By Wambui Ngugi
I clutched my rumbling, aching stomach as I rushed to the washroom for the fourth time since I woke up. The diarrhoea episode had started that morning after my early 5:00 a.m. snacking that had accompanied my studies. Squatting over the toilet bowl, the gush of watery stool passed out in a rush.
I thought hard about what part of the food handling had gone wrong. I hand-washed with soap before preparing the pancakes. The utensils were always thoroughly cleaned with liquid antibacterial soap. While slowly standing from the exhausting release, the thought came to me: either the cat or the chopping board. The chopping board I had used the previous night when preparing meat for dinner had only been rinsed and put to lean against the wall on the kitchen counter. That morning, I proceeded to chop my tomatoes and onions on it, which were then consumed rawHow could I miss that? I also pet the cat as I ate my breakfast when it nudged me softly to ask for a share of my meal. After the petting, I picked up my snack with unwashed hands and shared it equally between my cat and me. There were just too many holes for microbial entry into my food.
Anyway, just like me, most humans occasionally have a diarrhoea story. Sometimes they are hilarious stories of how the heat in the room seemed to elevate and sweat drenched their armpits as the stool was held in, only to rush to find a washroom when it got unbearable. Sometimes, they are as sad as death. Whichever way nobody wants a forever diarrhoea till death sorts it out.
Sadly, untreatable diarrhoea is slowly becoming a problem owing to the increasing antimicrobial resistance of various microbe strains. The CDC in its 2019 AMR threats report (dedicated to 48,000 families who lost loved ones to antimicrobial resistance) lists some of the diarrhea-causing microbes—non-typhoidal Salmonella, Salmonella Typhi, and Shigella, among others—as urgent and serious threats. This means they have the potential to spread and become a challenge to control. The additional sad fact is that no one is immune to drug-resistant infections. Even sadder is the fact that diarrhoea is the fifth leading cause of under-5-year-old deaths worldwide. However, three-quarters of the deaths from diarrhoea occur in those older than 5 years, with a high burden in those older than 70 years (WHO, 2017)
Diarrhoea is defined by the WHO as passing more than three liquid or loose stools in a day. The definition means that neither is the frequent passing of solid stools nor the passing of one squishy stool in a day considered diarrhoea. Normally diarrhoea may last a few hours, a few days, a few weeks, and sometimes become a more than 14 days affair. Some of the loose stools may be mucoid, rice-water-coloured, or bloody. The presentation of clinical features is determined by the microbe causing diarrhoea. Outside of the discomfort, diarrhoea may lead to a loss of water and salts. The loss of water leads to dehydration, which leads to death if water and electrolytes are not replaced.
There are four categories of diarrhoeal diseases: waterborne, water-washed, water-related, and water-based (Guandalini & Vaziri, 2011). Water-borne diseases are acquired when we drink water containing organisms such as typhoid, cholera, E. coli, Salmonella, among others. Whenever humans fail in hygiene, they may acquire the water-washed (“water washes away these diseases”), and these include trachoma and lice-borne diseases, among others. Water-based diseases are caused by parasites in the water, such as bilharzia, amoebae, and intestinal worms. Water-related diseases are caused by carriers who have water in their habitat cycle, e.g., malaria and yellow fever (caused by mosquitoes whose larvae hatch in water). Of these many causes of diarrhea, water-borne diseases such as typhoid and cholera are most closely tied to the risk of death. Outside of this water-surrounding classification, there are many other causes, some of which are non-infectious, such as celiac disease and factitious diarrhoea.
Unsanitary hygiene and contaminated water and food form the mainstays of diarrhoea causation.In low-and middle-income countries, diarrhoea is more prevalent due to lack of access to safe water, lack of access to basic sanitation, widespread habits of open defecation, malnutrition (which creates vulnerability to infection), and the presence of animals in food preparation areas. Recently, in developed countries, there has been evidence of diarrhoea resulting from the overuse of antibiotics, known as drug-induced diarrhoea.
Diarrhoea-causing organisms are gaining resistance to available medications. For instance, a 2020 literature review found that rates of multidrug-resistant typhoid and paratyphoid in sub-Saharan Africa had steadily increased over the past 30 years (Guandalini & Vaziri, 2011). In low- and middle-income countries, this has been attributed to the widespread availability and unregulated sale of antibiotics, poor drug quality assurance, and long-standing expectations for antibiotics. When people are infected with drug-resistant strains that cause diarrhoea, they end up with longer hospital stays, larger hospital bills, costly medicine as the cheaper medicine fails, and higher chances of death (Collaborators, GBD, 2016). In addition, resistance to treatment allows for continued shedding of the microbes further sustaining transmission (Guandalini & Vaziri, 2011).
There is hope in prevention. Prevention consists of rigorous personal hygiene, rigorous home cleaning, hygienic food handling, clean water, and changes in health-seeking behaviour (Maillard, et al. 2020). Prevention reduces the frequency of diarrhoea-causing infections, thus reducing the frequency of antimicrobial use and helping to reduce the speed of emerging drug resistance.
Rigorous personal hygiene involves handwashing and alcohol rubs, avoiding nose picking, bathing, and proper disposal of personal body waste. Handwashing with soap has long been known to reduce germ numbers on our palms, thus preventing their passage to other surfaces and into our mouths. Studies have found that alcohol rubs (such as isopropyl sanitisers) and antimicrobial soap have a high effectiveness as compared to non-antimicrobial soap (Maillard, et al. 2020). Following the stepwise hand washing procedure improves efficacy even more. Nose-picking is discouraged as our noses act as filters for the air, which has many germs, making it a likely hub for the transmission of bacteria. Open defecation has long been known to be a transmission point for diarrhoeal infections. In LMICs, open defecation occurs more prevalently in the slum area, exposing residents to both resistant and non-resistant infectious agents, especially with the increased likelihood of contamination of the household water. The building of latrines and proper sewage systems would be a great solution (Maillard, et al. 2020).
Targeted, rigorous home hygiene is proven to be effective (Maillard, et al. 2020). It is called “targeted” as it aims at the places and times that are likely to cause microbial spread. Food handling, changing diapers, using the toilet, frequently touching surfaces such as couches, sneezing and coughing, laundering clothing and household items, caring for domestic animals, and caring for an infected family member who is shedding microbes comprise the moments and places to be targetted. Hands appear to be a link to all these processes. All these activities should be followed by handwashing. Hand washing clothes has been found to be a chain-link to spreading E. coli after examining the hands of women after washing clothes.
The use of soap-based mechanical cleaning is best followed by keeping the surfaces dry. Soaping removes the microbes while keeping a surface dry reduces the medium of water that increases bacterial growth. One study found that chopping boards, kitchen sponges, and cloths are reservoirs and disseminators of microbes. For this reason, kitchen sponges should be changed often, while the clothes should be soaked twice a day in sodium hypochlorite (e.g., Clorox and Jik among others). Secondary to the overuse of antibiotics in animals, meat may be laden with drug-resistant strains or genes that confer resistance Therefore, it is important to thoroughly wash knives and chopping boards after using them for chopping meat.
Clean water is not to be underestimated. This is directed at both household use and wastewater treatment. Modern wastewater treatment is only directed towards usual pollutants, not antimicrobials (Economics and World, 2021) Boiling and investments in water purification agents are to be considered in our households.
The second step in slowing resistance is to change health-seeking behaviour (Maillard, et al. 2020). This is a component involving vaccinations and appropriate antimicrobial use. The vaccination schedule prevents some diarrhoea causing agents such as rotavirus, Vibrio cholerae, and Salmonella Typhi; therefore, it is important that children and adults get their vaccinations when appropriate at the right time.Appropriate antimicrobial use can be promoted by seeking healthcare where pathogen testing is performed, followed by proper guideline-directed treatment (WHO, 2021).
Diarrhea happens to everyone, it has a multitude of causes, and there is hope and empowerment in prevention and being wise about healthcare behaviours.
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About the Author: Wambui Ngugi is a medical student at Kenya Methodist University. She is interested in seeing the science behind every story and is geared up to fight Antimicrobial Resistance.