Diarrheal Disease Surveillance Research Articles

Characteristics of Diarrheal Illnesses in Non-Breast Fed Infants Attending a Large Urban Diarrheal Disease Hospital in Bangladesh

BackgroundLack of breast feeding is associated with higher morbidity and case-fatality from both bacterial and viral etiologic diarrheas. However, there is very limited data on the characteristics of non–breastfed infants attending hospital with diarrheal illnesses caused by common bacterial and viral pathogens. Our objective was to assess the impact of lack of breast feeding on diarrheal illnesses in infants living in urban Bangladesh.MethodsWe extracted data of infants (0–11 months) for analyses from the data archive of Diarrheal Disease Surveillance System (DDSS) of the Dhaka Hospital of icddr,b for the period 2008–2011.ResultsThe prevalence of breastfeeding in infants attending the hospital with diarrhea reduced from 31% in 2008 to 17% in 2011, with corresponding increase in the prevalence of non-breastfed (chi square for trend <0.001). Among breastfed infants, the incidence of rotavirus infections was higher (43%) among the 0–5 months age group than infants aged 9–11 months (18%). On the other hand, among non-breastfed infants, the incidence of rotavirus infections was much higher (82%) among 9–11 months old infants compared to those in 0–5 months age group (57%) (chi square for trend <0.001). Very similar trends were also observed in the incidence of cholera and ETEC diarrheas among different age groups of breastfed and non-breastfed infants (chi square for trend 0.020 and 0.001 respectively). However, for shigellosis, the statistical difference remained unchanged among both the groups (chi square for trend 0.240).Conclusion and SignificanceWe observed protective role of breastfeeding in infantile diarrhea caused by the major viral and common bacterial agents. These findings underscore the importance of promotion and expansion of breastfeeding campaigns in Bangladesh and elsewhere.

Health and Nutritional Status of Young Foster Children Attending a Diarrhea Treatment Hospital in Bangladesh

There is scarcity of evidence-based information about socio-demographic as well as ailment factors associated with foster children in Bangladesh. Thus the aim of the present study was to determine the socio-economic, health and nutritional status of young foster children in urban Dhaka. A total of 208 (1%; n = 208/28,948) under-5 foster children were enrolled in the Diarrheal Disease Surveillance System of icddr,b between 1993-2012. Randomly selected under-5 children (n = 624) with a ratio of 1:3 were extracted and constituted as comparison group. Forty-three percent (n = 90) foster children were male. Lack of formal schooling of mother was higher among foster children compared to non-foster children (52% vs. 35%; p < 0.001). Higher proportion of foster children suffered from some or severe dehy-dration (60% vs. 47%; p = 0.001) and often received intravenous saline (12% vs. 5%; p = 0.002) in comparison to non-foster children. Significantly lower proportion of foster children had rotavirus diarrhea (26% vs. 43%; p < 0.001). In multivariate analysis, foster children were 2 times (95% CI: 1.31-4.32) more likely to be stunted and 194 times (95% CI: 82.25-457.76) more likely to be non-breastfed. Infants aged 6-11 months were 8 times (95% CI: 3.70-15.50) more likely to be foster compared to older children and probability of fostering was 7 times (95% CI: 3.96-13.33) higher among mothers with a median age of 25 years. The findings of our study clearly demonstrate the existing health and nutritional problems of foster children. Therefore, appropriate health and nutrition interventions are critical for foster children in Bangladesh.

Prolonged acute diarrhea in adults: Decades of observation from epidemiological perspective in urban Bangladesh

The study aimed to determine the epidemiological, clinical characteristics, and etiology of adults aged ≥20 years presented with prolonged acute diarrhea (≥7 days). A total of 18,210 adults aged ≥20 years were enrolled in the Diarrheal Disease Surveillance System of icddr,b between 1993-2012 and included into the analysis. Of these, 17,631 (97%) had duration of diarrhea ≤6 days, 418 (2%) diarrhea presented with a duration of 7 - 13 days and rest 161 (1%) had history of diarrhea ≥14 days. A higher proportion of adult individuals who had duration of diarrhea ≥14 days (70% vs. 56%; p male. At least 73% of all patients used oral rehydration solution; but proportion was lower among prolonged acute diarrhea groups. Use of antimicrobials was higher among those with duration 7 - 13 days (81%) and ≥14 days (81%). Diarrhea lasting ≥14 days, 47% were suffering from chronic energy deficiency and 30% had history of smoking. Individuals with diarrhea ≥7 days less frequently presented with vomiting, watery stool, frequency of stool >10 times/24 hours, drowsy or lethargy, fast breathing, some or severe dehydration, received intravenous saline for initial corrections of dehydration and stayed for longer duration in hospital (≥24 hours) but more often presented with abdominal pain. Stool microscopic examination showed less frequent presence of red blood cells (36% vs. 44%; p = 0.043) and fecal leucocytes (50% vs. 59%; p = 0.029) among individuals with diarrhea ≥14 days compared to those with ≤6 days. None was infected with Vibrio cholerae (≥14 days) (3% for 7 - 13 days); however, isolation rate of Aeromonas was higher among adults with duration for ≥14 days (11%). Only 15% with ≥14 days were positive for Shigella contrary to 19% (7 - 13 days) and 56% (≤6 days). Differences in sociodemographic, clinical presentation and etiology varied with duration of diarrhea among adults.

Urban-Rural Differentials in Using Antimicrobials at Home among Under-5 Children with Diarrhea

Due to self-limiting course of disease, use of antimicrobials in childhood diarrhea should be limited; however, irrational use is widely reported and is considered as a potential challenge for controlling its rational use. Thus, the present study aimed to describe urban-rural differentials with regard to socio-demographic characteristics, clinical features, and etiologic distribution in antimicrobial use and identify predictors of its use at home before coming to the hospital. From the database (January, 2010 to December, 2012) of Diarrheal Disease Surveillance System (DDSS) of urban Dhaka Hospital and rural Matlab Hospital of icddr,b, we extracted relevant information of 4,245 under-5 children from Dhaka Hospital and 2,161 children from Matlab Hospital. In multivariate analysis, children from urban area were 1.53 times, children aged under 2 years were 1.31 times, better socio-economic status (monthly income >100 US$) were 1.34 times, distance to health facility >5 miles from home 1.63 times, use of oral rehydration solution at home 2.95 times, duration of diarrhea >24 hours 4.25 times, frequency of stool >10 times/24 hrs. 1.47 times, abdominal pain 1.30 times and rotavirus infection were 1.54 times more likely to use antimicrobials at home before coming to the hospital (all p<0.05). On the other hand, maternal illiteracy (OR-0.74), cough (0.83) and Vibrio cholerae infection (0.70) were less likely to influence antimicrobials use at home in study children (all p<0.05). Socio-economic characteristics, clinical features, and etiologic agents of under-5 children determine use of antimicrobials at home before presenting to health facility.

Etiology of Diarrhea among Severely Malnourished Infants and Young Children: Observation of Urban-Rural Differences over One Decade in Bangladesh

There is inadequate information on the etiology of diarrhea in severely malnourished (SM) young children. Thus, the study aimed to determine the etiology of diarrhea among severely malnourished (z score < ?3.00 SD) children in rural and urban Bangladesh. From the database (2000-2011) of Diarrheal Disease Surveillance Systems (DDSS) at rural Matlab and urban Dhaka hospitals of icddr,b, 2234 and 3109 under-5 children were found severely malnourished (underweight, stunted or wasted) respectively. Two comparison groups [moderately malnourished (MM) and well-nourished (WN)] were randomly selected in a ratio of 1:1:1. Children with all categories of SM were more likely to be infected with Vibrio cholerae (rural—11%; urban—15%), Shigella (16%; 9%), Salmonella (1%; 2%) and Campylobacter (3%; 4%); and less likely to have rotavirus (25%; 20%) compared to only one SM category. Isolation rate of Vibrio cholerae was significantly higher among SM both in rural and urban children (7%; 13%) than those of MM (5%; 10%) and WN (2%; 8%) and lower for rotavirus (30%; 31%), (34%; 43%), (35%; 47%) respectively (p < 0.01). However, for Shigella it was only higher among rural SM children (11%) [MM (9%), and WN (8%) (p < 0.01)]. The isolation rate of Salmonella in SM (2%) was similar to that in MM (2%; p = 0.72) but significantly higher than that in WN (1%; p < 0.01) among urban children. Isolation rates of bacterial enteric pathogens were higher but rotavirus was lower in SM children in both rural and urban area with geographical heterogeneity.

Changing Trend of Overweight and Obesity and Their Associated Factors in an Urban Population of Bangladesh

There is a scarcity of information examining the prevalence of overweight and obesity in the general population of Bangladesh. Thus, the present study aimed to estimate the changing trends and socio-demographic characteristics of overweight and obese individuals among an urban population inDhaka,Bangladesh. The present study included data from 49,532 patients enrolled in the Diarrheal Disease Surveillance System (DDSS) at theDhakaHospitalfrom 1993-2011. Overweight and obese was categorized among under-5 children (n = 508), 5 19 years (n = 96), and >19 years (n = 1330). Data was compared with normal weight and malnourished individuals of respective age strata. The proportion of overweight and obese increased from 0.64% 5.15% among children 0.001), 0.80% 6.70% among 5 19 years (p 0.001), and 3.66% 16.94% (p 0.001) among >19 years. Among those under-5, males [OR = 1.31 (95%CI 1.08, 1.57)] those with higher socio-economic status [1.99 (1.02, 3.82)], higher monthly mean family income [3.76 (2.41, 5.86)], non-slum residence [2.01 (0.74, 5.51)], high maternal literacy rate [3.66 (2.31, 5.79)], and using sanitary toilet [1.47 (1.07, 2.01)] were at higher risk of being overweight and obese compared to well-nourished and malnourished children. Among individuals 5 19 years, those with higher socioeconomic status and use of sanitary toilet were at higher risk of being overweight and obese. Among those >19 years, additionally males were less likely to be overweight and obese [0.59 (0.49, 0.68)]. Over the last two decades the prevalence of overweight and obesity in Dhaka city has increased at least five folds and it was much higher among those with better socioeconomic status.

Hotel Clinic-Based Diarrheal and Respiratory Disease Surveillance in U.S. Service Members Participating in Operation Bright Star in Egypt, 2009

We conducted clinic-based, influenza-like illness and diarrheal disease surveillance among U.S. service members participating in Operation Bright Star 2009. Epidemiologic data and samples were collected. Nasopharyngeal swab specimens were tested for viruses, and feces was tested for microbiologic, immunologic, and molecular diagnostics. A survey was used to collect self-reported data. From 1,529 surveys, 41% reported diarrheal disease and 25% reported respiratory illness (incidence rate = 62 of 100 versus 37 of 100 person-months; incidence rate ratio = 1.7, 95% confidence interval = 1.5-1.9). Enterotoxigenic Escherichia coli was identified in 74% (69 of 93) of fecal samples. In the influenza-like illness case series, 17% (9 of 52) were positive for influenza A; all were positive for pandemic (pH1N1) 2009 virus. Rates of decreased work performance reported by patients with diarrhea and influenza-like illness were similar (46% versus 48%; P = 0.8). Diarrheal diseases and respiratory illness remain common among deployed military personnel, with important operational impact. Despite an ongoing influenza pandemic, diarrheal disease incidence was higher than that of respiratory illness.

Where science meets policy: comparing longitudinal and cross-sectional designs to address diarrhoeal disease burden in the developing world

Longitudinal studies are considered preferable to cross-sectional studies for informing public health policy. However, when resources are limited, the trade-off between an accurate cross-section of the population and an understanding of the temporal variation should be optimized. When risk factors vary more across space at a fixed moment in time than at a fixed location across time, cross-sectional studies will tend to give more precise estimates of risk factor effects and thus may be a better source of data for policy judgments. We conducted a diarrhoeal disease surveillance of 5616 individuals within 19 Ecuadorian villages. This data set was used to mimic cross-sectional and longitudinal studies by restricting focus to a single week and a single village, respectively. We compared the variability in risk factor effect estimates produced from each type of study. For household risk factors, the effect estimates produced by the longitudinal studies were more variable than their cross-sectional counterparts, which can be explained by greater spatial than temporal variability in the risk factor distribution. For example, the effect estimate of improved sanitation was almost twice as variable in longitudinal studies. In our study, cross-sectional designs yielded more consistent evaluations of diarrhoea disease risk factors when those factors varied more between villages than over time. Cross-sectional studies can provide information that is representative across large geographic regions and therefore can provide insight for local, regional and national policy decisions. The value of the cross-sectional study should be reconsidered in the public health community.

Emerging trends in the etiology of enteric pathogens as evidenced from an active surveillance of hospitalized diarrhoeal patients in Kolkata, India

BackgroundThis study was conducted to determine the etiology of diarrhoea in a hospital setting in Kolkata. Active surveillance was conducted for 2 years on two random days per week by enrolling every fifth diarrhoeal patient admitted to the Infectious Diseases and Beliaghata General Hospital in Kolkata.ResultsMost of the patients (76.1%) had acute watery diarrhoea in association with vomiting (77.7%) and some dehydration (92%). Vibrio cholerae O1, Rotavirus and Giardia lamblia were the important causes of diarrhoea. Among Shigella spp, S. flexneri 2a and 3a serotypes were most predominantly isolated. Enteric viruses, EPEC and EAEC were common in children <5 year age group. Atypical EPEC was comparatively higher than the typical EPEC. Multidrug resistance was common among V. cholerae O1 and Shigella spp including tetracycline and ciprofloxacin. Polymicrobial infections were common in all age groups and 27.9% of the diarrhoea patients had no potential pathogen.ConclusionsIncrease in V. cholerae O1 infection among <2 years age group, resistance of V. cholerae O1 to tetracycline, rise of untypable S. flexnerii, higher proportion of atypical EPEC and G. lamblia and polymicrobial etiology are some of the emerging trends observed in this diarrhoeal disease surveillance.

Evaluation of Faecal Occult Blood Test and Lactoferrin Latex Agglutination Test in Screening Hospitalized Patients for Diagnosing Inflammatory and Non-Inflammatory Diarrhoea in Dhaka, Bangladesh

Background: Inflammatory diarrhoea (ID) resulting from Shigella, Salmonella, Campylobacter and Entamoeba histoly-tica requires specific diagnosis for therapy. Differentiation between ID and non-inflammatory diarrhoea (NID) is often not clinically possible. A faecal occult blood test (FOBT) correlates with faecal leucocytes. Lactoferrin indicates an inflammatory process as a marker for faecal leucocytes. We evaluated diagnostic values of lactoferrin latex aggluti- nation test (LT) either alone or in combination with FOBT, correlating with stool microscopy and microbiology in differentiating ID from NID. Methods: The study population constituted patients enrolled in 2% systematic sampling of patients under Diarrhoeal Disease Surveillance System of Dhaka Hospital, ICDDR,B. Results: Between July and November 2002, 594 patients were enrolled; evaluation of FOBT and LT were done in 448/594 (75%) patients from whom either a single enteropathogen (315/594, 53%) or no pathogen (133/594, 22%) were identified and 146 were excluded for multiple pathogens. Invasive and non-invasive pathogens were isolated from 24% and 76% of the patients. FOBT and LT were positive in 40% and 39% of the samples. The sensitivities, specificities, PPVs, NPVs, and accuracies of FOBT were 55, 63, 24, 87 and 62%, and LT were 52, 64, 23, 86 and 62%, respectively. Conclusion: FOBT and LT are not useful in differentiating ID from NID in diarrhoeal patients in Dhaka, Bangladesh.

Presumptive shigellosis: Clinical and laboratory characteristics of Bangladeshi patients

The aim of the study was to examine some selected clinical and laboratory parameters in distinguishing non-Shigella invasive diarrhoeas from culture-confirmed Shigella cases. We conducted a clinic-based, cross-sectional study at the Dhaka Hospital of ICDDR,B located in Bangladesh. In total, 389 patients of all age groups and of both genders, with a history of diarrhoea of less than 96 h and presence of visible blood and/or mucus in the stool were presumed to have shigellosis and enrolled in the study. Shigella was isolated from faecal cultures in 227 (58.4%) patients. The remaining 162 (41.6%) patients did not have Shigella isolated from their faecal cultures and constituted the comparison group. Another 238 randomly selected patients with non-Shigella diarrhoea from the Diarrhoeal Disease Surveillance System database of the Dhaka Hospital constituted another comparison group. Cases of culture-proven Shigella were similar to non-Shigella invasive diarrhoeal patients with presumptive shigellosis with regard to several biosocial variables. The nutritional status of children with shigellosis was significantly inferior to those with non-Shigella diarrhoea. The presence of macrophages more than 5/HPF in stool microscopic examination was significantly more frequent among patients infected with Shigella. Empirical antimicrobial therapy for shigellosis might be considered for malnourished diarrhoeal children presenting with history of visible blood and/or mucus in stool, and children older than 1 y of age. Further studies are needed in different geographical settings to identify clinical and laboratory parameters that could help identify patients with shigellosis.

Growth and diarrhoeal disease surveillance in a rural Ghanaian pre-school child population

This paper is a report of the first year of follow-up on 250 pre-school children in a village in Ghana. The mean weight for age and the mean height for age at the start of the study, ranged between 81 and 97% and 91 and 101·4% of the median WHO reference standards respectively. Classified according to Waterlow (1973) 59·6% of the children were normal, 27·2% were thin, 8·9% were stunted, 3·4% were wasted and 0·9% were stunted and wasted. The mean velocity of height gain was 26·8 cm/year at birth; 9·6 cm/year at age of six months and thereafter the rate decreased almost linearly to a rate of 5cm/year at the age of 60 months. The curve for weight velocity had a similar shape to that of the height. The rate was on the average 5 kg/year at birth, and 1·7 kg/year at age of six months. Children over 30 months of age gained approximately, 0·5 kg/year compared to an expected gain of about 2 kg/year. The mean incidence of diarrhoeal diseases was 1·9 episodes per child per year. 34·4% of the cohort did not report on any episode of diarrhoea over the one year period. Highest incidence occurred in children between the ages of 7 and 12 months. Children who were less than 80% of the standard weight for age at the start of the study had significantly more diarrhoeal episodes than the rest. The mean incidence of diarrhoeal diseases per year increased as both height for age and weight for height decreased. It is suggested that primary intervention against diarrhoeal morbidity might be better aimed at improving childhood nutrition.