Diarrheal diseases among internally home displaced ( idps ) in khartoum state ,

One hundred diarrheal specimens were collected from Dar-salam and Jabel awlia camps for IDPs during the period from November 2008 to April 2009. The specimens were transported in transport media and inoculated into a variety of selective media, the bacteria were identified later using API 20E, biochemical tests and slide agglutination test as a serotyping method. The results showed that Escherichia coli represent 72%, Shigella species represented 8%, Shigella sonnei alone represented 5% of them and was sensitive to Tetracycline, Gentamicin and Ciprofloxacin while the rest was Shigella dysentraie which was sensitive to Ciprofloxacin, Tetracycline, Gentamicin and Cotrimoxazol. Salmonella paratyphi C represent only 1% and was sensitive to Chloramphenicol, Gentamicin and Ciprofloxacin, Yersinia enterocolitica also have 1% infection rate and was sensitive to Ciprofloxacin, Tetracycline, Gentamicin and Chloramphenicol, while Campylobacter species composed 4% and was sensitive to Erythromycin, Ciprofloxacin and tetracycline.


INTRODUCTION
Diarrheal diseases are major causes of morbidity and mortality in developing countries especially in displace person, where large concentrations of people and poor hygienic conditions combine to generate major health risks that need special attention.The number of refugees and internally displaced persons in need of protection and assistance has increased from 30 million in 1990 to more than 43 million in 2005.Diarrhea can cause severe dehydration and poor absorption of nutrients, which in turn make affected individuals more susceptible to infectious diseases.Diarrhea in early childhood is associated with impaired growth, physical fitness, and cognitive development, which can lead to diminished future school performance and lower economic power (WHO, 2005).From a strictly medical perspective, diarrhea is defined as stool weight of more than 250 grams in 24 hours (Bass, 2000).
Water and sanitation play a crucial role in the transmission of diarrheal disease with 2.4 billion people lack access to basic sanitation, the majority of these unserved people (93%) live in Asia and Africa.These environmental factors contribute to approximately 94 percent of the 4 billion cases of diarrhea that the World Health Organization estimates to occur globally each year; 2 million of them die every year from diarrheal diseases (including cholera).Children under the age of 5 in developing countries bear the greatest burden and account for the majority of million deaths attributed to diarrhea annually (WHO, 2005).
It remains a problem in developed countries as well in the United States in which each child will have had 7-15 episodes of diarrhea by the age of 5 years, 9% of all hospitalizations of children less than 5 years old are associated with diarrhea and 300-500children die each year from this potentially preventable condition (Gangarosa et al., 1992).
There are three broad classes that encompass most cases of diarrhea: Non inflammatory diarrhea which is described as a watery, non-bloody the most common cause of non-inflammatory diarrhea is a bacterium that produces a toxin as Escherichia coli, Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, and V. cholerae.There is usually no blood loss.The second one is inflammatory diarrhea which is usually characterized by the presence of fever and blood in the stool, its common causes include infection with Campylobacter, Shigella, Salmonella, Yersinia species or infection with some species of Escherichia coli.Diarrhea due to these pathogens tends to be less voluminous.The last type is Enteric fever which is characterized by abdominal tenderness, confusion, prolonged high fever, prostration and occasionally a rash.Common causes of enteric fever-related diarrhea include Salmonella typhi or Salmonella paratyphi (Bass, 2000).

METHODS
A descriptive cross sectional study was conducted in both Jabel Awlia and Dar-alslam camps.Inclusion criteria is being home displaced, under 5 years of age and suffering from diarrheal disease.
A questionnaire, prepared in accordance with the objective of the study including personal information, socioeconomic status, source of drinking water, type of diet, main clinical signs and symptoms and history of taking antibiotics, was filled.
Diarrheal specimens were collected in clean, wide neck, leak proof and free of preservative containers.The processing of the samples was started by describing the macroscopic appearance of samples and if it contains mucus or blood, then wet preparations were applied to microscopically detect fecal leucocytes and presence of bacterial cells.
The specimens were transported in Carry Blair transport media (HiMedia).Smears from all the specimens were stained with basic fuchsin preliminary indicator to examine the presence of campylobacter's, and then were inoculated into plates of MaCconkey agar, Deoxy Chocolate Agar (DCA), Xylose Lysine Deoxycholate (XLD), Thiosulphate Citrate Bile Salt agar (TCBS) and Campylobacter selective agar (HiMedia).The plates were incubated aerobically at 37ºC for 24hrs except Compylobacter selective media which was incubated in microaerophilic atmosphere with 5% CO 2 for up to 48hrs.
Colonial morphology from each growing bacteria was established and smears from each one were stained by Grams' stain and then were identified using API20 E (bioMerieux SA, France).Serotyping identification (Mast, UK) was used only to determine the species of the genera Salmonella and Shigella which can not be obtain using API20E while Campylobacter was identified on the bases of characteristic appearance on culture medium, Grams' stain, oxidase, and catalase reactions.
The sensitivity spectrum of each of the isolates to different antibiotics was determined by standardized single disc diffusion method (Bauer et al., 1966).Results were analyzed using Microsoft Excel and Descriptive Statistics (Frequencies) of SPSS.

RESULTS
Out of the 100 stool samples bacteriologically screened for enteric bacteria Escherichia coli represented 72% of the total number, the higher prevalence of Escherichia coli was distributed among children age group (37%) followed by 25% in infant while adult and elderly have only 8 % and 2 % respectively.Shigella species accounted 8% of the total samples, distributing evenly among infants (uder 2 years) and children between 2 and 5 years, Shigella sonnei represented (5%) of them which showed sensitivity to Ciprofloxacin and tetracycline and resistance to Ampicillin and Cotrimoxazol followed by Shigella dysentriae (3%) which was sensitive to Ciprofloxacin, Tetracycline and Cotrimoxazol and resistant only to Ampicillin while four cases (4%) were confirmed as Campylobacter infection among infant age group (less than 2 years).(Toole and Waldman, 1990).

All cases of
The prevalence of Shigella (5%) and Salmonella(1%) recorded in our study is relatively similar to the findings of Desenclos et al., (2000) who documented prevalence rates of 3.5% and 2% to both Shigella and Salmonella respectively.While in another non refugee study, Beyene et al., (2003) in Jimma University Specialized Hospital in Ethiopia, Campylobacter species were isolated from 11.6% of the total patients (430 children) while Salmonella and Shigella species were 5.8% and 4.9% respectively among children, which is slightly differerent from our study comparing to the larger sample size?.Their study agrees with ours in the target group through which Campylobacter is more frequent (less than 2 years) and in the pattern of antimicrobial agents, while Salmonella and Shigella in their study were sensitive to chloramphenicol, gentamicin and kanamycin and showed resistance to trimethoprimsulfamethoxazole and ampicillin, while all Campylobacter isolates in their study were sensitive to tetracycline and erythromycin which is completely agrees with our results.
The prevalence of Y. enterocolitica (1%) recorded in our study was much lower compared with a study by Okwori, et al., (2007) who in a similar study documented a prevalence rate of (15%) among patients suffering from diarrhea in Jos (Nigeria).Studies in Africa has revealed low prevalence of diarrhea due to Y. enterocolitica unlike other parts of the world especially northern European countries with a frequency of up to 13% (Ostroff et al., 1994;WHO, 1983).Their isolates of Y. enterocolitica were susceptible to ciprofloxacin, floxavid, streptomycin and tetracycline which partially agrees with our results.
The risk factor in these camps is mainly sanitation which is shared between the residents and its consequences are increasing specially with shortage of clean water, presences of unknown carriers and the flies especially mosquitoes and house flies which may act as a fomite or mechanical carrier to the infection.

Table 1 :
Frequency of isolated pathogens among enrolled patients

Table 2 :
Antimicrobial Sensitivity Test to each isolate