CL/BMS/04/12 APS6022

PROJECT REPORT

Food poisoning or unexplained diarrhea

due to viral
infections among a Sri Lankan student
cohort
during the COVID-19 pandemic

Student Name – Indragi Ekanayake

Student ID – 20186944/CL/BMS/04/12
Supervisor – Mr. Budhil De Silva
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Declaration
Statement 1

This work has not previously been accepted in substance for any degree and is

not being concurrently submitted in candidature for any degree.

Signed:

Dated: 2022.06.13

Statement 2

This dissertation is the result of my own investigations, except where

otherwise stated. Where corrections services have been used, the extent and

nature of the correction is clearly marked in a footnote. Other sources are

acknowledges by footnotes giving explicit references. A bibliography is

appended.

Signed:

Dated: 2022.06.13

Statement 3

I hereby give consent for my dissertation, if accepted to be available for

photocopying and for inter library loan, and for the title and summary to be

made available to outside organizations.

Signed:

Dated: 2022.06.13
CL/BMS/04/12 APS6022

Acknowledgement

I would like to express my deepest appreciation to all those who provided me

an immense support till the successful completion of this assignment. This
paper and the research behind it would not have been possible without the
exceptional support of my supervisor, Mr. Budil De Silva. His enthusiasm,
knowledge and exacting attention to detail have been an inspiration and kept
my work on track from my first encounter to the final draft of this paper.
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Contents

Declaration ............................................................................................................................................................... 2
Acknowledgement ................................................................................................................................................... 3
Abstract .................................................................................................................................................................... 5
Introduction ..............................................................................................................................................................6
3.1 Acute Diarrhea ................................................................................................................................. 8
3.2 Chronic Diarrhea .............................................................................................................................. 9
Methodology .......................................................................................................................................................... 10

Results ....................................................................................................................................................................11
Symptoms and Physical Health Status ..........................................................................................................12
Covid -19 Related Symptoms and Information ............................................................................................ 14
Discussion .............................................................................................................................................................. 17
Limitations ............................................................................................................................................................. 24
Conclusion ............................................................................................................................................................. 25
References ..............................................................................................................................................................26

Table of Figures
Figure 1 : Percentage of Diarrhea survey participants had during past 2 months ......................... 12

Figure 2 :Percentage of participants who had travelled outside during past 2

months ................................................................................................................................... 13

Figure 3 : Percentage of body discomfort during past 2 months ..................................................14

Figure 4 : Percentage of participants, with regards testing for Covid-19 ......................................15

Table of Tables
Table 1 : Comparison of viral infections which have diarrhea as a similar
symptom (CDC,2020) ........................................................................................................ 21

Table 2 : Laboratory findings of symptoms with Covid-19 diarrhea and Covid -

19 without diarrhea patients (Pan et al., 2020) ......................................................................22
CL/BMS/04/12 APS6022

Abstract

The Covid-19 pandemic causing severe acute respiratory syndrome is a global

emergency. However, there is growing evidence that Covid-19 affects other
systems, and one is the gastrointestinal system, which has a variety of organ-
related symptoms as well as potential consequences for diagnosis and
transmission. One of the most common signs of gastrointestinal involvement
is diarrhea. There has been an increase in the number of diarrhea cases
recorded.

This study will focus on diarrhea developed from different viral infections and
diarrhea associated with Covid-19 infections.

A community-based cross-sectional study will be conducted on a minimum of

50 participants using an online questionnaire. The data collected will be
analyzed to determine the prevalence and associated determinants of viral
diarrheal diseases in the context of the covid-19 pandemic. This knowledge
could help researchers figure out how to prevent diarrheal disease and how
gastrointestinal involvement is linked to COVID-19 infections.
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Introduction

The coronavirus is a single-stranded RNA virus with a diameter of 80–120 nm.

There are been four categories of virus identified as (α,β,γ, and δ) coronavirus.
Six coronaviruses cause infection in humans, with the 2019 new coronavirus
(SARS-CoV-2) becoming the seventh member of the coronavirus family to
cause infection in humans.

According to Rauf et al., 2020, COVID-19 spreads mostly by individual-to-

individual transmission via inhaling droplets from sneezing and coughing
through close contact. COVID-19 viral transmission via contaminated regions
or fomites after contact with the nose, eyes and mouth.

SARS human-to-human transmission is still under investigation, however it is

currently thought to occur by air droplets, through airborne transmission and
faecal ,oral dissemination are other possibilities. The extremely contagious virus has
quickly spread over the world, affecting health systems, economics, and
governments.(Gu,2020).

SARS-CoV-2 infection can be symptom free or related with coronavirus disease 2019
(COVID-19), which has a wide range of respiratory clinical symptoms ranging from
pulmonary edema,dry cough fever, and dyspnea to acute respiratory distress
syndrome, multiple organ failures and pneumonia necessitating hospitalization and,
death van happen in worst [Link], vomiting, hemoptysis, diarrhoea and
headache are some of the less prevalent symptoms.(D’Amico, 2020)

Food poisoning is caused by consumption of contaminated food or water

containing various food-borne pathogens, such as viruses, bacteria and
parasites, resulting in mild to severe health outcomes with common symptoms
of viral gastroenteritis including abdominal cramps, nausea, watery diarrhea,
vomiting, fever, headaches and muscle aches. Commonly, Norovirus and
Rotavirus cause diarrheal infections. However, recent studies have reported
SARS- CoV-2 infections affecting the gastrointestinal (GI) tract with COVID-
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19 patients presenting with symptoms of diarrhea. This study will focus on

diarrhea developed from different viral infections and diarrhea associated with
Covid-19 infections.

A community-based cross-sectional study will be conducted on a minimum of

50 participants using an online questionnaire. The data collected will be
analysed to determine the prevalence and associated determinants of viral
diarrheal diseases in the context of the covid-19 pandemic. This information
would aid in the identification of effective diarrheal illness prevention
measures and the interrelation of gastrointestinal involvement with COVID-19
infections.

Diarrhea is known as the passing of watery or loose stools more than three
time in a day due to an excessively high fluid content of stool or an abnormal
rise in regular stool fluidity, consistency, or volume from what is considered
typical for an individual, according to the World Health Organization (WHO).

Although diarrhoea was initially identified in a small percentage of cases, it is

now been to an increasing number of patients. Diarrhoea is a common
condition of corona-virus infections; it was found in up to 30 percent of
MERS-CoV patients and 11 percent of SARS-CoV patients.

After 2022 April, there has been an increase in the number of diarrhea cases
[Link] incidences of COVID-19 showing only with
gastrointestinal symptoms and no respiratory symptoms.

This section of the research looks into the epidemiological data, patient
characteristics, causes, therapeutics, and prevention of Covid-19-associated
diarrhea. American journal of Medicine, Stat Perals, PubMed, and Research
gate research papers were used for studies on diarrhea associated with Covid-
19 until April 2022. According to clinical studies, diarrhea affects anywhere
from 2% to 50% of the population.(D’Amico, 2020)
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Diarrhea is categorized into acute or chronic and infectious or non-infectious

based on the duration and type of symptoms. Bacterial foodborne infections
(226,526,634) were more common than viral (138,513,782) and parasitic
foodborne illnesses (10,284,561) worldwide. Norovirus, on the other hand,
was responsible for the most annual cases (124,803,946) and 34,929 deaths,
representing a fatality rate of 0.028.

3.1 Acute Diarrhea

Acute diarrhea defines an infection which lasts for a maximum 2 weeks and it
is self-limited. Mostly, acute diarrhea caused by a viral infection (norovirus,
rotavirus) due to food poisoning, but can be parasitic (Cryptosporidium,
Giardia) or bacterial (Vibrio cholera, Staphylococcus aureus, Escherichia coli,
Clostridium perfringens, Bacillus cereus) as well. Symptoms include, watery
stools, vomiting, abdominal cramps, nausea. Hand washing, hygienic food
preparation, access to clean water, and vaccines are all recommended for
preventing acute diarrhea.

According to Barr and Smith, 2014, Escherichia-coli (E-coli) results in

abdominal pain with bloody diarrhea without any fever. Consumption of pork,
seed sprouts, uncooked or raw beef, raw milk and poultry can result in
foodborne illness which is associated with E-coli. Consumption of
contaminated water and food such as, lettuce, shellfish and fruits causes
norovirus or rotavirus (CDC, 2021). Medical conditions associated with acute
diarrhea are short bowel syndrome, ischemic colitis, malabsorption, lactose
intolerance, adrenocortical insufficiency, medullary thyroid cancer,
hyperthyroidism, carcinoid tumors, Crohn disease, bowel obstruction,
diverticulitis, systemic infections, appendicitis and human immunodeficiency
virus (HIV).
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3.2 Chronic Diarrhea

Chronic diarrhea is known as a non-infection which lasts for a minimum of 4

weeks of time. Common causes of chronic diarrhea are inflammatory bowel
disease (IBD), side effects of medication and malabsorption. Symptoms
include, stools with blood, bloating, abdominal pain, fever and tenesmus (Barr
and Smith, 2014).

Lactose intolerance is a kind of watery diarrhea in which the intestinal lumen

secretes more water. Bloating, gas, and watery diarrhea are common
symptoms in patients. Enzyme lactase breaks down lactose in the colon. The
epithelial cells can easily absorb the byproducts. Lactose cannot be digested
when lactase is absent or reduced, therefore it relics in the intestine. Lactose is
osmotically active, which means it draws and holds water, resulting in
diarrhea (watery).

Celiac disease and chronic pancreatitis are two common causes of fatty
diarrhea. The pancreas secretes enzymes that facilitate in the digestion of
meals. The pancreas secretes enzymes that helps in the digestion of proteins,
lipids and carbs. Those resulting products are available for uptake in the
intestines once they have been broken down. Malabsorption occurs in patients
with chronic pancreatitis due to inadequate enzyme release. Upper abdominal
pain, gas, and foul-smelling, thick pale feces are common symptoms of fat
malabsorption.

Watery stools are caused by damage to the gut epithelium in bacterial and
viral diarrhea. The digestive tract is lined by epithelial cells, which aid in the
absorption of electrolytes, water, and other solutes. Injury to the epithelial
cells caused by infectious etiologies leads to increase the permeability of the
intestine. Because the epithelial cells have been destroyed, they are not
capable of absorbing water from the intestinal lumen, resulting in loose stool
(Nemeth and Pfleghaar, 2021).
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Methodology

This community-based online cross sectional study was approved by the

Ethical Committee of Cardiff Metropolitan University- faculty of Health
Sciences. Participation was voluntary and anonymous.

We gathered data using a Google Docs-based online self-administered

questionnaire and shared an online invitation post with a link to the
questionnaire on popular social media platforms in Sri Lanka, such as
Instagram, WhatsApp, and Facebook. Participants were Sri Lankan students
who were currently studying and residing in the country.

The survey was designed using previous research and the situation in Sri
Lanka during the pandemic. The final questionnaire consist of twenty two
questions and divided into three sections; demographics features, symptoms
and physical health status and COVID-related symptoms and information.

Data collection

The survey was carried out from 10 April 2022 to 10 May 2022. Participation
for the survey was completely voluntary, and all the participants were
provided with a consent form and an information sheet before conducting the
survey. Furthermore, purpose of the survey, ethical considerations and the
confidentiality of individual data were clearly mentioned to the participants.
They were asked to answer as many questions as possible. They could, leave
the question if they were unsure of the response. A total of 50 individual
questionnaire responses were gathered.

Study Population & Study Size

Study population were all Sri Lankan students who were participated
randomly.
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Statistical Analysis

The data was entered into Excel for documentation purposes. SPSS was used
to explore further into the data. A total of 05 participants were eliminated from
the study after accurately answering less than 70% of the questions and
omitting critical responses. Descriptive statistics of the sample's demographic
factors and each question item were utilized to summarize the findings.

Results

Over the duration of one month, from April 7 to May 7, 55 participants

completed the online survey. Only 50 participants data were used to the
project report and 5 participants were excluded from the study due to older age
they did not meet the study rules and regulations.

The majority of people who participated to the survey were female (55.6%)
followed by male (463%). This might not always represent the proportion of
people who had diarrhoea during the pandemic [Link] female and male
participants' median ages were 26 years. The majority of those who responded
were students (88.9%) in tertiary education level (35.8%)

Regarding the age, 27.8% were between 20 - 25 years, 7.5% were 16 - 20

years and 22.3% were age 26-38 years. The mean ages of Sri Lankan student
cohort were 25% .Forty eight (88.9%) participants were doing there Bachelors
degree while 11.1% participants were doing Masters or PhD.

Results indicated that 46.6% participants from Western province, 40.9% from
Central province, 1.9 % from North Central province and least number of
participants 5.7% from North Western province has participated.

When considering about the house hold size, majority of participants were
living in a family with 3 to 5 people which is 70.4% . Least number of
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participants were living alone which is 3.7%. Other participants were living in
a family with 6 or more 13% and with 2 members 13% respectively.

Symptoms and Physical Health Status

According to the results 85.4% participants have food from outside during the
past 2 months and other 14.6% people have not taken food from outside
during the past 2 months.

Moreover, results indicated that 41.7% people have had diarrhea during the
past 2 months while 58.3% people have not had diarrhea during the past 2
months.

According to the people who had suffered with diarrhea had stomach cramps
24.2% (8 responses), nausea and vomiting 27.3% (9 responses) , 6.1% had
headaches and 42.4% (14) people had no any above mentioned symptoms.

Majority (47.16%) of participants had a moderate rate of diarrhea while 33.3%

and 19% people had minimal and severe diarrhea respectively.

Figure 1: Percentage of Diarrhea survey participants had during past 2

months
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Figure 2:Percentage of participants who had travelled outside during past

2 months

Results of the survey indicated that 52.4% (11) participants had a frequency of
a twice a day and 23.8% (5) people had a frequency of thrice and more that
trice a day.

During the past 2 months participants who suffered from diarrhea had passed
the tools suddenly (61.5%) while others had not (38.5%).

10 people (68%) had a very less appetite during diarrhea. 24% participants had
moderate and 8% people had a higher appetite during dairrhea.

Survey results indicate that 66.7% (18) people have taken self medication in
order to treat diarrhoea while 33.3% (9) people have gone for a hospital or
either to a family doctor.

Survey participants who had taken self medication for diarrhea had helped to
reduce the symptoms of 73.9% (17 participants) and for 26.1% (6 participants)
had not helped to reduce the symptoms of diarrhoea.

87% of participants had travelled outside during past 2 months while 13%
were at home.
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Covid -19 Related Symptoms and Information

Symptoms of body discomfort in the past 2 months for the people who had
participated the online survey results can indicate as below.

Majority of people had suffered from headaches (39.6%), while 27.1% (13
people) had persistent fever (>38℃ for at least 1 day ) and loss of taste.
20.8% (10 people) were suffering from chills, sore throat, loss of smell and
cough. 22.9% (11 people) had dizziness. Results indicated that 16.7% (8
people) were suffered from diarrhoea during the past 2 months. 16.7% (8
people) had difficulty of breathing. 14.6% (7 people) had persistent fever and
cough or difficulty of breathing. 10.4% (7 people) had all the above
mentioned symptoms during the past 2 months of Covid-19 outbreak, while
35.4% (17 people) had none of the above symptoms.

Figure 3: Percentage of body discomfort during past 2 months

33.3% (16 people) have mentioned that they have directly had a contact with
a person who had Covid -19 during the past 2 months. Frequency of a 41.7%
(20 people) had not contacted a Covid-19 patient while 25% (12 people)
were not sure whether they contact a Covid-19 patient or not.

32 out of 50 (66.7%) participants have not tested positive for Covid -19. 12
out of 50 participants (25%) people have tested positive for Covid -19 while
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8.3% (4%) participants have not performed the Covid -19 test (Rapid antigen
or PCR).

Figure 4: Percentage of participants, with regards testing for Covid-19

Among the people who have had tested positive for Covid-19 , 48.1%
participants were under self quarantine and other 51.9% Covid -19 patients
were not under quarantine during the past 2 months.

Among the people who were under quarantine, 100% have not admitted to
hospital for treatments of Covid-19 during past 2 months.

Results indicated that 100% of the participants have had received both local
and western treatment while none of the participants had either local or
western treatments alone.

During the Covid -19 outbreak participants who were tested positive for
Covid-19, 69.3% (9 people ) had taken only 5 days to recover from the
symptoms. 7.7% (1 participant) had taken 6 days to one month of a period to
recover from the symptoms.

Among all the participants majority of people have had taken 2 doses (58.3%)
of vaccine while least number of participants 4.2% (2) have had only one
dose of the vaccine.29.2% (14 participants) have taken the complete dose (3
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doses) of vaccine and 4 people (8.3%) people have not had none of the
vaccines.
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Discussion

Random participants who participated for the survey indicated that diarrhoea was
very less common symptom of Covid-19 virus.

When considering of the age group, most of the participants were students who were
between 22 - 28 years. Main advantage of having majority of a young group is that
they are up to date and knowledgeable which which helps to conduct the research in a
proper manner and to get the accurate outcome.

According to the results, majority of participants were living in Western province.

Since Western province was the most affected province during the Covid-19 outbreak
1st wave , this makes the results more accurate and there’s a possibly to get the
expected outcome as well.

Most of the participants are living in a family with 3-5 house hold size, which is
usually a common Sri Lankan house hold size. According to Gillies et al., 2022 have
shown that members of three to five house hold size has a greater impact on Covid-19
and its symptoms than members of two (Motarjemi et al., 1993).

According to the results many respondents have taken food from outside
which indicates a high possibility of consumption of contaminated food.
Contamination of food is a major issue in developing countries like Sri Lanka
due to high inflation. Due to unhealthy activities, People are particularly
sensitive to food borne diseases, and by consumption of contaminated food,
they are more prone to get intoxications or infections , which can lead to
severe health issues and death. Food borne diseases are responsible for a
significant part of diarrhoeal infections, and they can be caused by chemical or
biological [Link] pathogens that cause diarrhoeal illnesses have been
discovered. Bacteria such as E -coli are among them. Salmonella spp, Shigella
spp, Escherichia coli, Vibrio cholerae, Entamoeba histolytica and rotavirus are
some other pathogens.
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When considering the results, many participants have had self medications for
diarrehea and more than half of the participants have got cured. According to
Paeditric Child Health et al., 2003, probiotics, oral rehydration solutions and
drugs modifying gut motility are recommended as self medication. Oral
rehydration solutions (electrolyte/ glucose combinations) stimulate sodium-
glucose transportation in the gastrointestinal tract, which increases water
absorption. They are quite efficient in preventing dehydration and the terrible
repercussions that come with it. Probiotics are live microbial nutrients (yeast
and bacterial strains) that are expected to regulate or restore the composition
of gut microflora, and so may be effective in the diarrhoeal treatment.
However, there is little evidence that probiotic medication decreases pathogen
colonization or helps in protecting against species like Vibrio cholerae or E.
coli in adults (Mittra & Rabani et al., 1990).

During the period of December 2021 - April 2022 Sri Lankan people were
severely infected with more contagious Omicron variant (B.1.411). According
to Menni et al., 2022, the COVID-19 symptoms generated by the Omicron
variation last roughly two days less than the Delta variants
[Link], compared to Delta, a significant Omicron outbreak
was 25% less likely to result in a hospitalization among fully vaccinated
people.

Reduction of symptoms during the period of Omicron was particularly

noticeable in patients who had three vaccination doses. During the Omicron-
dominant months, symptoms remained roughly 5-7 days. The symptoms
reduced to 5-7 days during the period of Omicron was particularly noticeable
in patients who had two vaccination doses. Depending on the results, we can
come to a conclusion that survey participants were infected with Omicron.

CDC 2022 mentioned the symptoms of COVID-19 [Link] cough,

muscle or body aches,diarrhea , fever or chills, loss of taste or smell, nausea or
vomiting, fatigue, congestion or runny nose, sore throat and shortness of
CL/BMS/04/12 APS6022

breath or difficulty breath. According to the survey results 67.3% of

participants had all of the above symptoms and they have confirmed that they
were infected with Covid-19 virus. According to the results, most common
symptoms among survey participants were chills, loss of smell, loss of taste,
dizziness and cough.

Nearly 39% of participants were infected were Covid-19 virus. Among them
33% were tested positive for Covid-19 , merely 59.3% people had mentioned
that they were not tested positive for Covid-19 and at the same time those
59.3% of people have had the same symptoms as a Covid-19 patient. Reason
behind this conflict is as soon as a people gets common symptoms (like cough,
sore throat , runny nose) they are willing to get Covid-19 tests. Hence, there’s
no time for virus to incubate and as a result of that almost all the tests results
are being negative. CDC 2022, recommends to get done a Covid-19 test at
least 5 days after a close interaction with COVID-19 patient was confirmed or
suspected due to the incubation period of the virus.

Results are showing that 100% of participants have not admitted to the
hospital, which indicates that the variation of Covid-19 is not much sever than
the other variations were in Sri Lanka. Moreover, 100% of participants have
used both western and traditional medication. Sri Lanka is a country which is
mainly based on traditional medicine than western medicine.

Majority of people have taken only the 2nd dose. According to Fieselmann et
al., 2022, the findings demonstrate a lack of knowledge among users, as well
as the dissemination of misconceptions about COVID-19 and immunization,
health concerns, insufficient information, organizational mistrust, and all
contribute to a low potential gain of vaccination for COVID-19.

According to Wise et al., 2022 study findings participants were infected in the
period of during the omicron wave were less likely to lose their sense and sore
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throats were more common. Furthermore, half of the study participants had
loss of smell, persistence cough and fever as the most common symptoms of
Omicron wave. When comparing with this survey, all most same percentage
of participants had above symptoms.

In clinical investigations, the rate of diarrhea caused by SARS-CoV-2

infection ranges from2% to 50% of cases, and in a cohort review of twenty
four (24) publications involving three thousand forty two (3042) patients, the
overall diarrhea rate was 10.4% (Gaber, 2020). Guan et al., 2020 stated that
417 out of 1099 COVID-19 patients had diarrhea.

Xu, et al.,2019 stated that patients who had COVID-19 for a short period of
time did not developed diarrhea. However, patients who had symptoms for
more than ten (10) days, developed about 9%. Case reports on COVID-19 in
children is limited; nevertheless, diarrhea was recorded in 8.8% of cases in
171 children, who were averagely 7 years old. (Lu et al., 2020).

According to Klopfenstein, et al., 2020, in a retrospective study conducted at a

hospital in France hospital, diarrhea was a key symptom in forty eight percent
(48%) of patients with SARS-CoV-2 infection, and it was the sixth most
prevalent symptom. Patients ranged in age from 18 to 56 years old, Females
had a higher rate which was 58 percent. It began 4.5 days (1.8) after the onset
of the first gastrointestinal symptoms, and nearly half of the patients
experienced at least one other GI symptom in addition to diarrhea. It's worth
noting that 3.6 percent of patients had been diagnosed with inflammatory
bowel disease earlier

The American Gastroenterological Association (AGA) recently released new

expert recommendations in gastroenterology, stating that while diarrhea can be
the major symptom in COVID-19, as before GI symptoms are unique, with an
overall prevalence of 7.7% (95 percent) for diarrhea and a cohort prevalence
of 7.9% among 35 studies involving 9,717 patients. However, as the epidemic
CL/BMS/04/12 APS6022

spreads and more data is collected globally, these figures may need to be
revised

However, there are some other viral infections which have the diarrhea as
similar symptom.

Table 1: Comparison of viral infections which have diarrhea as a similar symptom

(CDC,2020)

Coronavirus Norovirus Rotavirus

Diarrhea Loose or watery Diarrhea

diarrhea
Nausea Nausea Vomiting
Cough Stomach pain Stools with blood or
black stools
Fever or chills Fever -mild High fever
Vomiting Vomiting Dehydration
Runny nose Abdominal cramps Unresponsiveness
Headache Headache Body pain

Due to the country situation we were unable to conduct a wet laboratory

project. Pan et al., 2020 has mentioned about his Laboratory finding of
symptoms with COVID-19 with diarrhea versus COVID-19 without diarrhea
patients.
CL/BMS/04/12 APS6022

Table 2: Laboratory findings of symptoms with Covid-19 diarrhea and

Covid -19 without diarrhea patients (Pan et al., 2020)

Characteristics COVID-19 with COVID-19 without

diarrhea diarrhea
Alanine Normal range Normal range
aminotransferase
Aspartate Normal range Normal range
aminotransferase
Monocyte count Lower Normal range
Electrolyte No significant difference No significant difference
Blood count No significant difference No significant difference
Kidney function No significant difference No significant difference
Prothrombin level Higher Lower
prolongation

Diagnostics tests

Fasting tests, blood tests, stool tests, hydrogen breath tests and endoscopy
(flexible sigmoidscopy, colonscopy, upper gastrointestinal (GI) endoscopy)
are using to diagnose diarrhea. Furthermore, molecular diagnostic methods
also using to diagnose diarrhea.

According to Platts-Mills et al., 2012, infectious disease diagnosis is becoming

more reliant on molecular diagnostics. Amplification of DNA or RNA is used
in most of these assays, with PCR being the most frequent amplification
approach. Tuberculosis, gonorrhea, chlamydia, and a variety of viral infections
such as coronavirus, norovirus and rotavirus have FDA-approved nucleic acid
amplification tests in the United States. Molecular diagnostic approaches are
beneficial when compared to other diagnosis processes since they target the
pathogen's proteome or genome, making them a reliable and a specific method
of diagnosis.
CL/BMS/04/12 APS6022

The frontline diagnostic strategy for detecting SARS-CoV-2 infection in

suspected patients is real time RT-PCR. A technique, which is a nucleic acid-
based. Even at a low level of pathogens in a sample, RT-PCR method can give
accurate results due to extremely sensitivity. It's a nucleic acid-based approach
for amplifying a target gene/nucleotide present in a sample, which aids in
differentiation and detection a particular disease from other pathogens (Islam
and Iqbal, 2020).

Although quantitative PCR is highly sensitive, molecular methods may result

in the discovery of modest amounts of enteropathogens with unknown clinical
significance. This is especially problematic in developing nations, where some
enteropathogens, such as Giardia lamblia, are prevalent. (Platt-Mills et al.,
2012).

Moreover, single - plex PCR is another diagnostic method. A single pair of

primers is used in singleplex PCR to amplify one target at a time. The
amplified target can be detected using a variety of methods, including
flfluorescent molecules or gel-based electrophoresis with sequence-specific
probes being the most common. Fluorescence can be examined after each
amplification cycle in PCR using these probes or intercalating dyes, and this
method is referred to as "real-time" PCR. PCR has been around for a long time
and is usually more sensitive than other procedures (Platts-Mills et al., 2012).
Both viral and bacterial enteropathogen detection rates increased, and the
number of samples with multiple infections found increased as well. This
approach has been used to detect a variety of viruses from feces, including
Rotavirus, Adenovirus, Astroviruses, and many other enteric viruses (Islam
and Iqbal, 2020).

De Boer et al., 2010 says, it is possible to use a combination of traditional and

molecular approaches to get good results. For instance, PCR could be used as
a high-sensitivity screening test to identify which samples require further
testing.
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Treatment
Replacing fluid and electrolyte loss is a crucial part of diarrhea management
(encourage patients to consume diluted fruit juice). IV fluid rehydration may
be required in more severe episodes of diarrhea. Eating foods with less fiber
may help to firm up your stools. A bland 'BRAT' diet of oatmeal, white rice,
broth/soup, toast, bananas and applesauce, is well tolerated and may help to
alleviate symptoms (Santos, 1986). To lower the frequency of stools, anti-
motility or anti-secretory drugs can be used along with anti-diarrheal therapy.
Those should be avoided by adults who have high fever or bloody diarrhea
since they can exacerbate severe intestinal illnesses. Patients who have more
severe symptoms may benefit from empiric antibiotic therapy with an oral
fluoroquinolone. Supplementing with probiotics has been demonstrated to
lessen the duration of symptoms and the severity in patients with acute
diarrhea, and should be encouraged (Dekate, et al., 2013).

Limitations

In spite of advantages, several limits must be noted.

The questionnaire was administered online, which may increase the number of
people who could participate in the study, which is an added advantage.
However, the age category might be a minor impact on our research study/
survey. The participant cohort was made up of a randomly selected sample of
students. Therefore, gender comparison might be impossible. To confirm the
findings of the current study, more research with larger and more
representative samples are required (e.g., If the survey is doing for 100
participants, the results will be more accurate). Furthermore, due to the reason
of the study depends on participants, the results could be skewed by social
desirability bias. I believe that these limitation impacted our outcomes to some
CL/BMS/04/12 APS6022

level. Furthermore, there’s a high possibility of misleading answers due to

lack of unawareness for the sake of answering.

In future, study might include a greater range of data sources. Future, research
could also look into the value of implementing newly discovered COVID-19-
related symptoms and other viral infections which have the same symptoms
(diarrhea) and it will aid in prevent from misdiagnosis of COVID-19 viral
infection with the other viral infections.

However, we believe the instability of the estimate did not fundamentally

affect our interpretation of the results

Our work includes various flaws that can be exploited in future research. First,
this study can only be considered preliminary; more follow-up tracing
investigations at various stages are needed to track the pandemic's ongoing
effects and the effectiveness of public policy and private sector responses.
Second, the focus of this research is on the impact of diarrhea at the
conclusion of the Covid -19 epidemic. As a result, the results may not be
completely accurate.

Finally, cultural and societal factors could have altered the questionnaire's
construct, as well as its convergent and discriminant validity. As a result, more
applications of this instrument in other countries are needed to acquire more
knowledge about the sources of stress that affect students' wellness in other
countries around the world.
CL/BMS/04/12 APS6022

Conclusion

According to the results obtained from the survey, it shows that diarrhea can
be a mild symptom of Covid-19 patients during the period of survey
conducted. Survey was conducted during the 4th wave of Covid-19 which is
known to be Omicron variant (B.1.411). There’s a mild impact on results due
the below reasons. During the 4th wave of Covid-19, country lock-down was
lifted as well as rules and regulation were diminished. Hence, people moved to
the normal lifestyle. Results indicated that almost every participant had
travelled outside and had food from outside. In conclusion, depending on the
results I believe that, diarrhea might not a direct symptom of Covid-19
patients who had participated in my research survey. Another fact that would
have contributed to increasing the diarrhea might be due to diarrhea patients
having meals from outside which might be spoiled or not in a good condition
due to long term storage of food in previous lock down period.

In other hand, COVID-19 patients are more likely to experience

gastrointestinal symptoms, with almost 50% reporting a gastrointestinal
symptoms in addition to respiratory symptoms and fever. Patients may also
present with stomach problems in the absence of respiratory symptoms in rare
cases. Patients with gastrointestinal symptoms have a longer period from
beginning to admission and evidence of more laboratory derangements,
including higher liver enzymes testing and extended coagulation, when
compared to COVID-19 individuals without digestive symptoms. Digestion
symptoms, such as diarrhea, may be one of COVID-19's presenting features;
they may appear before respiratory symptoms in some cases, and in rare
circumstances, they may be the only presenting symptom of COVID-19.
CL/BMS/04/12 APS6022

References

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3. D’Amico, F., Baumgart, D.C., Danese, S. and Peyrin-Biroulet, L. (2020).

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4. de Boer, R.F., Ott, A., Kesztyüs, B. and Kooistra-Smid, A.M. (2010).

Improved detection of five major gastrointestinal pathogens by use of a
molecular screening approach. J Clin Microbiol. 48,(11):4140-6.
5. Dekate, P., Jayashree, M. and Singhi, S.C. (2013). Management of acute
diarrhea in emergency room. Indian J Pediatr. 80,(3):235-46

6. Fieselmann, J., Annac, K., Erdsiek, F., Yilmaz-Aslan, Y. and Brzoska, P.

(2022). What are the reasons for refusing a COVID-19 vaccine? A
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7. Gillies CL, Rowlands AV, Razieh C, Nafilyan V, Chudasama Y, Islam N,

Zaccardi F, Ayoubkhani D, Lawson C, Davies MJ, Yates T, Khunti K.
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observational study. J R Soc Med. 2022 Apr;115(4):138-144.

8. Gu J., Han B., Wang J. COVID-19: Gastrointestinal manifestations and

potential fecal-oral transmission. [published online ahead of print, 2020
Mar 3] Gastroenterology. 2020:S0016–S5085. (20)3028
CL/BMS/04/12 APS6022

9. Islam, K.U. and Iqbal, J. (2020). An Update on Molecular Diagnostics for

COVID-19. Frontiers in Cellular and Infection Microbiology, 10.

10. Menni, C., Valdes, A.M., Polidori, L., Antonelli, M., Penamakuri, S.,
Nogal, A., Louca, P., May, A., Figueiredo, J.C., Hu, C., Molteni, E.,
Canas, L., Österdahl, M.F., Modat, M., Sudre, C.H., Fox, B., Hammers,
A., Wolf, J., Capdevila, J. and Chan, A.T. (2022). Symptom prevalence,
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SARS-CoV-2 during periods of omicron and delta variant dominance: a
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11. Mitra AK & Rabbani GH. A double-blind, controlled trial of Bioflorin

(Streptococcus faecium SF68) in adults with acute diarrhea due to Vibrio
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12. Motarjemi, Y., Käferstein, F., Moy, G., & Quevedo, F. (1993).
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Wang, J., Hu, C., Jin, Y., Niu, X., Ping, R., Du, Y., Li, T., Xu, G., Hu, Q.,
& Tu, L. (2020). Clinical Characteristics of COVID-19 Patients With
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diagnosis of diarrhea: current status and future potential. Current
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CL/BMS/04/12 APS6022

Appendices

Participant Consent Form

Participant name:

Project title:

Food poisoning or unexplained diarrhea due to viral infections among a Sri Lankan student cohort
during theCOVID-19 pandemic

Name of Principal Investigator:

Indragi Ekanayake

Please complete the following section by putting your signature or initials in the
designated boxes to indicate that you have given informed consent.

1. I confirm that I have understood my role as a participant by reading the

participant information sheet.

2. I confirm that I was given the appropriate time and information needed come to
my decision.

3. I confirm that my involvement in the study is strictly voluntary and no unethical

practice was involved in coercing or influencing my decision.

4. I understand that my responses in the survey are anonymized and cannot be

retracted upon concluding the collection period, which is yet to be determined
due to pending ethical approval.

5. I understand that even after the collection period is over, the university will
retain the anonymized data for verification purposes.

6. I understand that once the data analysis has ended my right to be forgotten and
my right to erase my data cannot be exercised as all the data are anonymized.

7. I give my informed consent to take part in this research.

CL/BMS/04/12 APS6022

Participant’s Signature: Date:

Investigator’s Signature: Date:

Any information you provide will be treated in accordance with data protection
principles for the purposes specified within the Participant Information Sheet.
Cardiff Metropolitan University will process your personal data in line with Article
6(1)(a) and Article 9(2)(a) of the General Data Protection Regulation 2018 which
specifies that your personal data can only be processed with your explicit consent.
By signing this form and ticking the boxes above you are confirming that you have
understood the reasons for obtaining your data and you are happy for the study to
proceed. Please note that you have the right to withdraw consent at any point.
Should you wish to invoke that right please contact healthethics@[Link]
CL/BMS/04/12 APS6022

Food poisoning or unexplained diarrhea due to

viral infections among a Sri Lankan student
cohort during the COVID-19 pandemic

Information Sheet

This research project is mainly focusing on diarrhea developed from different viral infections and diarrhea
associated with Covid-19 infections. Diarrhea is known as the passing of watery or loose stools
more than three times in a day. Diarrhea is mainly caused by consumption of spoiled food or
water containing various viruses, bacteria, and parasites resulting in mild to severe health
outcomes with common symptoms including stomach cramps, nausea, watery diarrhea,
vomiting, fever, headaches and muscle aches.

Recently, scientists have reported COVID-19 virus affecting the digestive tract with COVID-19
patients presenting symptoms of diarrhea. The wide spread of COVID-19 has disrupted the well-
being and world economic activities of people. This survey aims to provide the capability of
identifying new outcomes and generating strategies to create valuable opportunities for a
better exploration of the diarrhea associated viral infection impact of the ongoing Coronavirus
global outbreak. Outcome of the survey helps to understand insights of COVID-19 virus along
with diarrhea.

Data will be collected from consenting participants in the form of an online questionnaire that
will include information on diarrhea related symptoms associated with different viral infections,
similar symptoms associated with Covid-19 infected individuals’ treatment, and recovery.

The data collected will be analyzed to identify the most commonly observed symptoms for the
illness developed by the participants and make comparisons with similar symptoms reported for
COVID-19 patients. The participation would be from a minimum of 50 individuals to ensure the
validity of the data generated and conclusions drawn from the analysis. This survey will not
record identifying personal information (name, contact number, email address, or IP address).
CL/BMS/04/12 APS6022

Therefore, responses will remain anonymous. Collected data will be stored in a password
protected computer which and can only be accessed through the principal supervisor.

This is an online survey and we do not perceive any risk to you in completing it.
CL/BMS/04/12 APS6022

Questionnaire on diarrhea and related symptoms in

COVID-19 infectedindividuals
Thank you very much for your willingness to participate in a survey study titled, “Food
poisoning or unexplained diarrhea due to viral infections among a Sri Lankan student cohort
during COVID-19 pandemic “.No personally identifiable information will be collected.

Part A: Demographics

1. Gender: ⃝ Male ⃝ Female

2. Age:

3. Education level ⃝ University: Bachelor ⃝ University: Master or PhD

4. Residential area during

the COVID-19 outbreak. Please specify City

5. Household size: ⃝ 1 person ⃝ 2 persons ⃝ 3-5 persons ⃝ 6 persons or more

Part B: Symptoms and physical health status

7. Have you experienced diarrhea during past 2 months?

⃝ No ⃝ Yes

8. Have you traveled outside of your resident in the past 2months? ⃝ No ⃝ Yes

9. Have you taken food from outside during past 2 months? ⃝ No ⃝ Yes
CL/BMS/04/12 APS6022

10. If yes, rate the severity of diarrhea, ⃝ Minimal ⃝ Moderate ⃝ Severe

11. Diarrhea frequency (how many times) per day? ⃝ Twice ⃝ Thrice ⃝ More

12. During last 2 months when you had diarrhea did you,

suddenly pass stools ⃝ No ⃝ Yes experience abdominal discomfort ⃝

No ⃝ yes

13. Were you vaccinated when you tested positive for Covid-19?

⃝ Fully (2 dose) ⃝ 1 dose ⃝No

[Link] taken to recover from symptoms

[Link] you experienced any of the below symptoms during diarrhea?

Stomach cramps ⃝ No ⃝ Yes

Nausea and vomiting ⃝ No ⃝ Yes
Headache ⃝ No ⃝ Yes

16. Appetite during diarrhea, ⃝ Less ⃝ Moderate ⃝ High

[Link] you taken any self-medication for diarrhea? ⃝ No ⃝ Yes

[Link] yes, did it help your diarrhea? ⃝ No ⃝ Yes

CL/BMS/04/12 APS6022

Part C: Covid related symptoms and information

[Link] of body discomfort in the past 2 months (please check all that apply)

⃝ Persistent fever (>38°C for at least 1 day)

⃝Chills ⃝ Dizziness

⃝ Loss of taste ⃝ Diarrhea

⃝ Sore throat ⃝ Headaches

⃝ Loss of smell ⃝ Cough

⃝Difficulty breathing ⃝ Persistent fever and cough or difficulty breathing

[Link] you directly or indirectly had contact with patients suffering from COVID-19 in past 2
months?

⃝ No (skip to Part D) ⃝ Yes

21. Were you tested for COVID-19 in the past 2 months? ⃝ No ⃝ Yes

[Link] you under quarantine by government health officer in the 2 months?

⃝ No ⃝ Yes

[Link] you admitted to the hospital in the past 2 months? ⃝ No ⃝ Yes

[Link] received ⃝ Local ⃝ Western ⃝Both

CL/BMS/04/12 APS6022