Fluid Replacement and Heat Stress, 1993

Pp. 111-115. Washington, D.C.

National Academy Press

9

Acute Diarrheal Diseases

Robert Whang1

INTRODUCTION

Diarrheal diseases represent an enormous health problem worldwide. The annual economic impact of these diseases represents significant losses that can be measured in the billion of dollars of lost productivity and the loss of health resources necessary to treat diarrheal diseases. Mortality in the young and the loss of economic potential from these premature deaths are inestimable when one factors in the morbidity, pain, and suffering resulting from these diseases. Diarrhea can be defined as two to three times the usual number of bowel movements having a liquid consistency, or diarrheal stool can be defined as one that assumes the shape of the container (Samadi et al., 1983). On a worldwide basis it is estimated that 750 million to 1 billion cases occur annually among children under 5 years of age, accounting for between 3 million and 6 million deaths. Diarrheal diseases are second only to respiratory disease in frequency and prevalence in underdeveloped countries (Gorbach and Hoskins, 1980). The success or failure of military campaigns from antiquity to modern times has been influenced by the presence or absence of diarrheal diseases. In recent times, for the years 1966 to 1968, the U.S. Army in Vietnam had peak months with an annualized rate of 70 cases per 1,000 (Ognibene and Barrett, 1982).

1  

Robert Whang, Chief, Medical Service, Veteran's Administration Hospital, 921 N.E. 13th Street, Oklahoma City, OK 73104



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FLUID REPLACEMENT AND HEAT STRESS Fluid Replacement and Heat Stress, 1993 Pp. 111-115. Washington, D.C. National Academy Press 9 Acute Diarrheal Diseases Robert Whang1 INTRODUCTION Diarrheal diseases represent an enormous health problem worldwide. The annual economic impact of these diseases represents significant losses that can be measured in the billion of dollars of lost productivity and the loss of health resources necessary to treat diarrheal diseases. Mortality in the young and the loss of economic potential from these premature deaths are inestimable when one factors in the morbidity, pain, and suffering resulting from these diseases. Diarrhea can be defined as two to three times the usual number of bowel movements having a liquid consistency, or diarrheal stool can be defined as one that assumes the shape of the container (Samadi et al., 1983). On a worldwide basis it is estimated that 750 million to 1 billion cases occur annually among children under 5 years of age, accounting for between 3 million and 6 million deaths. Diarrheal diseases are second only to respiratory disease in frequency and prevalence in underdeveloped countries (Gorbach and Hoskins, 1980). The success or failure of military campaigns from antiquity to modern times has been influenced by the presence or absence of diarrheal diseases. In recent times, for the years 1966 to 1968, the U.S. Army in Vietnam had peak months with an annualized rate of 70 cases per 1,000 (Ognibene and Barrett, 1982). 1   Robert Whang, Chief, Medical Service, Veteran's Administration Hospital, 921 N.E. 13th Street, Oklahoma City, OK 73104

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FLUID REPLACEMENT AND HEAT STRESS The etiology of acute diarrheal diseases can be divided into three categories: viral, bacterial, and parasitic. In developed nations, such as the United States, rotaviruses and Norwalk-like viruses (10%-27%) are frequent causes of diarrhea (Guerrant et al., 1985). In contrast, in the tropics enterotoxigenic Escherichia coli (E. coli) (21%-23%), Shigella, (8%-11%), and Campylobacter (7%-14%) predominate as causative agents of acute diarrhea. Similarly, enterotoxigenic E. coli (47%), Shigella (1%-22%), and Salmonella (4%-7%) are the principal causative agents in travelers' diarrhea. It is anticipated that troops rapidly deployed from the continental United States to tropical areas will be at risk for travelers ' diarrhea. Enteric infections can be divided into three types: luminal, mucosal, and systemic (Guerrant et al., 1985). Luminal enteric infections are caused by organisms such as E. coli, Vibrio cholera, (V. cholera) Staphylococcus, and Giardia. Diarrhea is caused by enterotoxins that interfere with absorption in the small bowel. In luminal enteric infections, diarrheal stools are watery and there are no fecal white blood cells. Mucosal enteric infections can be caused by Shigella, Campylobacter jejuni, Salmonella, and Clostridium difficile. There is colonic mucosal invasion by bacteria, causing an inflammatory dysentery with the presence of fecal polymorphonuclear leukocytes. In systemic enteric infections the ileum is involved with the potential invasion of the blood stream and enteric fever. Examples of causative agents are Salmonella typhi, Yersinia, and Campylobacter fetus. What is the distribution of diarrheal diseases worldwide? Travelers ' diarrhea is found in Mexico, Central and South America, the Caribbean, Africa, the littoral Mediterranean, and Asia (Steffen, 1986). The incidence of travelers' diarrhea ranges as high as 50% in these regions. The incidence of dysentery (diarrhea with fever or blood in stools) among travelers to Mexico, Central and South America, Africa, and Asia ranges upwards of 9%-11%. Signs and symptoms of travelers' diarrhea include gas (79%), fatigue (74%), cramps (68%), nausea (61%), fever (56%), abdominal pain (55%), anorexia (53%), headaches (39%), chills (30%), and vomiting (29%) (Gorbach and Hoskins, 1980). In small bowel diarrhea caused by E. coli, Giardia, V. cholera, or reovirus, the location of pain is in the midabdomen, with large volumes of watery diarrhea causing dehydration (Gorbach and Hoskins, 1980). Proctoscopy is normal. With large bowel diarrhea caused by Shigella, invasive E. coli, or amebiasis, the pain is in the lower abdomen and in the rectum. The stool volume is usually small and may be mucoid (dysenteric). Blood and leukocytes are very common in the stool. Proctoscopic findings include a friable and hemorrhagic mucosa and mucosal ulcers. What is the efficacy of prophylactic treatment of acute diarrheal diseases? For Peace Corps volunteers, doxycycline, 100 mg twice weekly,

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FLUID REPLACEMENT AND HEAT STRESS provided protection in 27% of individuals (Santosham et al., 1981). However, doxycycline at 100 mg once daily provided protection in 81% of U.S. military personnel in Mexico (Freeman et al., 1983). In a multidrug study in Mexico, bactrim provided 71% protection during a 21-day study, and 95% protection for a 14-day study, bicozamycin provided 100% protection, and 88% of subjects taking norfloxacin were protected from travelers' diarrhea (Dupont et al., 1986). Bismuth subsalicylate in liquid form (60 ml four times a day) and tablets (600 mg four times a day) provided 77% and 87% protection, respectively (Steffen et al., 1986). Thus, both antibiotic and nonantibiotic prophylaxis provided excellent short-term protection ranging from 14 to 21 days. Guerrant et al. (1985) state that the appropriate treatment for the vast majority of cases (of acute diarrhea) is simple and effective: oral glucose-and electrolyte- containing rehydration solution. Effective repletion of extracellular and total body water is accomplished by enhancement of small bowel reabsorption of sodium and water by glucose (solvent drag) (Field, 1977). A second generation of oral rehydration solutions (ORSs), the so-called super ORSs, are currently under study (Edelman, 1985). In these super ORS formulations, glycine as well as rice powder augment the effect of glucose in enhancing sodium and water reabsorption by the gut. For example, compared with glucose and electrolyte ORSs, glycerine, glucose, and electrolyte ORSs reduced the volume of stool output from 253 to 126 ml/kg as well as the duration of acute diarrhea from 43 to 30 h (Edelman, 1985). The ideal ORS for the U.S. Army would serve multiple clinical uses: (1) alleviate fasting and prevent heat injury in encapsulated troops - Military Operational Protective Posture-A (MOPPA), (2) prevent heat injury, (3) treat heat casualties except for heat stroke, and (4) treat acute diarrhea. A powder formulation (Armyde) containing Na, 22.8 meq; Cl, 25.5 meq; K, 9.5 meq; Mg, 5.2 meq; PO4, 3.2 mg; and glucose, 25 g per packet, was studied under moderate field heat conditions in June 1988 at Fort Hood, Texas. These studies were carried out jointly by the Military Nutrition and Heat Research Division, U.S. Army Research Institute of Environmental Medicine, and the 44th Evacuation Hospital (an Army Reserve Unit) and the results detailed in a technical report (Rose et al., 1989). It is designed such that one packet of this glucose electrolyte powder diluted in one canteen of potable water would be used for heat injury and heat casualty treatments (Na, 22.8 meq/liter; Cl, 25.5 meq/liter; K, 9.5 meq/liter; HCO3, 10 meq/liter; Mg, 5.2 meq/liter; PO4, 3.2 meq/liter, and glucose, 25 g, whereas two packets per canteen (Na, 45.6 meq/liter; Cl, 51 meq/liter; K, 19 meq/liter; HCO3, 20 meq/liter; Mg, 10.4 meq/liter; PO4, 6.3 meq/liter; and glucose, 50 g/liter) would be used in the treatment of acute diarrhea. In this

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FLUID REPLACEMENT AND HEAT STRESS initial study no clinical symptoms were noted among the subjects who drank Armyade. Biochemical assessment (serum creatinine, chloride, total protein, albumin, glucose, sodium, potassium, magnesium, blood urea nitrogens, cholesterol, triglyceride) of subjects following 8 days of drinking Armyade did not demonstrate any abnormal changes. While the safety of Armyade appears to have been confirmed, the efficacy under rigorous field conditions in the heat remains to be demonstrated in future studies. With respect to the potential of acute diarrheal disease and heat injuries in troops rapidly deployed from the continental United States to the tropics, I propose consideration of the following future operational approach: (1) diarrhea prophylaxis (e.g., antibiotic or bismuth subsalicylate tablets), (2) oral rehydration solution (e.g., Armyade at two packets per canteen), and (3) heat injury prophylaxis (e.g., Armyade at one packet per canteen). The purpose of this approach is to conserve and maximize fighting strength in troops who are rapidly deployed to those areas where travelers' diarrhea is a significant problem, such as Central and South America, Africa, or Asia. CONCLUSIONS Diarrheal diseases are a major health problem in developing countries (Asia, Africa, and Latin America) with an incidence of approximately 750 million to 1 billion cases per year in children under 5 years of age. Diarrheal diseases have afflicted armies from antiquity to modern times. World-wide, glucose-electrolyte rehydration solutions represent a significant contribution to the treatment of diarrhea and have demonstrable efficacy. Oral rehydration solutions are still undergoing modification, including the addition of glycine to the glucose electrolyte solution or rice powder in place of glucose (super ORSs). To ensure maximum fighting efficiency for infantry units deployed at the front or behind enemy lines, consideration should be given to providing diarrhea prophylaxis (e.g., doxycycline) and glucose-electrolyte packets for treatment of diarrhea while these units are in action. There appears to be merit in considering a multipurpose (heat injury prevention, treatment, and replacement of diarrheal losses) glucose-electrolyte packet for use by field troops.

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FLUID REPLACEMENT AND HEAT STRESS ACKNOWLEDGEMENT The author thanks Viola Jim for expert assistance in preparing this manuscript. REFERENCES Dupont, H.L., C.D. Ericsson, P.C. Johnson, and F.J. Cabada. 1986 Antimicrobial agents in the prevention of travelers' diarrhea. Rev. Infect. Dis. 8:S167-S171. Edelman, R. 1985 Prevention and treatment of infectious diarrhea. Am. J. Med. 78 (suppl. 6B):99-106. Field, M. 1977 New strategies for treating watery diarrhea. N. Engl. J. Med. 297:1121-1122. Freeman, L.D., D.R. Hooper, D.F. Lathen, D.P. Nelson, W.O. Harrison, and D.S. Anderson. 1983 Brief prophylaxis with doxycycline for the prevention of travelers ' diarrhea. Gastroenterology 84:276-280. Gorbach, S.L., and D.W. Hoskins. 1980 Travelers' diarrhea. Dis. Mon. 27:1-44. Guerrant, R.L., D.S. Shields, S.M. Thorson, J.B. Schorling, and D.H.M. Groschel. 1985 Evaluation and diagnosis of acute infectious diarrhea. Am. J. Med. 78(suppl. 6B):91-98. Ognibene, A.J., and O. Barrett, Jr., eds. 1982 Internal Medicine in Viet Nam, Vol 2. Office of the Surgeon General and Center of Military History. U.S. Army, Washington, D.C. 534 pp. Rose, M.S., P.C. Szlyk, R.P. Francesconi, L.S. Lester, L. Armstrong, W. Matthew, A.V. Cardello, R.D. Popper, I. Sils, G. Thomas, D. Schilling, and R. Whang. 1989 Effectiveness and Acceptability of Nutrient Solutions in Enhancing Fluid Intake in the Heat. Technical Report. No. T10-89. U.S. Army Research Institute of Environmental Medicine Natick, Mass. 238 pp. Samadi, A.R., R. Islam, and M.I. Huq. 1983 Replacement of intravenous therapy by oral rehydration solution in a large treatment centre for diarrhea with dehydration. Bull. W.H.O. 61:471-476. Santosham, M., R.B. Sauk, J.L. Froehlich, H. Greenberg, R. Volken, A. Kapikian, C. Javier, F. Orskov, I. Orskov. 1981 Biweekly prophylactic doxycycline for travelers' diarrhea. J. Infect. Dis. 143:598-602. Steffen, R. 1986 Epidemiologic studies of travelers' diarrhea, severe gastrointestinal infections, and cholera. Rev. Infect. Dis. 8:S122-S130. Steffen, R., R. Heusser, and H.L. DuPont. 1986 Prevention of travelers' diarrhea by nonantibiotic drugs. Rev. Infect. Dis. 8:S151-S159.

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