[Evaluation of the ambulatory treatment of acute diarrhea in infants. Réseau interhospitalier d'evaluation des pratigues médicales dans les affections courantes de l'enfant]

[Epidemiological and clinical study of rotavirus acute diarrhea in infants at the hospital Jason Sendwe Lubumbashi, Democratic Republic of Congo]

Introduction

Le rotavirus est un problème de santé publique, non seulement dans les pays en développement où tous les enfants sont infectés avant l’âge de deux à trois ans mais aussi dans les pays développés où les conditions d'hygiène sont bonnes. La présente étude est la première à fournir des informations sur la prévalence de l'infection à rotavirus dans les diarrhées aiguës des nourrissons dans la ville de Lubumbashi. Elle s'est fixée comme objectifs de déterminer la fréquence hospitalière ainsi que la saisonnalité, les caractéristiques sociodémographiques, cliniques et évolutives de l'infection à Rotavirus chez les nourrissons admis à l'hôpital Jason Sendwe de Lubumbashi pour une diarrhée aiguë.

Méthodes

Il s'agit d'une étude descriptive et transversale menée pendant la période allant du 1^er janvier au 31 décembre 2012. Les paramètres épidémio-cliniques et évolutifs (âge, sexe, saison, signes cliniques, nombre journalier de selles et évolution) des enfants diagnostiqués positifs au rotavirus ont été comparés à ceux des enfants dont le test au rotavirus était négatif. Le degré de signification était de 5%.

Résultats

Nous avons récolté 193 cas de diarrhées aiguës dont 104 nourrissons étaient infectés par le rotavirus soit 53,8%. Des taux élevés des diarrhées à rotavirus sont enregistrés au cours de la saison sèche comparativement à la saison des pluies (p0,05). Par ailleurs, les enfants infectés par le rotavirus étaient 6 fois plus susceptibles de présenter une déshydratation modérée/sévère (p0,05).

Conclusion

Le rotavirus est confirmé dans la ville de Lubumbashi et touche souvent les enfants d’âge ≤12 mois, pendant la saison sèche sans distinction de sexe et conduit rapidement à une déshydratation modérée/sévère. Une prise en charge adaptée et précoce permet d’éviter les décès et l'assainissement du milieu, le lavage des mains, la prise d'eau potable et la vaccination contre le rotavirus sont les mesures préventives les plus efficaces contre les rotavirus et à conseiller dans notre communauté.

Cost-effectiveness analysis of vaccination against rotavirus with RIX4414 in France

BACKGROUND

It is estimated that annually 300 000 cases of rotavirus-induced gastroenteritis (RVGE) occur in children aged up to 5 years in France. A two-dose vaccine against rotavirus infection (RIX4414; Rotarix, GlaxoSmithKline), has been shown to be highly effective against severe RVGE.

OBJECTIVE

This study evaluated the cost effectiveness of general vaccination against rotavirus using RIX4414 in France.

METHODS

A Markov model simulated RVGE events and the associated outcomes and costs relating to general vaccination of infants against rotavirus infection using RIX4414 (Rotarix) in a birth cohort of children aged up to 5 years in France with a combined adjustment for age distribution with the seasonality of the infection. Costs and outcomes were estimated from a limited societal perspective, including direct medical costs paid out of pocket or by third-party payers, as well as the proportion of direct medical costs reimbursed by the health authorities. Indirect costs were not included in the base-case analysis. The primary outcome measure was the incremental cost per QALY.

RESULTS

Vaccination with RIX4414 incurred an incremental cost of 44 583 Euro per QALY at a public price of 57 Euro per vaccine dose. Univariate sensitivity analyses showed that the parameters with the largest influence on the results were the transition probabilities of severe diarrhoea, seeking medical advice and emergency visits, utility scores of diarrhoea (mild) in children and infants, and the discount rate for benefits. Probabilistic multivariate sensitivity analysis confirmed these results. The acceptability curve indicated that 94% of the results were under an informal threshold of 50 000 Euro per QALY. Comparing our results with those of a recently published study using pooled data for two rotavirus vaccine products in France, the main differences are explained by differences in model structure and in data input values. They include a different age distribution of the infection, shorter duration of the at-risk period (3 years instead of 5 years), different vaccine efficacy, different unit cost data, different disease duration, and different disutility values for the health states in the model. There is a need for agreed standards to improve comparability of results from different studies.

CONCLUSIONS

The results demonstrate that a generalized vaccination strategy with RIX4414 would be cost effective in France from a limited societal perspective, depending on the baseline assumptions for disease progression and on utility scores selected.

[Morbidity and cost of rotavirus infections in France]

BACKGROUND

Rotavirus is the most common cause of severe diarrhea in children. Morbidity and mortality related to rotavirus infection is not well known in temperate countries in general, and in France in particular.

OBJECTIVES

The aim of this study was estimate the morbidity, mortality, and cost related to the rotavirus infection in France, in order to assess the potential impact of a vaccination program.

METHODS

A birth cohort was followed until 5 years of age using a decision tree model. Rotavirus infection incidence rates were modeled according to age, seasons, and breast-feeding status.

RESULTS

Based on estimates from a decision model, we found that in France, rotavirus infection was responsible for 300,000 annual episodes of acute diarrhea, 138,000 visits to general practitioners, 18,000 hospitalizations, and 9 deaths. The annual direct cost related to rotavirus infection care was estimated at 28 million euros.

CONCLUSION

This study demonstrates the high morbidity and cost of care associated with rotavirus infection in France. The decision tree model developed in this study could be used in the future to estimate the potential effectiveness, cost and cost-effectiveness of childhood vaccination strategies using new rotavirus vaccines.

[Treatment of acute diarrhea: prescription patterns by private practice pediatricians]

Acute gastroenteritis remains a frequent illness in infants and children with still important morbidity and mortality rates. Oral rehydratation solutions (ORS) and early refeeding are the main recommendations. Indication of drugs remains limited.

OBJECTIVE

To evaluate the management of acute diarrhea by private practice pediatricians of France.

METHODS

A questionnaire concerning ORS, dietary formula, antidiarrheal diet, antibiotherapy, antidiarrheal drugs was sent to all 2907 private pediatricians of France.

RESULTS

Six hundred twenty-nine questionnaires were analyzed (22%). Three hundred and ninety-seven pediatricians (63%) prescribed systematically an ORS, 294 (47%) changed formula, 412 (66%) prescribed a regimen. Antibiotic was prescribed after coproculture (81%), when glairy and bloody diarrhea (65%), associated infectious disease (63%), toxi-infectious syndrome (42%) or immunodeficiency were present (28%). Most pediatricians (97%) prescribed at least one drug: diosmectite (84%), Lactobacillus acidophilus (63%), Saccharomyces boulardii (62%), racecadotril (62%), loperamide (28%), attapulgite de Mormoiron (26%), nifuroxazide (20%). Drugs were prescribed more often for their effectiveness than for comfort.

CONCLUSION

This study demonstrates the discrepancies that remain between recommendations and practical care in the treatment of acute diarrhea in children. Private French pediatricians often prescribe drugs.

[Management of acute infantile diarrhoea: a study on community pharmacy counseling in the Midi-Pyrenees region]

Counselling by community pharmacists is becoming an accepted standard for pharmacy practice. However, drugs available in children without prescription form are scarce, and most of the over-the-counter drugs have not been tested and approved in children.

OBJECTIVES

The aim of this study was to investigate attitude and knowledge of community pharmacists about advice and treatment in children with acute diarrhoea.

MATERIAL AND METHODS

We sent a postal questionnaire to a sample of 176 community pharmacies in the Midi-Pyrénées area (South western France), asking what they would give as advice and/or drugs in a simulated case of acute diarrhoea in an eight-month-old baby. For each question (interview of the mother, counselling about hygiene and dietetics, monitoring and drugs), we compared pharmacists answers to available evidence-based data and/or guidelines in the literature and to Summary Products Characteristics (SPC) for each reported drug. Forty one percent of pharmacies answered, giving 101 exploitable questionnaires.

RESULTS

Only 48.5% of subjects have recommended a rehydration solution. 71.3% recommended an inadequate beverage (soda) and 40% recommended stopping food intake despite WHO guidelines. Most of pharmacists (77%) noticed a drug with an appropriate indication and a paediatric mention in the SPC. However, in 12.9% of cases, drugs were contra-indicated or inadequate (loperamide, nifuroxazide, microorganisms available in capsules).

CONCLUSION

Even if an appropriate advice was given by most of the responders, improvements in advice are needed: too many pharmacists recommended anti-diarrhoeal drugs and withholding milk despite evidence about their lack of effectiveness on dehydration prevention. Conversely, rehydration solutions, which have been proved their effectiveness since many years, are not sufficiently proposed.

La mauvaise prise en charge de la diarrhée de l'enfant en France

Every year in France infant diarrhoea is responsible for the death of 50-80 children under the age of 5 and the hospitalization of approximately 50,000 children principally related to the deshydration which it causes. A significant number of these deaths and hospitalizations could be avoided by simple measures aimed at preventing dehydration, measures which have been codified and internationally promoted by the WHO for the past 25 years. In France, a large number of physicians do not yet apply them; they do not prescribe oral rehydration salts in case of infant diarrhoea, but prescriable antidiarrhoeal drugs which are ineffective on dehydration and are formally rejected by the WHO in these cases. Looking through the prism of this collective failure, one can identify the various causes which put into question the entire French health system: Lack of epidemiological observation; Lack of targeting health actions and initiatives towards children; Insufficient medical culture; Very ambiguous relationships between the state and the pharmaceutical industry; System of continuing medical education strongly linked to the pharmaceutical industry and incapable, to date, of raising up the challenge of a change in practice, which is nevertheless necessary.

Le poids médico-économique des gastro-entérites aiguës de l’enfant : l’éclairage du Programme de Médicalisation des Systèmes d’Information (PMSI)

OBJECTIVES

To estimate the burden of hospitalized infectious gastroenteritis of children younger than 5 years of age and associated costs.

METHODS

We analyzed 1997 hospital discharges with a primary diagnosis of gastroenteritis or a secondary diagnosis of gastroenteritis with gastroenteritis symptoms or complications as primary diagnosis and compared the deaths with those of the national mortality data.

RESULTS

Gastroenteritis was associated with 51,125 hospitalizations which accounted for 11.4% of hospitalization discharges for this age group and an annual rate of 1,385 per 100,000 children <5-year-old. Most gastroenteritis (56%) were registered as "probably infectious", 36% as "viral" (43% of which were coded "rotavirus") and 8% as "bacterial" (of which 60% were coded "Salmonella"). The seasonal peak was winter for rotaviral, viral and "probably infectious" gastroenteritis, summer for those related to salmonellosis. Incidence increased inversely with age: 3606/100,000 infants <1-year-old, 257/100,000 4-year-old children. Complications (especially dehydration) were observed in 21% of viral gastroenteritis and 17% of bacterial gastroenteritis. At least, 14 deaths were found in both hospital discharge and mortality data. The mean duration of stay (3.2 days) was significantly higher in infants <1-year-old, viral etiology, association with complications or bronchiolitis. The costs of hospitalization could be estimated to 62 million Euros.

DISCUSSION

Our results are similar to those obtained in other developed countries. Despite variations in encoding the discharge reports, data has proven to be effective to describe national trends for this health event. Our study indicates that the public health burden and economic impact of prevention and control measures can be monitored through hospital discharge surveillance.

[Nutritional treatment of acute diarrhea in an infant and young child]

This paper written by the Comité de nutrition de la Société française de pédiatrie is specially devoted to the nutritional treatment of infant and child acute diarrhea, i.e. oral rehydration with salts solution and feeding. It complements an article on drug therapy of child acute diarrhea written by the Groupe francophone d'hépatologie, gastroentérologie et nutrition pédiatriques, and published in this same issue of the Archives de pédiatrie.

[Rehydration modalities for acute diarrhea in hospitalized infants. Impact of a permanent short-stay pediatric observation unit]

OBJECTIVE

To analyze hospital treatment of infants with acute gastroenteritis, especially the variations in modes of rehydration, hospitalization rates and lengths of stay, related to paediatrician permanency with a short-stay observation unit at their disposal.

METHODS

This prospective multicentric study during two rotavirus epidemic periods included 1,187 infants (mean age 10 +/- 6 months) with acute gastroenteritis resulting or not in dehydration. During the first period, 12 volunteer hospitals were included. During the second period, we compared six (among the 12) hospitals where infants were admitted in emergency care or pediatric units without pediatric 24-h permanency, with a pediatric emergency care unit having pediatric permanency with a short-stay observation unit.

RESULTS

During the first period, 32% were dehydrated and 6% had hypovolemic shock on admission. The hospitalization rate was 81%. Only 19% of dehydrated infants had exclusively oral rehydration, and 19% of normohydrated infants had intravenous rehydration. During the second period, the hospitalization rate was 42% in the pediatric emergency care unit (28% in the short-stay unit and 14% in hospitalization units) versus 77% in the six hospitals. In the pediatric emergency care unit as compared to the six hospitals, there were a reduction of 65% of hospitalization days, 58% of intravenous accesses, and 66% of laboratory tests.

CONCLUSION

Our findings suggest that a paediatric permanency with a short-stay observation unit at their disposal improves quality of treatment and is cost-effective.