Gastrointestinal Infections: Causes, Symptoms, Diagnosis and Treatment

Question 1
• Raj, a 10 year old boy came to your PHC with complaints of vomiting
, mild fever and yellowish discoloration of urine for past 5 days. His
father told that few more children from his locality has the same
symptoms and went for native treatment. What would be the
incubation period of the infection?
a) 15-50 days
b) 45-60 days
c) 14-180 days
d) 15-64 days

Question 2
• Washerman hands are seen in
a) Typhoid
b) Cholera
c) Shigellosis
d) amoebiasis

Question 3
• The Ty2a Oral vaccine (TYPHORAL Vaccine) is a
a) Subcutaneously administered live attenuated vaccine
b) Orally administered live attenuated vaccine
c) Orally administered killed vaccine
d) Intramuscularly injected killed vaccine

Question 4
• Vaccine associated paralytic polio (VAPP) commonly occurs with
a) Type 3 followed by type 1
b) Type 2
c) Type 1 followed by type 3
d) Type 1 alone

Question 5
• A 7 year old child presented at casualty with history of multiple
episodes of diarrhea vomiting, not able to drink any liquid, sunken
eyes, dry mouth, lethargic and floppy. What would be first line of
management?
a) Antibiotics
b) Ringer lactate
c) Oral rehydration therapy with appropriate antibiotics
d) Normal saline

Question 6
• The guinea worm larvae develop best between the temperature of?
a) 17.5 – 22 ⁰C
b) 19 – 25 ⁰C
c) 23.5 – 29 ⁰C
d) 12 – 18 ⁰C

Question 7
• Mode of transmission of Ascariasis
a) Eating partially cooked pork
b) Through mosquito bite
c) Drinking water containing eggs
d) Tsetse fly

Question 8
• Chandlers index measures
a) No of hookworms present in 1g of faeces
b) Ratio of number of worm infestation cases in an area
c) No. of worms present in the drinking water
d) No. of mosquito bites in one hour

Question 9
• Which of the following is false about AFP?
a) Every case of AFP in any child under 6 years should be reported.
b) The number of AFP cases reported each year is used as an indicator of a
country’s ability to detect polio
c) Two stool specimens taken 24-48 hours apart are required.
d) Specimens should be transported in reverse cold chain

Question 10
• Main components of reduced osmolarity ORS.
a) Sodium, potassium and calcium
b) Sodium, zinc and glucose
c) Sodium, glucose and chloride
d) Sodium citrate and calcium

Global health sector strategy on viral hepatitis – 2016-2021
TARGETS
a. Global target of reducing new cases of chronic HBV & HCV by 90%
b. Reducing deaths due to viral hepatitis by 65% by 2030
c. Key interventions of GLOBAL HEALTH SECTOR STRATEGY for viral
hepatitis:
• Prevention interventions
i. Three dose hep B vaccine for infants
ii. Prevention of HBV perinatally using Hepatitis B vaccines
iii. Blood safety and injection safety
iv. Harm reduction of persons who use drugs
• Treatment interventions
i. Diagnosis of HBV and HCV
ii. Treatment of HBV and HCV & treatment interventions

National viral hepatitis control programme (2017)
Central sector scheme launched during 12th Five year plan.
OBJECTIVES:
Establish laboratory network & provide lab support.
To ascertain the prevalence of different zones.
Develop technical material for generating awareness.

Cholera
• It is an acute diarrhoeal disease
• Caused by Vibrio cholerae O1 and O139
• Agent
• Vibrio Cholerae is comma shaped gram negative bacteria
• Its antigenic structure consist of H and O antigen
• Within O group1, two subtypes-Classical and El Tor
• Host
• Cholera affects all the age groups mostly in the lower socioeconomic class

• Environment:
• Contaminated food and water are the main source of infection
• Pollution and poor personal hygiene favours the infection
• Mode of transmission:
• Faecally Contaminated water and food
• Direct contact from person to person through contaminated fingers

Epidemiology
• Number of cholera cases reported to WHO going to rise
• In 2016 alone, a total of 132,121 cases were notified from 38 countries
including 2420 deaths
• Cholera remains a global threat
• In India the introduction of cholera El tor subtype in 1964
• During 2017 about 494 cases were reported with 3 deaths in India

Clinical features
• Stage of evacuation: Profuse painless watery diarrhoea followed by
vomiting
• Stage of collapse: It is due to dehydration. The classical signs are
sunken eyes, hollow cheeks, scaphoid abdomen, washerman hands and
feet, shallow and quick respiration
• Stage of recovery: Here the patient shows the clinical improvement

Laboratory Diagnosis
Collection of specimen
• Stool sample directly into VR medium
• Rectal swab
• Culture methods
• Culture in bile salt agar medium TCBS
• It appears as translucent moist raised colonies
• Motility
• Darting motility seen by hanging drop method

Control of cholera
• Verification of diagnosis
• Notification
• Early case finding
• Establishment of treatment cases
• Rehydration therapy
• Adjuncts to therapy
• Epidemological investigations
• Sanitation measures
• Chemoprophylaxis
• Vaccination
• Health education

Vaccination
Three types of oral vaccine
• Dukoral (WC- rBS)
• Sanchol and mORCVAX
• Euvichol

Programmes
• Diarrhoeal disease Control Progamme
• During the year 1980-82 , strategy of the National Cholera Control
Progamme undergone changes now termed as Diarrhoeal disease
control Progamme
• Oral Rehydration Control Progamme
• The main objective is to prevent dehydration

• Typhoid fever is the result of systemic infection mainly by S.typhi found
only in man.
• The term enteric fever include both typhoid fever(caused by S.typhi) and
paratyphoid fever (caused by S.paratyphi ‘A’,’B’ and ‘C’).
• Reservoir : Man is the only reservoir. carriers are more important than
cases.

•Age: Highest incidence occurs in the 5-19 years of age group.
•Sex: Males > Females.
•More clinical cases of typhoid are reported among males than females;
But carrier rate is more common in females. Males carriers, probably, are
more dangerous because they can spread the bacilli more because of work
culture of country(males working predominant)
•Incubation period:10-14 days

Carriers
There are following types of carriers:
1) Convalescent carriers: Shed bacilli for 3 weeks to 3 months
after clinical cure.
2) Temporary carriers: Shed bacilli for 3 months to 1year after
clinical cure.
3) Chronic carriers (includes permanent carriers): Shed bacilli
for more than 1 year after

Treatment
•Cases: For empirical therapy , ceftriaxone (a cephalosporine) is the drug
of choice. For susceptible organisms ciprofloxacin is the drug of choice.
•Carrier: ampicillin or Amoxicillin is given for 6 weeks , with or without
cholecystectomy.

Antityphoid vaccines
Two safe and effective vaccines are licensed and available:
1)The Vi polysaccharide vaccine (TYPHIM Vi Vaccine)
• It contains purified Vi capsular polysaccharide from Ty2 strain.
• It is given as single dose by subcutaneous or intramuscular route.
• Its confers protection 7 days after the infection.

The Ty2a Oral vaccine (TYPHORAL Vaccine)
• It is an orally administered live attenuated vaccine.
• It contains >109viable organisms of live attenuated Ty21a strain which
lacks enzyme UDP-galactose-4-epimerase(gal E mutant).
• Vaccine is administered on 1,3 and 5th day,i.e. a 3-dose regimen.
• Vaccine confers the protection 7 days after the last dose.
• The recommendation is to repeat the series (3 doses) every 3 years for
people living in endemic areas and every year for individuals travelling from
non- endemic to endemic countries.

• Maximum cases of typhoid fever in 2017 were reported from
Bihar followed by Andhra Pradesh. Other states with large number of
cases are UP, MP, Maharashtra and Odisha.

POLIO
• Acute viral infection caused by an RNA virus
• Infects the human alimentary tract
• May infect the central nervous system, about 1%, causing paralysis
and death

• Type 1(P1): It is most common type and causes more epidemics. It is most
difficult to eradicate.
• Type-2(P2): It is most antigenic and most easily eradicable.
• Type-3(P3): It is associated with vaccine associated paralytic polio (VAPP)
and most commonly associated with paralysis caused by wild poliovirus.
• Period of communicability is 7-10 days before and after onset of symptoms.
• Main age group affected: 6 months to 3 years, slight male preponderance

Clinical features
• Subclinical (inapparent) infections (95%): Most common and play a
predominant role in the spread of infection.
• Minor (abortive) illness (4.8%) : Present with fever, sore throat, headache
and malaise.
• Aseptic meningitis/ non-paralytic polio (1%): There are signs and
symptoms of meningitis.
• Paralytic polio (<1%): There is flaccid paralysis with absent reflexes.
Respiratory paralysis is the common cause of death

Risk of paralytic polio is increased by :
Tonsillectomy,
tooth extraction,
adenoidectomy,
strenuous physical exercise,
fatigue,
intramuscular infection and
cortisone administration.

Laboratory diagnosis
• Viral culture of stool specimens collected from both AFP cases and their
contacts is the most sensitive and effective way to rule out transmission
of either polio virus or vaccine derived virus.
• Laboratory diagnosis is based on viral isolation from faecal samples 24-
48 hours apart.

Types of specimen
• Stool
• CSF
• Throat
• Blood
• If probable case dies, a definite diagnosis of polio can be made or
rejected by autopsy examination of spinal cord.

Adequate specimen for polio
• 2 specimens
• Within 14 days of onset of AFP
• Atleast 24 hours apart
• Adequate volume (8-10gm/adult thumb size)

Problem statement
• India has not reported any polio cases since 13 January 2011
• 25th Feb 2012 India was removed from the list of polio endemic countries
by WHO.
• On 27th March 2014, India was certified as polio free countries,
• Now there are three endemic countries : Nigeria, Pakistan and
Afghanistan.
• No serotype- 2 (type 2) wild polio virus (P2) has been detected in the world
since 1999, type 1 and type 3 has been detected.

Polio vaccines
• Two types of vaccines are used throughout the world :
• Inactivated Polio Vaccine
• Oral polio vaccine

Polio surveillance
• It is the most important part of whole polio eradication
ACUTE FLACCID PARALYSIS SURVEILLANCE
AFP is defined as acute onset(<4 weeks) of flaccid paralysis(reduced tone) without
other obvious cause in children<15 years of age. Poliomyelitis is the most
important etiology of AFP; other causes are GB syndrome, transverse myelitis and
traumatic neuritis. WHO recommends the immediate reporting and investigation of
every case of AFP in children less than 15 years

Polio surveillance
Cases of AFP are classified as POLIO if:
• Wild polio virus is isolated from any stool specimen.
Cases of AFP without isolation of wild polio virus may be classified
as polio compatible if:
• Stool specimens were inadequate and
• Residual weakness was present 60 days after onset of paralysis or 60 day
follow- up was not done.

Polio surveillance
Four steps of AFP surveillance:
Finding and reporting children with AFP
• Every case of AFP in any child under 15 years should be reported.
• The number of AFP cases reported each year is used as an indicator of
a country’s ability to detect polio, even in countries where the disease
no longer occurs.

Polio surveillance
Transporting stool sample for analysis
• All children (<15 years )with AFP should be reported and tested for wild
poliovirus within 48 hours of onset.
• Two stool specimens taken 24-48 hours apart are required.
• Specimens are transported in cold box at4-8 deg.C.
• Specimen should arrive at laboratory within 72 hours of collection.

Polio surveillance
Isolating polio virus
• Polio virus should be isolated and should be distinguished between
wild and vaccine-derived virus.
Mapping the virus
• Tests are carried out to determine where the strain may have
originated.

Mop up activity
• Mop-up activity is a house-to-house activity where two rounds of
polio immunization,4-6 weeks apart are conducted to limit
transmission of wild poliovirus. Under the mop-up activity, children
below 5 years of age are covered in affected and neighbouring districts
around every detected positive poli

Polio eradication and end game strategic
plan(2013-2018)
• The plan has 4 objectives:
• Detect and interrupt all poliovirus transmission :by the end of 2014.
• Strengthen immunization system and withdraw OPV.
• Containment and certification of eradication: of all WHO regions by end of
2018.
• Legacy planning.

Rationale and timelines for OPV withdrawal
• Why replace trivalent OPV with bivalent OPV?
• Until April 2016, tOPV was an important component of routine
immunization programmes . tOPV contains all three poliovirus serotypes
(1, 2 and 3), and the use of this vaccine has led to the eradication of wild
poliovirus type 2 (WPV2), with the last case occurring in 1999. The last
detected case of WPV3 was in 2012
• Even as the remaining strains of wild poliovirus are being eradicated, the
switch from tOPV to bOPV was a major step to combat cVDPV and
VAPP. Over 90% of cVDPV cases, and approximately 40% of VAPP
cases, are due to the type 2 component of tOPV. The type 2 component of
tOPV also interferes with the immune response to poliovirus types 1 and 3

• Given the risk the type 2 component of tOPV poses to a world free of
WPV2, tOPV was replaced with bOPV in routine programmes and
supplementary immunization activities (SIAs). bOPV contains type 1 and
3 serotypes only, and can help stop transmission of WPV1 and 3 and
reduce the risk of VAPP and cVDPVs.
• The introduction of IPV will help to reduce risks associated with the
withdrawal of OPV type 2, facilitate interruption of transmission with the
use of monovalent OPV type 2 in the case of outbreaks, and hasten
eradication by boosting immunity to poliovirus types 1 and 3.

Key dates around the switch
• May 2015
The World Health Assembly endorsed the process and tentative timelines.
• September 2015
Target date for national operational plans to be finalized, based on the guidelines
available.
• October 2015
As part of a readiness review, SAGE assessed the epidemiology of persistent
type 2 cVDPVs.

• April 2016
Two week window for the switch from tOPV to bOPV, followed by a two-
week validation phase.
• May 2016
tOPV is no longer used globally in routine immunization, nor in SIAs.
• NATIONAL SWITCH DAY: 25 TH APRIL 2016
• NATIONAL VALIDATION DAY: 9 TH MAY 2016

Oral rehydration solution
• The fluid recommended for replacement by oral route is reduced
osmolarity ORS(Low Na ORS)
• ORS therapy is based on the observation that glucose given orally
enhances the absorption of salt and water.
• The solution should be made fresh daily and used within 24 hours.

Condition Well alert Restless iritable Lethargic or unconscious;
Floppy
Eyes Normal Sunken Very sunken and dry
Tears Present Absent Absent
Mouth and tongue Moist Dry Very dry
Thirst Drinks normally,
not thirsty
Thirsty,drinks eagerly Drinks poorly,or not able to drink
Skin pinch Goes back
quickly
Goes back
Slowly
Goes back very
Slowly
Decide The patient has
No signs of
dehydration
If the patient has
Two or more
Signs,including at least
one sign,there is
Some dehydration
If the patient has two or
More signs,including at
Least one signs,there is
Severe dehydration
Treat Use treatment
Plan A
Weight the
Patient,treatment
Plan B
Weight the patient and use
Treatment
Plan C

TREATMENT PLAN A TREATMENT PLAN B TREATMENT PLAN C
No signs of
Dehydration
Some physical signs
Of dehydration
Severe dehydration
Mothers educated to use
increased amounts of home
available fluids.
ORS packets given for use at
home.
Breast feeding should be
continued.
Rehydration therapy:
Correction of existing water
and electrolyte deficit.
75 ml/kg ORS in first 4 hours.
Maintenance therapy:
Replacement of ongoing losses
due to continuing diarrhoea.
Begins when signs of
dehydration disappear usually
in first 4 hours
10-20ml/kg ORS for each liquid
stool.
Best IV fluid solution is Ringer
lactate
Normal saline can be used
Dextrose is not effective
100ml/kg
is to be given as :
AGE FIRST
(30ml/kg)
THEN
(70
ml/kg)
< 12
months
1 hour 5 hour
12 months
to 5 years
30
minutes
2 ½ hours

Dracunculiasis
• Vector borne parasitic disease caused by infestation of Dracunculus medinensis (guinea
worm).
• Man is the definite host and cyclops is the intermediate host.
• Infection is acquired by drinking of cyclops contaminated water( water based disease).
• Man is the only reservoir (no animal reservoir).
• Cycle in cyclops is cyclo-developmental.
• The larvae develop best between 25-30 deg c and will not develop below 19 degree c.

• Therefore, the disease is limited to tropical and sub tropical regions. In
India, the last report case was in July 1996.
• On completion of zero incidence for 3 years, India was declared free of
guineaworm disease.
• India certified for elimination of Guineaworm by WHO in Feb 2000 and
India certified Guineaworm disease free in Feb 2001.

Eradication strategy
• Provision of safe drinking water
• Control of Cyclops
• Health education of public: Boiling or Sieving of drinking water
• Surveillance
• Guinea worm eradication programme

Ascariasis
• Most common helminthic infection and worm infestation in India
• Causative agent: Ascaris lumbricoides.
• Reservoir: Man
• Infective form : embryonated egg containing rhabditiform larva.
• Mode of transmission: faeco-oral route by ingestion of embryonated
egg
• Incubation period : 2 months.

Ascariasis
Clinical features :
Loss of appetite, abdominal pain, malnutrition, obstruction, appendicitis,
perforation, allergic reaction.
• Due to migrating larva: Loefflers syndrome (eosinophilia pneumonia).
Diagnosis : demonstration of eggs in feces.
• Treatment :Mebendazole or Albendazole. Pyrantel palmoate is the choice
in pregnancy.

Hookworm infestation
• Ancyiostoma duodenale (old world hookworm )
Necator americanus (new world hookworm).
• Reservoir: Man
• The habitat is small intestine (jejunum > duodenum >ileum).
• Infective form : filarial form larvae
• Mode of transmission :through penetration of skin

• Plasma forms the main source of nourishment for hookworm, the RBCs pass
out from the hookworm practically unchanged into the lumen of host
intestine.
• Average blood loss by hookworm infection is 0.03ml/day (by Necator
americanus) to 0.2ml/day(by Ancylostoma duodenale).
• There is iron deficiency anemia and hypoalbuminemia.

• Morbidity and mortality from hookworm infection depends on the
worm load.
• Chandler worked out an index, Chandler’s index, on the basis of
average number of hookworm eggs per gram of feces for the entire
community.

Chandler’s index (endemic index)
Average no. of eggs per gram of stool
• Below 200 -- Hookworm infection is not significant
• 200-250 --- Potential danger
• 250-300 --- Minor public health problem
• Above 300--- Important public health problem

Taeniasis
• Zoonotic cestode : Taenia saginata (beef tapeworm)
• Taenia solium (pork tapeworm).
• Habitat : small intestine (jejunum)
• Definite host: Man (for both)
• intermediate host :Pig (T.solium) cattle (T.saginata )

Taeniasis
• Mode of transmission of tapeworm : Undercooked beef or pork
containing cysticercus bovis.
• Human cysticercosis: can occur in any organ
• Neurocysticercosis - increased intracranial pressure, hyrocephalous &
death

Question 1
• Raj, a 10 year old boy came to your PHC with complaints of vomiting,
mild fever and yellowish discoloration of urine for past 5 days. His
father told that few more children from his locality has the same
symptoms and went for native treatment. What would be the
incubation period od the infection?
a) 15-50 days
b) 45-60 days
c) 14-180 days
d) 15-64 days

Gastrointestinal Infections: Causes, Symptoms, Diagnosis and Treatment

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