Diseases transmitted by the fecal-oral route include viral, bacterial, protozoan and helminth infections. Major causes globally and in developing countries include rotavirus, cholera, typhoid, bacterial diarrhea and amoebiasis. Risk factors include lack of access to clean water and sanitation. Prevention strategies center on improving hygiene, water quality and sanitation to break the transmission cycle. Challenges to control include poverty, lack of surveillance and cultural practices.

1. DISEASES TRANSMITTED
BY FECAL-ORAL ROUTE
Kilimnjaro Christian Medical University College (KCMUCo)
Emmanuel H. Mtui
Ummi Abdul
Situ Mhunzi

2. Outline
1. Introduction
2. Epidemiology
3. Prevention and Control measures
4. Challenges
5. References

3. Introduction
Definition
Diseases 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)

4. Fecal-oral Transmission route
(AMREF, 2007)

5. 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.

6. 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)

7. 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)

8. Dose Dependency of Diarrhea Diseases
Large 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)

9. 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)

10. Major Risk Factors
• Inadequate safe water supply
• Poor sanitation
• Poor personal hygiene
(WHO, 2016; AMREF, 2007; GAPPD, 2013)

11. Global Diarrhea related deaths among
children
(UNICEF, 2015)

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

13. 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)

14. 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)

15. 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)

16. 2015/2016 Tanzania Cholera Outbreak
• 23 mainland regions and 5 island regions were
affected.
• 24108 reported cases
• 378 cholera deaths
(WHO, 2016b)

17. Factors associated with spread
• Limited access to safe water
• Lack of sanitation facilities
• Poor hygienic practices
(WHO, 2016b)

18. Public Health Response
Multisectoral National Cholera Taskforce
• Ministry of Health Tanzania
• WHO
• UNICEF
• CDC
• Red Cross Society
• Others
(WHO, 2016b)

19. Six technical sub-committees
• Water and sanitation and hygiene (wash)
• Social mobilization
• Surveillance
• Laboratory
• Case management
• Logistic and administrative.
(WHO, 2016b)

20. 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)

21. 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)

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

23. 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)

24. 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)

25. 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)

26. 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)

27. Break the Transmission Cycle
(Amref, 2007)

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

29. 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 )

30. 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)

31. References
African 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].

32. 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].