Frequently Asked Questions
Health and Sanitation
The following table shows how South Africa compares to other countries in the world with regard to supply of safe drinking water:
Percentage of the population with access to safe drinking water (2000)
Note: All industrialized countries (as listed by UNICEF) with data available are at 100%.
Ref: United Nations Childrens Fund (UNICEF). New York, NY. "Safe Drinking Water." Excerpt from "Progress since the World Summit for Children: A Statistical Review." September 2001.
Dizziness, tiredness, headache, muscle cramps, nausea.
Generally people cannot survive without water for longer than 3 days. It depends on the circumstances, for example, it may be shorter if you are lost in the bush in mid-summer, and it may be longer if you are inactive, stuck inside in mid-winter.
Rehydration fluid is a mixture of sugar (8 teaspons), salt (half a teaspoon) and water (1 litre).
- 70% of the human body is made up of water.
- 85% of the brain is made up of water.
- The transparency of the media of the eye to light is maintained by water.
- Sound is conducted through the inner ear by liquid.
- Water (cerebrospinal fluid) serves as a cushion for the brain and spinal cord.
- The sense organs of equilibrium depend upon the presence of water.
- Water is important in equalizing the temperature throughout the body.
- Water serves as a lubricant for moving parts such as joints, the heart and intestine.
- Water dissolves or holds in suspension other materials in protoplasm.
- Water moistens the surface of the lungs for gas diffusion.
- Water is required for digestion, absorption, metabolism, secretion and excretion.
- Water helps prevent constipation.
- Helps dissolve minerals and other nutrients to make them accessible to the body.
- Water carries nutrients and oxygen to the cells and removes waste matter from the body.
Lack of sanitation in slum areas is a huge problem worldwide, and it leads to severe problems in terms of disease and the spread of poverty.
In order to bring adequate sanitation services to informal settlements, all role players, the communities, local government, national government, NGO's and private business need to be involved.
The following case study highlights the importance of some of these role players:
In February 2003 the United States launched the Community Water and Sanitation Facility to expand water and sanitation services in slum communities. The Facility works towards achieving the objectives of the Johannesburg Plan of Implementation of the World Summit for Sustainable Development to improve water and sanitation for the world’s poor, and to the achievement of the Millennium Development Goal of significantly improving the lives of 100 million slum dwellers by 2020. The U.S. launched the Facility with seed funding of $2 million within the context of the Cities Alliance.
Cities Alliance is a donor coalition committed to the vision, “Cities Without Slums” and has 14 contributing members, including Canada, France, Italy, Japan, Germany, the Netherlands, Norway, Sweden, the United States, the United Kingdom, the Asian Development Bank, the United Nations Environment Programme, UN-Habitat and the World Bank.
The Community Water and Sanitation Facility supports local authorities and their partners in working through public-private partnerships to expand water and sanitation services to slum communities. The Facility provides grants that leverage local resources at least 2:1 to support:
- Expansion of water and sanitation services through funding of community endorsed construction;and Risk-sharing and innovative financing to mobilize resources to improve water and sanitation provision to the urban poor.
- The Facility supports partnerships that enhance service delivery by combining the efforts and resources of the public sector with those of the private sector and non-governmental organizations (NGOs). Proposals requesting funding are screened by the Cities Alliance Secretariat to ensure that they meet the eligibility criteria. Proposals are then subject to a more intensive, independent technical assessment process. Contributing members of the Cities Alliance give final funding approval.
- The Facility is open to all countries, but requires that at least two members of the Cities Alliance co-sponsor the application and that the local authorities are committed to city-wide slum upgrading and are undertaking the reforms necessary to enable viable public-private partnerships that improve water and sanitation services for the urban poor.
Community Water and Sanitation
Public-Private Partnerships Are Essential to Bringing Water and Sanitation Services to Slum Communities
Emerging Community Water and Sanitation Facility activities underscore the importance of public-private partnerships to achieve sustainable provision of water and sanitation services in slum communities. Several USAID country missions are working with partners to broker activities for Facility support.
USAID/South Africa is working with the British Department for International Development and the Municipal Infrastructure Investment Unit, a non-profit corporation funded by the Government of South Africa, to increase and improve water and sanitation services to 1,000,000 disadvantaged persons in five municipalities. The Facility is being asked to fund technical assistance to local authorities to help the targeted cities improve the management and monitoring of water and sanitation provision in urban areas.
The objective is to increase local capital investment in these better managed services so that the targeted cities can expand water and sanitation provision to the urban poor. USAID will provide use of the Development Credit Authority (DCA) credit enhancement to facilitate local lenders making funds available to these municipalities that improve their water and sanitation management performance. The leverage is expected to be over 36:1 with the Facility contributing $460,000 to partners’ contributions of $16,675,000.
USAID/Panama is creating an alliance in Panama City to bring sewerage lines and a treatment plant to a marginalized community of 12,500 people that collectively identified the need for sanitation services. During community workshops, local medical workers indicated that toddlers and women working in the house were disproportionately affected by skin and gastrointestinal problems due to the lack of sanitation services.
In response to the community’s needs, USAID through the Community Water and Sanitation Facility, is helping to broker a public-private alliance with the Ministry of Health, Panama Canal Authority, the National Institute for Water and Sanitation, the Municipality of Panama, two local businesses and the community to construct sewerage lines and a treatment plant. This partnership, when fully implemented, will help protect the Panama Canal watershed and tap into local capital financing by scaling up the intervention into other communities in the watershed. The leverage is expected to be 4:1 with a substantial contribution from local private businesses of over $1 million.
USAID/India is working with Shelter Associates, a community-based organization representing slum dwellers in Sangli, to construct toilets for the use of 25,000 persons. The objectives of the proposed activity are:
- to develop community-level toilet construction and management plans in consultation with local government authorities,
- to assist the municipality in implementing the community-level plans, and
- to begin the preparatory work for a citywide slum upgrading strategy.
The Facility will be asked to fund technical assistance and construction materials for public toilets. The leverage is expected to be 2:1.
The $2 million U.S. contribution, when combined with support from other Cities Alliance members, is expected to meet the funding target of $4 to $10 million over five years. It is anticipated these resources will mobilize more than $60 million from public and private partners for water and sanitation access in slum communities.
Boil the water for at least 10 minutes OR add bleach to the water
If you need a lot of water
add 1 teaspoon of Jik or Javel to 25 litres of water and mix it. Leave the water in the container overnight or for at least 2 hours before using the water.
If little water is needed
you add 5 drops of bleach to one liter of water and leave it for half an hour before use.
Other methods include building a sand filter with different sizes of clean gravel and sand, boiling the water or exposing it to sunlight for a few days.
A water vector disease is a disease that needs water as part of the life cycle of the organism that causes the disease. A good example is malaria. You cannot get malaria from direct contact with water, but the Anopheles mosquito, which carries the Plasmodium parasite which causes malaria, needs stagnant water during the larval and pupa stages of its life. For this reason, people living close to ponds or dams, or even rainwater puddles in warmer, subtropical climates, have a higher risk of contracting malaria.
Cholera is a sickness caused by germs (Vibrio cholerae) that attack a person's stomach and it is characterized by a massive loss of body fluids, through diarrhea and vomiting.
The following information has been supplied regarding cholera and how it may be contracted:
What is Cholera?
Cholera is a sickness caused by germs (vibrio cholerae) that attack a person's stomach and it is characterized by a massive loss of body fluids, through diarrhea and vomiting.
Which signs should one look for?
- Watery runny stomach. Stool with appearance of “rice water”.
- Severe dehydration.
- The person loses a lot of water very quickly.
- Feels weak and complains of cramps in arms and legs.
How is cholera transmitted?
- Water that is safe at point of collection is often exposed to faecal contamination during collection, transport and use in the home, mainly by unclean hands.
- Any person can contract the disease by ingesting contaminated water or food contaminated by Vibrio cholera.
- From one person to another.
- The bacteria can also survive in food especially seafood.
- Infections can be acquired from ice cubes prepared from contaminated water.
How do the germs spread from one person to another?
- The disease is spread by poor sanitation.
- When infected people empty their bowels, the germs come out with the stool. The stool gets onto a person's hands or into drinking water or onto food.
- The germs can spread to other people when they drink the water or eat the food, which looks OK, but contains germs.
- Once inside the body, it can make that person sick.
How can we stop cholera?
- There are a few things that people can do so that germs do not spread from one person to another:
- Always wash your hands after going to the toilet and before preparing food.
- It is best to build and use one toilet.
- The toilet should be kept clean.
- The toilet should be far away from the river or stream that is used for drinking or washing.
- Wash your hands each time after you have been to the toilet Wash your hands each time before you touch food or work with food.
- Wash fruit and vegetables before you eat them.
How can water be made clean and safe?
Boil the water for at least 10 minutes OR add bleach to the water.
If you need a lot of water
add 1 teaspoon of Jik (bleach) to 25 litres of water and mix it. Leave the water in the container overnight or for at least 2 hours before using the water.
If little water is needed
you add 5 drops of bleach to one liter of water and leave it for half an hour before use.
How can you help someone who has cholera?
A person can die from Cholera very quickly. This is due to loss of water and body salt and sugar.
Most important is to give a water, salt and sugar mixture in large amounts.
A special mixture which can be made at home.
Take 1 litre clean water, 8 level teaspoons sugar, half level teaspoon salt. Mix all together.
This mixture must be given by mouth as soon as the person passes the first watery stool.
Rand Water purifies the water through a conventional purification process, resulting in water that is sparkling clear, safe to drink, and meets the SANS 241 drinking water quality specification.
The disease is spread by poor sanitation. When infected people empty their bowels, the germs come out with the stool. The stool gets onto a person's hands or into drinking water or onto food. The germs can spread to other people when they drink the water or eat the food, which looks OK, but contains germs.
Once inside the body, it can make that person sick.
Water that is safe at point of collection is often exposed to faecal contamination during collection, transport and use in the home, mainly by unclean hands.
Any person can contract the disease by ingesting contaminated water or food contaminated by Vibrio cholerae.
The bacteria can also survive in food, especially seafood. Infections can be acquired from ice cubes prepared from contaminated water.
- Watery runny stomach. Stool with appearance of “rice water”.
- Severe dehydration.
- The person loses a lot of water very quickly.
- Feels weak and complains of cramps in arms and legs.
A person can die from cholera very quickly. This is due to loss of water and body salt and sugar. Most important is to give a water, salt and sugar mixture in large amounts.
A special mixture which can be made at home:
Take 1 Litre clean water, 8 level teaspoons sugar, half level teaspoon salt. Mix all together. This mixture must be given by mouth as soon as the person passes the first watery stool.
- Always wash your hands after going to the toilet and before preparing food
- It is best to build and use one toilet
- The toilet should be kept clean
- The toilet should be far away from the river or stream that is used for drinking or washing
- Wash your hands each time after you have been to the toilet Wash your hands each time before you touch food or work with food
- Wash fruit and vegetables before you eat them.
Typhoid fever, also known as enteric fever, Salmonella typhi or commonly just typhoid, is an illness. Common worldwide, it is transmitted by the ingestion of food or water contaminated with feces from an infected person. The bacteria then perforate through the intestinal wall and are phagocytosed by macrophages. Salmonella typhi, more correctly called Salmonella enterica enterica typhi, then alters its structure to resist destruction and allow them to exist within the macrophage.
This renders them resistant to damage by PMN's, complement and the immune response. The organism is then spread via the lymphatics while inside the macrophages. This gives them access to the reticuloendothelial system and then to the different organs throughout the body. The organism is a Gram-negative short bacillus that is motile due to its peritrichous flagella. The bacteria grows best at 37 °C/99 °F – human body temperature.
Flying insects feeding on faeces may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. Public education campaigns encouraging people to wash their hands after defecating and before handling food are an important component in controlling spread of the disease. According to statistics from the United States Center for Disease Control, the chlorination of drinking water has led to dramatic decreases in the transmission of typhoid fever in the U.S.
A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of infecting others. According to the Centers for Disease Control approximately 5% of people who contract typhoid continue to carry the disease after they recover. The most famous asymptomatic carrier was Mary Mallon (commonly known as "Typhoid Mary"), a young cook who was responsible for infecting at least 53 people with typhoid, three of whom died from the disease. Mallon was the first apparently perfectly healthy person known to be responsible for an "epidemic".
Typhoid fever is characterised by a sustained fever as high as 40 °C (104 °F), profuse sweating, gastroenteritis, and non-bloody diarrhea. Less commonly a rash of flat, rose-coloured spots may appear.
Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week.
In the second week of the infection, the patient lies prostrated with high fever in plateau around 40 °C (104 °F) and bradycardia (Sphygmo-thermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around 1/3 patients. There are rhonchi in lung bases.
The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea-soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. (The major symptom of this fever is the fever usually rises in the afternoon up to the first and second week.)
In the third week of typhoid fever a number of complications can occur:
- Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually non-fatal.
- Intestinal perforation in distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
- Metastatic abscesses, cholecystitis, endocarditis and osteitis
The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of the third week the fever has started reducing (defervescence). This carries on into the fourth and final week.
Where resistance is uncommon, the treatment of choice is a fluoroquinolone such as ciprofloxacin otherwise, a third-generation cephalosporin such as ceftriaxone Gramocef-Oor cefotaxime is the first choice. Cefixime is a suitable oral alternative.
Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, amoxicillin and ciprofloxacin, have been commonly used to treat typhoid fever in developed countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%.
When untreated, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of untreated cases. In some communities case-fatality rates may be as high as 47%.
Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to human. Typhoid can only spread in environments where human faeces or urine are able to come into contact with food or drinking water. Careful food preparation and washing of hands are therefore crucial to preventing typhoid.
There are two vaccines currently recommended by the World Health Organization for the prevention of typhoid: these are the live, oral Ty21a vaccine (sold as Vivotif Berna) and the injectable Typhoid polysaccharide vaccine (sold as Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline). Both are between 50 to 80% protective and are recommended for travelers to areas where typhoid is endemic. There exists an older killed whole-cell vaccine that is still used in countries where the newer preparations are not available, but this vaccine is no longer recommended for use, because it has a higher rate of side effects (mainly pain and inflammation at the site of the injection).
Micro-organisms enter our bodies through ingestion, when we eat or drink something, through the air that we breathe, or through our blood stream, if we have an open wound.
Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions. Therefore, to maintain a charge balance in the lumen, sodium is carried with it, along with water.
Osmotic diarrhea occurs when too much water is drawn into the bowels. This can be the result of maldigestion (e.g., pancreatic disease or Coeliac disease), in which the nutrients are left in the lumen to pull in water. Osmotic diarrhea can also be caused by osmotic laxatives (which work to alleviate constipation by drawing water into the bowels). In healthy individuals, too much magnesium or vitamin C or undigested lactose can produce osmotic diarrhea and distention of the bowel.
A person who has lactose intolerance can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who have fructose malabsorption, excess fructose intake can still cause diarrhea. High-fructose foods that also have a high glucose content are more absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult for the body to absorb and, in large amounts, may lead to osmotic diarrhea.
Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections.
Motility-related diarrhea is caused by the rapid movement of food through the intestines (hypermotility). If the food moves too quickly through the GI tract, there is not enough time for sufficient nutrients and water to be absorbed. This can be due to a vagotomy or diabetic neuropathy, or a complication of menstruation. Hyperthyroidism can produce hypermotility and lead to pseudodiarrhea and occasionally real diarrhea. Diarrhea can be treated with antimotility agents (such as loperamide). Hypermotility can be observed in patients who have had portions of their bowel removed, allowing less total time for absorption of nutrients.
Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids, and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis.
Generally, if there is blood visible in the stools, it is not diarrhea, but dysentery. The blood is trace of an invasion of bowel tissue. Dysentery is a symptom of, among others, Shigella, Entamoeba histolytica, and Salmonella.
There are many causes of infectious diarrhea, which include viruses, bacteria and parasites. Norovirus is the most common cause of viral diarrhea in adults, but rotavirus is the most common cause in children under five years old. Adenovirus types 40 and 41), and astroviruses cause a significant number of infections.
The bacterium campylobacter is a common cause of bacterial diarrhea, but infections by salmonellae, shigellae and some strains of Escherichia coli (E.coli) are frequent. In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by Clostridium difficile often causes severe diarrhea.
Parasites do not often cause diarrhea except for the protozoan Giardia, which can cause chronic infections if these are not diagnosed and treated with drugs such as metronidazole, and Entamoeba histolytica.
Malabsorption is the inability to absorb food, mostly in the small bowel but also due to the pancreas.
Causes include celiac disease (intolerance to wheat, rye, and barley gluten, the protein of the grain), lactose intolerance (intolerance to milk sugar, common in non-Europeans), fructose malabsorption, pernicious anemia (impaired bowel function due to the inability to absorb vitamin B12), loss of pancreatic secretions (may be due to cystic fibrosis or pancreatitis), short bowel syndrome (surgically removed bowel), radiation fibrosis (usually following cancer treatment), and other drugs, including agents used in chemotherapy.
Inflammatory bowel disease
The two overlapping types here are of unknown origin:
- Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the rectum.
- Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the small bowel.
Diarrhea commonly results from gastroenteritis caused by viral infections, parasites or bacterial toxins. In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy patient usually recovers from viral infections in a few days. However, for ill or malnourished individuals, diarrhea can lead to severe dehydration and can become life-threatening without treatment.
Diarrhea can also be a symptom of more serious diseases, such as dysentery, cholera, or botulism, and can also be indicative of a chronic syndrome such as Crohn's disease or severe mushroom poisoning syndromes. Though appendicitis patients do not generally have violent diarrhea, it is a common symptom of a ruptured appendix. It is also an effect of severe radiation sickness.
Symptomatic treatment for diarrhea involves the patient consuming adequate amounts of water to replace that loss, preferably mixed with electrolytes to provide essential salts and some amount of nutrients. For many people, further treatment is unnecessary. The following types of diarrhea indicate medical supervision is required:
- Diarrhea in infants;
- Moderate or severe diarrhea in young children;
- Diarrhea associated with blood;
- Diarrhea that continues for more than two days;
- Diarrhea that is associated with more general illness such as non-cramping abdominal pain, fever, weight loss, etc.;
- Diarrhea in travelers, since they are more likely to have exotic infections such as parasites;
- Diarrhea in food handlers, because of the potential to infect others;
- Diarrhea in institutions such as hospitals, child care centers, or geriatric and convalescent homes.
Irritable Bowel Syndrome
Another possible cause of diarrhea is Irritable Bowel Syndrome (IBS). Symptoms defining IBS: abdominal discomfort or pain relieved by defecation and unusual stool (diarrhea or constipation or both) or stool frequency, for at least 3 days a week over the previous 3 months. IBS symptoms can be present in patients with a variety of conditions including food allergies, infective diarrhea, celiac, and inflammatory bowel diseases.
Treating the underlying condition (celiac disease, food allergy, bacterial dysbiosis, etc.) usually resolves the diarrhea. IBS can cause visceral hypersensitivity. While there is no direct treatment for undifferentiated IBS, symptoms, including diarrhea, can sometimes be managed through a combination of dietary changes, soluble fiber supplements, and/or medications.
It is important to note that IBS can often be confused with Giardiasis since false negative tests for giardia can result in a misdiagnoses of the actual cause, a parasitic infection.
Other important causes:
- Ischemic bowel disease. This usually affects older people and can be due to blocked arteries.
- Bowel cancer: Some (but not all) bowel cancers may have associated diarrhea. Cancer of the large intestine is most common.
- Hormone-secreting tumors: some hormones (e.g., serotonin) can cause diarrhea if excreted in excess (usually from a tumor).
- Bile salt diarrhea: excess bile salt entering the colon rather than being absorbed at the end of the small intestine can cause diarrhea, typically shortly after eating. Bile salt diarrhea is a bad side-effect of gallbladder removal. It is usually treated with cholestyramine, a bile acid sequestrant.
- Celiac Disease.
- Intestinal protozoa such as Giardiasis.
The symptoms are vomiting, stomach pains, mild fever and frequent watery bowel movements (upset stomach).
In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by mouth – oral rehydration therapy – or, in very severe cases, intravenously.
Diet restriction such as limiting milk has no effect on the duration of diarrhea. Medicines such loperamide (Imodium), bismuth subsalicylate (as found in Pepto Bismol and Kaopectate) may be beneficial, however they may be contraindicated in certain situations. Prescribed medications sometimes contain pain-killers, such as morphine or codeine, to counter the cramps that can accompany diarrhea.
Hepatitis A (formerly known as infectious hepatitis) is an acute infectious disease of the liver caused by the hepatitis A virus (HAV), which is most commonly transmitted by the fecal-oral route via contaminated food or drinking water. Every year, approximately 10 million people worldwide are infected with the virus. The time between infection and the appearance of the symptoms, (the incubation period), is between two and six weeks and the average incubation period is 28 days.
In developing countries, and in regions with poor hygiene standards, the incidence of infection with this virus is high and the illness is usually contracted in early childhood. HAV has also been found in samples taken to study ocean water quality. Hepatitis A infection causes no clinical signs and symptoms in over 90% of infected children and since the infection confers lifelong immunity, the disease is of no special significance to the indigenous population. In Europe, the United States and other industrialized countries, on the other hand, the infection is contracted primarily by susceptible young adults, most of whom are infected with the virus during trips to countries with a high incidence of the disease.
Hepatitis A does not have a chronic stage, is not progressive, and does not cause permanent liver damage. Following infection, the immune system makes antibodies against HAV that confer immunity against future infection. The disease can be prevented by vaccination and hepatitis A vaccine has been proven effective in controlling outbreaks worldwide.
The virus spreads by the faecal-oral route and infections often occur in conditions of poor sanitation and overcrowding. Hepatitis A can be transmitted by the parenteral route but very rarely by blood and blood products. Food-borne outbreaks are not uncommon, and ingestion of shellfish cultivated in polluted water is associated with a high risk of infection. Approximately 40% of all acute viral hepatitis is caused by HAV. Infected individuals are infectious prior to onset of symptoms, roughly 10 days following infection.
The virus is resistant to detergent, acid (pH 1), solvents (e.g., ether, chloroform), drying, and temperatures up to 60oC. It can survive for months in fresh and salt water. Common-source (e.g., water, restaurant) outbreaks are typical. Infection is common in children in developing countries, reaching 100% incidence, but following infection there is life-long immunity. HAV can be inactivated by: chlorine treatment (drinking water), formalin (0.35%, 37oC, 72 hours), peracetic acid (2%, 4 hours), beta-propiolactone (0.25%, 1 hour), and UV radiation (2 μW/cm2/min).
Early symptoms of hepatitis A infection can be mistaken for influenza, but some sufferers, especially children, exhibit no symptoms at all. Symptoms typically appear 2 to 6 weeks, (the incubation period ), after the initial infection.
Symptoms can return over the following 6–9 months and include:
- Abdominal pain
- Appetite loss
- Jaundice, a yellowing of the skin or whites of the eyes
- Sharp pains in the right-upper quadrant of the abdomen
- Weight loss
There is no specific treatment for hepatitis A. Sufferers are advised to rest, avoid fatty foods and alcohol (these may be poorly tolerated for some additional months during the recovery phase and cause minor relapses), eat a well-balanced diet, and stay hydrated. Approximately 15% of people diagnosed with hepatitis A may experience one or more symptomatic relapse(s) for up to 24 months after contracting this disease.
Hepatitis A can be prevented by vaccination, good hygiene and sanitation. Hepatitis A is also one of the main reasons not to surf or go in the ocean after rains in coastal areas that are known to have bad runoff.
The vaccine protects against HAV in more than 95% of cases for 10 years. It contains inactivated Hepatitis A virus providing active immunity against a future infection. The vaccine was first phased in 1996 for children in high-risk areas, and in 1999 it was spread to areas with elevating levels of infection.
The vaccine is given in two doses in the muscle of the upper arm. The first dose provides protection two to four weeks after initial vaccination; the second booster dose, given six to twelve months later, provides protection for up to twenty years.
Campylobacteriosis is an infection by the campylobacter bacterium, most commonly C. jejuni. It is among the most common bacterial infections of humans, often a foodborne illness. It produces an inflammatory, sometimes bloody, diarrhea or dysentery syndrome, mostly including cramps, fever and pain.
Campylobacteriosis is caused by Campylobacter organisms. These are curved or spiral, motile, non–spore-forming, Gram-negative rods. This is most commonly caused by C. jejuni, a spiral and comma shaped bacterium normally found in cattle, swine, and birds, where it is non-pathogenic. But the illness can also be caused by C. coli (also found in cattle, swine, and birds) C. upsaliensis (found in cats and dogs) and C. lari (present in seabirds in particular).
One effect of campylobacteriosis is tissue injury in the gut. The sites of tissue injury include the jejunum, the ileum, and the colon. C jejuni appears to achieve this by invading and destroying epithelial cells.
C jejuni can also cause a latent auto-immune effect upon the nerves of the legs which is usually seen several weeks after a surgical procedure of the adomen. the effect is known as an acute idiopathic demyelinating polyneuropathy (AIDP), i.e. Guillain-Barre Syndrome, in which one sees symptoms of ascending paralysis, dysaesthesias usually below the waist, and in the later stages respiratory failure.
Some strains of C jejuni produce a cholera-like enterotoxin, which is important in the watery diarrhea observed in infections. The organism produces diffuse, bloody, edematous, and exudative enteritis. In a small number of cases, the infection may be associated with hemolytic uremic syndrome and thrombotic thrombocytopenic purpura through a poorly understood mechanism.
The common routes of transmission for the disease-causing bacteria are fecal-oral, person-to-person sexual contact, ingestion of contaminated food (generally unpasteurized (raw) milk and undercooked or poorly handled poultry), and waterborne (ie, through contaminated drinking water). Contact with contaminated poultry, livestock, or household pets, especially puppies, can also cause disease. Animals farmed for meat are the main source of campylobacteriosis. A study published in PLoS Genetics (September 26, 2008) by researchers from Lancashire, England, and Chicago, IL, found that 97 percent of campylobacteriosis cases sampled in Lancashire were caused by bacteria typically found in chicken and livestock. In 57 percent of cases, the bacteria could be traced to chicken, and in 35 percent to cattle. Wild animals and environmental sources were accountable for just three percent of the disease.
The infectious dose is 1000-10,000 bacteria (although ten to five hundred bacteria can be enough to infect humans). Campylobacter species are sensitive to hydrochloric acid in the stomach, and acid reduction treatment can reduce the amount of inoculum needed to cause disease.
Exposure to bacteria is often more common during travelling, and therefore campylobacteriosis is a common form of travelers' diarrhea.
Infection with a Campylobacter species is one of the most common causes of human bacterial gastroenteritis. For instance, an estimated 2 million cases of Campylobacter enteritis occur annually in the U.S., accounting for 5-7% of cases of gastroenteritis. Furthermore, in the United Kingdom during 2000 campylobacter jejuni was involved in 77.3% in all cases of foodborne illness. 15 out of every 100,000 people are diagnosed with campylobacteriosis every year, and with many cases going unreported, up to 0.5% of the general population may unknowingly harbor Campylobacter in their gut annually.
A large animal reservoir is present as well, with up to 100% of poultry, including chickens, turkeys, and waterfowl, having asymptomatic infections in their intestinal tracts. An infected chicken may contain up to 109 bacteria per 25 grams, and due to the installations, the bacteria is rapidly spread to other chicken. This vastly exceeds the infectious dose of 1000-10,000 bacteria for humans.
The prodrome is fever, headache, and myalgias, lasting as long as 24 hours. The actual latent period is 2-5 days (sometimes 1-6 days). In other words, it typically takes 1-2 days until actual symptoms develop. These are diarrhea (as many as 10 watery, frequently bloody, bowel movements per day) or dysentery, cramps, abdominal pain, and fever as high as 40°C. In most people, the illness lasts for 2–10 days. This is classified as Invasive / Inflammatory Diarrhea, also known as Bloody Diarrhea or Dysentry.
Symptoms may also depend on route of transmission. In participants of anoreceptive intercourse, campylobacteriosis is more localized to the distal end of the colon and may be termed a proctocolitis.
There are other diseases showing similar symptoms. For instance, abdominal pain and tenderness may be very localized, mimicking acute appendicitis. Furthermore, Helicobacter pylori is closely related to Campylobacter and causes peptic ulcer disease.
In patients with HIV, infections may be more frequent, may cause prolonged of dirty brown diarrhea, and may be more commonly associated with bacteremia and antibiotic resistance. The severity and persistence of infection in patients with AIDS and hypogammaglobulinemia indicates that both cell-mediated and humoral immunity are important in preventing and terminating infection.
Campylobacter organisms can be detected on gram stain of stool with high specificity and a sensitivity of 60%, but are most often diagnosed by stool culture. Fecal leukocytes are present and indicate an inflammatory diarrhea.
The infection is usually self-limiting and in most cases, symptomatic treatment by reposition of liquid and electrolyte replacement is enough in human infections. The use of antibiotics is controversial. Note, that in initial assessment, a practitioner must ascertain where the patient is Dehydrated. Can the patient tolerate fluids by mouth or are they going to need IV fluids? Is the patients mucus membranes moist? How is the skin tugor? Are the eyes or fontanel sunken? Is the patient still urinating?
Antimotility agents, such as loperamide, can lead to prolonged illness or intestinal perforation in any invasive diarrhea, and should be avoided.
Antibiotic treatment has only a marginal benefit (1.32 days) on the duration of symptoms and should not be used routinely.
Erythromycin can be used in children, and tetracycline in adults. However, some studies show that erythromycin rapidly eliminates Campylobacter from the stool without affecting the duration of illness. Nevertheless, children with dysentery due to C. jejuni benefit from early treatment with erythromycin. Treatment with antibiotics, therefore, depends on the severity of symptoms. Quinolones are effective if the organism is sensitive, but high rates of quinolone use in livestock means that quinolones are now largely ineffective.
Trimethoprim-sulfamethoxazole and ampicillin are ineffective against Campylobacter.
In the past, poultry infections were often treated by mass administration of enrofloxacin and sarafloxacin for single instances of infection. The FDA banned this practice, as it, instead of eliminating the bacteria, only promoted the development of fluoroquinolone-resistant populations. A major wide-ranged fluoroquinolone used in humans is ciprofloxacin.
Currently growing resistance of the campylobacter to fluoroquinolones and macrolides is a major concern.
Gastroenteritis (also known as gastro, gastric flu, tummy bug in the United Kingdom, and stomach flu, although unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine (see also gastritis and enteritis) and resulting in acute diarrhea. The inflammation is caused most often by an infection from certain viruses or less often by bacteria, their toxins, parasites, or an adverse reaction to something in the diet or medication. Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year, and is a leading cause of death among infants and children under 5.
At least 50% of cases of gastroenteritis due to foodborne illness are caused by norovirus. Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus.
Different species of bacteria can cause gastroenteritis, including Salmonella, Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, and others. Some sources of the infection are improperly prepared food, reheated meat dishes, seafood, dairy, and bakery products. Each organism causes slightly different symptoms but all result in diarrhea. Colitis, inflammation of the large intestine, may also be present.
Risk factors include consumption of improperly prepared foods or contaminated water and travel or residence in areas of poor sanitation. It is also common for river swimmers to become infected during times of rain as a result of contaminated runoff water.
Infectious gastroenteritis is caused by a wide variety of bacteria and viruses.
It is important to consider infectious gastroenteritis as a diagnosis per exclusionem. A few loose stools and vomiting may be the result of systemic infection such as pneumonia, septicemia, urinary tract infection and even meningitis. Surgical conditions such as appendicitis, intussusception and, rarely, even Hirschsprung's disease may mislead the clinician. Endocrine disorders (e.g. thyrotoxicosis and Addison's disease) are disorders that can cause diarrhea. Also, pancreatic insufficiency, short bowel syndrome, Whipple's disease, coeliac disease, and laxative abuse should be excluded as possibilities.
For a list of bacteria causing gastroenteritis, see above. Pseudomembranous colitis is an important cause of diarrhea in patients often recently treated with antibiotics.
If gastroenteritis in a child is severe enough to require admission to a hospital, then it is important to distinguish between bacterial and viral infections. Bacteria, Shigella and Campylobacter, for example, and parasites like Giardia can be treated with antibiotics.
Viruses causing gastroenteritis include rotavirus, norovirus, adenovirus and astrovirus. Viruses do not respond to antibiotics and infected children usually make a full recovery after a few days. Children admitted to hospital with gastroenteritis routinely are tested for rotavirus A to gather surveillance data relevant to the epidemiological effects of rotavirus vaccination programs. These children are routinely tested also for norovirus, which is extraordinarily infectious and requires special isolation procedures to avoid transmission to other patients. Other methods, electron microscopy and polyacrylamide gel electrophoresis, are used in research laboratories.
Symptoms and signs
Gastroenteritis often involves stomach pain or spasms, diarrhea and/or vomiting, with non-inflammatory infection of the upper small bowel, or inflammatory infections of the colon.
The condition is usually of acute onset, normally lasting 1–6 days, and is self-limiting.
- Nausea and vomiting
- Loss of appetite
- Abnormal flatulence
- Abdominal pain
- Abdominal cramps
- Bloody stools (dysentery - suggesting infection by amoeba, Campylobacter, Salmonella, Shigella or some pathogenic strains of Escherichia coli)
- Fainting and Weakness
The main contributing factors include poor feeding in infants. Diarrhea is common, and may be followed by vomiting. Viral diarrhea usually causes frequent watery stools, whereas blood stained diarrhea may be indicative of bacterial colitis. In some cases, even when the stomach is empty, bile can be vomited up.
A child with gastroenteritis may be lethargic, suffer lack of sleep, run a low fever, have signs of dehydration (which include dry mucous membranes), tachycardia, reduced skin turgor, skin color discoloration, sunken fontanelles, sunken eyeballs, darkened eye circles, glassy eyes, poor perfusion and ultimately shock.
No specific diagnostic tests are required in most patients with simple gastroenteritis. If symptoms including fever, bloody stool and diarrhea persist for two weeks or more, examination of stool for Clostridium difficile may be advisable along with cultures for bacteria including Salmonella, Shigella, Campylobacter and Enterotoxic Escherichia coli. Microscopy for parasites, ova and cysts may also be helpful.
The objective of treatment is to replace lost fluids and electrolytes. Oral rehydration is the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration.
The primary treatment of gastroenteritis in both children and adults is rehydration, i.e., replenishment of water and electrolytes lost in the stools. Depending on the degree of dehydration, this can be done by giving the person oral rehydration therapy (ORT) or through intravenous delivery. Complex-carbohydrate-based Oral Rehydration Salts (ORS) such as those made from wheat or rice have been found to be superior to simple sugar-based ORS.
Sugary drinks such as soft drinks and fruit juice are not recommended for gastroenteritis in children under 5 years of age as they may make the diarrhea worse. Plain water may be used if specific ORS are unavailable or not palatable.
Centers for Disease Control and Prevention (CDC) recommends that breastfed infants continue to be nursed on demand and that formula-fed infants should continue their usual formula immediately upon rehydration with ORS in amounts sufficient to satisfy energy and nutrient requirements and at the usual concentration. Lactose-free or lactose-reduced formulas usually are not necessary.
Children receiving semisolid or solid foods should continue to receive their usual diet during episodes of diarrhea. Foods high in simple sugars should be avoided because the osmotic load might worsen diarrhea; therefore, soft drinks (carbonated or flat), juice, gelatin desserts, and other high simple sugar foods should be avoided. The practice of withholding food is not recommended and immediate normal feeding is encouraged.
The BRAT diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over normal feeding.
Gastroenteritis is usually an acute and self-limited disease that does not require pharmacologic therapy.
Antibiotics are usually not useful for gastroenteritis, although they are sometimes used if symptoms are severe or a susceptible bacterial cause is isolated or suspected. If antibiotics are decided on, a fluoroquinolone or macrolide is often used.
Pseudomembranous colitis, usually caused by antibiotics use, is managed by discontinuing the causative agent and treating with either metronidazole or vancomycin.
Antimotility drugs have a theoretical risk of causing complications, clinical experience however has shown this to be unlikely. They are thus discouraged in people with bloody diarrhea or diarrhea complicated by a fever.
Loperamide, an opioid analogue, is commonly used for the symptomatic treatment of diarrhea. Loperamide is not recommended in children as it may cross the blood brain barrier due to its immaturity and cause toxicity.
Bismuth subsalicylate (BSS), an insoluble complex of trivalent bismuth and salicylate, can be used in mild-moderate cases.
Antiemetic drugs may be helpful for vomiting in children. Ondansetron has some utility with a single dose associated with less need for intravenous fluids, fewer hospitalizations, and decreased vomiting. Metoclopramide also might be helpful.
Some probiotics have been shown to be beneficial in preventing and treating various forms of gastroenteritis. Fermented milk products (such as yogurt) also reduce the duration of symptoms.
The World Health Organization recommends that infants and children receive a dietary supplement of zinc for up to two weeks after onset of gastroenteritis. A 2009 trial however did not find any benefit from supplementation.
Dehydration is a common complication of diarrhea. It can be made worse with the withholding fluids or the administration of juice / soft drinks. Malabsorption of lactose, the principal sugar in milk, may occur. It may increase the diarrhea, however, is not a reason to discontinue breastfeeding.
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