Food

and Water borne diseases

Travel Medicine, 5th semester 2012/2013
Dr. Henry M.F. Palandeng, M.Sc
Department of Community Medicine
Faculty of Medicine, University of Sam Ratulangi

 Despite advances in hygiene, consumer

knowledge, food treatment and processing,
fooborne diseases mediated by pathogenic
microorganisms or microbial toxins sLll
represent a signicant treat to public health
worldwide.

Facts

Globally, the WHO has

esLmated that
approximately 1.5
billion episodes of
diarrhea and more
than 3 million deaths
occurred in children
under 5 years of age,
and a signicant
proporLon of these
results from
consumpLon of food
mainly food of animal
origin with microbial
pathogens and toxins
3

 The basic human requirement for the intake of

food and water places every single human
being at risk of contracLng infecLon by food-
and waterborne pathogens. This is especially
true in a large part of the world, where food
and water supplies cannot be guaranteed free
from contaminaLon.

 The disLncLon can be subtle, and is not

always clear-cut, because some pathogens can
act as both food-borne and waterborne
agents, or present dierent levels of risk as a
contagion during dierent life cycle stages

Diarrheal Disease Pathways

SOURCE

Prss-stn et al., 2008

MEDIUM

ENVIRONMENT

INTERFACE

DeniLons
1. Water-borne disease: Diseases caused by
ingesLon of water contaminated by human or
animal excrement, which contain pathogenic
microorganisms
2. Food-borne disease: Diseases caused by
ingesLon of Food contaminated by human or
animal excrement, which contain pathogenic
microorganisms
3. Diarrhea: The passing of 3 or more watery or
loose stools in a 24-hour period.
7

DeniLons
4. Outbreak: Sudden occurrence of an epidemic in
relaLvely limited geographic area. While an outbreak
is usually limited to a small focal area, an epidemic
covers larger geographical areas & has more than one
focal point.
5. Outbreak of waterborne or foodborne diseases refers
to two or more cases suspected to occur due to
drinking or eaLng from the same source. Usually must
conrmed by isolaLon of the pathogen or its toxin. In
some infecLons such as Cholera, isolaLon from one
case enough to announce outbreak.
6. Endemic: persistence occurrence of an epidemic in
certain area.
8

DeniLons
8. Surveillance is the systemaLc and Lmely
collecLon of exisLng clinical or laboratory
data about the health condiLons in a dened
populaLon.
It is a rouLne acLvity in health departments that
can dene the burden and magnitude of a
condiLon that we hope to control or prevent

9. DALY: disability adjusted life years

9

Reportable Foodborne Diseases (USA)

Salmonellosis*1

Shigellosis*1

Shiga toxin-producing
E. Coli (STEC)*

Campylobacteriosis*

Giardiasis

Hepatitis A

Listeriosis*

Cyclosporiasis

Cholera*

Cryptosporidiosis

Amebiasis

Botulism

Trichinosis

Yersiniosis*

Suspected Foodborne Outbreak

Reportable within 72 hours

Reportable within 24 hours
Reportable immediately

* Requires isolate submission

1Submit suscepLbility test results

10

The most common waterborne

pathogens:
Cholera,
bacillary dysentery,
Entero-Hemorrhagic
Escherichia Coli (EHEC),
Viral hepaLLs A,
Viral hepaLLs E

Campylobacter,
Cryptosporidium
Giardia IntesLnalis,
Calici virus
shigellosis,
typhoid fever

11

Global situaLon
Poor water quality conLnues to pose a major
threat to human health. Diarrheal disease alone
amounts to an esLmated 4.1 % of the total DALY
global burden of disease and is responsible for
the deaths of 1.8 million people every year
(WHO, 2004).
It was esLmated that 88% of that burden is
ahributable to unsafe water supply, sanitaLon
and hygiene and is mostly concentrated on
children in developing countries.
12

Cases
It is esLmated that, on an annual basis, there
are 76 million cases of foodborne illness in the
United States.
Each year, 5,000 people die from foodborne
illnesses , and there are 325,000 food-related
hospitalizaLons

13

14

Waterborne diseases
The Centers for Disease Control and PrevenLon
(CDC) esLmates that each year infecLous
waterborne diseases account for approximately 2
billion episodes of diarrhea leading to an
esLmated 1 million deaths worldwide.
Most of these diarrheal deaths occur among
children in developing countries, but the elderly
and immunocompromised populaLons are also at
an increased risk for waterborne infecLons.
15

 Not all diarrheas caused by pathogens and

Not all foodborne and waterborne disease
cause diarrhea
Not all causes of diarrhea are known or
idenLed
Not all gastroenteriLs pathogens are known or
idenLed too
16

Burden of Diarrheal Diseases

Diarrheal diseases are vastly underesLmated
211 million cases es#mated in the US annually
(Mead et al., 1999)
Reported cases

Actual cases
> 38 x reported cases

17

 In a mulLcentre European study, pathogens were

idenLed in 65% of stool samples from children
with acute diarrhea, a rate similar to that
reported in developing countries.
In Jordan, pathogens were found in 66.4% of 265
children aged <5 years with diarrhea
Cases of gastroenteriLs and diarrhea detected
and/or reported to public health authoriLes
represent only a small fracLon of those that
occur.
18

General Disease Traits

Most commonly, exposure to infecLous food or water result

in symptoms relaLng to gastrointesLnal funcLon, including
diarrhea, nausea, vomiLng, cramps and jaundice.
Incubation Period

Symptoms

Hours

Vomiting

Day

Vomiting, Diarrhea

Bacterial infections

Days

Diarrhea (bloody),
fever

Parasitic infections

Week

Watery diarrhea

Preformed toxins
Viral infections
(i.e. norovirus)

19

Emerging Foodborne Diseases

Appeared recently
Extended to new vehicles of transmission
Started to increase rapidly in incidence or
geographic range
Been widespread for many years but only
recently idenLed through new or increased
knowledge or methods of idenLcaLon and
analysis of the disease agent
20

Emerging Foodborne Diseases Major

trends
Changes in environment (technology, climate,
etc)
Mass producLon and globalisaLon of food supply
Economic development
InternaLonal travel and trade
Changing character of the populaLon
Breakdown in public health
Lifestyle changes
Microbial adaptaLon
21

Factors contribuLng to the global

incidence of foodborne and
waterborne diseases
Poor sanitary condiLons
MalnutriLon
Changing demographics (increasing populaLon of
infants, elderly)
Inadequate public health infrastructure
Inadequate hygienic and technological condiLons of
food producLon
Inadequate cooking, reheaLng and storage condiLons
Increasing tourism and internaLonal trade
Increasing animal movement and insucient control of
borders
22

Factors contribuLng to the global

incidence of foodborne disease
Increasing internaLonal trade of animal and food
Inadequate legislaLon and ocial control system
Emerging/reemerging foodborne pathogens
AcquisiLon of virulence and anLbioLc genes by
nonpathogenic bacteria
AdaptaLon and enhanced survival of pathogens
in food
Inadequate consumer educaLon

23

 The ability to detect waterborne (or

foodborne) outbreaks depends on the
capacity of local public health agencies and
laboratories to idenLfy cases of illness and link
these in a Lmely manner to a common source
of exposure or to an eLologic agent.
Clinicians???

24

25

Some of the pathogens

Entamoeba histolyLca
A. Epidemiology:
E. histolyLca is an intesLnal protozoan causing
amebiasis or amebic dysentery worldwide.
it is more common in tropical countries or other areas
with poor sanitary condiLons.
It is esLmated that up to 10% of the world's
populaLon may be infected with E. histolyLca and in
many tropical countries the prevalence may approach
50%.
There are an esLmated 50 million cases of amebiasis
per year and up to 100,000 deaths.
27

B. Life Cycle:
Mature cysts are ingested
via contaminated water,
food or hands.
ExcystaLon occurs in the
small intesLne and
trophozoites are released
and migrate to the large
intesLne. They mulLply
by binary ssion and
produce cysts , which are
passed in the feces.
28

Campylobacteriosis
Campylobacters are bacteria that are a major
cause of diarrheal illness in humans and are
generally regarded as the most common
bacterial cause of gastroenteriLs worldwide.
In developed and developing countries, they
cause more cases of diarrhea than, for
example, foodborne Salmonella bacteria. In
developing countries, children under the age
of two years are more aected, someLmes
resulLng in death.
29

 In almost all developed countries, the incidence of human

campylobacter infecLons has been steadily increasing for several
years. The reasons for this are unknown.
An esLmated 2.4 million persons are aected each year in USA
In a study from Algeria, Campylobacters were isolated in 17.7% of
411 child paLents with diarrhea and in 14.9% of the 247 controls
(ahended for vaccinaLon). Breast feeding was seen as protecLve
They are prevalent in food animals such as poultry, cahle, pigs,
sheep, ostriches and shellsh; and in pets, including cats and dogs
The main route of transmission is generally believed to be
foodborne, via undercooked meats and meat products, as well as
raw or contaminated milk. The ingesLon of contaminated water or
ice is also a recognized source of infecLon.

30

Giardia lamblia
Caused by The protozoan parasite Giardia
lamblia.
Transmission InfecLon usually occurs through
ingesLon of G. cysts in water (including both
unltered drinking-water and recreaLonal
waters) contaminated by the faeces of
infected humans or animals.
Geographical distribuLon: Worldwide
31

Giardia lamblia
A. Epidemiology:
It is the most common idenLed cause of water-borne
disease associated with breakdown of water puricaLon
systems.
Second most common parasite in the US (arer pinworms.)
2-5% of samples sent for fecal analysis in the US are
posiLve for Giardia. 30% in developing countries.
It has worldwide distribuLon. The incidence is esLmated at
200 million cases per year.
Typically Giardia is non-invasive and quite oren results in
asymptomaLc infecLons. SymptomaLc giardiasis is
characterized by acute or chronic diarrhea and/or other
gastro-intesLnal manifestaLons.
32

Salmonella Prevalence
Factors which favor the conLnued presence in the food
chain
Ubiquity of salmonella in the environment
Intensive husbandry pracLces in the meat, sh, and
shellsh industries
Lack of microbiological control on animal feeds favors the
conLnued prevalence of this pathogen in the food chain

Poultry products remain the main reservoir of

salmonella
Eggs and egg products are also a concern since there is
Transovarian transmission of the pathogen into the
interior of the egg
33

Salmonella Prevalence
Developed countries= more than 80% of the Salmonella cases occur
individually rather than in outbreaks
Large Salmonella Outbreaks

Foods linked to transmission include milk powder, raw milk, cheddar cheese,
egg products, and liver pate
Some fruits and vegetables have also been linked to outbreaks-cantaloupes,
chocolate, mustard dressing

InfecLous dose will vary, as few as 1 to 10 cells

Foods with a high fat content may have a low infecLous dose due to the
organism being trapped in micelles which protect it against acidic ph
Salmonellosis in the U.S. is 40,000 to 140,000cases annually
Recent years a notable increase in cases related to a mulL-drug resistant S.
typhimurium DT104
Case-fatality and hospitalizaLon rates due to this strain are twice that of other
Salmonella infecLons

34

Salmonella (cont.)
carrier state may last from many weeks to years with
faecal shedding
convalescent carrier

chronic carrier: ~3% of persons infected with S. typhi ,

~0.1% of those infected with non-typhoidal
salmonellae
InfecLous dose typically about 1,000,000 bacteria
much lower if the stomach pH is raised
much lower if the vehicle for infecLon is chocolate
protects the bacteria in their passage through the
stomach an infecLous dose of about 100 bacteria
35

36

Cryptosporidium parvum
First described in 1907 as an intracellular protozoan parasite, and
In 1976 two cases of human diarrhea idenLed
Increased dramaLcally with the AIDS epidemic, by 1986 4% of AIDS
paLents had cryptosporidiosis with a 61% fatality rate
In 1993 naLonal ahenLon (USA) was focused on Cryptosporidium
Milwaukee (outbreak) over 400,000 cases
Las Vegas thousands more

CDC says that currently there are at least 30,000 cases of

Cryptosporidium annually
Transmission is fecal/oral: outbreaks associated
outbreaks associated with faulty water puricaLon

37

Cholera
Classically a water borne disease causing
bacteria.
EaLng or drinking contaminated food or water
containing vibrio cholerae bacteria. Transmihed
by fecally contaminated water or food.
Contaminated food and not water a more likely
source in developed countries.
SensiLve to climate and grows rapidly in warmer
environmental temps.
Humans are the main reservoir. Shell sh and
plankton are the only animal reservoirs.
38

Cholera
Increased risk results from overcrowding, poor sanitaLon
and inadequate water supplies. High risk in refugee and
emergency-aected populaLons without access to safe
water supply.
One single laboratory conrmed case consLtutes an
outbreak.
Outbreaks generally last 3 weeks to 3 months, or can be
endemic.
All persons, regardless of age, are suscepLble to cholera
infecLon.
more common in Africa, Asia and east Europe:

In 1994 95 countries and in 2004 55 countries reported

cases of cholera
39

40

Cholera
Among infected persons:
75% will have no symptoms
20% will have mild or moderate diarrhea
< 5% will have severe clinical cholera infecLon

Ahack rate varies from 1-2% in open

situaLons, to > 5% in emergency situaLons.
Up to 50% of paLents may die in the absence
of treatment, but with proper treatment case
fatality rate (CFR) can be <1%
41

Cholera
The main danger from cholera is rapid
dehydraLon. It must be treated quickly.
Unless paLents receive rehydraLon they can
die, someLmes in a few hours.
Most cholera cases can be treated
successfully with oral rehydraLon therapy.
However, the few that become severely
dehydrated need intravenous uid iniLally and
anLbioLc treatment
42

Cholera
In the long term, improved water supply,
sanitaLon and hygiene, and beher living
condiLons are crucial to prevenLng cholera.
Oral Vaccine (Dukoral) licensed and available in
some countries. Consists of killed V.cholera
organisms and B subunit. SLmulates anLbacterial
and anLtoxic immunity. Two doses given 1-6
weeks apart. The ecacy reached 50% within 3-5
years. The rate may decline with Lme

44

45

46

Control of food-borne and water-

borne diseases
WHO esLmates that 94% of diarrheal cases
are preventable through modicaLons to the
environment, including through intervenLons
to increase the availability of clean water, and
to improve sanitaLon and hygiene.

47

Public Health Approach

Surveillance: passive and acLve
Epidemiology for earlier diagnosis
Early response to outbreaks
Public health lab. support for rapid and
accurate diagnosis
Rapid communicaLon links
CommunicaLon to public
EducaLon on prevenLon and/or detecLon

48

Situasi di Indonesia

PENDAHULUAN
Air sangat erat hubungannya bagi kehidupan manusia.
Disamping sebagai bagian dari tubuh manusia, air
diperlukan untuk menunjang kebutuhan maupun
kegiatan kehidupan mnusia sehari-hari.
Sebesar 50-70 % bagian berat badan tubuh manusia
terdiri dari air. PenLngnya air bagi tubuh manusia
terlihat 80 % darah terdiri dari air, 25 % dari tulang, 75
% dari urat syaraf, 80 % dari ginjal, 70 % dari haL.
Kehilangan air 15 % dari berat badan manusia akan
menyebabkan kemaLan.
Orang dewasa perlu minum 1,5 sampai 2 liter air per
hari.

 Air merupakan kebutuhan dasar bagi kehidupan,

juga manusia dalam hidupnya selalu memerlukan
air untuk berbagai keperluan seperL mandi,
mencuci, memasak, buang air besar, dan berbagai
akLvitas hidup lainnya.
Mengingat bahwa berbagai penyakit dapat
dibawa oleh air kepada manusia pada saat
manusia memanfaatkannya, maka tujuan utama
penyediaan air bersih bagi masyarakat adalah
mencegah penyakit bawaan air.

 Water borne disease adalah salah satu

penyakit yang ditularkan melalui air. penyakit
yang ditularkan melalui air minum, dimana air
yang diminum mengandung kuman penyakit
atau bahan kimia yang beracun. Penyakit yang
ditularkan antara lain penyakit Kholera,
Dysentri, Typhoid, HepaLLs infecLosa (oleh air
yang mengandung kuman) dan penyakit
Gastro enteritris

Penyakit yang tergolong dari Water

borne disease
Tifus
Penyakit Lfus merupakan penyakit infeksi akut yang disebabkan oleh bakteri
Salmonella typhi. Penyakit ini diakibatkan oleh kurang memelihara kebersihan
lingkungan dan mengonsumsi makanan yang Ldak higienis.
Penyakit Lfus menular melalui air dan makanan yang tercemar oleh air seni dan
Lnja penderita penyakit ini. Penyakit Lfus dapat juga ditularkan oleh kotoran yang
dibawa oleh lalat dan kecoa dan menempel di tempat-tempat yang
dihinggapinya.Penularan kuman terjadi melalui mulut, masuk ke dalam lambung,
menuju kelenjar limfoid usus kecil, kemudian masuk ke dalam peredaran darah.
Pada umumnya, mereka yang terinfeksi penyakit ini akan mengalami keluhan dan
gejala seperL demam Lnggi, sakit kepala, mual, muntah, nafsu makan menurun,
sakit perut, diare atau sembelit (sulit buang air besar). Suhu tubuh meningkat
terutama pada sore dan malam hari.
Pencegahan penyakit Lfus dapat dilakukan dengan membiasakan melindungi
makanan dari hewan pembawa penyakit, seperL lalat, kecoa dan Lkus; mencuci
tangan dengan sabun setelah buang air dan sebelum makan; serta menghindari
membeli jajanan di tempat-tempat yang kurang bersih.

Data Penyakit Tifus Di Sulawesi Utara Tahun 2009

54%
54%

52%

50%

48%

46%

46%

44%

42%
Laki - laki
Perempuan

 Dari Grak diatas, yang menderita Tifus pada tahun

2009, sebanyak 572 orang, yaitu laki-laki sebanyak 308
orang atau sebesar 54 %, dan perempuan sebanyak
264 orang atau sebesar 46%.9
Surveilans Departemen Kesehatan RI, frekuensi
kejadian demam Lfoid di Indonesia pada tahun 1990
sebesar 9,2 dan tahun 1994 terjadi peningkatan
menjadi 15,4 per 10.000 penduduk. Insidens demam
Lfoid bervariasi di Lap daerah dan biasanya terkait
dengan sanitasi lingkungan, di daerah rural (Jawa
Barat) 157 kasus per 100.000 penduduk, sedangkan di
daerah urban ditemukan 760-810 kasus per 100.000
penduduk.

Kolera

Kolera adalah penyakit menular yang disebabkan oleh bakteri Vibrio cholerae yang menyerang usus kecil. Bakteri
ini biasanya masuk ke dalam tubuh melalui air minum yang terkontaminasi akibat sanitasi yang buruk.
Di dalam tubuh manusia, bakteri Vibrio cholerae akan menghasilkan racun yang menyebabkan usus halus
melepaskan sejumlah besar cairan garam dan mineral dari dalam tubuh. Bakteri ini amat sensiLf terhadap asam
lambung, sehingga penderita yang kekurangan asam lambung cenderung menderita penyakit ini.
Penderita kolera akan mengalami gejala mulai dari diare hebat, keram perut, mual, muntah, hingga dehidrasi.
Kolera dapat menyebar luas dengan sangat cepat, terutama di lingkungan yang Ldak bersih.
Penyakit ini memiliki Lngkat kemaLan Lnggi. Pada kasus wabah kolera di Provinsi Papua bulan Juni 2006 lalu,
tercatat 5.108 kasus kolera dengan 170 kemaLan. Oleh karena itu, penderita yang mengalami gelaja-gejala seperL
yang telah disebutkan di atas sebaiknya segera diberikan pertolongan dengan mengantarkannya ke rumah sakit
atau puskesmas agar untuk diberi cairan infus.Obat infus harus diberikan selekas mungkin. Semakin cepat cairan
infus diberikan, semakin baik.
Sebagai pertolongan pertama, penderita kolera harus diberi air minum dalam jumlah cukup banyak, karena
kemaLan pada kolera lebih disebabkan kekurangan cairan, bukan keganasan bakteri kolera.
Jagalah kebersihan rumah yang ada penderita kolera. Dalam kondisi itu, usahakan untuk selalu menggunakan
sendok saat menyantap makanan dan lebih sering mencuci tangan dengan sabun. Muntahan dan Lnja penderita
kolera merupakan sumber bakteri kolera. Oleh karena itu, kamar mandi dan kamar kecil sebaiknya dibersihkan
dengan menggunakan larutan anLsepLk pembasmi bakteri.

Data Penyakit Kolera Di Sulawesi Utara Tahun 2009

100%
90%
80%
70%
60%
50%

71%
29%
Data Penyakit Kolera Di
Sulawesi Utara Tahun 2009

40%
30%
20%
10%
0%
Laki - laki
Perempuan

 Dari Grak diatas, yang menderita Kolera pada

tahun 2009, sebanyak 7 orang, yaitu laki-laki
sebanyak 5 orang atau sebesar 71 %, dan
perempuan sebanyak 2 orang atau sebesar 29
%.9
Dari Ditjen PP-PL, Depkes RI, prol PP-PL 2006.
penyakit kolera di Indonesia terdapat 78
kasus.

Disentri
Penyakit disentri merupakan peradangan pada usus besar. Gejala
penyakit ini ditandai dengan sakit perut dan buang air besar encer
secara terus-menerus (diare) yang bercampur lendir, nanah, dan
darah.
Berdasarkan penyebabnya disentri dapat dibedakan menjadi dua,
yaitu disentri amuba dan disentri basiler. Disentri amuba
disebabkan oleh infeksi parasit Entamoeba histolyLca dan disentri
basiler disebabkan oleh infeksi bakteri Shigella.
Bakteri tersebut dapat tersebar dan menular melalui makanan dan
air yang sudah terkontaminasi kotoran dan bakteri yang dibawa
oleh lalat. Lalat merupakan serangga yang hidup di tempat yang
kotor dan bau, sehingga bakteri dengan mudah menempel di
tubuhnya dan menyebar di seLap tempat yang dihinggapi.

 Bakteri masuk ke dalam organ pencernaan mengakibatkan pembengkakan

hingga menimbulkan luka dan peradangan pada dinding usus besar. Inilah
yang menyebabkan kotoran penderita sering kali tercampur nanah dan
darah. Gejala yang akan dialami penderita disentri biasanya berupa
mencret dan perut mulas, bahkan sering kali penderita merasakan perih di
anus akibat terlalu sering buang air.
Serupa dengan penanganan penyakit gangguan pencernaan lainnya,
penderita disentri harus segera mendapat asupan cairan untuk mencegah
terjadinya dehidrasi. Dalam keadaan darurat, dehidrasi ringan dapat
diatasi dengan pemberian oralit. Jika cairan yang hilang Ldak segera
terganLkan, dapat menyebabkan kemaLan pada penderita.
Langkah pencegahan yang dapat dilakukan untuk menganLsipasi penyakit
disentri adalah dengan memperhaLkan pola hidup sehat dan bersih;
menjaga kebersihan makanan dan minuman dari kontaminasi kotoran dan
serangga pembawa bakteri; dan membiasakan untuk selalu mencuci
tangan sebelum makan.

Data Penyakit Diare Di Sulawesi Utara Tahun 2009

100%
90%
80%
70%
60%
50%

49%
51%

40%
30%
20%
10%
0%
Laki - laki
Perempuan

Data Penyakit Diare

Di Sulawesi Utara
Tahun 2009

 Dari grak diatas, yang menderita diare pada

tahun 2009, sebanyak 20.415 orang, yaitu
laki-laki sebanyak 10048 orang atau sebesar
49 %, dan perempuan sebanyak 10367 orang
atau sebesar 51 %.9