DIARRHEA--PART ONE

 

Most of us have, on occasion, eaten or drank water or food that contained an infectious bacterium or virus and endured a few days of cramps and frequent urgent bowel movements.  The CDC (spot on) advises people that the primary goal in treating diarrhea should be preventing dehydration or appropriately rehydrating persons presenting with dehydration.” The agency advises people to drink oral rehydration solutions (ORS) such as Pedialyte® (Abbott Laboratories)* or Gastrolyte® (Aventis Pharmaceuticals)* or similar commercially available solutions.  https://www.cdc.gov/disasters/disease/diarrheaguidelines.html

In this blog I’d like to provide a little historical background, explain what oral rehydration fluid does and how it should be taken.... and suggest that Gatorade may be OK for athletes who sweat a lot, but it’s not the best choice for people who have diarrhea and are losing a lot of fluid.   

          My story starts with the grand daddy of all diarrheal diseases, cholera.

It’s spread by contaminated water and most people who get the disease have a mild attack.  One in ten infected people have severe watery diarrhea and, according to the World Health organization, 1.3 to 4 million people have a bad bout each year.  21,000 to 143,000 die. Vibrio cholerae is a curve shaped bacteria that lives in water.  It produces a toxin that causes cells lining the intestines to pour out large amounts of the fluid.  Infected people don’t absorb water normally.  When people rapidly lose a large amount of fluid and electrolytes (salts) some die.  The Britannica claims “the ancient Greek physicians Hippocrates (5th–4th century BCE)) referred to an illness that may well have been cholera” …whatever that means.  Westerners were largely unaware of the problem before the first modern epidemic in 1817. 

The bacterium that causes the disease probably inhabited the principle river of India, the Ganges, for centuries.   “In the early 1890s a bacteriologist named Ernest Hankin studied cholera outbreaks along the banks of the Ganges and noted that the water was periodically contaminated with sewage and dead bodies, but cholera outbreaks were brief.  Some think this is the result of a cycle of life.  They believe that phages, viruses that attack bacteria, periodically destroyed populations of vibrio Cholera and “purify the water.” Then cholera bacteria that were resistant to the phage emerge and create a population of the resistant bacteria.  Later a new phage population materializes.

https://www.bbc.com/future/article/20161115-the-viruses-that-may-save-humanity

file:///C:/Users/User/Dropbox/PC/Documents/ojsadmin,+Self-purifying+properties+of+the+Ganges.pdf//

 A lethal strain of Cholera emerged from the Ganges Delta of India in the 1800s and caused a series of worldwide epidemics. Infected people developed severe diarrhea and became dehydrated. Many died. The disease was spread by ships trading goods in Thailand, China, and Japan. In 1831, a vessel whose sailors had the illness docked in the English town of Sunderland. After they disembarked, the infection spread through the U.K. and killed thousands.In the early 1800s people knew that some water made them ill and they “determined the quality of water based on its taste.”Children drank a brew made from boiled water and adults tended to imbibe ale. In 1854, an epidemic of diarrhea broke out in the Soho district of London. Many became dehydrated and over 600 people died. At the time, most households didn’t have piped-in water. People used communal pumps and stored their fecal matter in nearby cesspools. Sewage was dumped in the Thames, and the river smelled.

A London physician named John Snow saw his patients suffering and suspected an intestinal poison had contaminated the local water. A vegetarian and teetotaler, Snow mapped the location of the people who contracted the illness and convinced town officials that the Broad Street pump was the source of the epidemic. They removed the pump handle and the diarrhea “almost immediately” trickled to a stop. Snow was, of course, disbelieved and denounced by many.  In the 1870’s someone opened a pub in London’s Soho and named it after John.  It’s still there. 

No one knows what caused the severe outbreak of diarrhea back then, but most believe it was cholera.

Twenty-nine years after the pump handle was removed, the German researcher Robert Koch traveled to Egypt during a cholera outbreak. He cultured and examined the stools of the people who had the infection and he identified the responsible germ. It was a “bacillus and it was bent like a comma.”

In the late 1800s, people learned that waterborne outbreaks of typhoid fever, dysentery, and cholera were caused by bacteria and that chlorine killed the germs. In 1905, a municipal water sand filter failed in a city in England, there was a typhoid outbreak, and the city started adding chlorine to their municipal water. Three years later, Jersey City, New Jersey, joined them. Chlorine is currently added to “over 98 percent of all U.S. municipal water,” and outbreaks of typhoid fever have been virtually eliminated. (Chlorine does not kill parasites like giardia and cryptosporidium.)

In the last century, we’ve learned a lot about diarrheal diseases and their treatment, but half the world’s population still live in tightly packed dwellings and don’t have pipes that bring water in or fecal waste out. When people defecate outside (because the feces smell), their waste enters streams that flow into the rivers that are the source of drinking water. According to the CDC, one in nine childhood deaths worldwide are the result of diarrhea.  The culprits responsible include bacteria like E. coli, salmonella, shigella, and cholera.

When I was a freshman med student, a biochemistry professor who looked like the movie star Robert Wagner spent10 years of his life proving that the water we drink isn’t merely passively absorbed. Salt and water are sometimes pushed into our body by a biochemical “pump” that is fueled by glucose.

I took notes when the professor lectured and I passed the exam, but I didn’t understand why a person would spend years of his life learning how salt and water move across the small bowel membrane. I later learned that when the cholera bacteria infect the small bowel, the organism forces a large amount of liquid to leak into the lumen of the intestines. Infected people develop watery diarrhea, don’t absorb much fluid, and often die of dehydration.

Our lecturer, Robert Crane, showed that if a teaspoon of salt and two tablespoons of sugar are added to a liter of clean water, a biochemical reaction powers the liquid across the membrane of the small intestine, and people can be rehydrated. The World Health Organization distributes a version of Crane’s solution, and drugstores in the U.S. sell it as Pedialyte. The discovery of the sodium and sugar “co-transport” mechanism has saved more lives than most of the expensive medications advertised on television.

Crane was born in New Jersey and wasn’t interested in science before he entered college. During the Second World War, he was a deck officer on a navy destroyer that “took a bomb” at the Battle of Leyte Gulf. His vessel was later part of the fleet of ships that carried Douglas MacArthur back to the Philippines in 1944. After the war, he earned a PhD in chemistry at Harvard, married a biochemist, and started working on his pump theory. In 1978, he was awarded the Nobel Prize.

There has been a 90% decline in diarrhea-related deaths since the 1980s.  The CDC and the World Health Organization have web sites that advise people how to symptomatically treat travelers and other infectious diarrheal diseases.

How to prepare ORS with packets per IFRC-- The International Federation of Red Cross and Red Crescent. Oral rehydration fluid probably only works when it is  taken without food or other liquids. 

1.     ORS packets can be obtained at your local National Society branch or at a health centre in the community. They come in the form of a powder which needs to be diluted before use.

 Wash hands with soap and clean water. Pour all the powder from one sachet of ORS into a clean container that will hold at least one litre of liquid. Follow the instructions on the packet to find out how much water is needed to dilute the contents of each packet. Pour the indicated amount of the safe water available into the container and mix it with the powder. Always use clean water to dilute ORS (see Action Tool Clean, safe household water).

2.     Instructions for home rehydration   Rice water can be used instead of regular water to prepare the ORS and carrot soup, fruit juice or a smashed banana can be added to change the taste. Carrot soup or fruit juice can also be added to ready made ORS sachets as children may not always like the taste otherwise.

Instructions for making home-made sugar/salt solution: ** should only be used when ORS packets are not available**

Wash your hands with soap and water before preparing the solution.

In a clean container mix:

One litre of safe water.

Half a small spoon of salt (3.5 gms).

Four big spoons (or eight small spoons) of sugar (40 gms).Stir the salt and the sugar until they dissolve in the water.   

https://epidemics.ifrc.org/volunteer/action/09-preparing-oral-rehydration-solution-ors

 In 1991, a massive hurricane blew across Hispaniola, the Caribbean island that is shared by the Dominican Republic and Haiti. At the time, Haitians hadn’t witnessed a case of cholera for more than a hundred years. The U.N. brought in relief workers from Bangladesh and they lived with the people. Seventy percent of the island’s households had either rudimentary toilets or none at all. A few months later, the water people drank contained the strain of cholera bacteria that was common in Bangladesh. Approximately 665,000 Haitians developed severe diarrhea and over 8,000 died. In 2006, fifteen years after the epidemic started, a nonprofit called SOIL started supplying compostable toilets and trying to help solve the island’s waste problem.

On the Mode of Communication of Cholera
by John Snow, M.D.
London: John Churchill, New Burlington Street, England, 1855

 “The son of a York farmer, John Snow moved to London where he studied medicine, and became a member of the Royal College of Surgeons ten years before “the first case of Asiatic cholera” came to “the great city.” The illness arrived in the body of a seaman who died a few hours after the illness “seized” him.  The sailor had been working on a steamer where “the disease was prevailing.” Shortly after the man’s death his body was removed from the room he had been renting and another man moved in.  Eight days later the newcomer developed severe diarrhea and fever—cholera.”

The Origin of the Haitian Cholera Outbreak Strain | NEJM

Robert Crane biochemist https://iubmb.onlinelibrary.wiley.com/doi/full/10.1002/iub.366

Cholera and Ganges delta https://www.passporthealthusa.com/2018/02/the-history-of-cholera-and-the-ganges-delta/

Cholera in Haiti

https://www.nejm.org/doi/full/10.1056/nejmoa1012928

https://www.nejm.org/doi/full/10.1056/NEJMp1012997

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1915905

 

 

 

 

 

 

Comments

Post a Comment

Popular posts from this blog

what is targeted chemotherapy

  According to AI There are about 3 billion pairs of nucleotides.   Most of the nucleotides are involved in turning a fertilized cell into a being.   2 percent of the nucleotides are genes and they direct the cells to make various proteins.    There are about 20,000 protein coding genes and each gene contains the instructions for making a single protein.   20 to 30 percent of the proteins the cell makes perform a function in the cell membrane.     One type of membrane protein is called a receptor tyrosine kinase (RTK).   it penetrates the membrane and sticks out inside and outside the cell.   When the outside of this protein is activated—a signal travels through the protein and the inside portion of the protein directs a cell to act a certain way.   It, for example, can tell a cell to grow, divide, die etc.   the outside extension of each receptor has a pocket.   When the right molecule is inserted into the poc...
Read more

?? THE SNAKE ANTIVENOM OF THE FUTURE.

  An article in the October issue Science described a new drug that could save the lives of up to 100,000 Africans.   It’s 3 years away from trials in humans but if it works—who knows.   The article claims that each year about 100,000 Africans are killed by venomous snakes and the current antivenom isn’t very effective for a number of reasons.   “This new kind of antivenom has proved protective only in mice so far. But   “It’s a potential game changer if all goes well.” To make their antivenum Laustsen-Kiel and colleagues injected mixtures of venoms from 18 African snakes into llamas and alpacas and the animals made antibodies. Their antibodies are smaller than those of horses and humans and have only one protein chain, instead of two, on each arm of the Y-shaped molecule. Each arm, dubbed a nanobody, can be separated from its base while remaining able to bind a target molecule, such as a toxin . The isolated arms lack the animal-specific sections th...
Read more

MALARIA

  ACCORDING TO THE WORLD HEALTH ORGANIZATION Globally in 2023, there were an estimated 263 million malaria cases and 597 000 malaria deaths in 83 countries. The WHO African Region carries a disproportionately high share of the global malaria burden. In 2023, the WHO African Region was home to 94% of malaria cases (246 million) and 95% (569 000) of malaria deaths. Children under 5 accounted for about 76% of all malaria deaths in the Region. Malaria  is a  mosquito-borne infectious disease     people who are bitten by infected mosquitoes often develop a “ fever ,  fatigue ,  vomiting , and  headaches , and in severe cases, it can cause  jaundice ,  seizures ,  coma , or  death . [1] [9]  Symptoms usually begin 10 to 15 days after being bitten   The current therapy is Artemisinin.   It’s discovery led to a Nobel Prize in 2015. The World Health Organization began to recommend ACTs as the front-line treatment for ma...
Read more