Viral Bacterial Protozoa Worms Toxins Polio

Hepatitis A, E

Viral diarrhoeas such as rotavirus and adenovirus

Typhoid and paratyphoid

Cholera

Bacillary dysentery

Anthrax

Bacteria diarrhoeas such as Yersinia, Campylobacter, E. coli

Amoebiasis

Giardiasis

Ascariasis

Enterobiasis

Trichuriasis

Taeniasis

Hydatidosis

Botulism

Staphylococcal food poisoning

Enterotoxigenic coli diarrhea

Fecal-oral diseases

(AMREF, 2007)

Diarrhea Diseases• Diarrhea is a passage of 3 or more loose or liquid stools

per day, or more frequent than normal for an individual. (WHO, 2016c)

• Dysentery is diarrhea in which the loose or watery stool contains visible blood. (WHO, 2010)

• Common causes of dysentery are Shigella dysentriae causing bacillary dysentery and Entamoeba histolytica causing amoebic dysentery. (AMREF, 2007)

Dose Dependency of Diarrhea DiseasesLarge dose:• Due to gastric HCL, some infections require large dose

for them to be transmitted e.g. cholera and typhoid fever.

• Accidental infection by contact or contamination by flies is rare for such diseases.

Small dose:• Organisms resistant to gastric HCL can cause infection

in low doses e.g. Amoebic and bacterial dysentery.(AMREF, 2007)

Global Epidemiology of Diarrhea Diseases• 1.7 billion cases of diarrhea annually

• Pre school and school children, immunocompromised and travelers are more at risk.

• The developing countries are more affected

• E. coli and Rotavirus are the leading causes of diarrhea in developing countries.

(WHO, 2016c; AMREF, 2007 & WHO,2016c)

Major Risk Factors

• Inadequate safe water supply

• Poor sanitation

• Poor personal hygiene

(WHO, 2016; AMREF, 2007; GAPPD, 2013)

Global Diarrhea related deaths among children

(UNICEF, 2015)

Percentage of deaths among under-fives attributable to diarrhoea (UNICEF, 2015)

Diarrhea Diseases in Tanzania

• 4th leading cause of death in the general population(6%)

• Prevalence among under fives was 15.6% (Highest in Kigoma 27.3% and lowest in Tabora 8%)

• Diarrhea specific mortality rate among under-fives was 8%

(CDC, 2017; UNICEF, 2016 & TDHS, 2016)

Cholera - global picture• Acute diarrhea caused by V. cholera

• 1.3 – 4 million cases annually

• 21000 – 143000 deaths annually

• 172 454 cases and 1304 deaths from 42 countries in 2015

(WHO, 2016a)

Cholera – Global Picture

• Common outbreaks after natural disasters where access to safe water and proper sanitation is limited.

• Endemic – Reported in 3 of the past 5 years.

• Epidemic – Reported in 1 of the past 5 years.

(WHO, 2016a)

2015/2016 Tanzania Cholera Outbreak• 23 mainland regions and 5 island regions were

affected.

• 24108 reported cases

• 378 cholera deaths

(WHO, 2016b)

Factors associated with spread

• Limited access to safe water

• Lack of sanitation facilities

• Poor hygienic practices

(WHO, 2016b)

Public Health ResponseMultisectoral National Cholera Taskforce

• Ministry of Health Tanzania• WHO• UNICEF• CDC• Red Cross Society• Others

(WHO, 2016b)

Six technical sub-committees

• Water and sanitation and hygiene (wash)• Social mobilization• Surveillance • Laboratory• Case management• Logistic and administrative.

(WHO, 2016b)

Interventions done:• Community mobilization to promote personal hygiene, safe

water and good sanitation.

• Distributing chlorine for household water treatment

• Conducting routine water sampling and lab analysis for contamination.

• Strengthening case management centers

• Risk management during burial of deceased cholera patients.(WHO, 2016b)

Continued risk of cholera in Tanzania

• Vast geographical distribution of cases

• Persistence of poor access to safe water and sanitation

• Suboptimal surveillance and laboratory capacity in certain districts

• Geographical mobility of symptomatic and asymptomatic cases

(WHO, 2016b)

Distribution of Soil Transmitted Helminths in Tanzania (GAHI, 2017)

Poliomyelitis• Is a highly infectious viral disease that invades the

nervous system resulting to paralysis within hours. 0.5% of infected develop irreversible paralysis.

• 5 to 10% of the paralyzed die due to paralysis of respiratory muscles.

• Mainly affects under-fives

• Polio has been reduced by 99% since 1988

(WHO, 2016d)

Poliomyelitis

• Total of 35 wild poliovirus (WPV cases) and 4 circulating Vaccine Derived Poliovirus (cVDPV)

• Endemic Countries – Afghanistan, Pakistan and Nigeria.

• Outbreak countries – Guinea, Madagascar and Lao

• Tanzania has eliminated polio virus.

(Global Polio Eradication Initiative, 2017)

Prevention and control

• Ensuring safe disposal excreta (use of toilets/latrines and Safe disposal of children feces)

• Ensuring safe water supply eg. WASH program

• Improving personal hygiene e.g. Hand washing with soap

(GAPPED, 2013 & Bawankule et al., 2017)

Prevention and control

• Immunization e.g. Polio, rotar virus vaccine and cholera vaccines .

• Mass drug administration.eg de worming programs

• Community outreach and education programs

(GAPPED, 2013; OXFAM, 2012; WHO, 2005 & Bawankule et al., 2017)

Break the Transmission Cycle

(Amref, 2007)

Protect, Prevent and Treat Framework. (GAPPED, 2013)

Cont…• Exclusive breast feeding (Non breast feeding infants have

2.8 times higher risk of dying of diarrhea and there is 32% increased incidence of diarrhea in non breastfeeding)

• Use of disinfectants such as chlorine lime and ashes

• Insecticide spraying to reduce flies

• For the diseased people, Re-hydration and electrolyte replacement are the mainstay of treatment.

(GAPPED, 2013; OXFAM, 2012 & WHO, 2005 )

Challenges

• Poor social economic status• Underlying diseases and conditions such as HIV, TB and

Malnutrition• Environmental and seasonal factors• Poor surveillance system• Acceptance/rejection of vaccination and mass deworming

programs• Cultural practice

(The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies, 2008; Connolly MA, 2005; Lamond & Kinyanjui, 2012 & WHO, 2013)

ReferencesAfrican Medical Research Foundation, 2007. DIRECTORATE OF LEARNING SYSTEMS DISTANCE EDUCATION PROGRAMME Unit 3 Travel Medicine In Relation to Communicable Diseases, Nairobi. Available at: https://www.google.com/search?rct=j&q=amref diseases of fecal-oral contamination.Bawankule, R., Singh, A., Kumar, K. and Pedgaonkar, S. (2017). Disposal of children’s stools and its association with childhood diarrhea in India. BMC Public Health, 17(1).CDC, 2016. CDC in Tanzania Emerging Disease Threats, Atlanta. Available at: https://www.cdc.gov/globalhealth/countries/tanzania/pdf/tanzania_factsheet.pdf [Accessed January 12, 2017].Connolly MA, 2005. Communicable Disease Control in Emergencies: A Field Manual, Available at: http://linkinghub.elsevier.com/retrieve/pii/S0099176706002650.Global Polio Eradication Initiative, 2017. Polio Today – GPEI. Available at: http://polioeradication.org/polio-today/ [Accessed January 12, 2017].Lamond, E. & Kinyanjui, J., 2012. Cholera Outbreak Guidelines: Preparedness, Prevention and Control, Available at: http://policy-practice.oxfam.org.uk/publications/cholera-outbreak-guidelines-preparedness-prevention-and-control-237172.London Applied & Spatial Epidemiology Research Group, 2017. Distribution of soil-transmitted helminth survey data in Tanzania | Global Atlas of Helminth Infections. Available at: http://www.thiswormyworld.org/maps/distribution-of-soil-transmitted-helminth-survey-data-in-tanzania [Accessed January 12, 2017].

MoHCDGEC, 2016. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2015-2016 Key Indicators, Dar es salaam. Available at: https://dhsprogram.com/pubs/pdf/PR74/PR74.pdf [Accessed November 11, 2016].The Johns Hopkins and the International Federation of Red Cross and Red Crescent Societies., 2008. Control of communicable diseases Control of communicable diseases in emergencies,UNICEF, 2016. Diarrhoeal Disease - UNICEF DATA. Available at: https://data.unicef.org/topic/child-health/diarrhoeal-disease/ [Accessed January 12, 2017].WHO, 2013. Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea ( GAPPD ). Who/Unicef, pp.1–61. Available at: http://apps.who.int/iris/bitstream/10665/79200/1/9789241505239_eng.pdf.WHO, 2016a. WHO | Cholera. WHO. Available at: http://www.who.int/mediacentre/factsheets/fs107/en/ [Accessed January 11, 2017].WHO, 2016b. WHO | Cholera – United Republic of Tanzania. WHO. Available at: http://www.who.int/csr/don/22-april-2016-cholera-tanzania/en/ [Accessed January 12, 2017].WHO, 2016c. WHO | Diarrhoeal disease. WHO. Available at: http://www.who.int/mediacentre/factsheets/fs330/en/ [Accessed January 11, 2017].WHO, 2010. WHO | Dysentery. WHO.WHO, 2016d. WHO | Poliomyelitis. WHO. Available at: http://www.who.int/mediacentre/factsheets/fs114/en/ [Accessed January 13, 2017].