Progress and barriers for the control of diarrhoeal disease

Systematic druggable genome-wide Mendelian randomization identifies therapeutic targets for sarcopenia

BACKGROUND

There are no effective pharmacological treatments for sarcopenia. We aim to identify potential therapeutic targets for sarcopenia by integrating various publicly available datasets.

METHODS

We integrated druggable genome data, cis-eQTL/cis-pQTL from human blood and skeletal muscle tissue, and GWAS summary data of sarcopenia-related traits to analyse the potential causal relationships between drug target genes and sarcopenia using the Mendelian Randomization (MR) method. Sensitivity analyses and Bayesian colocalization were employed to validate the causal relationships. We also assessed the side effects or additional indications of the identified drug targets using a phenome-wide MR (Phe-MR) approach and investigated actionable drugs for target genes using available databases.

RESULTS

MR analysis identified 17 druggable genes with potential causation to sarcopenia in human blood or skeletal muscle tissue. Six of them (HP, HLA-DRA, MAP 3K3, MFGE8, COL15A1, and AURKA) were further confirmed by Bayesian colocalization (PPH4 > 90%). The up-regulation of HP [higher ALM (beta: 0.012, 95% CI: 0.007-0.018, P = 1.2*10-5) and higher grip strength (OR: 0.96, 95% CI: 0.94-0.98, P = 4.2*10-5)], MAP 3K3 [higher ALM (beta: 0.24, 95% CI: 0.21-0.26, P = 1.8*10-94), higher grip strength (OR: 0.82, 95% CI: 0.75-0.90, P = 2.1*10-5), and faster walking pace (beta: 0.03, 95% CI: 0.02-0.05, P = 8.5*10-6)], and MFGE8 [higher ALM (muscle eQTL, beta: 0.09, 95% CI: 0.06-0.11, P = 6.1*10-13; blood pQTL, beta: 0.05, 95% CI: 0.03-0.07, P = 3.8*10-09)], as well as the down-regulation of HLA-DRA [lower ALM (beta: -0.09, 95% CI: -0.11 to -0.08, P = 5.4*10-36) and lower grip strength (OR: 1.13, 95% CI: 1.07-1.20, P = 1.8*10-5)] and COL15A1 [higher ALM (muscle eQTL, beta: -0.07, 95% CI: -0.10 to -0.04, P = 3.4*10-07; blood pQTL, beta: -0.05, 95% CI: -0.06 to -0.03, P = 1.6*10-07)], decreased the risk of sarcopenia. AURKA in blood (beta: -0.16, 95% CI: -0.22 to -0.09, P = 2.1*10-06) and skeletal muscle (beta: 0.03, 95% CI: 0.02 to 0.05, P = 5.3*10-05) tissues showed an inverse relationship with sarcopenia risk. The Phe-MR indicated that the six potential therapeutic targets for sarcopenia had no significant adverse effects. Drug repurposing analysis supported zinc supplementation and collagenase clostridium histolyticum might be potential therapeutics for sarcopenia by activating HP and inhibiting COL15A1, respectively.

CONCLUSIONS

Our research indicated MAP 3K3, MFGE8, COL15A1, HP, and HLA-DRA may serve as promising targets for sarcopenia, while the effectiveness of zinc supplementation and collagenase clostridium histolyticum for sarcopenia requires further validation.

Supporting evidence-based rotavirus vaccine introduction decision-making and implementation: Lessons from 8 Gavi-eligible countries

Despite the 2009 World Health Organization recommendation that all countries introduce rotavirus vaccines (RVV) into their national immunization programs, just 81 countries had introduced RVV by the end of 2015, leaving millions of children at risk for rotavirus morbidity and mortality. In response, the Rotavirus Accelerated Vaccine Introduction Network (RAVIN) was established in 2016 to provide support to eight Gavi-eligible countries that had yet to make an RVV introduction decision and/or had requested technical assistance with RVV preparations: Afghanistan, Bangladesh, Benin, Cambodia, Democratic Republic of Congo, Lao People's Democratic Republic, Myanmar, and Nepal. During 2016-2020, RAVIN worked with country governments and partners to support evidence-based immunization decision-making, RVV introduction preparation and implementation, and multilateral coordination. By the September 2020 program close-out, five of the eight RAVIN focus countries successfully introduced RVV into their routine childhood immunization programs. We report on the RAVIN approach, describe how the project responded collectively to an evolving RVV product landscape, synthesize common characteristics of the RAVIN country experiences, highlight key lessons learned, and outline the unfinished agenda to inform future new vaccine introduction efforts by countries and global partners.

Antimicrobial potential and rhodamine B dye degradation using graphitic carbon nitride and polyvinylpyrrolidone doped bismuth tungstate supported with in silico molecular docking studies

The environmental-friendly hydrothermal method has been carried out to synthesize Bi2WO6 and g-C3N4/PVP doped Bi2WO6 nanorods (NRs) by incorporating different concentrations of graphitic carbon nitride (g-C3N4) as well as a specified quantity of polyvinylpyrrolidone (PVP). Bi2WO6 doped with g-C3N4 provides structural and chemical stability, reduces charge carriers, degrades dyes, and, owing to lower bandgap energy, is effective for antibacterial, catalytic activity, and molecular docking analysis. The purpose of this research is the treatment of polluted water and to investigate the bactericidal behavior of a ternary system. The catalytic degradation was performed to remove the harmful rhodamine B (RhB) dye using NaBH4 in conjunction with prepared NRs. The specimen compound demonstrated antibacterial activity against Escherichia coli (E. coli) at both high and low concentrations. Higher doped specimens of g-C3N4/PVP-doped Bi2WO6 exhibited a significant improvement in efficient bactericidal potential against E. coli (4.55 mm inhibition zone). In silico experiments were carried out on enoyl-[acylcarrier-protein] reductase (FabI) and β-lactamase enzyme for E. coli to assess the potential of Bi2WO6, PVP doped Bi2WO6, and g-C3N4/PVP-doped Bi2WO6 NRs as their inhibitors and to justify their possible mechanism of action.

Facile Synthesis of Vanadium Oxide/Carbon Spheres-Doped Nickel Oxide Functioned as a Nanocatalyst and Bactericidal Behavior with Molecular Docking Analysis

Vanadium oxide (V₂O₅) and carbon spheres (Cs)-doped NiO₂ nanostructures (NSs) were prepared using the co-precipitation approach. Several spectroscopic and microscopic techniques, including X-ray diffraction (XRD), UV-vis, FTIR, TEM, and HR-TEM investigations, were used to describe the as-synthesized NSs. The XRD pattern exhibited the hexagonal structure, and the crystallite size of pristine and doped NSs was calculated as 29.3, 32.8, 25.79, and 45.19 nm, respectively. The control sample (NiO₂) showed maximum absorption at 330 nm, and upon doping, a redshift was observed, leading to decreased band gap energy from 3.75 to 3.59 eV. TEM of NiO₂ shows agglomerated nonuniform nanorods exhibited with various nanoparticles without a specific orientation; a higher agglomeration was observed upon doping. The (4 wt %) V₂O₅/Cs-doped NiO₂ NSs served as superior catalysts with a 94.21% MB reduction in acidic media. The significant antibacterial efficacy was estimated against Escherichia coli by measuring the zone of inhibition (3.75 mm). Besides their bactericidal analysis, V₂O₅/Cs-doped NiO₂ was shown to have a binding score of 6.37 for dihydrofolate reductase and a binding score of 4.31 for dihydropteroate synthase in an in silico docking study of E. coli.

The economic impact of the introduction of universal rotavirus vaccination on rotavirus gastroenteritis related hospitalisations in children in Ireland

BACKGROUND

Rotavirus gastroenteritis (RVGE), a vaccine preventable disease, remains a common cause of severe gastroenteritis in children globally. Ireland introduced the universal rotavirus vaccination to the national immunisation programme in 2016. In this paper the economic impact on RVGE related hospitalisations amongst children under 5 years is examined.

METHODS

Using national data from all Irish public hospitals, an Interrupted Times Series Analysis (ITSA) compares RVGE hospitalisations amongst children under 5 years, pre- and post-vaccine introduction. Costs are estimated and ITSA results are compared to the counterfactual to estimate the economic impact of the vaccine. A probit model examines patient characteristics pre- and post-vaccine introduction.

RESULTS

Vaccine introduction coincided with lowered RVGE related hospitalisations. While this effect was delayed (1 year) there is evidence of a sustained impact. RVGE patients' post-vaccine introduction were likely to be over 2 years (p = 0.001) and length of stay was lower on average (p = 0.095). The counterfactual analysis revealed 492 RVGE hospitalisations were avoided on average annually since the introduction of the vaccine. This has an estimated economic value of €0.92 million per annum.

CONCLUSIONS

Following the introduction of the rotavirus vaccine in Ireland, hospitalisations for RVGE decreased significantly and those hospitalised were older and with a reduced length of stay on average. This has the potential for significant cost savings for the Irish healthcare system.

Direct outpatient cost per case of acute gastroenteritis in Trinidad and Tobago, 2021

The burdens associated with acute gastroenteritis involve billions of dollars in expenses, coupled with significant morbidity and mortality globally. To reduce these burdens, health officials and policymakers require up-to-date data (health and economic) to request and allocate resources in guiding the development and implementation of preventative strategies. In 2021, the estimate for one case of acute gastroenteritis was calculated using multiple sources of data: the 2009 national health burden survey on acute gastroenteritis; a 2021 telephone survey of five major private hospitals; a 2021 telephone survey of 30 private pharmacies; and the 2021 Minimum Wages Act of Trinidad and Tobago. For each case of illness, an average cost of $1614 TTD ($238 USD) was estimated. For residents who sought private health care, the average GP visit cost was $500-$700 TTD ($73-$103 USD), while costs for medication prescribed ranged between $327 and $1166 TTD ($48-$172 USD). Productivity losses amounted to almost $21.7 million TTD ($3.2 million USD) for residents who took time off from work or required caregiving services. The overall annual cost was estimated to be $204 million TTD ($30.1 million USD) and, therefore, warrants measures by health officials to reduce the economic and social burdens of acute gastroenteritis in Trinidad and Tobago.

The effects of fluid absorption and plasma volume changes in athletes following consumption of various beverages

BACKGROUND

To verify the hydration effects of oral rehydration solution (ORS) on athletes by comparing the degrees of fluid absorption and plasma volume changes following beverage consumption, including ORS.

METHODS

Thirty-one participants visited the testing laboratory 4 times at 1-week intervals to consume 1 L of beverage (e.g., water, ORS, and two sports drinks [SpD]) for 30 min on each visit. The urine output was measured 4 times at 1 h, 2 h, 3 h, and 4 h after beverage consumption. A blood sample was collected 3 times at 1 h, 2 h, and 3 h after beverage consumption. Body weight was measured once in 4 h after beverage consumption.

RESULTS

Body weight change was smaller for ORS than for water, SpD1, and SpD2 (p < 0.05). Cumulative urine output in 4 h was lower for ORS, SpD1, and SpD2 than for water (p < 0.05), and it was lower for ORS than for SpD2 (p < 0.05). BHI in 4 h was higher for ORS, SpD1, and SpD2 than for water (p < 0.05), and it was higher for ORS than for SpD2 (p < 0.05). There was no significant difference in PVC for different beverages at all test times, i.e.., 1 h, 2 h, and 3 h.

CONCLUSIONS

We evaluated the hydration effects of the consumption of beverages, such as water, SpD, and ORS in athletes. ORS and SpD were more effective than water. A comparison between ORS and SpD showed that the result could vary depending on the type of SpD.

Understanding the use of oral rehydration therapy: A narrative review from clinical practice to main recommendations

Background and Aims

Fluid loss due to diarrhea remains a significant cause of mortality among children under the age of 5.

Methods

Oral rehydration therapy (ORT) is a first‐line therapeutic measure to compensate the volume loss due to diarrhea and vomiting among gastroenteritis patients. Despite adequate knowledge, the practice of ORT is limited, particularly in developing countries.

Results

Several recommendations are provided regarding the use of ORT to treat hypovolemia, however, the information regarding its adequate usage is restricted within the healthcare centers and professionals.

Conclusion

This review highlights the importance of providing recommendations regarding the use of ORT. We also discuss the barriers and alternatives that might limit its use.

An overview of nanomaterial-based novel disinfection technologies for harmful microorganisms: Mechanism, synthesis, devices and application

Harmful microorganism (e.g., new coronavirus) based infection is the most important security concern in life sciences and healthcare. This article aims to provide a state-of-the-art review on the development of advanced technology based on nanomaterial disinfection/sterilization techniques (NDST) for the first time including the nanomaterial types, disinfection techniques, bactericidal devices, sterilization products, and application scenarios (i.e., water, air, medical healthcare), with particular brief account of bactericidal behaviors referring to varied systems. In this emerging research area spanning the years from 1998 to 2021, total of ~200 publications selected for the type of review paper and research articles were reviewed. Four typical functional materials (namely type of metal/metal oxides, S-based, C-based, and N-based) with their development progresses in disinfection/sterilization are summarized with a list of synthesis and design. Among them, the widely used silver nanoparticles (AgNPs) are considered as the most effective bacterial agents in the type of nanomaterials at present and has been reported for inactivation of viruses, fungi, protozoa. Some methodologies against (1) disinfection by-products (DBPs) in traditional sterilization, (2) noble metal nanoparticles (NPs) agglomeration and release, (3) toxic metal leaching, (4) solar spectral response broadening, and (5) photogenerated e^-/h⁺ pairs recombination are reviewed and discussed in this field, namely (1) alternative techniques and nanomaterials, (2) supporter anchoring effect, (3) nonmetal functional nanomaterials, (4) element doping, and (5) heterojunction constructing. The feasible strategies in the perspective of NDST are proposed to involve (1) non-noble metal disinfectors, (2) multi-functional nanomaterials, (3) multi-component nanocomposite innovation, and (4) hybrid techniques for disinfection/sterilization system. It is promising to achieve 100% bactericidal efficiency for 10⁸ CFU/mL within a short time of less than 30 min.

Global Burden and Trends of Norovirus-Associated Diseases From 1990 to 2019: An Observational Trend Study

Introduction

As an important pathogen causing diarrheal diseases, the burden and change in the death rate of norovirus-associated diseases (NADs) globally are still unknown.

Methods

Based on global disease burden data from 1990 to 2019, we analyzed the age-standardized death rate (ASDR) of NADs by age, region, country, and Socio-Demographic Index (SDI) level. The discrete Poisson model was applied in the analysis of NADs' spatiotemporal aggregation, the Joinpoint regression model to analyze the trend of death burden of NADs over 30 years, and a generalized linear model to identify the risk factors for the death rate from NADs.

Results

The ASDR of NADs significantly decreased by a factor of approximately 2.7 times, from 5.02 (95% CI: 1.1, 11.34) in 1990 to 1.86 (95% CI: 0.36, 4.16) in 2019 [average annual percent change (AAPC) = −3.43, 95% CI: −3.56, −3.29]. The death burden of NADs in 2019 was still highest in African regions despite a great decline in recent decades. However, the ASDR in high SDI countries presented an uptrend [0.12 (95% CI: 0.03, 0.26) in 1990 and 0.24 (95% CI: 0.03, 0.53) in 2019, AAPC = 2.52, 95% CI: 2.02–3.03], mainly observed in the elderly over 70 years old. Compared to children under 5 years old, the 2019 death rate of elderly individuals over 80 years old was much higher in high SDI countries. The generalized linear model showed that factors of the number of physicians (RR = 0.67), the proportions of children under 14 years old (RR = 1.21), elderly individuals over 65 years old (RR = 1.13), educational level (RR = 1.03) and urbanization proportion (RR = 1.01) influenced the ASDR of NADs.

Conclusions

The death burden of NADs has remained high in developing regions over the last three decades and has increased among the elderly in countries with high SDI levels, even though the global trend in NAD-associated deaths has decreased significantly in the past three decades. More effective public health policies against NADs need to be implemented in high SDI regions and for the elderly.

Home-based management practice of diarrhea in under 5 years old children and associated factors among caregivers in Ginchi town, Oromia region, west Ethiopia

Objective:

The study was aimed to assess the home-based management practice of diarrhea and associated factors among caregivers in children under 5 years old at Ginchi town, Oromia region, West Ethiopia.

Methods:

A community-based cross-sectional study was conducted among 335 caregivers in Ginchi town. Data were collected using face-to-face interviewing questionnaires by using a systematic sampling technique. Data were entered into Epi-data version 3.5.1 and exported to statically software package for social science version 23.0 for analysis. Descriptive analyses were carried out. Bivariable and multivariable logistic regressions were done to identify predictors of home-based management practice of diarrhea in children under 5 years old.

Result:

The study had a total of 326 participants, with a 97.3% response rate. Accordingly, 193 (59%) have a good home-based management practice of diarrhea in children under the age of 5 years. Attended elementary school (adjusted odds ratio (95% confidence interval), 0.17 (0.06, 0.47)), high school education (adjusted odds ratio (95% confidence interval), 0.04 (0.013, 0.126)), monthly income in second class (adjusted odds ratio (95% confidence interval), 0.19 (0.04, 0.94)), and being mother in child relationship (adjusted odds ratio (95% confidence interval), 1.27 (1.4, 4.20)) were the identified predictors of home-based management practice of diarrhea in children under 5 years old.

Conclusion:

More than half of the respondents have a good home-based management practice of diarrhea in children under 5 years old. Caregivers’ educational status, being mothers of the child, and monthly income were the identified predictors. As a result, health education and awareness programs for caregivers on diarrhea control, proper use of oral rehydration solution, home-based fluid preparation, and diarrhea prevention are critical.

Optimising the management of childhood acute diarrhoeal disease using a rapid test-and- treat strategy and/or Lactobacillus reuteri DSM 17938: a multicentre, randomised, controlled, factorial trial in Botswana

INTRODUCTION

The study aim was to determine if rapid enteric diagnostics followed by the provision of targeted antibiotic therapy ('test-and-treat') and/or Lactobacillus reuteri DSM 17938 would improve outcomes in children hospitalised in Botswana with acute gastroenteritis.

METHODS

This was a multicentre, randomised, factorial, controlled, trial. Children aged 2-60 months admitted for acute non-bloody diarrhoea to four hospitals in southern Botswana were eligible. Participants were assigned to treatment groups by web-based block randomisation. Test-and-treat results were not blinded, but participants and research staff were blinded to L. reuteri/placebo assignment; this was dosed as 1×10⁸ cfu/mL by mouth daily and continued for 60 days. The primary outcome was 60-day age-standardised height (HAZ) adjusted for baseline HAZ. All analyses were by intention to treat. The trial was registered at Clinicaltrials.gov.

RESULTS

Recruitment began on 12 June 2016 and continued until 24 October 2018. There were 66 participants randomised to the test-and-treat plus L. reuteri group, 68 randomised to the test-and-treat plus placebo group, 69 to the standard care plus L. reuteri group and 69 to the standard care plus placebo group. There was no demonstrable impact of the test-and-treat intervention (mean increase of 0.01 SD, 95% CI -0.14 to 0.16 SD) or the L. reuteri intervention (mean decrease of 0.07 SD, 95% CI -0.22 to 0.08 SD) on adjusted HAZ at 60 days.

CONCLUSIONS

In children hospitalised for acute gastroenteritis in Botswana, neither a test-and-treat algorithm targeting enteropathogens, nor a 60-day course of L. reuteri DSM 17938, were found to markedly impact linear growth or other important outcomes. We cannot exclude the possibility that test-and-treat will improve the care of children with significant enteropathogens (such as Shigella) in their stool.

TRIAL REGISTRATION NUMBER

NCT02803827.

Emerging 2D materials for antimicrobial applications in the pre- and post-pandemic era

Infectious diseases caused by viral or bacterial pathogens are one of the most serious threats to humanity. Moreover, they may lead to pandemics, as we have witnessed severely with the coronavirus disease 2019 (COVID-19). Nanotechnology, including technological developments of nano-sized materials, has brought great opportunities to control the spreading of such diseases. In the family of nano-sized materials, two-dimensional (2D) materials with intrinsic physicochemical properties can efficiently favor antimicrobial activity and maintain a safer environment to protect people against pathogens. For this purpose, they can be used alone or combined for the disinfection process of microbes, antiviral or antibacterial surface coatings, air filtering of medical equipment like face masks, or antimicrobial drug delivery systems. At the same time, they are promising candidates to deal with the issues of conventional antimicrobial approaches such as low efficacy and high cost. This review covers the antiviral or antibacterial activities of 2D materials and highlights their current and possible future applications. Considering their intrinsic properties, 2D materials will become part of the leading antimicrobial technologies for combating future pandemics anytime soon.

Simultaneous Efficient Decontamination of Bacteria and Heavy Metals via Capacitive Deionization Using Polydopamine/Polyhexamethylene Guanidine Co-deposited Activated Carbon Electrodes

The contamination of pathogenic micro-organisms and heavy metals in drinking water sources poses a serious threat to human health, which raises the demand for efficient water treatments. Herein, multi-functional capacitive deionization (CDI) electrodes were developed for the simultaneous decontamination of bacteria and heavy metal contaminants. Polyhexamethylene guanidine (PHMG), an antibacterial polymer, was deposited on the surface of the activated carbon (AC) electrode with the assistance of mussel-inspired polydopamine (PDA) chemistry. The main characterization results proved successful co-deposition of PDA and PHMG on the AC electrode, forming a hydrophilic coating layer in one step. Electrochemical analyses indicated that the AC-PDA/PHMG electrodes presented satisfactory capacitive behaviors, with outstanding salt adsorption capacity and cycling stability. The modified electrodes also exhibit excellent disinfection performance and heavy metal adsorption performance. The bacterial elimination rate of co-deposited electrodes grew along with the increase in the PHMG content. Particularly, AC-PDA/PHMG₂ electrodes successfully removed and deactivated 99.11% Escherichia coli and 98.67% Pseudomonas aeruginosa (10⁴ CFU mL^-1) in water within 60 min. Furthermore, three flow cells made by AC-PDA/PHMG₂ electrodes connected in series achieved efficient removal of salt, heavy metals such as lead and cadmium, and bacteria simultaneously, which indicated that the adsorption performance is significantly improved compared with pristine AC electrodes. These results denote the enormous potential of this one-step prepared multi-functional electrodes for facile and effective water purification using CDI technology.

Demographic Attributes of Knowledge, Attitude, Practices, and One Health Perspective Regarding Diarrhea in Pakistan

Background: Loose bowels is a clinical sign of gastrointestinal transport channel proteins, channels, and physical and chemical boundaries being harmed, prompting issues of water and electrolyte transport in the intestinal system. It is still considered as a major reason for emergency visits to hospitals in low-middle income countries. Zinc is a suitable treatment along with ORS for diarrhea. KAP surveys are usually conducted to collect information about general or specific topics of a particular population. The objective of this study was to investigate the knowledge, attitude, practices (KAP), and one health perspective regarding diarrhea among the participants from urban and rural populations of Rawalpindi and Islamabad, Pakistan.

Methods: Data was collected by conducting a survey among residents of twin cities over a period of 6 months (from July 2020 to December 2020). The questionnaire compromised socio-demographic features and the degree of KAP with respect to diarrhea management and control. One way ANOVA tests were applied to observe the demographic relationship and various factors influencing knowledge, attitude, practices, and one health perspective about diarrhea.

Results: A total of 338 subjects participated in the study. Female subjects were in the majority with 63% while the rest were male. A majority of the participants were between 15–25 years of age and 79.6% participants were un-married. The leading ethnic group was Punjabi with 52.7%; the lowest ethnic group were of Sindhi ethnicity with 8.6%. Age has a significant association with respect to knowledge and attitude. Religion has a significant association with respect to knowledge, practices, and one health, while education/qualification has an association with knowledge. The rest of the variables found no association with each other.

Conclusion: It is concluded from the recent study that most residents of the twin cities of Pakistan knew about diarrhea and had a good attitude and practices toward it. Age, religion, and education have different roles regarding different diseases in the population of Pakistan. The current study has its limitations as well. Parts of the study were conducted in the capital of Pakistan which is more developed as compared to other areas of Pakistan. It would be better to explore the remote areas of Pakistan where basic amenities of life such as education, wealth, and unemployment are not available. It is important to create more awareness among community members. They should be aware how dangerous these viruses and bacteria can be. Other parts of Pakistan should also be explored for better understanding that will help in making a nationwide health policy.

The Cost-Effectiveness of Community Health Workers Delivering Free Diarrhea Treatment: Evidence from Uganda

Community health workers (CHWs) are a vital part of the health infrastructure in Uganda and in many other low- and middle-income countries. While the need for CHWs is clear, it is less clear how they should dispense health products to maximize the health benefits to their community. In this study, we assess the cost-effectiveness of several competing CHW distribution strategies in the context of treatment for child diarrhea. We used data from a 4-armed cluster-randomized controlled trial to assess the cost-effectiveness of 1) free distribution of oral rehydration salts (ORS) via home deliveries prior to diarrhea onset (free delivery arm), 2) free distribution via vouchers where households retrieved the treatment from a central location (voucher arm), 3) a door-to-door sales model (home sales arm), and 4) a control arm where CHWs carried out their activities as normal. We assessed the cost-effectiveness from the implementor's perspective and a societal perspective, in terms of cost per case treated with ORS and cost per disability adjusted life-year (DALY) averted. Free delivery was the most effective strategy and the cheapest from a societal perspective. Although implementor costs were highest in this arm, cost savings comes from households using fewer resources to seek treatment outside the home (transport, doctor fees, and treatment costs). From the implementors' perspective, free delivery costs $2.19 per additional case treated and $56 per DALY averted relative to the control. Free delivery was also extremely cost-effective relative to home sales and vouchers but there was a large degree of uncertainty around the comparison with vouchers. Free distribution of ORS by CHWs prior to diarrhea onset is extremely cost-effective compared to other CHW distribution models. Implementers of CHW programs should consider free home delivery of ORS.

Barriers and facilitators to implementation of oral rehydration therapy in low- and middle-income countries: A systematic review

BACKGROUND

Oral rehydration therapy (ORT) is an effective and cheap treatment for diarrheal disease; globally, one of the leading causes of death in children under five. The World Health Organization launched a global campaign to improve ORT coverage in 1978, with activities such as educational campaigns, training health workers and the creation of designate programming. Despite these efforts, ORT coverage remains relatively low. The objective of this systematic review is to identify the barriers and facilitators to the implementation of oral rehydration therapy in low and middle-income countries.

METHODS

A comprehensive search strategy comprised of relevant subject headings and keywords was executed in 5 databases including OVID Medline, OVID Embase, OVID HealthStar, Web of Science and Scopus. Eligible studies underwent quality assessment, and a directed content analysis approach to data extraction was conducted and aligned to the Consolidated Framework for Implementation Research (CFIR) to facilitate narrative synthesis.

RESULTS

The search identified 1570 citations and following removal of duplicates as well as screening according to our inclusion/exclusion criteria, 55 articles were eligible for inclusion in the review. Twenty-three countries were represented in this review, with India, Bangladesh, Egypt, Nigeria, and South Africa having the most representation of available studies. Study dates ranged from 1981 to 2020. Overarching thematic areas spanning the barriers and facilitators that were identified included: availability and accessibility, knowledge, partnership engagement, and design and acceptability.

CONCLUSION

A systematic review of studies on implementation of ORT in low- and middle-income countries (LMICs) highlights key activities that facilitate the development of successful implementation that include: (1) availability and accessibility of ORT, (2) awareness and education among communities, (3) strong partnership engagement strategies, and (4) adaptable design to enhance acceptability. The barriers and facilitators identified under the CIFR domains can be used to build knowledge on how to adapt ORT to national and local settings and contribute to a better understanding on the implementation and use of ORT in LMICs. The prospects for scaling and sustaining ORT (after years of low use) will increase if implementation research informs local applications, and implementers engage appropriate stakeholders and test assumptions around localized theories of change from interventions to expected outcomes.

REGISTRATION

A protocol for this systematic review was developed and uploaded onto the PROSPERO international prospective register of systematic reviews database (Registration number: CRD420201695).

Low Osmolarity Oral Rehydration Salt Solution (LORS) in Management of Dehydration in Children

Justification

The IAP last published the guidelines “Comprehensive Management of Diarrhea” in 2006 and a review in 2016. The WHO in 2002 and the Government of India in 2004 recommended low osmolarity rehydration solution (LORS) as the universal rehydration solution for all ages and all forms of dehydration. However, the use of LORS in India continues to be unacceptably low at 51%, although awareness about ORS has increased from a mere 14% in 2005 to 69% in 2015. Availability of different compositions of ORS and brands in market added to the confusion.

Process

The Indian Academy of Pediatrics constituted a panel of experts from the fields of pediatrics, pediatric gastroenterology and nutrition to update on management of dehydration in children with particular reference to LORS and issue a current practice guideline. The committee met twice at CIAP HQ to review all published literature on the aspect. Brief presentations were made, followed by discussions. The draft paper was circulated by email. All relevant inputs and suggestions were incorporated to arrive at a consensus on this practice guideline.

Objectives

To summarize latest literature on ORT and empower pediatricians, particularly those practicing in rural areas, on management of dehydration by augmenting LORS use.

Recommendations

It was stressed that advantages of LORS far out-weigh its limitations. Increased use of LORS can only be achieved by promoting better awareness among public and health-care providers across all systems of medicine. LORS can also be useful in managing dehydration in non-diarrheal illness. More research is required to modify ORS further to make it safe and effective in neonates, severe acute malnutrition, renal failure, cardiac and other co-morbidities. There is an urgent need to discourage production and marketing all forms of ORS not in conformity with WHO approved LORS, under a slogan “One India, one ORS”.

Low Osmolarity Oral Rehydration Salt Solution (LORS) in Management of Dehydration in Children

JUSTIFICATION

The IAP last published the guidelines "Comprehensive Management of Diarrhea" in 2006 and a review in 2016. The WHO in 2002 and the Government of India in 2004 recommended low osmolarity rehydration solution (LORS) as the universal rehydration solution for all ages and all forms of dehydration. However, the use of LORS in India continues to be unacceptably low at 51%, although awareness about ORS has increased from a mere 14% in 2005 to 69% in 2015. Availability of different compositions of ORS and brands in market added to the confusion.

PROCESS

The Indian Academy of Pediatrics constituted a panel of experts from the fields of pediatrics, pediatric gastroenterology and nutrition to update on management of dehydration in children with particular reference to LORS and issue a current practice guideline. The committee met twice at CIAP HQ to review all published literature on the aspect. Brief presentations were made, followed by discussions. The draft paper was circulated by email. All relevant inputs and suggestions were incorporated to arrive at a consensus on this practice guideline.

OBJECTIVES

To summarize latest literature on ORT and empower pediatricians, particularly those practicing in rural areas, on management of dehydration by augmenting LORS use.

RECOMMENDATIONS

It was stressed that advantages of LORS far out-weigh its limitations. Increased use of LORS can only be achieved by promoting better awareness among public and health-care providers across all systems of medicine. LORS can also be useful in managing dehydration in non-diarrheal illness. More research is required to modify ORS further to make it safe and effective in neonates, severe acute malnutrition, renal failure, cardiac and other co-morbidities. There is an urgent need to discourage production and marketing all forms of ORS not in conformity with WHO approved LORS, under a slogan "One India, one ORS".

Zinc is an important inter-kingdom signal between the host and microbe

Zinc (Zn) is an essential trace element in living organisms and plays a vital role in the regulation of both microbial virulence and host immune responses. A growing number of studies have shown that zinc deficiency or the internal Zn concentration does not meet the needs of animals and microbes, leading to an imbalance in zinc homeostasis and intracellular signalling pathway dysregulation. Competition for zinc ions (Zn²⁺) between microbes and the host exists in the use of Zn²⁺ to maintain cell structure and physiological functions. It also affects the interplay between microbial virulence factors and their specific receptors in the host. This review will focus on the role of Zn in the crosstalk between the host and microbe, especially for changes in microbial pathogenesis and nociceptive neuron-immune interactions, as it may lead to new ways to prevent or treat microbial infections.

Are oral rehydration solutions optimized for treating diarrhea?

BACKGROUND

A historical turning point occurred in the treatment of diarrhea when it was discovered that glucose could enhance intestinal sodium and water absorption. Adding glucose to salt water (oral rehydration solution, ORS) more efficiently replaced intestinal water and salt losses.

AIM

Provide a novel hypothesis to explain why mainstream use of ORS has been strongly recommended, but weakly adopted.

METHODS

Traditional (absorptive) and novel (secretory) physiological functions of glucose in an ORS were reviewed.

RESULTS

Small amounts of glucose can stimulate both intestinal absorption and secretion. Glucose can exacerbate a net secretory state and may aggravate pathogen-induced diarrhea, particularly for pathogens that affect glucose transport.

CONCLUSION

A hypothesis is made to explain why glucose-based ORS does not appreciably reduce diarrheal stool volume and why modern food science initiatives should focus on ORS formulations that replace water and electrolytes while also reducing stool volume and duration of diarrhea.

Oral rehydration salts therapy use among children under five years of age with diarrhea in Ethiopia

Background: Oral rehydration salts (ORS) therapy for diarrheal diseases is considered an effective therapy that can be applied in many resource-poor settings. Nevertheless, it has been consistently underutilized, and as a result, its potential to reduce child mortality has not been fully exploited. In Ethiopia, the use of ORS therapy for children under five has been inadequate. Like any other health behavior, the provision of ORS therapy to children during diarrheal episodes by caregivers is complex and context dependent. Identifying the factors may help promote wider application.

Design and methods: We used data from the 2016 Ethiopia Demographic and Health Survey (EDHS-2016). Samples were selected by a two-stage stratified cluster sampling method. We used data on children under five years of age whose mothers (aged 15-49 years) reported that the child had had diarrhea within two weeks before the survey was conducted (n=1221). The dependent variable was whether these children received ORS therapy. The contextual independent factors were socio-demographic variables (mothers’ age, child’s age, child’s sex, child’s place of residence, household wealth, and mother/ husband/partner’s education levels and work status), as well as media exposure and healthcare utilization.

Results: The prevalence of ORS therapy use among the children was 30%. Mothers who had made at least four prenatal visits during their last pregnancy were 87% more likely to use ORS therapy for their children than those who had fewer prenatal visits (OR=1.874; CI: 1.140-3.082; p=0.013).

Conclusions: Integrating efforts for scaling-up ORS use with prenatal health care services may have an extra benefit of promoting children’s wellbeing and survival.

Product review of the rotavirus vaccines ROTASIIL, ROTAVAC, and Rotavin-M1

Rotavirus is the leading cause of severe dehydrating gastroenteritis and death due to diarrhea among children under 5, causing over 180,000 under-5 deaths annually. Safe, effective rotavirus vaccines have been available for over a decade and are used in over 98 countries. In addition to the globally available, WHO-prequalified ROTARIX (GSK) and RotaTeq (Merck), several new rotavirus vaccines have attained national licensure - ROTAVAC (Bharat Biotech) and ROTASIIL (Serum Institute of India), licensed and manufactured in India and now WHO-prequalified, and Rotavin-M1 (PolyVac), licensed and manufactured in Vietnam. In this review, we summarize the available clinical trial and post-introduction evidence for these three new orally administered rotavirus vaccines. All three vaccines have demonstrated safety and efficacy against rotavirus diarrhea, although publicly available preclinical data are limited in some cases. This expanding product landscape presents a range of options to optimize immunization programs, and new presentations of each vaccine are currently under development.

Lower-Dose Zinc for Childhood Diarrhea - A Randomized, Multicenter Trial

BACKGROUND

The World Health Organization recommends 20 mg of zinc per day for 10 to 14 days for children with acute diarrhea; in previous trials, this dosage decreased diarrhea but increased vomiting.

METHODS

We randomly assigned 4500 children in India and Tanzania who were 6 to 59 months of age and had acute diarrhea to receive 5 mg, 10 mg, or 20 mg of zinc sulfate for 14 days. The three primary outcomes were a diarrhea duration of more than 5 days and the number of stools (assessed in a noninferiority analysis) and the occurrence of vomiting (assessed in a superiority analysis) within 30 minutes after zinc administration.

RESULTS

The percentage of children with diarrhea for more than 5 days was 6.5% in the 20-mg group, 7.7% in the 10-mg group, and 7.2% in the 5-mg group. The difference between the 20-mg and 10-mg groups was 1.2 percentage points (upper boundary of the 98.75% confidence interval [CI], 3.3), and that between the 20-mg and 5-mg groups was 0.7 percentage points (upper boundary of the 98.75% CI, 2.8), both of which were below the noninferiority margin of 4 percentage points. The mean number of diarrheal stools was 10.7 in the 20-mg group, 10.9 in the 10-mg group, and 10.8 in 5-mg group. The difference between the 20-mg and 10-mg groups was 0.3 stools (upper boundary of the 98.75% CI, 1.0), and that between the 20-mg and 5-mg groups was 0.1 stools (upper boundary of the 98.75% CI, 0.8), both of which were below the noninferiority margin (2 stools). Vomiting within 30 minutes after administration occurred in 19.3%, 15.6%, and 13.7% of the patients in the 20-mg, 10-mg, and 5-mg groups, respectively; the risk was significantly lower in the 10-mg group than in the 20-mg group (relative risk, 0.81; 97.5% CI, 0.67 to 0.96) and in the 5-mg group than in the 20-mg group (relative risk, 0.71; 97.5% CI, 0.59 to 0.86). Lower doses were also associated with less vomiting beyond 30 minutes after administration.

CONCLUSIONS

Lower doses of zinc had noninferior efficacy for the treatment of diarrhea in children and were associated with less vomiting than the standard 20-mg dose. (Funded by the Bill and Melinda Gates Foundation; ZTDT ClinicalTrials.gov number, NCT03078842.).

A study of treatment preference for diarrhea among Tengger people in Pasuruan, East Java, Indonesia

Purpose

This study aims to describe the treatment preference, especially in relation to traditional medicine, modern health care and a combination of both, in diarrheal cases among the Tengger ethnic minority group.

Design/methodology/approach

A cross-sectional survey was conducted in all eight villages of Tosari District, Pasuruan Regency, East Java Province. Tengger people were major resident in the area for generations. Convenience sampling and a face-validated structured questionnaire were used to recruit and face-to-face interview 377 Tengger people.

Findings

The study found that modern health care was the dominant preference (52%, n = 196) selected by Tengger people when they have an episode of diarrhea, compared to traditional medicines and mixed approach. Most respondents opted to visit one facility or to stay at home (64.3%, n = 242). Statistical significant relationships were found between treatment choice and age (p < 0.001), sex (p < 0.001), religion (p = 0.011), distance (p < 0.001), educational background (p < 0.001) and job (p < 0.001). A clear pattern between treatment choice and age was revealed with younger groups tended to choose modern health care, while older groups more preferred the traditional approach.

Practical implications

This work could provide an insight that when the young Tengger people are having uncomplicated and common health illness, such as diarrhea, they tend to use modern treatment approach.

Originality/value

This study fulfilled an identified need to explore the trend of treatment approach across generations in the Tengger society as a model of the minor ethnic group in Indonesia.

A noninvasive method to study the evolution of extracellular fluid volume in mice using time-domain nuclear magnetic resonance

Maintaining water homeostasis is fundamental for cellular function. Many diseases and drugs affect water balance and plasma osmolality. Water homeostasis studies in small animals require the use of invasive or terminal methods that make intracellular fluid volume and extracellular fluid volume (ECF) monitoring over time stressful and time consuming. We examined the feasibility of monitoring mouse ECF by a noninvasive method using time-domain nuclear magnetic resonance (TD-NMR). This technique allows differentiation of protons in a liquid environment (free fluid) from protons in soft tissues containing a majority of either small molecules (lean) or large molecules (fat). Moreover, this apparatus enables rapid, noninvasive, and repeated measurements on the same animal. We assessed the feasibility of coupling TD-NMR analysis to a longitudinal metabolic cage study by monitoring mice daily. We determined the effect of 24-h water deprivation on mouse body parameters and detected a sequential and overlapping decrease in free fluid and lean mass during water deprivation. Finally, we studied the effect of mineralocorticoids that are known to induce a transient increase in ECF but for which no direct measurements have been performed in mice. We showed, for the first time, that mineralocorticoids induced a transient ~15% increase in free fluid in conscious mice. TD-NMR is, therefore, the first method to allow direct measurement of discrete changes in ECF in conscious small animals. This method allows analysis of kinetic changes to stimuli before investigating with terminal methods and will allow further understanding of fluid disorders.

Energy-transfer-mediated oxygen activation in carbonyl functionalized carbon nitride nanosheets for high-efficient photocatalytic water disinfection and organic pollutants degradation

Polymeric photocatalysts are promising candidates for water purification, however their catalytic performance are still unsatisfactory due to the fast charge recombination that leads to low reactive oxygen radicals production. In this study, a conceptual energy-transfer-mediated photocatalytic oxygen activation system over polymeric carbon nitride without the need of electron-hole separation is proposed, exhibiting remarkable singlet oxygen triggered bacteria inactivation performance as well as organic pollutants degradation. By structure and excitonic effect modulation, the oxygen activation process changes from the traditional electron-transfer mechanism to the final energy-transfer pathway, leading to the selective generation of singlet oxygen with high efficiency. The generated singlet oxygen is found to fervently attack the bacteria membrane, creating irreparable pores or holes on the cell membrane for cytoplasmic contents leaking out to accelerate bacteria destruction. The work demonstrated here offers a new photocatalytic oxygen activation pathway for achieving high-efficient reactive oxygen species generation performance without the need of charge separation.

The incidence, aetiology, and adverse clinical consequences of less severe diarrhoeal episodes among infants and children residing in low-income and middle-income countries: a 12-month case-control study as a follow-on to the Global Enteric Multicenter Study (GEMS)

Background

Diarrheal diseases remain a leading cause of illness and death among children younger than 5 years in low-income and middle-income countries. The Global Enteric Multicenter Study (GEMS) has described the incidence, aetiology, and sequelae of medically attended moderate-to-severe diarrhoea (MSD) among children aged 0–59 months residing in censused populations in sub-Saharan Africa and south Asia, where most child deaths occur. To further characterise this disease burden and guide interventions, we extended this study to include children with episodes of less-severe diarrhoea (LSD) seeking care at health centres serving six GEMS sites.

Methods

We report a 1-year, multisite, age-stratified, matched case-control study following on to the GEMS study. Six sites (Bamako, Mali; Manhiça, Mozambique; Basse, The Gambia; Mirzapur, Bangladesh; Kolkata, India; and Bin Qasim Town, Karachi, Pakistan) participated in this study. Children aged 0–59 months at each site who sought care at a sentinel hospital or health centre during a 12-month period were screened for diarrhoea. New (onset after ≥7 diarrhoea-free days) and acute (onset within the previous 7 days) episodes of diarrhoea in children who had sunken eyes, whose skin lost turgor, who received intravenous hydration, who had dysentery, or who were hospitalised were eligible for inclusion as MSD. The remaining new and acute diarrhoea episodes among children who sought care at the same health centres were considered LSD. We aimed to enrol the first eight or nine eligible children with MSD and LSD at each site during each fortnight in three age strata: infants (aged 0–11 months), toddlers (aged 12–23 months), and young children (aged 24–59 months). For each included case of MSD or LSD, we enrolled one to three community control children without diarrhoea during the previous 7 days. From patients and controls we collected clinical and epidemiological data, anthropometric measurements, and faecal samples to identify enteropathogens at enrolment, and we performed a follow-up home visit about 60 days later to ascertain vital status, clinical outcome, and interval growth. Primary outcomes were to characterise, for MSD and LSD, the pathogen-specific attributable risk and population-based incidence values, and to assess the frequency of adverse clinical consequences associated with these two diarrhoeal syndromes.

Findings

From Oct 31, 2011, to Nov 14, 2012, we recruited 2368 children with MSD, 3174 with LSD, and one to three randomly selected community control children without diarrhoea matched to cases with MSD (n=3597) or LSD (n=4236). Weighted adjusted population attributable fractions showed that most attributable cases of MSD and LSD were due to rotavirus, Cryptosporidium spp, enterotoxigenic Escherichia coli encoding heat-stable toxin (with or without genes encoding heat-labile enterotoxin), and Shigella spp. The attributable incidence per 100 child-years for LSD versus MSD, by age stratum, for rotavirus was 22·3 versus 5·5 (0–11 months), 9·8 versus 2·9 (12–23 months), and 0·5 versus 0·2 (24–59 months); for Cryptosporidium spp was 3·6 versus 2·3 (0–11 months), 4·3 versus 0·6 (12–23 months), and 0·3 versus 0·1 (24–59 months); for enterotoxigenic E coli encoding heat-stable toxin was 4·2 versus 0·1 (0–11 months), 5·2 versus 0·0 (12–23 months), and 1·1 versus 0·2 (24–59 months); and for Shigella spp was 1·0 versus 1·3 (0–11 months), 3·1 versus 2·4 (12–23 months), and 0·8 versus 0·7 (24–59 months). Participants with both MSD and LSD had significantly more linear growth faltering than controls at follow-up.

Interpretation

Inclusion of participants with LSD markedly expands the population of children who experience adverse clinical and nutritional outcomes from acute diarrhoeal diseases. Since MSD and LSD have similar aetiologies, interventions targeting rotavirus, Shigella spp, enterotoxigenic E coli producing heat-stable toxin, and Cryptosporidium spp might substantially reduce the diarrhoeal disease burden and its associated nutritional faltering.

Funding

Bill & Melinda Gates Foundation.

Efficacy of zinc supplementation in the management of acute diarrhoea: a randomised controlled trial

Background: Zinc has been recommended for the treatment of acute diarrhoea; however, there are heterogeneous reports regarding its efficacy.Aim: This study investigated the efficacy of zinc supplementation on the treatment outcomes of children admitted to hospital with acute diarrhoea.Methods: A double-blind, randomised, placebo-controlled trial was conducted in the Srinakharinwirot University Hospital's Paediatric Department, Thailand. Eligible children were randomly allocated to receive either zinc bisglycinate (15 mg elemental zinc) or a placebo. The study protocol was registered in the Thai Clinical Trials Registry (TCTR20190423004).Results: Of 86 patients, 50 (58.1%) were male and the mean age (range) was 2.5 years (6 months to 9.3 years). The median (IQR) number of hours to recovery from diarrhoea was significantly less in the zinc group than in the controls [44 (24-48) vs 52 (36-80) hours, respectively, p < 0.01]. The median (IQR) number of stools was significantly lower in the zinc group [5 (3-12)] than in the controls [7 (4-17), p = 0.02]. The median (IQR) duration of intravenous fluid therapy was 40 (24-56) hours in the zinc group and 56 (40-73) in the control group (p < 0.01). The duration of hospitalisation was 60 (44-72) hours in the zinc group and 84 (56-136) hours in the controls (p < 0.01). There was good compliance by all participants in both groups.Conclusion: Zinc supplementation can reduce the time to resolution of acute diarrhoea, the length of hospital stay and the frequency of stools. Zinc supplementation is recommended as a routine strategy for Thai children with acute diarrhoea.

Synergistic effect of Bi-doped exfoliated MoS2 nanosheets on their bactericidal and dye degradation potential

Nanosheets incorporated with biological reducing agents are widely used to minimize the toxic effects of chemicals. Biologically amalgamated metal oxide nanomaterials have crucial importance in nanotechnology. In this study, bare and bismuth (Bi)-doped molybdenum disulfide (MoS2) nanosheets were synthesized via a hydrothermal method. Different Bi weight ratios of 2.5, 5, 7.5 and 10% were incorporated in a fixed amount of MoS2 to evaluate its catalytic and antimicrobial activities. Doped nanosheets were characterized using XRD, FTIR and UV-vis spectroscopy, FESEM, HRTEM, Raman, PL, DSC/TGA, EDX, XRF and XPS analysis. The XRD spectra confirmed that the doped nanosheets exhibit a hexagonal structure and their crystallite size increases gradually upon doping. The morphology and interlayer d-spacing of doped MoS2 were determined by FESEM and HRTEM. The presence of functional groups in the doped nanosheets was confirmed using FTIR, PL and Raman analysis. The absorption intensity increased and the corresponding measured band gap energy decreased with doping. The thermal stability and weight loss behaviour of the prepared samples were studied using DSC/TGA. The doped MoS2 nanosheets showed a higher catalytic potential compared to undoped MoS2. The doped Bi nanosheets exhibited higher antimicrobial activity against Gram-positive Staphylococcus aureus (S. aureus) and Gram-negative Escherichia coli (E. coli) at different concentrations of Bi (0.075 and 0.1), showing a tendency to counter the emerging drug resistance against pathogenic bacterial diseases. Consequently, significant inhibition zones were recorded against (MDR) S. aureus ranging from 2.25 to 3.3 mm and 3.25 to 5.05 mm at low and high concentrations of doped-Bi nanosheets and against Gram-negative E. coli ranging from 1 to 1.45 mm at high concentrations. In conclusion, the Bi-doped MoS2 nanocomposite has exhibited significant potential for use in industrial dye degradation applications. Its antibacterial properties can also mitigate health risks associated with the presence of several well-known pathogens in the environment.

A Half Century of Oral Rehydration Therapy in Childhood Gastroenteritis: Toward Increasing Uptake and Improving Coverage

Termed by the Lancet, as "potentially the most important medical advance of the twentieth century," therapy with oral rehydration solutions (ORSs) has been essential to reducing mortality in children less than 5 years (under five) with infectious gastroenteritis and diarrhea. The target of the diarrhea-control programs in the 1990s was to achieve ORS use in 80% of diarrhea cases by the year 2000. Nevertheless, nearly 20 years later, global uptake remains limited to only a third of the cases. Our analysis shows that from 1990 to 2017, mean ORS coverage in Countdown countries [the 81 Countdown-to-2030 priority countries, which together account for 95% of maternal deaths and 90% of under-five deaths] increased from ~ 30% to nearly 40%. Flawed government policies, inadequate supplies, and lack of awareness among health workers and communities all contributed to this shortfall in coverage. Moreover, imperfect measurement methodology is implicated in questionable coverage data. A multipronged approach focusing on the manufacture, supply, training, and behavioral change is essential to ensure that ORS is used in all epidemic diarrhea cases globally, especially in the under-five population.

Gelatin tannate for acute diarrhoea and gastroenteritis in children: a systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness and safety of gelatin tannate (GT) for reducing the duration of the acute diarrhoea and gastroenteritis (ADG) in children.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials, LILACS and grey literature, published from inception to October 2018. No language restrictions.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials in children with ADG, comparing GT with placebo.

RESULTS

Of 797 titles identified, we included three studies (276 children). We performed a random effects model meta-analysis for the main outcome (diarrhoea duration). We did not find significant differences between GT and placebo for diarrhoea duration (mean difference (MD)=-15.85 hours; 95% CI -42.24 to 14.82, I²=92%; three studies), stool frequency at day 2 (MD=0.11 stools/day; 95% CI -0.39 to 0.62: I²=26%; two studies), diarrhoea at day 3 (risk ratio [RR]=0.46; 95% CI 0.06 to 3.47: I²=73%; two studies), vomiting (RR=1.31; 95% CI 0.95 to 1.80: I²=0%; two studies) or adverse events (RR=0.86; 95% CI 0.27 to 2.66: I²=0%; two studies). Most common adverse events included abdominal pain and nausea.

CONCLUSION

The effect of GT was no different to placebo for mean diarrhoea duration (low certainty on the evidence) and stool frequency at day 2 (high certainty) and for the presence of diarrhoea at day 3 (very low certainty) of vomiting (moderate certainty) and of adverse events (low certainty).

PROSPERO REGISTRATION NUMBER

CRD42018087902.

Incidence and Risk Factors for Severe Dehydration in Hospitalized Children in Ujjain, India

Diarrhoea contributes significantly to the under-five childhood morbidity and mortality worldwide. This cross-sectional study was carried out in a tertiary care hospital in Ujjain, India from July 2015 to June 2016. Consecutive children aged 1 month to 12 years having “some dehydration” and “dehydration” according to World Health Organization classification were eligible to be included in the study. Other signs and symptoms used to assess severe dehydration were capillary refill time, urine output, and abnormal respiratory pattern. A questionnaire was administered to identify risk factors for severe dehydration, which was the primary outcome. Multivariate logistic regression modeling was used to detect independent risk factors for severe dehydration. The study included 332 children, with mean ± standard deviation age of 25.62 ± 31.85 months; out of which, 70% (95% confidence interval [CI] 65 to 75) were diagnosed to have severe dehydration. The independent risk factors for severe dehydration were: child not exclusive breastfed in the first six months of life (AOR 5.67, 95%CI 2.51 to 12.78; p < 0.001), history of not receiving oral rehydration solution before hospitalization (AOR 1.34, 95%CI 1.01 to 1.78; p = 0.038), history of not receiving oral zinc before hospitalization (AOR 2.66, 95%CI 1.68 to 4.21; p < 0.001) and living in overcrowded conditions (AOR 5.52, 95%CI 2.19 to 13.93; p < 0.001). The study identified many risk factors associated with severe childhood dehydration; many of them are modifiable though known and effective public health interventions.

Socio-economic determinants and environmental hygiene factors of female caregiver burden in two selected low-income communities in Cape Town, South Africa

Introduction

Studies on female caregiver burden and its determinants in relation to physical environment and social support in low-income and middle-income countries are limited. This study evaluates the relationship between caregiving physical environment, social support and well-being of female caregivers and care recipients in Cape Town, South Africa.

Methods

One hundred (100) each of black African and coloured female caregivers from two different population settlements were randomly selected. Structured questionnaire was employed to gather information from caregivers. Description and correlation analyses were used to examine the association between health status of care recipients, environmental hygiene factors and female caregiver burden.

Results

About 49.5% of the female caregivers were between 50-59 years and worked full-time (≥40 hours per week). Better hygiene environment and working conditions are major determinants of caregiver burden and care recipient's physical health. Better hygiene conditions in the kitchen and toilet significantly increased care recipients' and caregivers’ physical health (P<0.05). Diarrhoea was found to be significantly associated with poorer environmental hygiene. Over 50% of the reported diarrhoea cases were among care recipients with poorer kitchen and toilet hygiene. Bad environmental hygiene increased the risk of diarrhoea among care recipients and caregivers. Physical health of the care recipients and social grants influenced the burden on the female caregiver.

Conclusion

Increase social grants and attention to environmental conditions of caregiving will improve the physical health and living standard of the care recipients and caregivers.

Promising performance of chemically exfoliated Zr-doped MoS2 nanosheets for catalytic and antibacterial applications

Nanostructured materials incorporated with biological reducing agents have shown significant potential for use in bactericidal applications. Such materials have also demonstrated considerable efficacy to counter effects of chemical toxicity. In this study, nanostructured molybdenum disulfide (MoS₂) was doped with various concentrations (2.5, 5, 7.5, 10 wt%) of zirconium (Zr) using a hydrothermal route in order to assess its antimicrobial and catalytic potential. Doped and control samples were characterized with various techniques. X-ray diffraction (XRD) analysis confirmed the presence of the hexagonal phase of MoS₂ and identification of various functional groups and characteristic peaks (Mo bonding) was carried out using FTIR spectra. Micrographs obtained from FESEM and HR-TEM showed a sheet-like surface morphology, while agglomeration of nanosheets was observed upon doping with nanoparticles. To seek further clarity regarding the layered features of S–Mo–S planes, the defect densities and electronic band structure of pure MoS₂ and doped MoS₂ samples were investigated through Raman analysis. Optical properties of Zr-doped MoS₂ nanosheets were assessed using a UV-vis spectrophotometer and the results indicated a red-shift, i.e., movement of peaks towards longer wavelengths, of the material. Dynamics of migration and recombination of excited electron–hole pairs were investigated using PL spectroscopy, which was also used to confirm the presence of exfoliated nanosheets. In addition, the synthetic dye degradation potential of pure and doped samples was investigated in the presence of a reducing agent (NaBH₄). It was noted that doped MoS₂ showed superior catalytic activity compared to undoped MoS₂. The nanocatalyst synthesized in this study exhibited enhanced antibacterial activity against E. coli and S. aureus at high concentrations (0.5, 1.0 mg/50 μl). The present study suggests a cost-effective and environmentally friendly material that can be used to remove toxins such as synthetic dyes and tannery pollutants from industrial wastewater.

Nanostructured materials incorporated with biological reducing agents have shown significant potential for use in bactericidal applications.

Etiologies of diarrhea and drug susceptibility patterns of bacterial isolates among under-five year children in refugee camps in Gambella Region, Ethiopia: a case control study

Background

Despite substantial global effort and updated clinical management guidelines, diarrhea continues to be among leading worldwide causes of morbidity and mortality in children. Infectious diarrhea, the most common form of diarrhea causes substantial morbidity and mortality among children in developing countries, and the muddled use of antibiotics needs caution due to potential problems of drug-resistance. The aim of this study is to identify etiologies of diarrhea and drug susceptibility patterns of bacterial isolates in under-five children in refugee camps in Gambella Region, Ethiopia.

Methods

An institution- based matched case control study was conducted using a questionnaire-based interview from June to December 2017 in Pugnido and Teirkidi refugee camps. Stool samples were collected and parasites causing diarrhea were identified by wet mount microscopy. Conventional culture supplemented with API 20E identification kit was used to identify Salmonella and Shigella species. Antibiotic susceptibility of bacterial isolates was investigated by using the disk diffusion method. The association between etiologies and diarrhea was analyzed using McNemar test or Fisher exact test with 95% confidence interval at a level of significance of P < 0.05.

Results

The overall prevalence of enteric pathogens were 55 (41.0%) in diarrhea cases and 18 (13.4%) in healthy controls. The detected etiologies include Giardia lambia (28), Shigella spp. (16), E. hystolyotica/dispar (13), Ascaris lumbricoides (10), Salmonella spp. (6), Cryptosporidium parvum (6), Hymenolepis nana (4) and Isospora belli (3). All isolates were sensitive to kanamycine and ceftazidime. The high resistance rate was observed against ampicillin (100%), amoxicillin (100%), erythromycin (52%), chloramphenicol (47.5%), tetracycline (40.5%), cotrimoxazole (34.8%) and amoxicillin-clavulanic acid (33%). The majorities of the isolates had a low rate of resistance to ciprofloxacin (8.7%), naldxic acid (8.7%) and amikacin (13%).

Conclusions

Giardia lamblia, E. Hystolytica/dispar, and Shigella spp are the common etiologies of diarrhea in children in the studied refugee camps. The study also showed that significant numbers of bacterial isolates were resistant to the commonly used antimicrobial drugs. Therefore, improving clinical laboratory services and promoting evidence-based drug prescription may reinforce proper use of antibiotics and reduce the emergence of microbial resistance.

The calcium-sensing receptor: A novel target for treatment and prophylaxis of neratinib-induced diarrhea

Diarrhea is one of the most commonly reported adverse effect of hemotherapy and targeted cancer therapies, such as tyrosine kinase inhibitors (TKI), which often significantly impact patient quality of life, morbidity, and mortality. Neratinib is an oral, irreversible pan-HER tyrosine kinase inhibitor, which is clinically active in HER2-positive breast cancer. Diarrhea is the most common side effect of this potent anticancer drug and the reasons for this adverse effect are still largely unclear. We have recently shown that activation of the calcium-sensing Receptor (CaSR) can inhibit secretagogue-induced diarrhea in the colon, therefore we hypothesized that CaSR activation may also mitigate neratinib-induced diarrhea. Using an established ex vivo model of isolated intestinal segments, we investigated neratinib-induced fluid secretion and the ability of CaSR activation to abate the secretion. In our study, individual segments of the rat intestine (proximal, middle, distal small intestine, and colon) were procured and perfused intraluminally with various concentrations of neratinib (10, 50, 100 nmol L-1). In a second set of comparison experiments, intraluminal calcium concentration was modulated (from 1.0 to 5.0 or 7.0 mmol L-1), both pre- and during neratinib exposure. In a separate series of experiments R-568, a known calcimimetic was used CaSR activation and effect was compared to elevated Ca2+ concentration (5.0 and 7.0 mmol L-1). As a result, CaSR activation with elevated Ca2+ concentration (5.0 and 7.0 mmol L-1) or R-568 markedly reduced neratinib-induced fluid secretion in a dose-dependent manner. Pre-exposure to elevated luminal calcium solutions (5.0 and 7.0 mmol L-1) also prevented neratinib-induced fluid secretion. In conclusion, exposure to luminal neratinib resulted in a pronounced elevation in fluid secretion in the rat intestine. Increasing luminal calcium inhibits the neratinib-associated fluid secretion in a dose-dependent manner. These results suggest that CaSR activation may be a potent therapeutic target to reduce chemotherapy-associated diarrhea.

Probiotics and Paraprobiotics in Viral Infection: Clinical Application and Effects on the Innate and Acquired Immune Systems

Recently, the risk of viral infection has dramatically increased owing to changes in human ecology such as global warming and an increased geographical movement of people and goods. However, the efficacy of vaccines and remedies for infectious diseases is limited by the high mutation rates of viruses, especially, RNA viruses. Here, we comprehensively review the effectiveness of several probiotics and paraprobiotics (sterilized probiotics) for the prevention or treatment of virally-induced infectious diseases. We discuss the unique roles of these agents in modulating the cross-talk between commensal bacteria and the mucosal immune system. In addition, we provide an overview of the unique mechanism by which viruses are eliminated through the stimulation of type 1 interferon production by probiotics and paraprobiotics via the activation of dendritic cells. Although further detailed research is necessary in the future, probiotics and/or paraprobiotics are expected to be among the rational adjunctive options for the treatment of various viral diseases.

Silver Nanowire-Modified Filter with Controllable Silver Ion Release for Point-of-Use Disinfection

Waterborne diseases related to unsafe water are still major threats to public health in some developing countries and rural areas. Providing affordable and safe drinking water globally remains a great challenge in the coming decades. In this study, we develop a high-throughput and conductive silver nanowire (AgNW)-modified composite filter via depositing thin and ultralong AgNWs on a macroporous substrate. An electrochemical filtration cell (EFC) equipped with the composite filter achieves controllable Ag⁺ release at a μg L^-1 level and superior bacterial inactivation performance (>6-log inactivation efficiency) with an operation voltage of only 1 V at a high flux of 100 m³ h^-1 m^-2. Under such operation conditions, each composite filter (effective area: 0.79 cm²) can treat at least 750 mL of the bacterial suspension (∼10⁷ CFU mL^-1 of Escherichia coli) with a low effluent Ag⁺ concentration below 50 μg L^-1 and almost negligible energy consumption of only ∼70 J m^-3.

Increasing coverage of pediatric diarrhea treatment in high-burden countries

Background

Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc.

Methods

We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions.

Results

Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21–23%) to 48% (95% CI = 47–50%) and program states in Nigeria, from 38% (95% CI = 32–40%) to 55% (95% CI = 51–58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies.

Conclusions

Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.