Epidemiology of Diarrhea Diseases

Course Objectives Definition Measurement of Diarrhea Burden Global Burden of Diarrheal Disease Burden of Diarrheal Disease in
Epidemiology of Selected Diseases II: Diarrhea
Yusuf Misau, PhD
Child Health And Mortality Prevention Surveillance Project
College of Medical Sciences
Abubakar Tafawa Balewa University Bauchi
June 2023
Yusuf Misau, PhD ATBU College of Medical Sciences

Lecture Outline
1 Course Objectives
2 Definition
3 Measurement of Diarrhea Burden
4 Global Burden of Diarrheal Disease
5 Burden of Diarrheal Disease in Nigeria
6 Epidemiological Factors in Diarrhea transmission
7 Control and Prevention of Diarrhea

Course Objectives
At the end of this course, students will be able to:
Describe epidemiological characteristics of common diarrheal
disease
Describe case definition of diarrhea.
Describe common etiological agents of diarrhea.
Describe the local and international burden of diarrheal
diseases.
Understand how to investigate and control an outbreak of
diarrheal diseases in the community

Course Delivery
Lectures
Case Study
Group discussions/presentations (To be evaluated as part of
C.A.)

What is a diarrhea?
According to the WHO, Diarrhoea is defined as the passage of
three or more loose or liquid stools per day (or more frequent
passage than is normal for the individual).
NB: Frequent passing of formed stools is not diarrhoea,
ie,emphasis is on consistency not number, nor is the passing
of loose, ”pasty” stools by breastfed babies
Also, any number of stool containing blood in 24 hours

What is a diarrhea?
Acute Watery diarrhea: Last several hours to days. Prone to
dehydration and weight loss(without feeding). Commonly
caused by V Cholerae, E. Coli, Rotavirus
Acute bloody diarrhea: Otherwise called dysentry, hallmark is
visible blood in stool. Commonly caused by Shigella bacteria

What is a diarrhea?
Persistent diarrhea: Persistent diarrhoea, defined as diarrhoea
lasting at least 14 days, which carries a risk of both nutritional
compromise and of mortality in excess of that for acute
diarrhoea
While enteroaggregative E. coli and cryptosporidium have
been associated with persistent diarrhoea, often no specific
pathogen can be implicated
Seen in HIV/AIDS, certain cancers

ICD-10 Classification of Diarrhea
ICD codes for watery diarrhoea and dysentery
Symptom Aetiology ICD-10
Watery Diarrhea Cholera A00
Salmonella A02
Bacterial food poison A05
Other bacteria A04.0–A04.9
Giardiasis A07.1
Viral gastroenteritis A08
GE Presumed A09

ICD-10 Classification of Diarrhea
ICD codes for watery diarrhoea and dysentery
Symptom Aetiology ICD-10
Dysentery Shigella A03
Campylobacter A04.5
Yersinia A04.6
Amoebiasis A06
Dysentery, aetiology
unspecified
A09

Measurement of Diarrhea Burden
Longitudinal studies: Community longitudinal studies provide
the most reliable data for diarrhoeal disease incidence and, if
the study size is large enough, mortality estimates.
Active surveillance/Survey data/Vital registration: The
principal methods used for mortality assessment.

Burden of Diarrheal Disease
According to WHO, diarrheal disease is the second leading
cause of death in children under five years old.
Globally, there are nearly 1.7 billion cases of childhood
diarrheal disease every year
About 525 000 die children every year from diarrhea
Each child will experience 3-10 episode of diarrhea per year in
their life time

Burden of Diarrheal Disease in Nigeria
Diarrhea is second major cause of mortality among children in
Nigeria
Diarrhea causes about 16% of child’s death in Nigeria
An estimated 151,700 children die in Nigeria every year from
diarrhoea disease
Diarrhoea disease is associated with high under-five mortality
rate (U5MR) in Nigeria, currently at 128 per 1000

Factors in Diarrhea transmission
Agent
Reservoir
Host
Environment

Agent Factors in Diarrhea transmission
Viruses: Rotaviruses(major), adenoviruses, calviciviruses,
coronaviruses, adenoviruses, astroviruses, enteroviruses,
norwalk group of viruses, CMV
Bacterias: C Jejuni, ET E. Coli, Salmonella, V Cholerae, B
Cereus, S Aureus, Aeromonas, Y Enterolitica, C Defficile,
Chlamydia, Neisseria gonorrhoeae
Others: E Histolitica, Giardia Intestinalis, Crypro SPP,
Intestinal worms, cyclospora.

Agent Factors: Rotaviruses
Discovered in 1973, major cause of severe diarrhea in children
aged 6-24 months worldwide
Major cause of hospitalization and mortality among all
children with diarrhea worldwide
Causes 30% of all diarrhea death in Nigeria
Causes 200,000 deaths among children globally
About 25 million out-patients visits globally
Peak incidence during winter season
Transmitted feaco-orally, unlikely to respond to usual universal
prevention of good hygiene

Agent Factors: Bacterias
Enteric Bacterias: V. Cholerae 01, Salmonella, Shigella,
ETEC, C Jenuji
ETEC is major bacterial cause of acute watery diarrhea in
both children and adults in Africa
Causes 400 million episodes among children, 100 million
among older children 5-14 years
ETEC has two types of toxins, LT, ST( Heat labile and stable
respectively)
Spread by contaminated food and water
Salmonella causes inflammation of the bowel epithellium
Shigella spp have been isolated in 8% of all sample stools in
Northeast Nigeria, it causes about 1 million deaths globally.

Agent Factors: Other causes
Amoebiasis, Giardiasis, Cryptosporidium:
Affects mostly duodenum and Jejunum
Infants are more affected
Except in ISD, infections are mostly asymptomatic

Reservoirs Factors in Diarrhea transmission
Humans: E. Coli, Shigella, V.cholarae Giardia lalmblia,
E.histolitica
Animals: C Jejuni, Salmonella, Y.enteroalitica

Host Factors in Diarrhea transmission
Age: Children 6months-2years, 6-11months
Social: Poverty, low literacy, low income, unemployment
Constitutional: Prematurity, Reduced Gastric Acidity, ISD,
Poor Personal Hygiene, Poor Domestic Hygiene, Inappropriate
Feeding Practices
Insecurity, Internally displaced persons

Environmental Factors in Diarrhea transmission
Absolute seasonal variation
Viral diarrhea peaked during drier, cool season
Bacterial diarrhea peaked during warm, rainy season
In tropics, rotavirus persist through out the year

Modes of Diarrhea transmission
Feaco-oral route: water-borne, food-borne, direct contact with
formite

Control and Prevention of Diarrhea
The Diarrheal Disease Control program was first initiated by WHO
in 1980. Its conerstone is oral rehydration therapy (ORT). key
components of DDC proram include:
Short-term: Evidence Based Clinical Management
Long-Term:
Improved MCH care
Diarrhea prevention measures
Preventing diarrheal epidemics

Evidence Based Clinical Management of DDX
The effective clinical management of DDX must include:
Oral Rehydration Therapy
Intravevous rehydration
Maintenance of hydration
Appropriate feeding
Appropriate Antibiotics
Zinc supplementation

Improved Maternal and Child Health Services
These include:
Maternal nutrition
Child nutrition:
EBF
Approprite weaning practice
Supplementary feeding
Vitamin A supplimentation

Strategies for Prevention of Diarrhea
Sanitation
Health education
Improved MCH care
Immunization
Rotavirus vaccine

Prevention of Diarrhea Epidemics
Various surveillance systems within the community,
sub-district, district, regional and national levels.
Nigeria’s surveillance system was set up to evaluate cholera
and other diarrheal diseases occurrences, to detect disease
early and monitor, so that the best available evidence would
be used for decision making.
A highly sensitive case definition was used to capture any
patient aged 5 years or more who develops acute watery
diarrhea with or without vomiting.
Passive surveillance
Active surveillance

Group Work and Presentation
The DSNO of your state has reported an outbreak of cholera
diarrhea in a slump within your state. You are to investigate,
design a control and prevention of the outbreak and write a
report.
Group yourselves into 5 five teams
Each team should concentrate on one of the following:
1. Investigate that there was cholera outbreak, 2. describe the
history of cholera outbreak, its pathophysiology and its
epidemiological determinants for transmission, 3. outline case
management of cholera, 4. outline public health measures to
control cholera, 5. Cholera vaccine

Epidemiology of Diarrhea Diseases

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