All-cause Diarrhea Research Articles

Rapid impact of rotavirus vaccine introduction to the National Immunization Plan in Southern Israel: Comparison between 2 distinct populations

BackgroundRotavirus vaccines were licensed in Israel in 2007, and in 2011 the pentavalent-vaccine (RV5) was introduced into the Israeli National Immunization plan. AimTo determine the effect of rotavirus-vaccines on the incidence of hospital visits due to rotavirus gastroenteritis (RVGE) and all-cause diarrhea in Jewish and Bedouin children <5 year residing in southern Israel. MethodsWe conducted a population-based, prospective, observational study. Data from 2006 through 2013 were analyzed. Our hospital is the only medical center in the region, enabling age-specific incidences calculation. ResultsIn the pre-vaccine period, the overall RVGE hospital visits rates per 1000 in children <12, 12–23 and 24–59m were 16.1, 18.6 and 1.4 in Jewish children, respectively. The respective rates in Bedouin children were 26.4, 12.5 and 0.7 (P<0.001 for <12m).Hospitalization rates were higher among Bedouin than among Jewish children (60.0% vs. 39.7%, P<0.001). Vaccine uptake was faster in the Jewish vs. the Bedouin population.In the year following RV5 introduction, RVGE hospital visits rates declined by 82%, 70% (P<0.001 both) and 36% (P=0.092) in Jewish children <12, 12–23 and 24–59m, respectively. In Bedouin children, the respective RVGE rates declined by 70% (P<0.001), 21% (P=ns) and 14% (P=ns).Throughout the study, RVGE rates declined significantly in children <12, and 12–23m by 80% and 88% in Jewish children, respectively, and by 62 and 75% in Bedouin children, respectively (P<0.001 for all declines). In children 24–59m, RVGE rates declined by 46% (P=0.025) in Jewish children, but no reduction was observed in Bedouin children. The dynamics of all-cause diarrhea rates were similar to that of RVGE. ConclusionsSignificant reductions of RVGE rates were observed, following Rota-vaccine introduction in southern Israel in both Jewish and Bedouin children. However, the impact was faster and more profound in Jewish children, probably related to higher vaccine uptake and possibly to lifestyle differences.

Decline in severe diarrhea hospitalizations after the introduction of rotavirus vaccination in Ghana: a prevalence study.

BackgroundAlmost all diarrhea deaths in young children occur in developing countries. Immunization against rotavirus, the leading cause of childhood severe dehydrating acute diarrhea may reduce the burden of severe diarrhea in developing countries. Ghana introduced rotavirus and pneumococcal vaccination in the national expanded program on immunization in May 2012.MethodsReview of all-cause diarrheal hospitalization data for children aged 59 months and younger at 2 pediatric referral hospitals in southern Ghana from 2008 to 2014. The proportion of acute diarrhea (defined as 3 or more watery, non-bloody stools within 24 hours that has lasted for less than 7 days) cases caused by rotavirus was determined. Temporal trend and age group distribution of all-cause diarrhea and rotavirus gastroenteritis before and after introduction of the new vaccines were compared.ResultsOf the 5847 children hospitalized with all-cause diarrhea during the 74 months (January 2008 – February 2014), 3963 (67.8%) children were recruited for rotavirus surveillance and stool specimens were tested for rotavirus in 3160/3963 (79.7%). Median monthly hospitalization for all-cause diarrhea reduced from 84 [interquartile range (IQR) 62 – 105] during the 52 months pre-vaccination introduction to 46 (IQR 42 - 57) in the 22 months after implementation of vaccination. Significant decline in all-cause diarrhea hospitalization occurred in children aged 0 - 11 months: 56.3% (2711/4817) vs. 47.2% 486/1030 [p = 0.0001, 95% confidence interval (CI) 0.77 – 0.88] and there was significant reduction of rotavirus gastroenteritis hospitalization: 49.7% (1246/2505) vs. 27.8% (182/655) [p = 0.0001, 95% CI 0.32 - 0.47] before and after vaccine introduction respectively.ConclusionsImplementation of rotavirus vaccination program may have resulted in significant reduction of severe diarrhea hospitalization even though this observational study could not exclude the effect of other confounding factors. Continued surveillance is recommended to monitor the progress of this program.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-431) contains supplementary material, which is available to authorized users.

Bovine complex milk lipid containing gangliosides for prevention of rotavirus infection and diarrhoea in northern Indian infants.

Rotavirus (RV) is a leading cause of morbidity and mortality in children younger than 5 years of age, presenting commonly with diarrhoeal symptoms. In a prospective 12-week double-blind randomised controlled trial we assessed acceptability and efficacy of a high-ganglioside complex milk lipid (CML) for prevention of RV infection in 450 infants, ages 8 to 24 months, at 3 sites in northern India. Prevalence of diarrhoea and RV was unseasonably low at baseline (all-cause diarrhoea [ACD], n = 16; RV diarrhoea [RVD], n = 2; RV infection, RV positive [RV+], n = 20) and throughout the trial, with only 110 total episodes of ACD for 12 weeks (CML, n = 62; control, n = 48) of which 10 were RVD (CML, n = 4; control, n = 6). Mean duration that RVD persisted was lower in the CML group (2.3 ± 0.5 days) than that in the control group (3.8 ± 1.3 days, P = 0.03), but only 3 of 450 end of trial stool samples were identified as RV+ (<1%; CML, n = 2; control, n = 1). This hampered the assessment of efficacy of CML, despite the large a priori determined sample size. During the trial similar numbers of infants reported adverse events (AEs: CML 41%, control 46%), with the majority of events classified as mild and not related to the intervention. In conclusion, further clinical trials against a higher background of seasonal prevalence are necessary to assess efficacy of this nutritional intervention to prevent RVD. More important, however, high-ganglioside CML was acceptable for long-term consumption in infants ages 8 to 24 months.

Rotavirus vaccines in routine use.

Vaccines are now available to combat rotavirus, the most common cause of severe diarrhea among children worldwide. We review clinical trial data for available rotavirus vaccines and summarize postlicensure data on effectiveness, impact, and safety from countries routinely using these vaccines in national programs. In these countries, rotavirus vaccines have reduced all-cause diarrhea and rotavirus hospitalizations by 17%-55% and 49%-92%, respectively, and all-cause diarrhea deaths by 22%-50% in some settings. Indirect protection of children who are age-ineligible for rotavirus vaccine has also been observed in some high and upper middle income countries. Experience with routine use of rotavirus vaccines in lower middle income countries has been limited to date, but vaccine introductions in such countries have been increasing in recent years. The risk-benefit analysis of rotavirus vaccines is extremely favorable but other strategies to improve the effectiveness of the vaccine, particularly in lower middle income settings, should be considered.

Preventive zinc supplementation for children, and the effect of additional iron: a systematic review and meta-analysis

ObjectiveZinc deficiency is widespread, and preventive supplementation may have benefits in young children. Effects for children over 5 years of age, and effects when coadministered with other micronutrients are uncertain....

Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years of age.

Zinc deficiency is prevalent in low- and middle-income countries, and contributes to significant diarrhoea-, pneumonia-, and malaria-related morbidity and mortality among young children. Zinc deficiency also impairs growth. To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged six months to 12 years of age. Between December 2012 and January 2013, we searched CENTRAL, MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, Embase, African Index Medicus, Conference Proceedings Citation Index, Dissertation Abstracts, Global Health, IndMED, LILACS, WHOLIS, metaRegister of Controlled Trials, and WHO ICTRP. Randomised controlled trials of preventive zinc supplementation in children aged six months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalised children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions. Two authors screened studies, extracted data, and assessed risk of bias. We contacted trial authors for missing information. We included 80 randomised controlled trials with 205,401 eligible participants. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes were affected by risk of bias. The risk ratio (RR) for all-cause mortality was compatible with a reduction and a small increased risk of death with zinc supplementation (RR 0.95, 95% confidence interval (CI) 0.86 to 1.05, 14 studies, high-quality evidence), and also for cause-specific mortality due to diarrhoea (RR 0.95, 95% CI 0.69 to 1.31, four studies, moderate-quality evidence), lower respiratory tract infection (LRTI) (RR 0.86, 95% CI 0.64 to 1.15, three studies, moderate-quality evidence), or malaria (RR 0.90, 95% CI 0.77 to 1.06, two studies, moderate-quality evidence).Supplementation reduced diarrhoea morbidity, including the incidence of all-cause diarrhoea (RR 0.87, 95% CI 0.85 to 0.89, 26 studies, moderate-quality evidence), but the results for LRTI and malaria were imprecise: LRTI (RR 1, 95% CI 0.94 to 1.07, 12 studies, moderate-quality evidence); malaria (RR 1.05, 95% 0.95 to 1.15, four studies, moderate-quality evidence).There was moderate-quality evidence of a very small improvement in height with supplementation (standardised mean difference (SMD) -0.09, 95% CI -0.13 to -0.06; 50 studies), but the size of this effect might not be clinically important. There was a medium to large positive effect on zinc status.Supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46, five studies, high-quality evidence). We found no clear evidence of benefit or harm of supplementation with regard to haemoglobin or iron status. Supplementation had a negative effect on copper status. In our opinion, the benefits of preventive zinc supplementation outweigh the harms in areas where the risk of zinc deficiency is relatively high. Further research should determine optimal intervention characteristics such as supplement dose.

The effect of pharmacy restriction of clindamycin on Clostridium difficile infection rates in an orthopedics ward

A high consumption of clindamycin was noted in an orthopedics ward with high rates of Clostridium difficile infection (CDI). We restricted clindamycin for the entire ward. A reduction of 88% in CDI (1.07 to 0.12 × 1,000 patients-days, P = .056) and 84% for all-cause diarrhea (2.40 to 0.38 × 1,000 patients-days, P = .021) was achieved. Clindamycin was reduced 92.61% without an increase in other antibiotics. We identified high consumption of clindamycin as a risk factor for CDI.

Efficacy of a Travelers' Diarrhea Vaccine System in Travelers to India: Table 1

A patch vaccine containing heat-labile toxin (LT) from enterotoxigenic Escherichia coli (ETEC) has demonstrated to be beneficial in reducing the rate and severity of travelers' diarrhea in Latin America. To evaluate the efficacy of this transdermal vaccine system in an area with a different diarrheal pathogen profile, an additional phase 2 study was conducted in European travelers to India. For this multicenter, randomized, double-blinded, placebo-controlled field study 723 subjects were recruited; 603 (299 LT vaccine, 304 placebo) were included in the per-protocol-population (PPP). Although the LT patch induced a measurable LT immune response in recipients, it failed to protect against LT ETEC or all-cause diarrhea. In the PPP the incidence rate of diarrhea as per primary endpoint was 6.0% (18 of 299) in the vaccine group and 5.9% (18 of 304) in the placebo group. Additionally, lower than expected rates of LT ETEC diarrheas were observed in India. The vaccine delivery system frequently produced rash and pruritus at the site of application, long term hyperpigmentation persisted in a minority of LT recipients, and also few site reactions were noted in the placebo group. The evaluated patch vaccine failed to satisfy mainly with respect to protective efficacy. Noninvasive prophylactic agents against travelers' diarrhea, particularly vaccines against the most frequent pathogens, thus continue to be badly needed.

Impact of non-routine rotavirus vaccination on hospitalizations for diarrhoea and rotavirus infections in Spain

This study shows hospital discharges related to all-cause diarrhoea and rotavirus infection in children up to five years of age from 2005 to 2009 in Spain. Rotavirus vaccines have been available in Spain since late 2006 and early 2007. They are neither funded nor reimbursed by the National Health Care System. However, they are recommended by the Spanish Association of Pediatricians and prescribed by paediatricians. The vaccination coverage was 17% in 2007, 35% in 2008 and 38% in 2009. Among a total of 111,738 hospitalizations recorded, 24% (N=26,500) were coded as rotavirus and 14% (N=16,217) as diarrhoea of undetermined aetiology. The overall annual incidence of hospitalization was 991,235 and 144 per 100,000 children up to five years of age for all-causes diarrhoea, rotavirus infection and diarrhoea of undetermined aetiology respectively. The annual rate significantly decreased during the study period.Hospitalization rates for all-cause diarrhoea, rotavirus infection and diarrhoea of undetermined aetiology in children under five years of age in 2009 were 35, 37 and 36% lower than in the period 2005–2006, before rotavirus vaccine introduction. This decrease was greater in children <12 months of age: 42% for all-cause diarrhoea and 43% for rotavirus and diarrhoea of undetermined aetiology.The use of rotavirus vaccines, with relatively low vaccination coverage, in Spain has been shown to decrease hospitalizations for rotavirus gastroenteritis and all-cause diarrhoea during the study period.

Vaccines for preventing enterotoxigenicEscherichia coli(ETEC) diarrhoea

Infection with enterotoxigenic Escherichia coli (ETEC) bacteria is a common cause of diarrhoea in adults and children in developing countries and is a major cause of 'travellers' diarrhoea' in people visiting or returning from endemic regions. A killed whole cell vaccine (Dukoral®), primarily designed and licensed to prevent cholera, has been recommended by some groups to prevent travellers' diarrhoea in people visiting endemic regions. This vaccine contains a recombinant B subunit of the cholera toxin that is antigenically similar to the heat labile toxin of ETEC. This review aims to evaluate the clinical efficacy of this vaccine and other vaccines designed specifically to protect people against diarrhoea caused by ETEC infection. To evaluate the efficacy, safety, and immunogenicity of vaccines for preventing ETEC diarrhoea. We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and http://clinicaltrials.gov up to December 2012. Randomized controlled trials (RCTs) and quasi-RCTs comparing use of vaccines to prevent ETEC with use of no intervention, a control vaccine (either an inert vaccine or a vaccine normally given to prevent an unrelated infection), an alternative ETEC vaccine, or a different dose or schedule of the same ETEC vaccine in healthy adults and children living in endemic regions, intending to travel to endemic regions, or volunteering to receive an artificial challenge of ETEC bacteria. Two authors independently assessed each trial for eligibility and risk of bias. Two independent reviewers extracted data from the included studies and analyzed the data using Review Manager (RevMan) software. We reported outcomes as risk ratios (RR) with 95% confidence intervals (CI). We assessed the quality of the evidence using the GRADE approach. Twenty-four RCTs, including 53,247 participants, met the inclusion criteria. Four studies assessed the protective efficacy of oral cholera vaccines when used to prevent diarrhoea due to ETEC and seven studies assessed the protective efficacy of ETEC-specific vaccines. Of these 11 studies, seven studies presented efficacy data from field trials and four studies presented efficacy data from artificial challenge studies. An additional 13 trials contributed safety and immunological data only. Cholera vaccinesThe currently available, oral cholera killed whole cell vaccine (Dukoral®) was evaluated for protection of people against 'travellers' diarrhoea' in a single RCT in people arriving in Mexico from the USA. We did not identify any statistically significant effects on ETEC diarrhoea or all-cause diarrhoea (one trial, 502 participants, low quality evidence).Two earlier trials, one undertaken in an endemic population in Bangladesh and one undertaken in people travelling from Finland to Morocco, evaluated a precursor of this vaccine containing purified cholera toxin B subunit rather than the recombinant subunit in Dukoral®. Short term protective efficacy against ETEC diarrhoea was demonstrated, lasting for around three months (RR 0.43, 95% CI 0.26 to 0.71; two trials, 50,227 participants). This vaccine is no longer available. ETEC vaccinesAn ETEC-specific, killed whole cell vaccine, which also contains the recombinant cholera toxinB-subunit, was evaluated in people travelling from the USA to Mexico or Guatemala, and from Austria to Latin America, Africa, or Asia. We did not identify any statistically significant differences in ETEC-specific diarrhoea or all-cause diarrhoea (two trials, 799 participants), and the vaccine was associated with increased vomiting (RR 2.0, 95% CI 1.16 to 3.45; nine trials, 1528 participants). The other ETEC-specific vaccines in development have not yet demonstrated clinically important benefits. There is currently insufficient evidence from RCTs to support the use of the oral cholera vaccine Dukoral® for protecting travellers against ETEC diarrhoea. Further research is needed to develop safe and effective vaccines to provide both short and long-term protection against ETEC diarrhoea.

Promoting appropriate management of diarrhea: A systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India

Scaling up of evidence-based management and prevention of childhood diarrhea is a public health priority in India, and necessitates robust literature review, for advocacy and action. To identify, synthesize and summarize current evidence to guide scaling up of management of diarrhea among under-five children in India, and identify existing knowledge gaps. A set of questions pertaining to the management (prevention, treatment, and control) of childhood diarrhea was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. Childhood diarrhea is a significant public health problem in India; the point (two weeks) prevalence is 9 to 20%. Diarrhea accounts for 14% of the total deaths in under-five children in India. Infants aged 6 to 24 months are at the highest risk of diarrhea. There is a lack of robust nation-wide data on etiology; rotavirus and diarrheogenic E.coli are the most common organisms identified. The current National Guidelines are sufficient for case-management of childhood diarrhea. Exclusive breastfeeding, handwashing and point of use water treatment are effective strategies for prevention of all-cause diarrhea; rotavirus vaccines are efficacious to prevent rotavirus specific diarrhea. ORS and zinc are the mainstay of management during an episode of childhood diarrhea but have low coverage in India due to policy and programmatic barriers, whereas indiscriminate use of antibiotics and other drugs is common. Zinc therapy given during diarrhea can be upscaled through existing infrastructure is introducing the training component and information, education and communication activities. This systematic review summarizes current evidence on childhood diarrhea and provides evidence to inform child health programs in India.

Impact of rotavirus vaccination on diarrhoea mortality and hospital admissions in Brazil

To analyse the data reported by the national surveillance system of Brazil, including data on diarrhoea mortality and hospital admissions before and after rotavirus vaccine introduction, and evaluate the impact of its widespread use under operational conditions. Retrospective analysis of routinely collected data was reported by several surveillance systems of Brazil, comprising an 8-year period of all diarrhoea-related hospitalisations and deaths in children <5 years old (2002-2009). Linear regressions were used to compare trends of diarrhoea hospitalisations and deaths before and after vaccine introduction (2002-2005 vs. 2006-2009). There was a long-term reduction in hospitalisations that preceded the introduction of the vaccine. This reduction was more marked in <1-year-old than in 1- to 4-year-old children. All-cause diarrhoea hospitalisations decreased further after vaccine introduction and the decrease was larger in <1-year-old (-35.6%) than in 1- to 4-year-old children (-12.3%). The number of deaths was decreasing before vaccine introduction, and the decrease also accelerated after vaccine introduction, with deaths halving in <1-year-old and decreasing by 32.9% in 1- to 4-year-old children. The linear relationships between hospitalisations and deaths were statistically different before and after vaccine introduction. The data demonstrate a decreasing trend in all-cause diarrhoea-related hospitalisations and deaths in children <5 years of age. These reductions were steeper between 2006 and 2009, highlighting the potential beneficial effect of the rotavirus vaccine associated with all-cause diarrhoeal disease.

Acute diarrhoea in a community cohort of children who received an oral rotavirus vaccine in Northeast Brazil

Rotavirus is an important cause of childhood diarrhoea. A monovalent rotavirus vaccine (Rotarix®) was introduced into the Immunization Program of Brazil in 2006. In this study, we describe the incidence and burden of disease of rotavirus diarrhoea in two cohorts of children (vaccinated and unvaccinated). We followed two groups of 250 children under one year old, who were enrolled in December 2006 from a low-income residential area in Northeast Brazil. The children were monitored every two weeks for two years. Stool samples from children with diarrhoea were examined for the presence of rotavirus. Rotaviruses were genotyped using real time-polymerase chain reaction. The mean numbers of all-cause diarrhoea episodes/child (adjusted for age) in the first year were 0.87 and 0.84, in vaccinated and unvaccinated children, respectively. During the second year, the number of episodes/child decreased to 0.52 and 0.42. Only 16 (4.9%) of 330 stool samples were rotavirus-positive (10 vaccinated and 6 unvaccinated children) and only P[4]G2 rotaviruses were identified. All-cause diarrhoea episodes were more severe in unvaccinated children in the first year of age (p < 0.05), while vaccinated children had more severe episodes 18 months after vaccination. Rotavirus diarrhoea incidence was very low in both groups.

Decline in Rotavirus Hospitalizations and Health Care Visits for Childhood Diarrhea Following Rotavirus Vaccination in El Salvador

A recent postlicensure study from El Salvador showed that the monovalent rotavirus vaccine conferred 76% protection against rotavirus hospitalizations. We further examined the impact of rotavirus vaccination on the national burden of childhood diarrhea to help assess the total public health benefits of vaccination. We compared all-cause diarrhea and rotavirus-specific hospitalization rates during prevaccine year 2006, with postvaccine years 2008 and 2009 in children < 5 years of age from 7 sentinel surveillance hospitals. We also compared annual rates of diarrhea-related healthcare events during prevaccine years 2005 and 2006 with postvaccine years 2008 and 2009 to examine the national burden of healthcare utilization for all-cause diarrhea. Among sentinel surveillance hospitals, rotavirus hospitalization rates among children < 5 years of age declined by 81% (95% confidence interval [CI]: 78%-84%) in 2008 when 2-dose rotavirus vaccine coverage was 50% among infants < 1 year; the decline was 69% (95% CI: 65%-73%) in 2009 when 2-dose vaccine coverage was 61% among infants < 1 year, compared with 2006. The greatest declines were observed in children ≤ 1 year of age, although sizeable reductions were also observed among children ≥ 2 years in 2008. National diarrhea-related healthcare visits during rotavirus season decreased by 48% (95% CI: 47%-48%) in 2008 and by 35% (95% CI: 34%-35%) in 2009 compared with the mean rate from the 2005 and 2006 rotavirus seasons. Rotavirus vaccination had a substantial public health impact on rotavirus disease and overall diarrhea events in El Salvador. Important age-related changes in diarrheal incidence emphasize the need for ongoing rotavirus surveillance after vaccine introduction.

Cochrane review: Polymer‐based oral rehydration solution for treating acute watery diarrhoea

AbstractBackgroundAcute diarrhoea is one of the principal causes of morbidity and mortality among children in low‐income countries. Glucose‐based ORS helps replace fluid and prevent further dehydration from acute diarrhoea. Since 2004, the World Health Organization has recommended the osmolarity &lt; 270 mOsm/L (ORS ≤ 270 ) over the &gt; 310 mOsm/L formulation (ORS ≥ 310). Glucose polymer‐based ORS (eg prepared using rice or wheat) slowly releases glucose and may be superior.ObjectivesTo compare polymer‐based ORS with glucose‐based ORS for treating acute watery diarrhoea.Search strategyIn September 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library2008, Issue 3), MEDLINE, EMBASE, LILACS, andmRCT. We also contacted researchers, organizations, and pharmaceutical companies, and searched reference lists.Selection criteriaRandomized controlled trials of people with acute watery diarrhoea (cholera and non‐cholera associated) comparing polymer‐based and glucose‐based ORS (with identical electrolyte contents).Data collection and analysisTwo authors independently assessed the search results and risk of bias, and extracted data. In multiple treatment arms with two or more treatment groups, we combined outcomes as appropriate and compared collectively with the control group.Main resultsThirty‐four trials involving 4214 participants met the inclusion criteria: 27 in children, five in adults and two in both. Twelve trials used adequate methods to conceal allocation. Most compared polymer‐based ORS with ORS ≥ 310. There were fewer unscheduled intravenous infusions in the polymer‐based ORS group compared with glucose‐based ORS (ORS ≥ 310 and ≤ 270 groups combined) (RR 0.75, 95% CI 0.59 to 0.95; 2235 participants, 19 trials). Adults positive forVibrio choleraehad a shorter duration of diarrhoea with polymer‐based ORS than with ORS ≤ 270 (MD ‐7.11 hours, SD ‐11.91 to ‐2.32; 228 participants, 4 trials). Wheat‐based ORS resulted in lower total stool output in the first 24 hours compared with ORS ≤ 270 (MD ‐119.85 g/kg, SD ‐114.73 to ‐124.97; 129 participants, 2 trials). Adverse effects were similar for polymer‐based ORS and glucose‐based ORS.Authors' conclusionsPolymer‐based ORS shows some advantages compared to ORS ≥ 310 for treating all‐cause diarrhoea, and in diarrhoea caused by cholera. Comparisons favoured the polymer‐based ORS over ORS ≤ 270, but the analysis was underpowered. If specialists consider a potential role for polymer‐based ORS, further trials against the current standard (ORS ≤ 270) will be required.Plain Language SummaryPolymer‐based oral rehydration solution (ORS) ORS for acute diarrhoeaAcute diarrhoea is a common cause of death and illness in developing countries. Oral rehydration solutions (ORS) have had a massive impact worldwide in reducing the number of deaths related to diarrhoea.Most ORS is in the form of a sugar–salt solution, but over the years people have tried adding a variety of compounds ('glucose polymers') such as whole rice, wheat, sorghum, and maize. The aim is to slowly release glucose into the gut and improve the absorption of the water and salt in the solution. This review updates and expands on a 1998 Cochrane Review of rice‐based ORS, and assesses the available evidence on the use of polymer‐based ORS (both rice and non‐rice based) in comparison with the glucose‐based ORS.The original ORS was based on glucose and had an osmolarity of ≥ 310 mOsm/L (ORS ≥ 310). Glucose‐based ORS with a lower osmolarity was later introduced in attempts to improve efficacy, and is considered better at reducing the amount and duration of diarrhoea.Thirty‐four trials involving 4214 participants met the inclusion criteria: 27 in children; five in adults; and two in both. Most trials compared polymer‐based ORS with a sugar–salt ORS with a particular strength (ORS ≥ 310), which is slightly more salty than the currently agreed best formula (≤ 270 mOsm/L). The trials' methodological quality was variable.Fewer people in the polymer‐based ORS group needed a drip to be rehydrated compared with those in the glucose‐based ORS group. Adverse events were similar for polymer‐based ORS and glucose‐based ORS.The authors conclude that polymer‐based ORS show some advantages compared to glucose‐based ORS for treating diarrhoea of any cause and in diarrhoea caused by cholera. Limited evidence favoured the polymer‐based ORS over ORS ≤ 270. Further trials should compare the efficiency of ORS ≤ 270 with a polymer‐based ORS.

Incidence of Rotavirus and All-Cause Diarrhea in Northeast Brazil Following the Introduction of a National Vaccination Program

Rotavirus vaccines were introduced in Brazil in 2006; we evaluated their effects in the state of Sergipe, Brazil. We performed a cross-sectional survey of children with diarrhea attending emergency services in Aracaju, Brazil, between October 2006 and April 2008 and a cluster sampling survey to assess vaccination coverage. Vaccine efficacy was assessed using the screening method. Diarrhea consultation and hospitalization data (2003-2007) were obtained from state and national surveillance systems. Rotavirus was detected in 59 of 534 stool samples (11%) from children attending emergency services. The number of rotavirus-positive samples decreased from 18 of 74 (24%) in 2006 to 31 of 321 (9.5%) in 2007 and 10 of 136 (7.4%) in 2008 (P < .01). Diarrhea severity was greater in children with rotavirus (P < .01) but decreased over time (P < .001). Of the rotaviruses detected, 56 of 59 (95%) were P[4]G2 genotype, 1 was P[4]G-non-typeable (NT), 1 was P[NT]G2, and 1 was P[NT]GNT. Diarrhea consultations decreased from 3020 in 2004 to 604 in 2007; reductions were greatest among children under 5 years old. Diarrhea hospitalizations decreased from 2121 in 2003 to 1176 in 2007. Vaccine coverage was 90.3%. Vaccines were highly effective against the strain P[8]G1; efficacy against P[4]G2 genotype was 89% (95% confidence interval: 0.87-0.92) in Aracaju and 95% in Sergipe. Since vaccines were introduced in 2006, there has been an overall reduction in diarrhea consultations and hospitalizations in northeast Brazil, with the greatest reductions in young children. This might have resulted from vaccination and improved sanitation. Although a single rotavirus genotype (P[4]G2) was recovered, vaccine efficacy was high against this genotype.

Clostridium difficile Infections in Children

Clostridium difficile Infections in Children

Estimates of the economic burden of rotavirus‐associated and all‐cause diarrhoea in Vellore, India

To determine the cost of rotavirus and all-cause diarrhoea in Vellore, India. Parents of children <5 years of age accessing clinics, emergency rooms, or hospitals for acute diarrhoea completed a questionnaire detailing healthcare utilisation, medical and non-medical expenditures, and lost income. Faecal samples were screened for rotavirus and medical records were examined. Costs were estimated for inpatient and outpatient resource consumption, stratified by facility. Total societal costs of a hospitalised diarrhoeal episode were Rs 3278.50 (US$ 80.80) at a large referral hospital and Rs 1648.60 (US$ 40.60) at a smaller community hospital. Costs for rotavirus positive or negative gastroenteritis were similar. Median household expenditures per diarrhoeal episode at the referral and the community hospitals equalled 5.8% and 2.2% of the annual household income, respectively. Diarrhoeal disease in children constitutes a considerable economic burden. An appropriately priced and effective rotavirus vaccine may provide significant economic savings for the Indian household and healthcare system.

Environmental change and infectious disease: How new roads affect the transmission of diarrheal pathogens in rural Ecuador

Environmental change plays a large role in the emergence of infectious disease. The construction of a new road in a previously roadless area of northern coastal Ecuador provides a valuable natural experiment to examine how changes in the social and natural environment, mediated by road construction, affect the epidemiology of diarrheal diseases. Twenty-one villages were randomly selected to capture the full distribution of village population size and distance from a main road (remoteness), and these were compared with the major population center of the region, Borbón, that lies on the road. Estimates of enteric pathogen infection rates were obtained from case-control studies at the village level. Higher rates of infection were found in nonremote vs. remote villages [pathogenic Escherichia coli: odds ratio (OR) = 8.4, confidence interval (CI) 1.6, 43.5; rotavirus: OR = 4.0, CI 1.3, 12.1; and Giardia: OR = 1.9, CI 1.3, 2.7]. Higher rates of all-cause diarrhea were found in Borbón compared with the 21 villages (RR = 2.0, CI 1.5, 2.8), as well as when comparing nonremote and remote villages (OR = 2.7, CI 1.5, 4.8). Social network data collected in parallel offered a causal link between remoteness and disease. The significant and consistent trends across viral, bacterial, and protozoan pathogens suggest the importance of considering a broad range of pathogens with differing epidemiological patterns when assessing the environmental impact of new roads. This study provides insight into the initial health impacts that roads have on communities and into the social and environmental processes that create these impacts.

Rotavirus vaccine for preventing diarrhoea.

Rotaviruses cause viral gastroenteritis and result in more deaths from diarrhoea in children under 5 years of age than any other single agent, particularly in low- and middle-income countries. To assess rotavirus vaccines in relation to preventing rotavirus diarrhoea, death, and adverse events. We searched the Cochrane Infectious Diseases Group's trial register (October 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to October 2003), EMBASE (January 1980 to October 2003), LILACS (1982 to October 2003), Biological Abstracts (January 1982 to October 2003), reference lists of articles, and contacted researchers and rotavirus vaccine manufacturers. Randomized controlled trials comparing rotavirus vaccines to placebo, no intervention, or other rotavirus vaccines in children and adults. Two reviewers independently extracted data and assessed trial methodological quality, and contacted trial authors for additional information. Sixty-four trials provided information on efficacy and safety of three main types of rotavirus vaccine (bovine, human, and rhesus) for 21,070 children. Different levels of efficacy were demonstrated with different vaccines varying from 22 to 89% to prevent one episode of rotavirus diarrhoea, 11 to 44% to prevent one episode of all-cause diarrhoea, and 43 to 90% to prevent one episode of severe rotavirus diarrhoea. Rhesus vaccine demonstrated a similar efficacy against one episode of rotavirus diarrhoea (37 and 44% respectively), and one episode of all-cause diarrhoea (around 15%) for trials performed in high and middle-income countries. Results on mortality and safety of the vaccines were scarce and incomplete. We noticed important heterogeneity among the pooled studies and were unable to discard a biased estimation of effect. Current evidence shows that rhesus rotavirus vaccines (particularly RRV-TV) and the human rotavirus vaccine 89-12 are efficacious in preventing diarrhoea caused by rotavirus and all-cause diarrhoea. Evidence about safety, and about mortality or prevention of severe outcomes, is scarce and inconclusive. Bovine rotavirus vaccines were also efficacious, but safety data are not available. Trials of new rotavirus vaccines will hopefully improve the evidence base. Randomized controlled trials should be performed simultaneously in high-, middle-, and low-income countries.