Diarrhea In Bangladesh Research Articles

A Randomized Four Cell Clinical Trial of Zinc and Vitamin A in Undernourished Children with Persistent Diarrhoea in Bangladesh

A Randomized Four Cell Clinical Trial of Zinc and Vitamin A in Undernourished Children with Persistent Diarrhoea in Bangladesh

Aetiological, clinical and epidemiological characteristics of a seasonal peak of diarrhoea in Dhaka, Bangladesh.

During the spring peak of diarrhoea in Bangladesh, 113 consecutive patients who represented a systematic 4% sample of all patients attending an urban diarrhoea treatment facility between 18 and 23 April 1995 were studied. The study was conducted to characterize enteric pathogens associated with the spring peak of the diarrhoea outbreak in Bangladesh and to describe clinical and epidemiological features of the patients. The spring peak is traditionally thought to be mostly due to V. cholerae O1. However, the most common cause of diarrhoea among the study patients was enterotoxigenic Escherichia coli (36%) followed by Vibrio cholerae O1 (23%). The V. cholerae O1 patients attended significantly (p < 0.01) sooner after onset of diarrhoea than enterotoxigenic E. coli (ETEC) patients. Studies of behavioural and environmental characteristics are important to determine risk factors for observed higher proportion of ETEC infection during seasonal diarrhoea peaks.

Small bowel and fecal microbiology in children suffering from persistent diarrhea in Bangladesh.

The etiology of persistent diarrhea in children is multifactorial. The objective of the current study was to ascertain the role of microorganisms in the etiology and pathogenesis of persistent diarrhea in a group of children in Bangladesh. Enteric pathogens and total aerobic microflora were studied in the duodenal aspirates of 100 children with persistent diarrhea and compared with those in aspirates of 30 children with acute diarrhea, and those in aspirates of 15 healthy control children. The enteric pathogens in the stools of these children and in stools of an additional 38 patients with persistent diarrhea and 12 with acute diarrhea were also studied. Approximately two thirds of the patients with acute diarrhea and persistent diarrhea, and half of the control subjects had more than 10(5) organisms per milliliter of duodenal fluid. Significantly, more patients with persistent diarrhea had a greater variety of flora than did patients with acute diarrhea and control subjects. The predominant organisms in patients with acute diarrhea and in those with persistent diarrhea were Gram-negative rods, whereas those in control subjects were Gram-positive cocci. Significantly more acute diarrhea patients and persistent diarrhea patients had enteric pathogens isolated from stool than did control subjects. Diarrheagenic Escherichia coli, as a whole, were present in significantly more persistent diarrhea patients than in acute diarrhea patients and control subjects. Among diarrheagenic E. coli, enteroaggregative E. coli were significantly associated only with persistent diarrhea. Other organisms significantly associated with persistent diarrhea were Aeromonas spp. and Klebsiella spp. Some patients in the acute diarrhea and the persistent diarrhea groups had the same pathogens isolated from both the duodenal fluid and stool. In accordance with results of other studies, an association between enteroaggregative E. coli and persistent diarrhea was found in the present study. This suggests that therapy directed against enteroaggregative E. coli can be evaluated for management of some cases of persistent diarrhea.

Anticipating rotavirus vaccines: hospital-based surveillance for rotavirus diarrhea and estimates of disease burden in Bangladesh

Rotavirus is the most common cause of severe diarrhea in children worldwide, and a vaccine may soon be licensed and available for use in immunization programs. To assess the need for a rotavirus vaccine in Bangladesh, we estimated the disease burden of rotavirus diarrhea from national vital statistics for births and diarrheal deaths, together with hospital surveillance data on the proportion of severe childhood diarrhea attributed to rotavirus. From 1990 through 1993, hospital surveillance was conducted of a systematic, random 4% sample of >80,000 patients with diarrhea who sought care each year at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). Rotavirus was detected in 20% (1561 of 7709) of fecal specimens from children with diarrhea <5 years of age; 92% of all cases (1436) occurred in children <2 years of age, but only 3% (50) of cases occurred in infants <3 months of age. Children infected with rotavirus were more likely to have watery stools (P < 0.001), severe vomiting (P < 0.001) but less severe dehydration (P = 0.007) than children infected with other enteropathogens. We estimate that in this setting, where 18% of children die by age 5 and about 25% of these succumb to diarrhea, between 14,850 and 27,000 of the 3 million Bangladeshi children born in 1994 will die of rotavirus by the age of 5 years, equivalent to 1 rotavirus death per 111 to 203 children. The estimated burden of rotavirus diarrhea in Bangladesh is sufficiently great to warrant field testing of rotavirus vaccines for possible inclusion in the current immunization program.

Recent contributions of behavioural and biomedical scientists in applied anthropology of hygiene practices and management of diarrhoea in Bangladesh

In the past few years anthropologists, sociologists and biostatisticians have made contributions on hygiene practices and management of diarrhoea in relation to young children in rural Bangladesh. The cultural practices of caregivers with regard to washing hands after cleansing the anus of young children following defectation and disposing of the stool often do not fulfil the biomedical criteria for prevention of the transmission of diarrhoea-causing pathogens. These practices, being important determinants of prevention of transmission, were studied in the rural communities of Matlab, Bangladesh. Data were collected by observing the practices of caregivers of 404 children with diarrhoea chosen from 444 community cases recruited from the neighbourhood of the 218 hospitalized index cases. Observations were made regarding the cleansing of the anus of these children, washing of the hands of the caregivers, and disposal of the stool. It was observed that all the caregivers used bare hands and most used only water in cleaning the anus of the child. Also following the cleaning, most of the caregivers used only water to wash the soiled hand. Most of them used water collected in a pot, and only a small proportion used water from the direct source. The majority of caregivers disposed of the faeces in an unhygienic way.

Genomic characterization of rotavirus strains obtained from hospitalized children with diarrhoea in Bangladesh

Faecal samples were obtained from 111 children hospitalized with acute watery gastroenteritis in a children's hospital in Bangladesh from January to December, 1989. Rotavirus was detected as the aetiologic agent in 35 (32%) of these patients. The electrophoretic pattern of ds-RNA extracted from the rotaviruses showed 11 different migration patterns (six short and five long), as well as some short and long mixed profiles. All four major G serotypes were identified by amplification of a segment of the gene for VP7 using the polymerase chain reaction. A specific serotype could be assigned in 32 (91%) cases. Serotypes G1-G4 accounted for 11%, 37%, 11%, and 23% of isolates respectively. Three (9%) mixed serotypes were identified by this method and were found to be mixtures of serotypes G1 and G4, G2 and G4, and G3 and G4.

Hemagglutinating properties of enteroaggregative Escherichia coli.

Many intestinal bacterial pathogens possess hemagglutinating properties, which are indicative of their adhesive properties to the intestinal mucosal surface. To understand the bacteria-mucosa interaction, 41 strains of enteroaggregative Escherichia coli (EAggEC), a recently described category of diarrheagenic E. coli, isolated mostly from children with diarrhea in Bangladesh, India, Thailand, Central America, and South America were screened for mannose-sensitive hemagglutination and mannose-resistant hemagglutination of erythrocytes from humans, rats, mice, sheep, cattle, and rabbits. Some strains demonstrated mannose-sensitive hemagglutination of erythrocytes. Most isolates showed mannose-resistant hemagglutination of erythrocytes from all species except rabbits. The hemagglutination patterns could be classified into 18 groups. Studies with three selected isolates suggested that hemagglutinins are cell bound and are protein in nature. On the basis of the pattern of inhibition of hemagglutination by various chemicals, 39 isolates were classified into 19 groups. Hemagglutinations of many isolates were inhibited by sialic acid-containing compounds, suggesting that these compounds may be the receptors for these organisms on erythrocytes and possibly on the intestinal mucosa. These data indicate that strains of EAggEC are a heterogeneous group of organisms with different types of hemagglutinins or adhesins for the intestinal mucosal surface. Also, the adhesion characteristics of EAggEC strains may be too complex to be assessed by simple hemagglutination tests.

Isolation of Shigella dysenteriae serotypes 11, 12, and 13 from patients with diarrhea in Bangladesh

Nine isolates of bacteria biochemically resembling Shigella dysenteriae but not belonging to the 10 recognized serotypes were isolated from patients with diarrhea in Bangladesh. Further studies suggested that two, one, and six isolates belonged to the recently recognized S. dysenteriae serotypes 11, 12, and 13, respectively.

A comparative study of specific gene probes and standard bioassays to identify diarrhoeagenic Escherichia coli in paediatric patients with diarrhoea in Bangladesh

We compared the usefulness of gene probes with standard bioassays to identify diarrhoeagenic Escherichia coli amongst isolates from Bangladeshi children under 1 year of age with diarrhoea. E. coli isolates were analysed with specific gene probes for localised adhesiveness (LA), diffuse adhesiveness (DA), heat-labile toxin (LT), heat-stable toxin (ST), Shiga-like toxins (SLT I and SLT II), and enteroinvasiveness, and in bioassays for production of enterotoxins and cytotoxins, and for cell adherence. With 1136 isolates from 387 patients, there was general agreement between the two assay methods. When there was disparity, gene-probe-positive isolates gave negative results in the corresponding bioassay. In the HeLa cell adherence assay, 94% of the LA probe-positive isolates and 91.6% of the DA probe-positive isolates gave positive bioassay results for LA and DA respectively. Thirty-six of 39 LT probe-positive isolates and 73 of 86 ST probe-positive isolates gave positive results in the bioassays. Of 28 isolates that gave negative results in the suckling mouse assay but were initially positive with the probe for ST, 15 were later found to hybridize with the cloning vector for the ST probe. Addition of denatured vector DNA at a concentration of 10 micrograms/ml in the hybridisation solution eliminated these false positive results. None of the other probe-positive isolates hybridised with any of the cloning vectors used. The DNA hybridisation assay appeared to be a convenient alternative to bioassays for screening large numbers of isolates in epidemiological investigation.

Bacteremia During Diarrhea: Incidence, Etiology, Risk Factors, and Outcome

To determine the importance of bacteremia in hospitalized patients with diarrhea in Bangladesh, from September 1982 through August 1983 the authors obtained blood for culture from 1,824 patients who were suspected of having sepsis (44% of all admissions). Nontyphoid bacteremia occurred in 243 patients. The most common pathogens were the Enterobacteriaceae (n = 66 episodes), Staphylococcus aureus (n = 65), Pseudomonas aeruginosa and other non-glucose-fermenting bacilli (n = 50), Streptococcus pneumoniae (n = 40), and Haemophilus influenzae (n = 16). When compared with an equal number of control patients without bacteremia, bacteremic patients were significantly (p less than 0.05) more likely to be under 1 year of age (46.5% of bacteremic patients vs. 30.0% of control patients) and more often had abdominal tenderness (20.1% vs. 11.5%), hypoproteinemia (a serum protein level less than 60 g/liter) (58.9% vs. 42.9%), and a prior intravenous infusion (49.0% vs. 30.9%). The case-fatality rate was 29.7% in bacteremic patients versus 7.8% in controls (relative risk (RR) = 3.8, p less than 0.001). Factors that were associated with an increased risk of death in bacteremic patients were infection with a Gram-negative pathogen (RR = 2.48), decreased peristalsis (RR = 2.66), hypoproteinemia (RR = 3.36), hypothermia (RR = 2.54), and hypotension (RR = 2.19). Bacteremia appears to be an important link between diarrheal illness and death in Bangladesh. In children with diarrhea who are suspected of being septic, early implementation of antimicrobial therapy that is effective against the broad range of pathogens identified appears to be indicated.

Cryptosporidiosis: a Cause of Diarrhea in Bangladesh

Fecal samples from diarrheal patients and non-diarrheal controls were examined for Cryptosporidium oocysts in a year-long prospective study at a diarrhea treatment center in Dhaka, Bangladesh. Cryptosporidium oocysts were detected in 42 (3%) of 1,382 diarrheal patients but in none of 235 non-diarrheal controls. In 32 (76%) of 42 patients, no other enteropathogens were detected. Children less than 5 years of age were more commonly infected than older children (4.8% vs. 1.6%, P greater than 0.05) and adults (4.8% vs. 0.2%, P less than 0.01). A higher number of cases were detected during hot and humid months (April--July). Nineteen children less than 5 years of age (index cases) and their 71 family members were followed for 3 weeks after the release of the index cases from the hospital. Diarrhea continued for greater than 14 days (persistent diarrhea) in 8 (32%) index children. Cryptosporidium oocysts were detected in 1 (12.5%) of 8 family members who developed diarrhea during the follow-up period. Index cases excreted oocysts for 3-28 days (12.37 +/- 8.35 days). Almost all the patients recovered with oral rehydration. Cryptosporidium ssp. cause self-limited diarrhea episodes in children less than 5 years of age in Bangladesh, with a low frequency of intrafamilial transmission.

Patterns of Morbidity and Mortality in Typhoid Fever Dependent on Age and Gender: Review of 552 Hopitalized Patients with Diarrhea

Features of typhoid fever were correlated with age and gender through a review of the charts of 552 hospitalized culture-positive patients with diarrhea in Bangladesh. Seizures occurred more frequently in children from birth through 10 years of age (5%-11%) and pneumonia more frequently in children from birth through 5 years of age (8%-15%) than in older age groups (P less than .05), whereas intestinal perforation occurred more frequently in patients greater than or equal to 11 years of age (5%-25%) than in younger age groups (P less than .005). Compared with older age groups, children from birth through 10 years of age were more anemic, those from birth through 5 years of age had a higher mean white blood cell count, and those from birth through 1 year of age had a lower mean blood carbon dioxide content (all P less than .05). Female patients were more severely anemic than male patients (P less than .05). The case-fatality rate was 4.3% overall, with the highest rates for children from birth through 1 year of age (11%) and adults greater than or equal to 31 years of age (10%). Female patients had a higher case-fatality rate (6%) than male patients (3%), although the difference was not significant (P greater than .05). Death was independently associated with seizures, intestinal perforation, pneumonia, and delirium or coma. These results indicated that the patients with typhoid fever who were at highest risk of complications and death were children from birth through 1 year of age and adults greater than or equal to 31 years of age.

Efficacy of oral rehydration solution in correcting serum potassium deficit of children with acute diarrhoea in Bangladesh.

60 children in Bangladesh all under 4 years of age with acute watery diarrhea and moderate dehydration were treated with sucrose based oral rehydration solution (ORS) with 20mEq potassium chloride per liter and monitored to determine the efficacy of this fluid in raising serum potassium level. ORS only was given for the 1st 4 hours and then the child was given diluted mild formula and bread as well. No fruits or potassium rich fluid (e.g. green coconut water) were allowed during the study period. Rehydration as well as maintenance of fluid loss was done with ORS only. The serum potassium dropped significantly at 24 hours from the admission level and remained reduced at that level even after 48 hours of therapy with ORS. Of these 60 patients 22 were hypokalaemic on admission and 10 patients out of 19 remained so after 48 hours of therapy. Thus it appears that the present concentration of potassium in World Health Organization recommended ORS is not sufficient to correct deficits in some patients. The significance of these findings can be appreciated by considering the fate of infants in areas where diarrhea is hyperendemic who may have 3 attacks per year per child on average and who are in addition malnourished. Total potassium depletion may occur in these children during repeated diarrheal episodes resulting in higher morbidity and mortality. These findings suggest the need to raise the potassium concentration in ORS to above 20mEq per liter.

The aetiology of diarrhoea in children at an urban hospital in Bangladesh

Enteric pathogens were studied in 104 cases with acute diarrhoea and in 74 age and sex matched concurrent controls. One or more pathogens were isolated from 59·1% of cases compared with 20·4% of controls ( P < 0·001). Single enteropatnogens were detected in 33·7% and multiple enteropathogens in 25·4% of the cases. Enteropathogenic Escherichia coli (EPEC), Campylobacter jejuni, rotavirus, Vibrio cholerae non-O1 and enterotoxigenic Escherichia coli were the major pathogens detected. The high rate of isolation of EPEC from diarrhoea cases (23·1%) indicated a definite role for this pathogen in causing endemic diarrhoea in Bangladesh.

Infrequent detection of Yersinia enterocolitica in childhood diarrhea in Bangladesh.

In a search for Yersinia infection in Bangladesh, one isolate of Y. enterocolitica serotype 0:3 was obtained from stools of 1,450 children with fever and diarrhea and one of Y. enterocolitica serotype 0:8 was recovered from intestinal contents of 80 fatal diarrheal cases during postmortem examination. These results suggest that Yersinia infection is an infrequent cause of tropical diarrhea.

Enteropathogenic Escherichia coli diarrhea in hospitalized children in Bangladesh.

The role of enteropathogenic Escherichia coli (EPEC) was evaluated in a group of children with endemic diarrhea admitted to Dhaka Shishu Hospital in Dacca, Bangladesh. EPEC was detected in fecal samples of 23% of 104 cases and 8% of 74 concurrent control children. The most commonly isolated EPEC strains were serogroups O20a, O20c:K61; O20a, O20b:K84; O26:K60; and O18a, O18c:K77. Except for O26:K60, these groups had not been reported from Bangladesh. On testing for enterotoxin production, only two strains (serogroups O26:K60, O18a, and O18c:K77) were enterotoxigenic. None was enteroinvasive as tested in the guinea pig conjunctivitis model. Our study supports the concept that EPEC may be an important cause of endemic diarrhea in Bangladesh.

Characterization of enterotoxin and soluble hemagglutinin from Vibrio mimicus: identity with V. cholerae O1 toxin and hemagglutinin

Eight strains of Vibrio mimicus isolated from patients with diarrhoea in Bangladesh were all found to produce an extracellular toxin identical to cholera toxin produced by Vibrio cholerae O1 bacteria, with regard to subunit structure and immunological properties. Like cholera toxin, but in contrast to heat-labile enterotoxin from Escherichia coli most of the toxin from V. mimicus was found extracellularly and was proteolytically ‘nicked’ in its A subunit. This may relate to the finding that V. mimicus also produced an extracellular hemagglutinin which was immunologically indistinguishable from the soluble hemagglutinin/nicking protease of V. cholerae O1.

Characterization of enterotoxin and soluble hemagglutinin fromVibrio mimicus: identity withV. choleraeO1 toxin and hemagglutinin

Eight strains of Vibrio mimicus isolated from patients with diarrhoea in Bangladesh were all found to produce an extracellular toxin identical to cholera toxin produced by Vibrio cholerae O1 bacteria, with regard to subunit structure and immunological properties. Like cholera toxin, but in contrast to heat-labile enterotoxin from Escherichia coli most of the toxin from V. mimicus was found extracellularly and was proteolytically ‘nicked’ in its A subunit. This may relate to the finding that V. mimicus also produced an extracellular hemagglutinin which was immunologically indistinguishable from the soluble hemagglutinin/nicking protease of V. cholerae O1.

Serological evidence for chlamydial infection in patients with acute diarrhoea

Anti-chlamydial antibodies were detected in 25 of 93 patients with diarrhoea in Bangladesh. This first report of evidence for chlamydial infection in this country should stimulate a search for a causal relationship between chlamydiae and prevalent diseases of Bangladesh.

Consequences of hyponatraemia and hypernatraemia in children with acute diarrhoea in Bangladesh.

A total of 1330 children under 3 years of age who during 1979 had been admitted to the general ward of ICDDR,B Health Complex for diarrhoea with complications were studied retrospectively for the relation between types of dehydration, age, and nutritional state. Of the 1330 children, 276 (20.8%) were hyponatraemic, 969 (72.8%) isonatraemic, and 85 (6.4%) hypernatraemic. The incidence of hyponatraemia increased with age, while the incidence of hypernatraemia decreased with age. There was a strong relation between types of dehydration and nutritional state. The incidence of hyponatraemia was directly related to the degree of malnutrition. The case fatality rates for types of dehydration were 10.1% in hyponatraemia, 3.8% in isonatraemia, and 1.2% in hypernatraemia. These observations suggest that hyponatraemia is a serious complication of diarrhoea in Bangladesh.