Acute diarrhea, a significant burden to Thailand’s universal health care system: a nationwide database

We found that the burden of acute diarrheal diseases is a major problem in Thailand and accounts for 26% of admissions for digestive diseases and intestinal infectious diseases. The mortality rate is 0.5% of admissions in the 2010 Nationwide Hospital Admission Data. Diarrhea is a major cause of death worldwide and accounts for 842,000 deaths in 2012. However, the death rates vary widely as shown in Table 4 [8].

Table 4

The diarrheal disease burden and the pathogens

The different incidence rates between the countries may be inherent in the study design and the data base resource, therefore the comparison of outcomes between countries is difficult. The low rate of HIV infection rate in our study may be a consequence of under-reporting because there was no policy to test anti-HIV infection for all hospitalization. The risk factors associated with high mortality include virulent bacterial pathogens (e.g., enteropathogenic Escherichia coli, Vibrio cholera), age <5 years old, being elderly, or having low health care accessibility [9, 10]. There is a high risk of fecal contamination in drinking water sources in developing countries [11]. Recent data confirm that 60% of 1.8 billion people are drinking contaminated water, which is determined by the presence of >10 E. coli or thermotolerant coliforms/100 mL [11]. Contaminated drinking water is prevalent in Africa and Southeast Asia (53% and 35%, respectively) [11]. One of our limitations is the lacking data on the results of bacterial cultures in data management systems of the NHSO, Thailand during the study period. Previous studies showed that several pathogens such as rotavirus and norovirus may play important roles in causing gastroenteritis in children <5 years old worldwide [ 12,13,14,15]. In adults, the common causes of bacterial infection leading to diarrhea were Shigella infection, Campylobacter spp., Salmonella spp., shiga toxin-producing spp., and E. coli [16, 17]. A study from Qatar used a new technology to identify acute gastroenteritis pathogens in 288 patients and found viral and bacterial pathogens were the two most common pathogen types (46% and 12%, respectively) [18]. These findings are consistent with our local data of stool cultures from tertiary care hospitals, e.g. Vichaiyut hospital in Bangkok, Thailand. Patients with acute diarrhea accounted for approximately 10% of all admissions in each year in this hospital and acute diarrhea was ranked as one of the most common inpatient diseases. The data for 10,931 stool culture specimens from Thai inpatients presenting with diarrhea during the 10-year period (2004-2013) at this hospital are shown in Table 5.

Table 5

Result of stool culture for bacteria during the 10-year period (2004–2013) from Vichaiyut hospital, Bangkok. Thailand (local data)

The results show that 21% of stool cultures contained bacterial pathogens. The most common bacterial pathogens were Salmonella spp., Plesiomonas shigelloides, Aeromonas spp., and Vibrio spp. Similarly, results from real-time polymerase chain reaction assays identified bacterial pathogens in 8.3% of patients compared with 5.6% of patients using culture techniques [17]. Recent information suggests that the policy of improving drinking water and sanitation may reduce the risk of diarrhea [8, 11, 19, 20]. Therefore, improving health-related behavior such as increasing proper hand washing with soap and running water before meals and after defecation, avoiding raw seafood, and not contaminating food by using the same chopping block or chop sticks when processing raw and cooked food may all reduce the occurrence of diarrhea [21].

Our data show that a higher proportion of patients with complications or severe acute diarrhea lived in the central region than patients that survived. This result may be explained by the geography of the central region of Thailand, which has major seafood sources and coastal provinces popular for tourism. The current management for acute diarrhea in Thailand does not recommend identifying the pathogen causing acute diarrhea in all patients. We recommend preventing the chance of infection by hand washing, eating properly cooked food, and promoting good hygiene. The long-term consequences of infectious diarrhea include symptoms of irritable bowel syndrome (IBS) and have been reported by approximately 10% of patients with IBS [22],

The disease outcomes of patients with acute diarrhea in the 3 different health care coverage programs in Thailand showed that patients in the SSF group had a lower mortality and shorter length of hospital stay. This result may be explained by the younger age of this group of patients. The economic burden of acute diarrhea in Thailand was high at 30,035,807 USD or USD 140 per admission. The cost of food borne disease in the United States is 1068-1626 USD per patient. However, this average range of costs includes the basic cost, the productivity loss, and functional disability [23]. Our results are consistent with previous data showing diarrheal deaths or poor outcomes had 6-fold higher average cost per admission than surviving patients. Based on the low mortality rate of 0.5%, we conclude that our national health care coverage program may reduce costs and improve the quality and accessibility of health care. A national policy in Thailand is to educate our health care team to identify patients with severe acute diarrhea at high risk, and rapidly provide these patients intravenous fluid rehydration, empirically prescribed antibiotics, and stool examination with culture [24]. These steps are especially critical for elderly or immunocompromised patients [25]. Recently, data from China showed that the prescription of antibiotics in adult patients with acute diarrhea was about 61%, and nearly half received an inappropriate prescription [26].

The main strength of our study is the inclusion of data from cases of diarrhea included in the 2010 Nationwide Hospital Admission Data, which represents the disease burden and clinical outcomes of a developing country in Southeast Asia. Our study has some limitations. First, only the data from the patient discharge summary were collected, and the summary was not designed to include the details of demographic data, clinical data, indication for hospitalization, or causative agents. Second, most of our patients in Social Security Fund were younger than those in other health insurance schemes, including the Universal Coverage, and the Civil Servant Medical Benefits Scheme. Thus, we cannot determine the reason for the different treatment outcomes. Third, we did not include patients <19 years old. Approximately a quater of all hospitalized adults ≥19 years old were admitted more than once.

The current study is important because it provides findings for health policy makers to decrease the burden of acute diarrhea in Thailand. We support providing health education to the public to improve sanitation and food preparation to avoid infections. It is also important to perform bacterial cultures from stool samples to identify the disease causes and determine the sensitivity to antimicrobial agents.

The burden of acute diarrheal diseases is a major problem in Thailand and accounts for 26% of admissions for digestive and intestinal infectious diseases. The mortality rate was 0.5% of admissions in the 2010 Nationwide Hospital Admission Data. The patients with a high risk of death those >60 years old at admission, male, and patients with complications. Promoting public health education to improve hygiene and sanitation may avoid infections.