Introduction:A significant proportion of under-five diarrhea-related morbidity and mortality can be reduced by timely initiation of treatment. This study assessed determinants of timely treatment-seeking behavior for diarrheal disease among caregivers with under-five children in public hospitals in Sidama region, Ethiopia.Methods:A facility-based unmatched case-control study was conducted among public hospitals. Data were collected using KOBO Collect with a smartphone and analyzed using SPSS 26.Results:Three hundred two cases and 302 controls were included. Being urban resident (AOR = 0.251 (95% CI, 0.157, 0.401, p = 0.000)), mothers with no formal education (AOR = 0.397 (95% CI, 0.222, 0.713, p = 0.002)), child age < 24 months (AOR = 0.210 (95% CI, 0.121, 0.364, p = 0.000)), above 120 min walking distance from nearby health facility [AOR = 0.426 (95% CI, 0.211, 0.861, p = 0.017)] were negatively associated. Whereas, reported cost of treatment easy to pay (AOR = 7.988 (95% CI, 3.734, 17.091, p = 0.000)), community-based health insurance (CBHI) membership (AOR = 4.940 (95% CI, 3.124, 7.812, p = 0.000)), and a history of previous diarrhea (AOR = 1.702 (95% CI, 1.021, 2.837, p = 0.041)) were positively associated with timely treatment seeking behavior.Conclusion:Being urban residents, caregivers’ educational status, child age <24 months, and long walking distance from nearby health facility, low-cost of treatment, being a CBHI member, and a child with a history of previous diarrhea were independently associated with timely treatment-seeking. Therefore, it is important to design strategies to improve these factors by involving relevant stakeholders. Future researchers should consider strong designs like prospective cohort involving multiple health facilities to identify causal factors for timely treatment-seeking behavior.

Jharkhand was the first state in India to introduce ROTASIIL to reduce rotavirus diarrhea-related morbidity and mortality in children. This analysis focused on the burden of rotavirus diarrhea, associated risk factors, and the most prevalent rotavirus genotypes in children hospitalized with acute gastroenteritis (AGE). Surveillance of AGE in children aged under 5 y was carried out in 12 health facilities in four districts of Jharkhand from 2019 to 2023. Stool samples were screened for rotavirus, and the positive samples were subsequently genotyped. Factors associated with rotavirus positivity were identified using multivariable logistic regression. Of 3,319 children screened, 1,937 eligible children were included in the analysis. Of 1,801 stool samples tested, 39.8% were rotavirus-positive, with a peak prevalence in the winter months. The total family size [aOR 95% CI, 0.69 (0.55-0.86)], paternal education [aOR 95% CI, 0.68 (0.55-0.85)], age of the child [aOR 95% CI, 0.37 (0.25-0.55)], rotavirus vaccination status [aOR 95% CI, 0.66 (0.50-0.86)], and length of hospital stay [aOR 95% CI, 0.82 (0.66-1.01)] were significantly associated with rotavirus positivity. The most prevalent rotavirus genotypes were G2P[4], and G3P[8]. Rotavirus remains an important cause of gastroenteritis in children aged under 5 y, particularly in infants, despite the availability of rotavirus vaccination. Declining rotavirus positivity in children with AGE and changes in the distribution of rotavirus genotypes during the study period may be attributable to the effects of vaccination.

Background: Pancreatic ductal adenocarcinoma (PDAC) presents a challenge due to its poor prognosis. Irreversible electroporation (IRE) shows promise in improving margin clearance and increasing R0 and R1 indirect resection rates. Although IRE is believed to preserve surrounding tissues, this study aimed to assess postoperative refractory diarrhea as a severe complication and challenge the assumption of consistent tissue preservation. Methods: Patients undergoing pancreaticoduodenectomy (PD) with IRE for superior mesenteric artery (SMA) margin accentuation between May 2022 and April 2024 were included. Primary endpoints were diarrhea-related morbidity and mortality; secondary endpoints included R-status, recurrence, and metastases. IRE electrodes were initially positioned circumferentially around the SMA, but this approach was modified to hemi-circumferential placement and applied in six additional patients. Results: All five patients (median age 70, 80% female) in the initial cohort developed secretory diarrhea lasting a median of 6 months (IQR 5-6.5), with a median frequency of 5 stools/day (IQR 5-6.5). Two patients (40%) died due to diarrhea-associated cachexia. In contrast, among the six patients treated with the modified technique, patients' diarrhea resolved within a median of 8 days (IQR 6-10) without need for opioid or advanced antidiarrheal therapy. Conclusions: Circumferential IRE for SMA margin accentuation may damage the superior mesenteric plexus and induce severe, prolonged diarrhea. Hemi-circumferential application may mitigate this risk. Larger studies are required to validate these findings and optimize the use of IRE in PD.

The aim of this study was to evaluate the incidence of diseases as well as metabolic and zootechnical parameters in Holstein calves maintained in individual or collective housing systems in the extreme south of Brazil. One hundred calves were included immediately after birth and monitored for 90 days. Animals were randomly divided into two groups: individual stalls group (ISG; n=50) and collective stalls group (CSG; n=50). ISG calves were individually housed in 1.2m² wood pens and received 6 L of milk/day and concentrate food and water ad libitum for 90 days. Calves in the CSG were housed in groups of up to 25 animals, in a total of two stalls containing one animal per 3 m2. CSG calves received up to 8 L of milk/day at 0-15 days, milk ad libitum at 15-40 days, 7.2 L of milk. /day at 40-60 days, and gradual weaning at 60-90 days with concentrate food and water ad libitum, using an automatic feeder. In both groups, Zootechnical parameters (weight, thoracic perimeter, height at the withers, and rump width) were measured weekly during the first 28 days and once every 15 days until weaning. Blood samples were retrieved weekly during the first 28 days. Metabolic parameters evaluated in this study were total calcium, beta-hydroxybutyrate (BHBA), free fatty acids (FFA), and glucose. The animals were monitored daily for clinical signs of diseases diarrhea and respiratory symptoms. General morbidity was higher in CSG 92% compared to ISG 74% (p&lt;0.05). We observed increased diarrhea-related morbidity and a higher rate of recurrence in the ISG (50% and 60%, respectively; p&lt;0.05) compared to those in the CSG (both 20%, p&lt;0.05 between groups). The morbidity due to bronchopneumonia was higher in the CSG (92%) than in the ISG (74%, p&lt;0.05). Recurrence of bronchopneumonia and mortality were similar between groups (p&gt;0.05). Glucose, FFA, and BHBA concentrations were higher in the ISG (p&lt;0.05) and total calcium higher in CSG (p&lt;0.05). Finally, the weight and thoracic perimeter were higher in the CSG than those in the ISG, whereas the height and, rump width, at the withers was higher in the ISG than that in the CSG (p&lt;0.05). In conclusion, animals raised in a collective system with automatic feeders exhibited less diarrhea and increased serum calcium as well as improved zootechnical development, although they had a higher incidence of bronchopneumonia.

The aim of this study was to evaluate the incidence of diseases as well as metabolic and zootechnical parameters in Holstein calves maintained in individual or collective housing systems in the extreme south of Brazil. One hundred calves were included immediately after birth and monitored for 90 days. Animals were randomly divided into two groups: individual stalls group (ISG; n=50) and collective stalls group (CSG; n=50). ISG calves were individually housed in 1.2m² wood pens and received 6 L of milk/day and concentrate food and water ad libitum for 90 days. Calves in the CSG were housed in groups of up to 25 animals, in a total of two stalls containing one animal per 3 m2. CSG calves received up to 8 L of milk/day at 0-15 days, milk ad libitum at 15-40 days, 7.2 L of milk. /day at 40-60 days, and gradual weaning at 60-90 days with concentrate food and water ad libitum, using an automatic feeder. In both groups, Zootechnical parameters (weight, thoracic perimeter, height at the withers, and rump width) were measured weekly during the first 28 days and once every 15 days until weaning. Blood samples were retrieved weekly during the first 28 days. Metabolic parameters evaluated in this study were total calcium, beta-hydroxybutyrate (BHBA), free fatty acids (FFA), and glucose. The animals were monitored daily for clinical signs of diseases diarrhea and respiratory symptoms. General morbidity was higher in CSG 92% compared to ISG 74% (p&lt;0.05). We observed increased diarrhea-related morbidity and a higher rate of recurrence in the ISG (50% and 60%, respectively; p&lt;0.05) compared to those in the CSG (both 20%, p&lt;0.05 between groups). The morbidity due to bronchopneumonia was higher in the CSG (92%) than in the ISG (74%, p&lt;0.05). Recurrence of bronchopneumonia and mortality were similar between groups (p&gt;0.05). Glucose, FFA, and BHBA concentrations were higher in the ISG (p&lt;0.05) and total calcium higher in CSG (p&lt;0.05). Finally, the weight and thoracic perimeter were higher in the CSG than those in the ISG, whereas the height and, rump width, at the withers was higher in the ISG than that in the CSG (p&lt;0.05). In conclusion, animals raised in a collective system with automatic feeders exhibited less diarrhea and increased serum calcium as well as improved zootechnical development, although they had a higher incidence of bronchopneumonia.

To examine spatiotemporal variability and identify clustering patterns of hospitalization rates for diarrhea in children younger than five years in Mato Grosso, Brazil, from 2011 to 2020. An ecological study was conducted using hospitalization records associated with diarrhea from the Brazilian Hospital Information System/Unified Health System. The relative risk of hospitalization for diarrhea in each municipality was calculated using SaTScan software considering a statistical significance level of 5% and 999 Monte Carlo replications. A total of 13,315 diarrhea-associated hospitalizations for 5-year-old children were recorded. From 2011 to 2020, the annual rates for hospitalizations related to diarrhea decreased from 8.50 to 3.45/1,000 live births among children younger than one year and from 4.99 to 1.57 for children aged 1-4 years. Clusters of municipalities with high relative risk for hospitalizations due to diarrhea, statistically significant, predominated in the North, Northeast, and Southwest health administrative macro-regions of Mato Grosso for both age groups until 2016. From 2016 to 2020, clusters of the lowest relative risk were identified in the North and Center South health administrative macro-regions for children younger than five years. Results showed that hospitalization rates for diarrhea in children younger than five years reduced with the presence of low-risk clusters in Mato Grosso in the final years of the study. Public health surveillance should incorporate spatial analysis to investigate the diarrhea-related morbidity.

BackgroundReducing diarrhea-related morbidity and mortality is a global priority, particularly in low-resource settings. We assessed adherence to diarrhea case management indicators in the Global Enteric Multisite Study (GEMS) and Vaccine Impact of Diarrhea in Africa (VIDA) study.MethodsGEMS (2007–2010) and VIDA (2015–2018) were age-stratified case-control studies of moderate-to-severe diarrhea (MSD) in children aged <5 years. In this case-only analysis, we included children enrolled in The Gambia, Kenya, and Mali. A case with no dehydration received adherent care at home if they were offered more than usual fluids and at least the same as usual to eat. Children with diarrhea and some dehydration are to receive oral rehydration salts (ORS) in the facility. The recommendation for severe dehydration is to receive ORS and intravenous fluids in the facility. Adherent care in the facility included a zinc prescription independent of dehydration severity.ResultsFor home-based management of children with MSD and no signs of dehydration, 16.6% in GEMS and 15.6% in VIDA were adherent to guidelines. Adherence to guidelines in the facility was likewise low during GEMS (some dehydration, 18.5%; severe dehydration, 5.5%). The adherence to facility-based rehydration and zinc guidelines improved during VIDA to 37.9% of those with some dehydration and 8.0% of children with severe dehydration.ConclusionsAt research sites in The Gambia, Kenya, and Mali, suboptimal adherence to diarrhea case management guidelines for children aged <5 years was observed. Opportunities exist for improvement in case management for children with diarrhea in low-resource settings.

BackgroundDiarrheal illness remains one of the most common causes of death among children specifically those who live in developing countries. Appropriate mothers' knowledge and practice regarding acute diarrhea illness in children can considerably reduce diarrhea-related morbidity and mortality. So, the aim of this study was to evaluate mothers’ knowledge and practice regarding acute diarrheal illness in children.MethodThis cross-sectional study was conducted in a tertiary hospital in Riyadh, Saudi Arabia using a newly developed questionnaire that was distributed to King Abdullah Specialist Children. The calculated sample size was 375.ResultsA total of 375 mothers were included in this study and the majority of them (99%) were Saudis. More than half of the participants (61%) were university graduates. The majority (96.5%) chose previous experience as the main source of information about diarrhea while (40%) chose physician. Most of the mothers (69.6%) believed that teething is the leading cause of diarrheal illness in children. Regarding the treatment, fluid was recognized to be the major treatment for diarrhea as chosen by the mothers. Around (42.7%) of the respondents thought intravenous fluid is more effective than oral rehydration solution (ORS) in treating dehydration associated with diarrheal episodes. ORS was the main type of fluid (74.1%) which was selected by the mothers to be given during the diarrheal episode.ConclusionMothers showed good knowledge and practice overall in regard to acute diarrheal illness in children. However, this study revealed some misconceptions among the caregivers which necessitates more educational sessions to be conducted in the community and during the hospital visit.

BackgroundDiarrhea remains one of the leading causes of mortality and morbidity, despite the global progression of eradicating the burden of diarrhea-related morbidity and mortality in the past two decades. In Sub-Saharan African (SSA) countries, there is inadequate supply and sanitation of safe water. However, there is a lack of literature that estimates the impact of drinking water and sanitation service on childhood diarrhea in Kersa Demographic and Health Surveillance. Therefore, the current study aimed to assess the prevalence and effect of water supply and environmental sanitation on diarrhea among under-five children from 2017 to 2021 in Kersa Demographic and Health Surveillance, Eastern Ethiopia.MethodA prospective cohort study design was implemented among 6,261 children from the Kersa Health Demographic Surveillance System (HDSS), Eastern Ethiopia, from 1 January 2016 to 31 December 2021. STATA statistical software was used to extract data from the datasets. The binary logistic regression was used to identify the impact of water supply and environmental sanitation on diarrhea by controlling important confounders. The adjusted odds ratio (AOR) with a 95% confidence interval measures this association.ResultThe current study showed that among 6,261 under-five children, 41.75% of them had developed active diarrhea during the follow-up time. The final model depicted that having media exposure of 22% [AOR - 0.78 CI: (0.61, 0.98)], a protected tube well source of drinking water of 50% [AOR - 1.50, CI: (1.32, 1.71)], unprotected tube well source of drinking water of 66% [AOR - 1.66 CI: (1.27, 2.18)], having toilet facility of 13% [AOR - 0.87 CI: (0.78, 0.97)], and accessibility of source of water [AOR - 1.17 CI: (1.05, 1.30)] showed a significant association with diarrhea among under-five children.ConclusionThe prevalence of diarrhea is found to be high in the Kersa District. The main predictors of diarrhea under five were a lack of latrines, an unimproved source of drinking water, and a distance from access to drinking water. The study setting should focus on increasing the adequacy of safe drinking water and sanitation.

Background and Objective: Despite the availability of low-cost and effective interventions, diarrhea remains one of the leading causes of under-five morbidity and mortality in Nigeria. We assessed the relationships between the source and quality of treatment for children with diarrhea in Nigeria. Methods: We analyzed cross-sectional data on 3,956 under-five children with a recent diarrheal episode, from the 2018 Nigeria Demographic and Health Survey. The outcome was quality of diarrhea management based on the administration of the following treatment recommendations: oral rehydration salt (ORS), zinc supplementation, increased oral fluids, and continued feeding. The exposure was the source of treatment (none; traditional/informal; public hospitals/health centers; private hospitals/clinics; and community-based services). Using adjusted, multivariable logistic regression, we estimated the odds ratio (OR) and 95% confidence intervals (CI) to predict the factors related to the quality of diarrhea management. Results: In all, only 1 in 5 children received all the four recommended diarrhea interventions. The odds of good quality diarrhea management were higher among children who received treatment in public hospitals/health centers, private hospitals/clinics, and community-based services compared to those of children who did not receive treatment (OR=2.52, 95% CI=1.89-3.34; OR=2.46, 95% CI=1.90-3.16; and OR=1.91, 95% CI=1.40-2.59, respectively). Compared to children whose parents did not seek treatment, the odds of receiving ORS ranged from 2.1 times (OR: 2.11, 95% CI=1.44-3.11) for seeking care in traditional/informal sources to 12.3 times (95% CI=8.81-17.15) in public hospitals/health centers. We observed similar trends for zinc supplementation. The odds of increased oral fluids were higher in public and private hospitals/clinics (OR=1.44, 95% CI=1.03-2.01 and OR=2.08, 95% CI=1.57-2.76, respectively). Across all settings, the odds of continued feeding were significantly lower among children who received treatment compared to children who did not receive treatment. Conclusion and Implications for Translation: Our findings indicate poor quality diarrhea management across various treatment settings. Policies and programs that encourage caregivers to seek treatment and improve the quality of care may contribute to reducing childhood diarrhea-related morbidity and mortality in Nigeria. Copyright © 2021 Olorunsaiye et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

Context:Childhood diarrhea is still a major problem in developing countries, and the condition is worse in tribal areas.Aims:The study aims to assess the community perception related to diarrhea management in an aspirational district of Odisha, India.Subjects and Methods:A mixed-method study was conducted in Kandhamal, an aspirational district of Odisha, Eastern India, from June to October 2018. An in-depth interview was conducted among community health workers, and a cross-sectional survey was done for the household interview. The data were collected in a mobile-based application, Epicollect5, and in-depth interviews were recorded digitally.Statistical Analysis Used:The data were analyzed in the Statistical Package for Social Sciences (SPSS) version 22.0. Categorical variables are presented in proportions. Force-field analysis was conducted to assess the driving and restraining forces of diarrhea. Content analysis was done for the digitally recorded data.Results:Nine out of ten people were aware of the benefit of breastfeeding during diarrheal episodes in children aged under 5 years, and <50% were aware of zinc benefit. Poor sanitation, lack of safe water, poor hygiene practices, socioeconomic status, and illiteracy are the major challenges in diarrheal control in the tribal area.Conclusions:Improving the demand by creating community awareness regarding management of diarrhea, availability of essential drugs (ORS and zinc) at the community level, and capacity building of community health workers for management of diarrhea can reduce diarrhea-related morbidity and mortality in tribal areas of India. Handwashing, hygiene practices, and availability of safe water need to be promoted in the tribal region. In the long term, the socioeconomic determinants have to be addressed.

BackgroundHome visits by community health workers are promoted to improve the coverage and uptake of evidence-based newborn services and behaviours. However, evidence on the effectiveness of these home visits delivered through government systems at scale is limited, as is evidence from the post-neonatal period. From 2013 to 2017, the Government of India piloted an intervention called Home Based Newborn Care Plus with the goal of reducing pneumonia- and diarrhoea-related morbidity and malnutrition. Village-based Accredited Social Health Activists were incentivised to make quarterly home visits to infants between three and 12 months of age. After the pilot, the intervention was adapted and scaled up nationally (with an additional visit at 15 months of age) as a new programme called Home Based Care for Young Child.MethodsThe study used a quasi-experimental, difference-in-differences method to assess the quantitative impact on key outcome indicators by comparing changes over time in treatment districts with matched control districts. This was supplemented by a quantitative health worker survey and qualitative data collected at worker and community level.ResultsThe intervention led to a significant increase in the number of home visits, and their content became more aligned with Home Based Newborn Care Plus protocols. However, absolute levels of coverage remained low. The intervention had no detectable effect on the key outcomes of feeding practices, handwashing, iron and folic acid and oral rehydration solution supplementation, growth monitoring, and immunisation.ConclusionsGiven the scale up of Home-Based Care for Young Child, there is a need to identify appropriate and comprehensive support for Accredited Social Health Activists to attain high coverage and quality and deliver impact. This will require reconsidering current design elements (such as incentives) and solving the underlying demand side and system level challenges (such as workload and supply chains) constraining Accredited Social Health Activists.

BackgroundRotavirus vaccination is recommended in all countries to reduce the burden of diarrhea-related morbidity and mortality in children. In resource-limited settings, rotavirus vaccination in the national immunization program has important cost implications, and evidence for protection beyond the first year of life and against the evolving variety of rotavirus strains is important. We assessed the extended and strain-specific vaccine efficacy of a heat-stable, affordable oral rotavirus vaccine (Rotasiil, Serum Institute of India, Pune, India) against severe rotavirus gastroenteritis (SRVGE) among healthy infants in Niger.Methods and findingsFrom August 2014 to November 2015, infants were randomized in a 1:1 ratio to receive 3 doses of Rotasiil or placebo at approximately 6, 10, and 14 weeks of age. Episodes of gastroenteritis were assessed through active and passive surveillance and graded using the Vesikari score. The primary endpoint was vaccine efficacy of 3 doses of vaccine versus placebo against a first episode of laboratory-confirmed SRVGE (Vesikari score ≥ 11) from 28 days after dose 3, as previously reported. At the time of the primary analysis, median age was 9.8 months. In the present paper, analyses of extended efficacy were undertaken for 3 periods (28 days after dose 3 to 1 year of age, 1 to 2 years of age, and the combined period 28 days after dose 3 to 2 years of age) and by individual rotavirus G type. Among the 3,508 infants included in the per-protocol efficacy analysis (mean age at first dose 6.5 weeks; 49% male), the vaccine provided significant protection against SRVGE through the first year of life (3.96 and 9.98 cases per 100 person-years for vaccine and placebo, respectively; vaccine efficacy 60.3%, 95% CI 43.6% to 72.1%) and over the entire efficacy follow-up period up to 2 years of age (2.13 and 4.69 cases per 100 person-years for vaccine and placebo, respectively; vaccine efficacy 54.7%, 95% CI 38.1% to 66.8%), but the difference was not statistically significant in the second year of life. Up to 2 years of age, rotavirus vaccination prevented 2.56 episodes of SRVGE per 100 child-years. Estimates of efficacy against SRVGE by individual rotavirus genotype were consistent with the overall protective efficacy. Study limitations include limited generalizability to settings with administration of oral polio virus due to low concomitant administration, limited power to assess vaccine efficacy in the second year of life owing to a low number of events among older children, potential bias due to censoring of placebo children at the time of study vaccine receipt, and suboptimal adapted severity scoring based on the Vesikari score, which was designed for use in settings with high parental literacy.ConclusionsRotasiil provided protection against SRVGE in infants through an extended follow-up period of approximately 2 years. Protection was significant in the first year of life, when the disease burden and risk of death are highest, and against a changing pattern of rotavirus strains during the 2-year efficacy period. Rotavirus vaccines that are safe, effective, and protective against multiple strains represent the best hope for preventing the severe consequences of rotavirus infection, especially in resource-limited settings, where access to care may be limited. Studies such as this provide valuable information for the planning of national immunization programs and future vaccine development.Trial registrationClinicalTrials.gov NCT02145000.

Oral rehydration solution (ORS) is an evidence-based intervention to reduce diarrhoea-related morbidity and mortality, but consistently low rates of ORS use have been documented in Nigeria. To identify barriers to the optimal use of ORS for childhood diarrhoea in Nigeria and recommend appropriate interventions to improve uptake of ORS at community and facility levels. A quantitative cross-sectional survey of 400 mothers with children under 5 years of age was conducted in Nigeria to explore reasons for suboptimal utilization of ORS for childhood diarrhoea. An interviewer-administered questionnaire was used for data collection. Data were analysed using the statistical software SPSS version 21.0®. Sixty-one (15.3%) of the respondents were unaware of ORS. Of the 339 that were aware, their source of information was mainly hospital/health workers (81.1%). Among mothers that affirmed they could prepare ORS, only 64 (22.1%) prepared it correctly. Level of education significantly influenced awareness of ORS as well as its correct preparation. Nineteen mothers (5.6%) had difficulty getting ORS when needed, whereas 13 (3.8%) reported that it was difficult for them to remember how to prepare ORS. Four in ten children took ORS reluctantly or refused it outrightly. No cultural taboo concerning the use of ORS was reported. There is still a wide gap in the awareness of ORS and many caregivers prepared the solution incorrectly. We recommend that the method of preparation of ORS be clearly indicated on the sachets, and production of commercial 1-L water packages for ORS preparation be encouraged. Lay summaryOral rehydration solution (ORS) is an evidence-based intervention to reduce diarrhoea-related morbidity and mortality, but consistently low rates of ORS use have been documented in Nigeria. A quantitative cross-sectional study was carried out among 400 mothers to identify barriers to the optimal use of ORS for childhood diarrhoea and recommend appropriate interventions. Sixty-one (15.3%) of the respondents were unaware of ORS. Among mothers that affirmed they could prepare ORS, only 64 (22.1%) prepared it correctly. Level of education significantly influenced awareness of ORS as well as its correct preparation. Some mothers had difficulty getting ORS when needed, while some found it difficult to remember how to prepare it. Four in ten children took ORS reluctantly or refused it outrightly. No cultural taboo concerning the use of ORS was reported. The study showed that there is still a wide gap in the awareness of ORS and many caregivers prepared the solution incorrectly. Hence, we recommend that the method of preparation of ORS be clearly indicated on the sachets, and production of commercial 1-L water packages for ORS preparation be encouraged.

Studies on the association between infant and young child feeding (IYCF) practices and diarrhoea across regional India are limited. Hence, we examined the association between IYCF practices and diarrhoea in regional India. A weighted sample of 90,596 (North = 11,200, South = 16,469, East = 23,317, West = 11,512, Central = 24,870 and North-East = 3228) from the 2015–2016 National Family Health Survey in India was examined, using multivariate logistic regressions that adjust for clustering and sampling weights. The IYCF indicators included early initiation of breastfeeding (EIBF), exclusive breastfeeding (ExcBF), predominant breastfeeding (PBF), bottle feeding (BotF), continued breastfeeding (BF) at one-year, continued BF at two years, children ever breastfed and the introduction of solid, semi-solid or soft foods (ISSSF). Diarrhoea prevalence was lower among infants who were BF within one-hour of birth and those who were exclusively breastfed. Multivariate analyses revealed that continued BF at one and two years, and infants who were introduced to complementary foods had a higher prevalence of diarrhoea. EIBF and ExcBF were protective against diarrhoea in the regions of North, East and Central India. PBF, BotF and ISSSF were risk factors for diarrhoea in Central India. Continued BF at two years was a risk factor for diarrhoea in Western India. Findings suggested that EIBF and ExcBF were protective against diarrhoea in Northern, Eastern and Central India, while PBF, BotF, continued BF at two years and ISSSF were risk factors for diarrhoea in various regions in India. Improvements in IYCF practices are likely to reduce the burden of diarrhoea-related morbidity and mortality across regions in India.

Preparing for rotavirus vaccine introduction – A retrospective assessment of the epidemiology of intussusception in children below 2 years of age in Nepal

Transmissible gastroenteritis virus (TGEV) is an infective coronavirus (CoV) that causes diarrhea-related morbidity and mortality in piglets. For the first time, a natural recombination strain of a TGEV Anhui Hefei (AHHF) virus between the Purdue and the Miller clusters was isolated from the small intestine content of piglets in China. A phylogenetic tree based on a complete genome sequence placed the TGEV AHHF strain between the Purdue and the Miller clusters. The results of a computational analysis of recombination showed that the TGEV AHHF strain is a natural recombinant strain between these clusters. Two breakpoints located in the open reading frame 1a (ORF1a) and spike (S) genes were identified. The pathogenicity of the TGEV AHHF strain was evaluated in piglets, and the results show that TGEV AHHF is an enteric pathogenic strain. These results provide valuable information about the recombination and evolution of CoVs and will facilitate future investigations of the molecular pathogenesis of TGEV.Emerging Microbes & Infections (2017) 6, e74; doi:10.1038/emi.2017.62; published online 23 August 2017

Handwashing, but how? Microbial effectiveness of existing handwashing practices in high-density suburbs of Harare, Zimbabwe.

The gap between the efficacy and the effectiveness of household water treatment in reducing diarrhea-related morbidity indicates the need for a better understanding of the determinants of long-term behavior change. To explore the barriers to drinking water chlorination in the Peruvian Amazon, where diarrhea is endemic among under-5 children, we conducted qualitative research with 23 caregivers from peri-urban communities of Iquitos, Peru. Our inquiry drew on the Transtheoretical Model of behavior change and the Integrated Behavioral Model for Water, Sanitation, and Hygiene to identify the most relevant contextual, psychosocial, and technological determinants of initial action and long-term adoption of chlorination. Our findings suggest that the decision to try out this practice resulted from the combined effect of knowledge of chlorination benefits and product availability and affordability. Progress from action to adoption was influenced by caretakers' understanding of dosage, the packaging of chlorine products, knowledge and skills for multipurpose laundry bleach, the taste of treated water, and reinforcement. This analysis suggests that a focus on these determinants and the household domain may help to improve the sustainability of future intervention efforts.

Diarrhoea remains the second leading cause of death in children under 5 years. Moreover, morbidity as a result of diarrhoea is high particularly in marginalised communities. Frequent bouts of diarrhoea have deleterious and irreversible effects on physical and cognitive development. Children are especially vulnerable given their inability to mount an active immune response to pathogen exposure. Biological limitations are exacerbated by the long-term effects of poverty, including reduced nutrition, poor hygiene and deprived home environments. Drawing from available literature, this paper uses syndemic theory to explore the role of adverse biosocial interactions in increasing the total disease burden of enteric infections in low-resources populations and assesses the limitations of recent global calls to action. The syndemic perspective describes situations in which adverse social conditions, including inequality, poverty and other forms of political and economic oppression, play a critical role in facilitating disease–disease interactions. Given the complex micro- and macro-nature of childhood diarrhoea, including interactions between pathogens, disease conditions and social environments, the syndemic perspective offers a way forward. While rarely the focus of health interventions, technologically advanced biomedical strategies are likely to be more effective if coupled with interventions that address the social conditions of disparity.