Diarrheal Disease In Children Research Articles

EnterotoxigenicBacteroides fragilis–Associated Diarrhea in Children 0–2 Years of Age in Rural Bangladesh

The burden of enterotoxigenic Bacteroides fragilis (ETBF)-related diarrhea was determined in a birth cohort of 252 children in rural Bangladesh. Isolation rates of ETBF in stool and risk factors for acquisition of ETBF and disease were established. Of 382 B. fragilis-positive specimens, 14.4% of the strains found in them produced enterotoxin, as determined by a tissue-culture assay. The overall isolation rate of ETBF was 2.3% (40/1750) from diarrheal specimens and 0.3% (15/5679) from nondiarrheal specimens collected throughout the 2 years of the study (P < .001). ETBF was isolated from 20.3% (40/197) of the B. fragilis-positive diarrheal specimens and from 8.1% (15/185) of the B. fragilis-positive nondiarrheal specimens (P < .001) and was significantly associated with acute diarrheal disease in children > or = 1 year of age (P = .0001). The diarrheal illness was mild in nature. In conditional multivariate analyses that examined environmental and host risk factors, the presence of livestock in the household area was linked to the acquisition of ETBF (chickens, P < .05; cows, P = .06). ETBF was found to be a small but significant contributor to diarrheal disease in this rural community. Improved management of livestock may be useful for the prevention of ETBF infection.

Use of Probiotics in Children with Acute Diarrhea

Probiotics, defined as microbial cell preparations or components of microbial cells that have a beneficial effect on the health and well being of the host, have traditionally been used to treat and prevent a variety of infections. Beneficial effects of probiotics in acute infectious diarrhea in children seem to be: (i) moderate; (ii) strain-dependent; (iii) dose dependent; (iv) significant in watery diarrhea and viral gastroenteritis, but non-existent in invasive, bacterial diarrhea; and (v) more evident when treatment with probiotics is initiated early in the course of disease. Three large, randomized controlled trials (RCTs) provide evidence of a very modest effect (statistically significant, but of questionable clinical importance) of some probiotic strains (Lactobaccillus GG, Lactobaccillus reuteri, Bifodobacterium lactis) on the prevention of community-acquired diarrhea. We have found conflicting evidence from four RCTs on the efficacy of Lactobacillus GG and B. bifidum and Streptococcus thermophilus in the prevention of nosocomial diarrhea in children. Two RCTs in children provide evidence of a moderate beneficial effect of Lactobacillus GG in the prevention of antibacterial-associated diarrhea (AAD), but results in adults are conflicting. Data on the efficacy of other probiotic strains in AAD in children are very limited. In conclusion, to date, the most extensively studied and best documented clinical application of probiotics in children is for the treatment of acute watery diarrhea of rotaviral or presumably viral etiology. Studies documenting effects in other types of diarrheal diseases in children are limited, although some preliminary results are promising. The effects of different probiotic microorganisms are not equal. Only very few probiotic strains have been tested rigorously in RCTs. Many questions remain to be answered. Future clinical trials should evaluate carefully selected, precisely defined probiotic strains and address clinically important endpoints.

Epidemiologic and Clinical Characteristics of Rotavirus Disease During Five Years of Surveillance in Venezuela

To effectively introduce a rotavirus vaccine in developing countries, it is necessary to estimate the burden of rotavirus disease. Therefore we examined the epidemiologic and clinical features of rotavirus diarrhea in children younger than 5 years of age in Carabobo State and extrapolated these results to the rest of Venezuela. From January 1, 1998 to December 31, 2002, we conducted surveillance for rotavirus diarrhea in all children younger than 5 years of age at the Ciudad Hospitalaria Dr Enrique Tejera, in Valencia (Carabobo). Rotavirus is the major cause of diarrhea in children younger than 5 years of age in Venezuela, accounting for one-fourth (23%) of all episodes of diarrhea requiring medical treatment and one-third (33%) of those requiring hospitalization. Rotavirus diarrhea was responsible for 3% of all hospitalizations and 2% of all medical visits. In Valencia, rotavirus had a marked seasonal peak during the dry and cold months of the year. Rotavirus was most frequent in children 3-23 months of age, and 61% of the cases occurred by the age of 1 year. In addition, rotavirus diarrhea was more severe in younger children. Overall, by the age of 5 years, 1 child in 72 will be hospitalized and 1 in 24 will visit the clinic for rotavirus disease. In Venezuela, we estimated that each year, 118,000 children experience rotavirus illness requiring medical care and 39,000 children require hospitalization. This study confirms the significant impact of rotavirus disease in Venezuela. Rotavirus vaccines currently in development could diminish the morbidity associated with this common cause of childhood diarrheal disease.

Hospitalisation for gastroenteritis in Western Australia

Aims: To document gastroenteritis hospitalisations of the 1995–96 cohort of infants born in Western Australia to mid-2002, and to assess factors associated with their hospitalisations and readmissions. Methods: Retrospective analysis...

Surveillance of childhood diarrhoeal disease in Hong Kong, using standardized hospital discharge data.

Discharge information for all Hong Kong government hospitals, which is routinely collected through the Clinical Management System (CMS), was used to assess the relative importance of all causes of diarrhoeal illness and to address the issue of under-diagnosis of rotavirus by linking discharge diagnostic codes with actual laboratory results for one hospital. Of all children less than 5 years of age hospitalized in Hong Kong in the 2-year period July 1997 to June 1999, 12,257 (11%) were discharged with a primary diarrhoea diagnosis (74% coded as non-specified, 10.4% as rotavirus, 11% as Salmonella and 5% as other viral or bacterial). Linked laboratory and discharge data for one hospital demonstrated that 15% (n = 1522) of all admissions had a primary diarrhoea diagnosis and that 40% of these had a specimen sent for rotavirus testing, of which 37% were positive. However, 46% (67/145) of children with a diagnosis of rotavirus infection had no virology result, and 69% (172/248) of positive rotavirus results were in children with no diagnosis indicating rotavirus infection. Modification of the CMS to routinely combine existing computerized laboratory data with the CMS discharge diagnoses and to develop mechanisms to enhance reliability of discharge diagnosis coding could produce a powerful resource for disease surveillance, auditing and for monitoring the impact of future vaccination and other prevention programmes.

Interventions to Improve Children's Health by Improving the Housing Environment

Young children spend more than 90% of their time in the household environment-a likely place of exposure to hazardous substances. In the developing world, childhood diarrheal disease and acute lower respiratory infections represent a large portion of the global burden of disease and are strongly related to housing conditions. In the developed world, allergies and asthma are also strongly linked to housing conditions. Therefore, intervention to improve housing is essential to improve and maintain children's health. This paper will review several factors that have been shown to mediate housing and health relations, including psychosocial, environmental, socioeconomic, behavior-cultural, and physiological factors, and will provide examples of intervention to improve child health, with housing as a focus. Environmental contaminants found in the household include biological (for example, vector-borne diseases, dustmites, mold, water and sanitation-related), chemical (for example, lead, volatile organic compounds, asbestos) or physical (for example, radon, electric and magnetic fields). Socioeconomic factors include bousehold income, the ability to obtain adequate and appropriate housing, and the ability to implement ongoing preventative maintenance. Housing tenure has been used as a proxy for socioeconomic status and shown some relation with health outcome. Socioeconomic factors can be relevant to the ability of households to create social networks that affect bealth. Psychosocial factors, including stress and depression, can also be related to housing type or design. Behavioral-cultural factors include practices that might influence exposure to chemical, biological, or radiation hazards like time-activity patterns, including gender relations and household decision-making patterns. Physiological factors include genetics or the nutritional and immune status of household members, which can influence the extent to which other housing factors like biological or chemical contaminants adversely affect children. Examples of intersectoral interventions and strategies to improve child health globally, with housing and health as a focus, include integrated pest-management programs to control vector-borne diseases like malaria and Chagas disease and energyefficiency programs to improve thermal comfort and to reduce the presence of allergens like mold and dustmites. Other interventions include housing and health policy, regulation and standard setting, education, training, and participation.

Emerging nalidixic acid and ciprofloxacin resistance in non-typhoidal Salmonella isolated from patients having acute diarrhoeal disease.

BackgroundNon-typhoidal Salmonella are one of the key etiological agents of diarrhoeal disease. The appearance of multiple drug resistance along with resistance to quinolones in this bacterium poses a serious therapeutic problem, We determined the prevalence of nalidixic acid and ciprofloxacin resistance in non-typhoidal Salmonella isolated from faecal samples of patients with acute diarrhoeal disease attending the outpatient and inpatient departments of a hospital in Saudi Arabia during the years 1999 to 2002.MethodsNon-typhoidal Salmonella were isolated from faecal samples. Antimicrobial susceptibility was tested by the disc diffusion test MICs to nalidixic acid and ciprofloxacin were determined by the agar dilution method.ResultsDuring the study period, 524 strains of non-typhoidal Salmonella were isolated Strains belonging to serogroup C1 were the commonest (41.4%) followed by serogroups B and D (15.6% and 14.5%, respectively), Resistance to ampicillin was observed in 22.9% and to trimethoprim/sulfamethoxazole in 18.5% of the strains. Nalidixic acid resistance was encountered in 9.9% and ciprofloxacin resistance in 23% of the strains. Resistance to nalidixic acid significantly increased from 0.1% in 1999 to 5.5% in 2002 (P=0.0007) and ciprofloxacin resistance increased significantly from 0.1% in 1999 to 0.9% in 2002 (P=0.0001). MICs to nalidixic acid and ciprofloxacin were determined among 29 nalidixic acid-resistant strains of non-typhoidal Salmonella isolated during 2002. The MIC was >256 μg/mL to nalidixic acid and 8 to 16 μg/mL to ciprofloxacin.ConclusionThe increasing rates of antimicrobial resistance encountered among non-typhoidal Salmonella necessitate the judicious use of these drugs in humans. Moreover, these findings support the concern that the use of quinolones in animal feed may lead to an increase in resistance and should be restricted.

Childhood astrovirus-associated diarrhea in the ambulatory setting in a Public Hospital in Cordoba city, Argentina.

Human astroviruses have been increasingly identified as important agents of diarrheal disease in children. However, the disease burden of astrovirus infection is still incompletely assessed. This paper reports results on the epidemiological and clinical characteristics of astrovirus-associated diarrhea, as well as the impact of astrovirus infection on the ambulatory setting at a Public Hospital in Córdoba city, Argentina. From February 2001 through January 2002, 97 randomly selected outpatient visits for diarrhea among children < 36 months old were enrolled. A single specimen of stool from each child was collected and tested for astrovirus antigen by enzyme immunoassay. Astroviruses were detected in 12.37% of the diarrheal episodes. All the positive cases occurred in children 4 to 18 months, but the highest rate was in children aged 4 to 6 months (23.80%). The clinical symptoms of astrovirus associated-diarrhea were fever 41.66%, vomiting 25.00% and dehydration 8.33%; overall 16.66% required hospitalization. Astrovirus was identified through the year and no seasonally pattern was detected (cool semester 15.21% versus warm semester 9.80% p > 0.05). According to our estimation about one out of seventy-four children in this cohort would be assisted annually for an astroviral-diarrheal episode in the Public Hospital and one out of eight diarrheal cases could be attributed to astrovirus infection. Astrovirus is a common symptomatic infection in pediatric outpatient visits in the public hospital in the study area, contributing 12.37% of the overall morbidity from diarrhea.

Detection of pediatric respiratory and Diarrheal outbreaks from sales of over-the-counter electrolyte products

ObjectiveTo determine whether sales of electrolyte products contain a signal of outbreaks of respiratory and diarrheal disease in children and, if so, how much earlier a signal relative to hospital diagnoses. DesignRetrospective analysis was conducted of sales of electrolyte products and hospital diagnoses for six urban regions in three states for the period 1998 through 2001. MeasurementsPresence of signal was ascertained by measuring correlation between electrolyte sales and hospital diagnoses and the temporal relationship that maximized correlation. Earliness was the difference between the date that the exponentially weighted moving average (EWMA) method first detected an outbreak from sales and the date it first detected the outbreak from diagnoses. The coefficient of determination (r2) measured how much variance in earliness resulted from differences in sales' and diagnoses' signal strengths. ResultsThe correlation between electrolyte sales and hospital diagnoses was 0.90 (95% CI, 0.87–0.93) at a time offset of 1.7 weeks (95% CI, 0.50–2.9), meaning that sales preceded diagnoses by 1.7 weeks. EWMA with a nine-sigma threshold detected the 18 outbreaks on average 2.4 weeks (95% CI, 0.1–4.8 weeks) earlier from sales than from diagnoses. Twelve outbreaks were first detected from sales, four were first detected from diagnoses, and two were detected simultaneously. Only 26% of variance in earliness was explained by the relative strength of the sales and diagnoses signals (r2=0.26). ConclusionSales of electrolyte products contain a signal of outbreaks of respiratory and diarrheal diseases in children and usually are an earlier signal than hospital diagnoses.

The Impact of Oral Rehydration Therapy on Childhood Diarrhoeal Disease in Ilorin

Background: Diarrhoeal disease remains a leading cause of morbidity and mortality in childhood. The advent of oral rehydration therapy (ORT) including home treatment of diarrhoea has affected the incidence of dehydration. Objective: To assess the impact of oral rehydration therapy on childhood diarrhoeal disease. Design: Cross sectional study. Methods: The duration of the diarrhoeal illness, the degree of dehydration, treatment given at home and the outcome were studied in children seen at the Diarrhoea Training Unit (DTU) of the University of Ilorin Teaching Hospital during the periods July 1993 to June 1994 and July 1997 to June 1998. Results: Eight hundred and ninety one patients presented in the DTU over the one-year period in 1993/94 compared to 109 patients over the same period in 1997/98. There was a significantly higher mean duration of diarrhoea before presentation in the 1993/94 group (58.3 ± 13 hours) compared to the 1997/98 group (25.7 ± 6.1 hours) (t = 2.12, p Conclusion: The application of oral rehydration therapy resulted in the reduction of cases of severe dehydration seen in children with diarrhoea in Ilorin. The parents presented earlier in the 1997/98 than in the 1993/944 group but the use of antidiarrhoeal drugs was still common. There is therefore, a need for further training of health workers and mothers on the home management of diarrhoea. The use of drugs that are not indicated in the management of diarrhoea should be discouraged, while ORT use should be strengthened. Key words: Diarrhoea, Dehydration, Oral rehydration therapy, Anti-diarrhoeal drugs. Nigerian Journal of Paediatrics 2003;30:23-26.

Is hygiene promotion cost-effective? A case study in Burkina Faso.

To estimate the incremental cost-effectiveness of a large-scale urban hygiene promotion programme in terms of reducing the incidence of childhood diarrhoeal disease in Bobo-Dioulasso, Burkina Faso. Total and incremental costs of the programme were estimated retrospectively from the perspectives of the provider, from the households who change their behaviour as a result of the programme and from society (the sum of the two). The programme effects were derived from an intervention study that estimated the impact on handwashing with soap after handling child stools through a time-series method of observing 37 319 mothers. Using data from the literature, the associated reductions in childhood morbidity and mortality were estimated. The direct medical savings and indirect savings of caregiver time and lost productivity associated with child death were estimated from interviews with households and health workers. The cost and outcome data were combined to provide an estimate of the cost per mother who starts handwashing with soap as a result of the programme and the cost per case of childhood diarrhoea averted. The total provider cost (including start-up and 3-year running costs) was $302 507. Core programme activities accounted for 31% of the cost, administration 40%. The total cost to the 7286 households associated with changing behaviour during the 3 years of programme implementation was $160 125 ($7.3 per year per household). An estimated 8638 cases of diarrhoea, 864 outpatient consultations, 324 hospital referrals and 105 deaths were averted by the programme during this time. Savings to the provider from reduced treatment costs were estimated at $10 716 and savings to the households from averted treatment cost were $9136, resulting in a total saving to society of $19 852, increasing to $393 967 if indirect savings are included. The incremental provider cost per case of diarrhoea averted was $33.8. The incremental cost to society was $51.3 falling to $7.9 if indirect savings are included. If the programme were to be replicated elsewhere, savings in the international research input and start-up costs could reduce provider costs to $26.9 per case of diarrhoea averted. The annual cost of the programme represents 0.001% of the national health budget for Burkina Faso. The direct annual cost of implementing the programme at the household level represents 1.3% of annual household income. Hygiene promotion reduces the occurrence of childhood diarrhoea in Burkina Faso at less than 1% of the Ministry of Health budget and less than 2% of the household budget, and could be widely replicated at lower cost.

Diarrheal diseases in children from a water reclamation site in Mexico city.

This study was conducted to assess the risk of enteric diseases among children living in a water reclamation area in Mexico City. A geographic information system was used to define eligible wells and surrounding homesteads. Sixty-five water samples from five wells were tested for fecal coliform bacteria per 100 mL (FC/100 mL) during visits to 750 eligible households; caretakers only in those dwellings with children under 5 years old were interviewed throughout repeated cross-sectional surveys, conducted during 1999-2000. Data on diarrheal diseases were obtained from 761 children during the rainy season and 732 children during the dry season; their guardians also provided information on drinking water supply, sanitation, and socioeconomic variables. The presence of indicator organisms in groundwater samples pointed to fecal pollution; bacterial indicators, however, did not predict the health risk. The rates of diarrhea were 10.7% in the dry season and 11.8% in the rainy season. Children 1 year old showed the highest rate of diarrhea during the dry season [odds ratio (OR) = 2.1 with 95% confidence interval (CI), 0.99-4.71], particularly those from households perceiving unpleasant taste of tap water (OR, 1.7; 95% CI, 0.97-2.92) and consuming vegetables washed only with water (OR, 2.2; 95% CI, 1.10-4.39). Lower risk was observed in individuals enjoying full-day water supply (OR, 0.5; 95% CI, 0.27-0.86) and a flushing toilet (OR, 0.3; 95% CI, 0.16-0.67), as well as those storing water in covered receptacles (OR, 0.3; 95% CI, 0.15-0.80). Rainy season data suggested that children from households perceiving a color to their water had a higher rate of diarrhea than did those without such complaint (OR, 1.8; 95% CI, 0.93-3.67); recent consumption of food sold by street vendors was also a significant risk factor (OR, 1.6; 95% CI, 0.98-2.87). Groundwater is at risk of contamination, as indicated by the presence of FC/100 mL. The endemic pattern of diarrhea, however, reflects mostly inadequate housing, sanitation, and water-related practices. Health protection policy must be discussed.

Viral Causes of Diarrhea

Rotavirus is the most commonly recognized viral pathogen that produces diarrheal disease in children and the most common cause of severe gastroenteritis requiring hospitalization. However, a number of other viruses can cause diarrhea, and their clinical manifestations are important to recognize in the care of children who have gastroenteritis. The viruses include adenovirus, Norwalk virus, astrovirus, and calicivirus.Some generalizations can be made about viral diarrheal disease in infants and young children. Incubation periods are brief, usually 1 to 3 days. Infections can be asymptomatic, but if diarrhea develops, it frequently is associated with vomiting and fever. With the exception of rotavirus, the diarrhea produced by viral infection typically is mild to moderate. If stool studies are performed, they rarely reveal white blood cells or occult blood in the stool, and results of stool cultures are negative.Second only to rotavirus in frequency is adenovirus, which accounts for 5% to 10% of pediatric hospitalizations for acute gastroenteritis (compared with the 30% to 70% attributed to rotavirus). Serotypes 40 and 41 are the enteric strains known to cause gastroenteritis in children; these strains do not cause any of the respiratory symptoms commonly associated with other adenoviruses. The mean age of clinical illness in children is 1 to 2 years of age. Like rotavirus, transmission is by the fecal-oral route. Adenovirus has an incubation period of 8 to 10 days, which is considerably longer than that of the other common viruses. Symptoms last 5 to 12 days on average, with one third of children experiencing diarrhea for longer than 14 days. Patients may have vomiting or fever with adenoviral infection. Unlike rotavirus, there is very little seasonality associated with adenoviral gastroenteritis. An enzyme immunoassay test is available for detection of adenovirus, but it is not used frequently outside of research studies.Norwalk virus is also an important cause of viral gastroenteritis. This virus is spread both by the fecal-oral route and via contaminated food and water sources. Outbreaks of diarrheal disease can occur in child care, schools, and other settings, commonly affecting older children and adults. The incubation period is usually less than 48 hours. Unlike adenovirus, the course of illness with Norwalk virus gastroenteritis is brief, lasting fewer than 48 hours, and generally is characterized by vomiting.Less commonly recognized causes of viral diarrhea include astroviruses and caliciviruses. Astrovirus infections can be asymptomatic, but also can cause diarrheal illness, with more than 50% of children also experiencing vomiting and fever. Detected most commonly in the winter, astroviruses have a short incubation period of 1 to 2 days. Caliciviruses also can cause mild diarrhea in infants and toddlers, although symptoms are seen in older children and adults as well. Both of these virus families have been associated with outbreaks at child care centers and in association with consumption of contaminated food or water.The primary concern for all diarrheal disease is prevention and treatment of dehydration. Oral rehydration solutions, which are very effective in preventing and treating dehydration, are commercially available for children, and appropriate intravenous solutions may be used for fluid resuscitation of patients who do not tolerate oral fluids. All of the viral gastroenteritides are self-limited, and antibiotics play no role in their treatment.Comment: Worldwide, viruses are the leading cause of diarrhea. Among viruses, rotavirus is the major cause of severe diarrhea (Pediatr Rev. 1999;20:39–71). Unfortunately, vaccines have not provided the answer to rotaviral disease prevention. Handwashing and ensuring safe food and water supplies continue to be the mainstays of prevention of viral diarrhea.Tina L. Cheng, MD, MPHAssociate Editor, In Brief

Vitamin A Deficiency Changes Jejunal Mucosal Fatty Acid Profile in Rats

Changes in intestinal epithelial integrity have been postulated to explain the association between vitamin A status and diarrhoeal disease in children living in areas where vitamin A deficiency is a major public health problem. Fatty acids are an integral component of normal enterocyte structure, and changes to their profile in the intestinal mucosa may impact on the efficacy of the mucosal barrier. The aim of this study therefore was to determine the effect of vitamin A deficiency on intestinal mucosal fatty acid profile. Weanling male specific pathogen free rats were maintained on a vitamin A deficient diet for either 40-42 (subclinical deficiency) or 60-63 days (clinical deficiency), and compared with rats pair fed or allowed free access to the same diet, but supplemented with vitamin A (vitamin A sufficient). Fatty acid profile of jejunal mucosal homogenates was determined using gas chromatography. While subclinically vitamin A deficient rats had only minor differences in fatty acid profile as compared with pair fed and vitamin A sufficient rats, there were marked differences in a number of fatty acids in the clinically vitamin A deficient rats. Clinically vitamin A deficient rats had more arachidonic acid (C20: 4n-6) than pair fed rats, and less linoleic acid (C18: 2n-6) than both pair fed and vitamin A sufficient rats. These findings suggest that vitamin A deficiency modifies intestinal mucosal fatty acid composition such that there is an increase in proinflammatory eicosanoid precursors. This may contribute towards our understanding of a biological mechanism of the epidemiological association between vitamin A status and diarrhoeal disease.

Integrated Management of Childhood Illness (IMCI): a robust strategy.

Integrated Management of Childhood Illness (IMCI), a strategy fostering holistic approach to child health and development, is built upon successful experiences gained from effective child health interventions like immunization, oral rehydration therapy, management of acute respiratory infections and improved infant feeding. The core intervention of IMCI is integrated management of the five most important causes of childhood deaths-acute respiratory infections, diarrheal diseases, measles, malaria and malnutrition. Using a set of interventions for the integrated treatment and prevention of major childhood illnesses, the IMCI strategy aims to reduce death as well as the frequency and severity of illness and disability, thus contributing to improved growth and development. In health facilities, the IMCI strategy promotes the accurate identification of childhood illness (es) in the outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers and the provision of preventive services, and speeds up the referral of severely ill children. The strategy also aims to improve the quality of care of sick children at the referral level. It also creates a scientifically sound link between the management guidelines at the community level and the management approach in a referral centre. The strategy also envisages actual situations when referral is not possible and offers the best possible options in such circumstances. In the home setting, it promotes appropriate early home care and care-seeking, improved nutrition and prevention, and the correct implementation of prescribed care. In addition to its focus on treatment of illness in the health facility as well as at home, it also provides an opportunity for important preventive interventions such as immunization and improved infant and child nutrition including breastfeeding. The IMCI strategy reduces wastage of resources and avoids duplication of efforts that may occur in a series of separate disease control programs. The essential pillars include improvement in the case management skills of health personnel, improvement in health systems, and improvement in family and community practices. IMCI has been introduced in more than 80 countries and 19 of them have already scaled up IMCI implementation Even though it is too early to relate the decrease in childhood mortality with the introduction of IMCI in these countries, there are several indirect indicators which endorse its validity as a comprehensive and effective strategy. IMCI has helped countries to revise and update their child health policies, streamline the essential drug lists for children, increase service utilization, improve quality of care and nutritional counselling, improve health systems and improved family and community practices.

Diffuse and enteroaggregative patterns of adherence of Escherichia coli isolated from stools of children in northeastern Brazil

Childhood diarrheal diseases remain highly endemic in northeastern Brazil. The attributable fraction of all diarrheal diseases among children less than 2 years of age due to Escherichia coli was examined in a 2-year prospective study in two large urban centers of Brazil. Between May 1997 and June 1999, fecal E. coli isolates from 237 children with diarrhea (217 acute and 20 persistent cases) and 231 children without diarrhea (controls) attending two hospitals in Northeast Brazil were tested for their pattern of adherence to HEp-2 cells and for colony hybridization with DNA probes specific for the six pathotypes of diarrheagenic E. coli. Enteroinvasive E. coli, enterotoxigenic E. coli and enterohemorrhagic E. coli were not isolated from any children. Diffusely adherent E. coli (DAEC) and enteroaggregative E. coli (EAEC) were the most frequent isolates with similar frequencies from children with or without diarrhea. Atypical EPEC (EAF-negative) strains were isolated with similiar frequency from both cases (5.5%) and controls (5.6%). Enteropathogenic E. coli (typical EPEC) strains, characterized by localized adherence pattern of adherence, hybridization with the EAF probe, and belonging to the classical O serogroups, were significantly associated with diarrhea (P = 0.03). These E. coli strains associated with diarrhea accounted for 9% of all children with diarrhea. Collectively, in Northeast Brazil, E. coli strains comprise a small proportion of severe diarrhea prevalence in children.

Solar disinfection of drinking water protects against cholera in children under 6 years of age

BACKGROUND AND AIMSWe have previously reported a reduction in risk of diarrhoeal disease in children who used solar disinfected drinking water. A cholera epidemic, occurring in an area of Kenya...

Diarrhea in children under 5 years of age from Ifakara, Tanzania: a case-control study.

A matched case-control study was conducted in the Maternal and Child Health Clinic (MCH) in Ifakara, Tanzania, during the rainy season in order to elucidate the risk factors for and etiology of diarrheal diseases in children under 5 years of age. Cases (103) and controls (206) were matched for sex and age group. Precoded questionnaires with demographic details, clinical history, and physical signs were completed. Stools samples were collected for bacterial, parasitological, and viral studies. A high number of siblings (odds ratio [OR], 0.86; P = 0.027), the number of siblings surviving (OR, 0.82; P = 0.007), the birth order (OR, 0.85; P = 0.018) and the distance from the house to the water source (OR, 0.33; P = 0.011) were associated with the risk of diarrhea. There were high rates of enteropathogen isolates in stool samples from children without diarrhea (52.23%). Shigella species were the only enteropathogen statistically related with diarrhea (OR, 2.90; P < 0.029). Enterotoxigenic, enteropathogenic, and enteroaggregative strains of Escherichia coli were not related with diarrhea, and neither were Giardia lamblia or Salmonella species.

El Niæo linked to increase in childhood diarrheal disease, a leading cause of premature death

William Checkley recalled plotting into his computer the data for the number of hospital admissions and the time of year.When we did the analysis and started looking at the relative increase, thats when it hit us, said Checkley, a medical student at Johns Hopkins University in Maryland.

The Alleles of the bft Gene Are Distributed Differently among Enterotoxigenic Bacteroides fragilis Strains from Human Sources and Can Be Present in Double Copies

Enterotoxigenic Bacteroides fragilis (ETBF) strains are associated with diarrheal disease in children. These strains produce a zinc metalloprotease enterotoxin, or fragilysin, that can be detected by a cytotoxicity assay with HT-29 cells. Recently, three different isoforms or variants of the enterotoxin gene, designated bft-1, bft-2, and bft-3, have been identified and sequenced. We used restriction fragment length polymorphism analysis of the PCR-amplified enterotoxin gene to detect the isoforms bft-1 and bft-2 or bft-3 borne by ETBF. By sequencing the portion of the bft gene corresponding to the mature toxin in some strains and applying allele-specific PCR for strains categorized as bft-2 or bft-3, we found in our collection two strains harboring bft-3, a variant that had been described for isolates from East Asia. Analysis of 66 ETBF strains from different sources showed that bft-1 is the most frequent allele, being present in 65% of isolates; it is largely predominant in isolates from feces of adults, while bft-2 is present in isolates from feces of children. This association is statistically significant (P, 0.0064). Sixteen strains were examined by Southern hybridization using, as probes, the bft and second metalloprotease genes, both included in a pathogenicity islet. Five strains were found to harbor double copies of both genes, suggesting that the whole islet was duplicated. Four of these strains, harboring bft-1 (three strains) or bft-2 (one strain), were found to produce a large amount of biologically active toxin, as determined by a cytotoxicity assay with HT-29 cells. The strains harboring bft-3, either in a single copy or in double copies, produced the smallest amount of toxin in our collection.