Guidelines for gastroenteritis

Updated: June 2014
Epidemic Investigation Cell
Public Health Laboratories Division
National Institute of Health, Islamabad
Tel: 051- 9255237, 9255238, Fax: 051-9255575, 9255118, 9255099 Table of Contents
Acute Watery Diarrhea Invasive (bloody) Diarrhea/Dysentery Mode of transmission Case definition
Specimen Collection and Transportation
Common Sources of Infection
Fruit & Vegetables Food contaminated before, during and after Management
Prevention and control
Preventing spread of gastroenteritis in health Disinfecting clothing and disposing of dead Health Education How to make drinking water safe
Home water treatment Home water storage Hand washing with soap
Food safety
The Role of Laboratory
Handling of stool samples Reference Laboratory References

Acute Gastroenteritis can be caused by a number of infectious agents like bacteria, viruses
and parasites. Due to similar symptoms it is difficult to differentiate among viral, bacterial and
parasitic agents. Globally, there are an estimated two billion cases of diarrheal disease.
Which kill approx. 1.8 million people annually. Diarrheal disease is the 2 leading cause of
death and the leading cause of malnutrition in children under 5 years old and causes about
1.5 to 2 million deaths annually.
Proportion of Microorganisms isolated form AWD samples received
at NIH, 2012-2014 (198)
Acute Watery Diarrhea: Acute intestinal infection caused contaminated food or
water, causing copious, painless, watery diarrhoea that can quickly lead to severe
dehydration and death if not treated promptly. Diarrhea is the passage of loose or watery
stools at least 3 times or more in 24 hours Vibrio cholerae (O1 or O139 Ogawa, or Inaba El
Tor) is an important bacterial cause in endemic areas, often occurs in large epidemics.
80‐ 90% of episodes are of mild or moderate severity and are difficult to distinguish clinically
from other types of acute diarrhoea. Less than 20% of ill persons develop typical cholera with
signs of moderate or severe dehydration.
Invasive (bloody) Diarrhea/Dysentery is characterized by frank blood and mucus
in the stool accompanied by fever mostly caused by Shigella, Salmonella enterica,
Campylobacter, enterohemorrhagic Escherichia coli, entero invasive E. coli, and the
protozoan parasite Entamoeba histolytica. Dysentery or bloody diarrhea and persistent
diarrhea (loose, watery, or bloody stools of ≥14 days)
Cholera is acquired by the ingestion of an infectious dose of cholera vibrio bacteria.
Faecally contaminated water is usually the vehicle for transmission of infection, either directly or through the contamination of food. The soiled hands of infected persons may also contaminate food. There are more than 60 serogroup of Vibrio cholerae, but only serogroup 01 causes cholera. The EI Tor biotype has caused almost all of the recent cholera outbreaks. Mode of transmission:
Infection results from ingestion of organisms in food and water or directly from person to
person by the faecal oral route
Incubation Period: Few hours to 5 days
Seasonality: Throughout the year; higher incidence from April to November.
Reported AWD cases by Month in Pakistan, 2012-2014 (n=42,820)
Alert: One case of AWD is an alert and must be investigated.
Outbreak: One lab confirmed case or cluster of 6 or more cases in a single location.
Case definition
Suspected Case: A case of cholera should be suspected when:
 In an area where the disease is not known to be present, a patient aged 5 years or more develops severe dehydration or dies from acute watery diarrhoea.  In an area where there is a cholera epidemic, a patient aged 5 years or more develops AWD, with or without vomiting 2.2 Confirmed Case
A case of cholera is confirmed when Vibrio cholerae O1 or O139 is isolated from the stool
Note: Once Vibrio cholerae has been confirmed, the WHO clinical case definition is sufficient
to diagnose further cases in the area.
Specimen Collection and Transportation:
Fecal specimens should be collected in the early stages of any enteric illness, when pathogens are usually present in the stool in highest numbers, and before antibiotic therapy has started.  Collect stool specimens from a minimum of 10 persons who are suspected of being part of an outbreak and who meet the following criteria: o Currently have "rice water stool." o Had onset of illness less than 4 days before sampling. o Have not received antimicrobial treatment for the diarrheal illness.  Collect rectal swab or fresh stool sample during active diarrhoea period (preferably as soon as possible after onset of illness before the initiation of antibiotic therapy), and send to lab by overnight mail.  Stool specimens should be transported at 4‐8°C in Cary‐Blair transport medium or alkaline peptone water.  A complete lab request form with brief history of the patient should accompany each Note: Bacterial yields may fall significantly if specimens are not processed within 1‐2 days of
Reported AWD cases to DEWS by Province/Area in Pakistan, 2012-2014 (n=42,820)
Common sources of infection
Drinking water that has been contaminated at its source (e.g. by faecally contaminated
surface water entering an unprotected spring) or during storage (e.g. by contaminated water
entering an incompletely sealed underground storage tank), and ice made from contaminated
Fruit and vegetables grown at or near ground level and fertilized with night soil, irrigated
with water containing human waste, or "freshened" with contaminated water in the market, and
then eaten raw.
Food contaminated before, during or after preparation e.g. milk or other drinks or
foods mixed with contaminated water and not cooked, any food touched by soiled hands before consumption. Seafood; particularly shellfish, taken from contaminated water and eaten raw or
insufficiently cooked.
The mainstays of treatment are: correction of fluid and electrolyte losses, appropriate nutritional care, and treatment of co‐morbid conditions. Fluid and electrolytes management consists of two phases: i.e. replacement and maintenance. Oral Rehydration Solution (ORS), a mixture of water, salts, and glucose, in both the replacement and maintenance phase should be administered. In severe dehydration appropriate intravenous fluids (IVF) must be given. Micronutrients: The WHO recommends Zinc for children <5 years of age with diarrhea (10 mg/day for <6 months and 20 mg/day for 10 days for 6 months to 5 years) and Vitamin A for Children in developing countries. Antibiotics: Not indicated in AWD except in suspected cholera and dysentery. The sensitivity
pattern against Vibrio Cholerae observed at Microbiology Lab NIH revealed good for
Chloramphenicol, Ampicillin, Doxycycline, Ciprofloxine and Tetracycline.
Effective prevention requires a three pronged approach; improved drinking water supplies, adequate sanitation and health education. Hand‐washing after defecating, disposing of a child's stool and before preparing meals must be strongly advocated. District health authorities must regularly monitor restaurants, street vendors and other food outlets to ensure proper hygiene. Public health engineering departments must strengthen water quality monitoring and ensure proper chlorination till consumer's end. Surveillance must be strengthened for early detection of first case and timely application of control measures. In outbreak situations, the strategy aims to reduce mortality by ensuring access to treatment and controlling the spread of disease. Proper case management, sufficient pre‐positioned medical supplies and effective health education usually help in early control. PREVENTING SPREAD OF GASTROENTERITIS IN HEALTH FACILITIES
The following steps can help to reduce the spread of gastroenteritis infection in clinics and hospitals:  Provide plenty of water and soap for hand-washing, preferably in easily accessible, highly visible locations;  Wash hands with soap before and after examining each patient;  Ensure that health workers who care for dysentery patients (or other diarrhoea patients) do not prepare or serve food;  Wash and disinfect the clothes and bed linen of dysentery patients frequently.  Dispose of stools of dysentery patients in a latrine or toilet (if this is not possible, bury them). In larger health facilities, safe treatment and disposal of liquid waste from severe gastroenteritis patients, including excreta and vomit, can be mixed with disinfectants (e.g. cresol). Hospitals can use a prepared acid solution to mix with the waste to lower it to a pH below 4.5. After 15 minutes it is generally safe to dispose of this mixture in a toilet or latrine, or by burying it. The preferred method for disposing of semisolid waste is incineration, provided that the incinerator used is designed to destroy contaminated waste. The bags used to gather and carry the waste should also be burned, the transport vehicle should have an enclosed, leak-proof body, which should be cleaned after each use and disinfected regularly. DISINFECTING CLOTHING AND DISPOSING OF DEAD BODIES
 Prompt and thorough disinfection of a patient's clothing, personal articles and immediate environment can help to control spread of infection within a family. Effective and inexpensive disinfectants include: chlorinated lime powder, 2% chlorine solution, and a 1-2% solution of phenol.  Clothes should be washed thoroughly with soap and water, and then boiled or soaked in disinfectant solution. Sun drying of clothes is also helpful since direct sunlight will kill bacteria.  Utensils may be washed with boiling water or disinfectant solution.  The washing of contaminated articles, particularly clothes, in rivers and ponds,
which might be sources of drinking-water, or near wells, must be prohibited.

for people who die of cholera or of any other cause in a community affected by
cholera, can contribute to the spread of an epidemic. To reduce the spread of infection,
funerals should be held quickly and near the place of death.
Those who prepare the body
for burial can be exposed to high concentrations of bacterial contamination. Those who wash
the body should never prepare the food.
If funeral feasts cannot be cancelled, and if other
people are not available to prepare the food, meticulous hand washing with soap and clean
water is essential before food is handled. A designated health worker, present at the funeral
gathering, can be helpful in supervising the use of hygienic practices.
Health and hygiene messages should include methods of treating and storing drinking water, food safety, washing hands with soap and sanitation. It is particularly important to inform people that most cases of severe gastroenteritis including cholera can be treated with simple measures like ORS. Vaccination is not effective. There is no substitute for drinking only safe water, practicing good personal hygiene, and preparing food safely. VACCINATION
For a number of reasons, the vaccine currently available is of no help in controlling cholera:  The vaccine frequently lacks the required potency;  Even when potent, the vaccine is not very effective -- that is, not all persons who are vaccinated are protected;  Any protection that does occur lasts for only 3 -- 6 months; and  Vaccination does not reduce the incidence of asymptomatic infections or prevent the spread of infection. WATER SUPPLY
Water supplies should be adequate to meet all the needs of a population all year round. It is
recommended that a minimum of 20 litres of water per person per day be available. Health
clinics and hospitals require 40-60 litres per patient per day. Ideally, no dwelling should be
located more than 150 metres from a water source.
General guidelines for ensuring a safe water supply are given below.
Piped water must be properly chlorinated. Leaking joints should be repaired and constant
pressure should be maintained in the system to prevent the entry of contaminated groundwater.
Sewer pipes should also be well maintained and promptly repaired when any damage has
occurred so that sewage does not mix with piped water. Water pipes should never be below
sewer pipes in the ground and preferably three feet above them.
Where an exposed water source (a river, pond, or open well) is used for drinking water, it
should be protected from contamination by people and animals. This may require that a fence
be built around it. Drainage ditches should be dug to prevent storm water and other surface
water from flowing into the drinking-water source. Wells should be equipped with a well-head
drainage apron, and with a pulley, windlass, or pump. Other water sources should be provided
for bathing, washing and other purposes.
High priority should be given to ensuring the safe disposal of human waste. Sanitary systems
appropriate for local conditions should be constructed with the cooperation of the community.
Designs for latrine construction in different types of soils and climatic conditions can be found
Defecation, including in latrines, must not be allowed within 10 metres of the water
, and should be downhill, or downstream, from it. Health education messages should
stress the need for proper use of latrines by everyone, including children. They should also
stress the dangers of defecating on the ground or in, or near, the water supply. The disposal of
children's excreta in latrines should be emphasized. If children defecate on the ground, the
faeces should be picked up, using a scoop or shovel, and deposited in a latrine or buried.
When large groups of people congregate, as for fairs, funerals or religious festivals, particular
care must be taken to ensure the safe disposal of human waste. Where there is no latrine,
defecation should be performed in marked areas and a shovel provided to bury the faeces.
Where locally available water is likely to be contaminated, drinking-water should be
supplied by tankers or transported in drums, provided it is adequately chlorinated and a regular
supply can be ensured. The trucking of water is, however, expensive and difficult to sustain; it is
usually considered a short-term measure until a local supply can be established.
Making water safe by boiling: Heating water until it starts to boil vigorously is adequate to kill
bacterial pathogens. Boiled water should be stored in a separate sealed or covered container.
Water used for purposes other than drinking need not be boiled.
Making water safe by chlorination: The following guidelines for preparing a chlorine stock
solution and adding it to the drinking water should be followed both for home or institutional use:
First, prepare a Stock Solution: (1% concentration by weight of available chlorine);
Add to 1 liter (four glasses) of water:
33 grams (3 level tablespoons) of bleaching powder or chlorinated lime (30%), OR 15 grams of calcium hypochlorite (70%), OR 250 ml of sodium hypochlorite (5%), OR 110 ml of sodium hypochlorite (10%),  Store in a cool place in a closed container that does not admit light (such as a brown  This Stock Solution is usually stable for one month from the date of preparation.
Use of this Stock Solution to make water safe:
Add the 3 drops of Stock Solution to one litre of water, or according to the table below. Mix and
allow water to stand for 30 minutes before drinking.

Stock solution
0.6 ml or 3 drops Only clear water can be used for chlorination. If the water has suspended solid matter, it should either be filtered or allowed to settle so that only the clear portion is consumed. Making water safe by solar radiation
In an emergency situation, water can be purified by solar radiation. Water should be clear or
filtered until there is no suspended solid matter. Clear plastic bottles should be filled with water
and placed horizontally on a flat surface for about five hours in full sunlight, and the ultraviolet
radiation kills the micro-organisms. The process is even more effective if the bottom half of the
bottle is painted black or placed on a black sheet of plastic that absorbs more heat thus helping
to kill microbes more quickly. On cloudy days, the process could take as long as two days. Due
to this timing / solar power uncertainty, this solution is less reliable and sustainable unless it has
been established with some quality controls.
Use of ice
While many people are careful about consuming only safe water, they often ignore the fact that ice should also be prepared from purified, boiled, or chlorinated water. Ice balls sweetened with coloured sugar syrups sold in the market are often not hygienically prepared and should be avoided. HOME WATER STORAGE
Families should be encouraged to store drinking-water in covered containers that are cleaned daily, to keep drinking-water away from children and animals, and to use a long-handled dipper, kept specially for the purpose, to take water from the containers without allowing entrance of the hands. Another approach is to store drinking water in a narrow-mouthed jug, with an opening too small to allow the insertion of a hand. Cups and mugs should never be dipped into the container. Instead, water should be poured into the cups or mugs. It is also important to remember that water should be used within 24 hours of being stored. HAND-WASHING WITH SOAP
Washing hands with soap is one of the most effective measure to prevent transmission of gastroenteritis; it should be promoted in every family. Hand washing is particularly important after defecation, after cleaning a child who has defecated, after disposing of a child's stool, before preparing or handling food and before eating. Hand washing is practised more frequently where water is plentiful and within easy reach. During an epidemic of gastroenteritis, soap should be provided to those without it. Washed hands should be dried with clean cloths. FOOD SAFETY
Environmental health workers should monitor food-handling practices and be given the authority to stop street sales or close restaurants when their inspections reveal unsanitary practices Health education for the general population should stress the following messages concerning the preparation of food for adults, children and infants:  Do not eat raw food, except undamaged fruits and vegetables that are peeled and eaten immediately; Cook food until it is hot throughout; eat food while it is still hot, or reheat it thoroughly before eating; Wash and thoroughly dry all cooking and serving utensils after use; Keep cooked food and clean utensils separate from uncooked foods and potentially contaminated utensils; Wash hands thoroughly with soap before preparing food or eating food, or feeding children; Protect food from flies by means of fly screens. THE ROLE OF LABORATORY
Laboratory analysis of specimens from the first suspected cases is essential to exclude the
presence of cholera. Once the presence of cholera is confirmed, it is not necessary to examine
specimens from all cases or contacts. In fact, this should be discouraged since it places an
unnecessary burden on laboratory facilities and is not required for effective treatment.
10.1 Handling of stool samples
Stool specimens or rectal swabs from suspected cases should be promptly submitted for
laboratory examination in a transport medium (e.g. Cary-Blair medium), a supply of which should
be stocked by the local health center or health officer. If a transport medium is not available, a
cotton-tipped rectal swab can be soaked in the liquid stool, placed in a sterile plastic bag, tightly
sealed, and sent to the laboratory. Ideally, specimens should be collected before any antibiotics
are given to the patients.
The name, age, and address of the patient, the main clinical signs, and the date and time when
the specimen was obtained should be written on a request slip and sent with each specimen.
10.2 Reference laboratory
NIH Islamabad should be approached for guidance, providing culture media, training workers in
local and regional laboratories in appropriate isolation techniques, and monitoring the quality of
laboratory services.
WHO-Geneva. WHO Guideline for Cholera Control 1993. WHO-Geneva. Cholera outbreak: Assessing the outbreak response and improving preparedness. 2004.
Seasonal Awareness Alert Letter 30th Issue issued by National Institute of Health Islamabad Centers for Disease Control and Prevention (CDC). Global Disease Detection (GDD) Manual "Rapid Diagnostic Tests for Epidemic Diseases" 2011 (draft). WHO. Cholera vaccines: WHO position paper. Wkly Epidemiol Rec, 2010;85(13)117-128.


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