Infectious etiology and indicators of malabsorption or intestinal injury in childhood diarrhea

INTRODUCTION

The multifactorial etiology of gastroenteritis emphasizes the need for different laboratory methods to identify or exclude infectious agents and evaluate the severity of diarrheal disease.

OBJECTIVE

To diagnose the infectious etiology in diarrheic children and to evaluate some fecal markers associated with intestinal integrity.

MATERIALS AND METHODS

The study group comprised 45 children with diarrheal disease, tested for enteropathogens and malabsorption markers, and 76 children whose feces were used for fat evaluation by the traditional and acid steatocrit tests.

RESULTS

We observed acute diarrhea in 80% of the children and persistent diarrhea in 20%. Of the diarrheic individuals analyzed, 40% were positive for enteropathogens, with rotavirus (13.3%) and Giardia duodenalis (11.1%) the most frequently diagnosed. Among the infected patients, occult blood was more evident in those carrying pathogenic bacteria (40%) and enteroviruses (40%), while steatorrhea was observed in infections by the protozoa G. duodenalis (35.7%). Children with diarrhea excreted significantly more lipids in feces than non-diarrheic children, as determined by the traditional (p<0.0003) and acid steatocrit (p<0.0001) methods. Moreover, the acid steatocrit method detected 16.7% more fecal fat than the traditional method.

CONCLUSIONS

Childhood diarrhea can lead to increasingly severe nutrient deficiencies. Steatorrhea is the hallmark of malabsorption, and a stool test, such as the acid steatocrit, can be routinely used as a laboratory tool for the semi-quantitative evaluation of fat malabsorption in diarrheic children.

Genetic crosses within and between species of Cryptosporidium

Parasites and their hosts are engaged in reciprocal coevolution that balances competing mechanisms of virulence, resistance, and evasion. This often leads to host specificity, but genomic reassortment between different strains can enable parasites to jump host barriers and conquer new niches. In the apicomplexan parasite Cryptosporidium, genetic exchange has been hypothesized to play a prominent role in adaptation to humans. The sexual lifecycle of the parasite provides a potential mechanism for such exchange; however, the boundaries of Cryptosporidium sex are currently undefined. To explore this experimentally, we established a model for genetic crosses. Drug resistance was engineered using a mutated phenylalanyl tRNA synthetase gene and marking strains with this and the previously used Neo transgene enabled selection of recombinant progeny. This is highly efficient, and genomic recombination is evident and can be continuously monitored in real time by drug resistance, flow cytometry, and PCR mapping. Using this approach, multiple loci can now be modified with ease. We demonstrate that essential genes can be ablated by crossing a Cre recombinase driver strain with floxed strains. We further find that genetic crosses are also feasible between species. Crossing Cryptosporidium parvum, a parasite of cattle and humans, and Cryptosporidium tyzzeri a mouse parasite resulted in progeny with a recombinant genome derived from both species that continues to vigorously replicate sexually. These experiments have important fundamental and translational implications for the evolution of Cryptosporidium and open the door to reverse- and forward-genetic analysis of parasite biology and host specificity.

The Early Life Microbiota Is Not a Major Factor Underlying the Susceptibility to Postweaning Diarrhea in Piglets

Postweaning diarrhea (PWD) in piglets impair welfare, induce economic losses and lead to overuse of antibiotics. The early life gut microbiota was proposed to contribute to the susceptibility to PWD. The objective of our study was to evaluate in a large cohort of 116 piglets raised in 2 separate farms whether the gut microbiota composition and functions during the suckling period were associated with the later development of PWD. The fecal microbiota and metabolome were analyzed by 16S rRNA gene amplicon sequencing and nuclear magnetic based resonance at postnatal day 13 in male and female piglets. The later development of PWD was recorded for the same animals from weaning (day 21) to day 54. The gut microbiota structure and α-diversity during the suckling period were not associated with the later development of PWD. There was no significant difference in the relative abundances of bacterial taxa in suckling piglets that later developed PWD. The predicted functionality of the gut microbiota and the fecal metabolome signature during the suckling period were not linked to the later development of PWD. Trimethylamine was the bacterial metabolite which fecal concentration during the suckling period was the most strongly associated with the later development of PWD. However, experiments in piglet colon organoids showed that trimethylamine did not disrupt epithelial homeostasis and is thus not likely to predispose to PWD through this mechanism. In conclusion, our data suggest that the early life microbiota is not a major factor underlying the susceptibility to PWD in piglets. IMPORTANCE This study shows that the fecal microbiota composition and metabolic activity are similar in suckling piglets (13 days after birth) that either later develop post-weaning diarrhea (PWD) or not, which is a major threat for animal welfare that also causes important economic losses and antibiotic treatments in pig production. The aim of this work was to study a large cohort of piglets raised in separates environments, which is a major factor influencing the early life microbiota. One of the main findings is that, although the fecal concentration of trimethylamine in suckling piglets was associated with the later development of PWD, this gut microbiota-derived metabolite did not disrupt the epithelial homeostasis in organoids derived from the pig colon. Overall, this study suggests that the gut microbiota during the suckling period is not a major factor underlying the susceptibility of piglets to PWD.

Prospective Cohort Study of Cryptosporidium Infection and Shedding in Infants and Their Households

BACKGROUND

Cryptosporidium spp. are responsible for significant diarrheal morbidity and mortality in under-5 children. There is no vaccine; thus, a focus on prevention is paramount. Prior studies suggest that person-to-person spread may be an important pathway for transmission to young children. Here we describe a longitudinal cohort study of 100 families with infants to determine rates of cryptosporidiosis within households during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Families living in Mirpur, Bangladesh, with 1 infant aged 6-8 months were enrolled and followed with weekly illness survey and stool testing for Cryptosporidium for 8 months.

RESULTS

From December 2020 to August 2021, 100 families were enrolled. Forty-four percent of index children and 35% of siblings had at least 1 Cryptosporidium infection. Shedding of Cryptosporidium occurred for a mean (standard deviation) of 19 (8.3) days in index infants, 16.1 (11.6) days in children 1-5 years, and 16.2 (12.8) days in adults. A longer duration of Cryptosporidium shedding was associated with growth faltering in infants. There was a spike in Cryptosporidium cases in May 2021, which coincided with a spike in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases in the region.

CONCLUSIONS

In this intensive, longitudinal study of Cryptosporidium infection in families we found high rates of cryptosporidiosis in infants and children, and prolonged parasite shedding, especially among malnourished children. These data support that transmission within the household is an important route of exposure for young infants and that treatment of nondiarrheal infection to interrupt person-to-person transmission within the home may be essential for preventing cryptosporidiosis in infants.

Modulation of Host-Microbe Metabolism by Cholera Toxin

In order for successful fecal-oral transmission, enteric bacterial pathogens have to successfully compete with the intestinal microbiota and reach high concentrations during infection. Vibrio cholerae requires cholera toxin (CT) to cause diarrheal disease, which is thought to promote the fecal-oral transmission of the pathogen. Besides inducing diarrheal disease, the catalytic activity of CT also alters host intestinal metabolism, which promotes the growth of V. cholerae during infection through the acquisition of host-derived nutrients. Furthermore, recent studies have found that CT-induced disease activates a niche-specific suite of V. cholerae genes during infection, some of which may be important for fecal-oral transmission of the pathogen. Our group is currently exploring the concept that CT-induced disease promotes the fecal-oral transmission of V. cholerae by modulating both host and pathogen metabolism. Furthermore, the role of the intestinal microbiota in pathogen growth and transmission during toxin-induced disease merits further investigation. These studies open the door to investigating whether other bacterial toxins also enhance pathogen growth and transmission during infection, which may shed light on the design of novel therapeutics for intervention or prevention of diarrheal diseases.

Common infectious morbidity and white blood cell count in middle childhood predict behavior problems in adolescence

We examined the associations of middle childhood infectious morbidity and inflammatory biomarkers with adolescent internalizing and externalizing behavior problems. We recruited 1018 Colombian schoolchildren aged 5-12 years into a cohort. We quantified white blood cell (WBC) counts and C-reactive protein at enrollment and prospectively recorded incidence of gastrointestinal, respiratory, and fever-associated morbidity during the first follow-up year. After a median 6 years, we assessed adolescent internalizing and externalizing behavior problems using child behavior checklist (CBCL) and youth self-report (YSR) questionnaires. Behavior problem scores were compared over biomarker and morbidity categories using mean differences and 95% confidence intervals (CI) from multivariable linear regression. Compared with children without symptoms, CBCL internalizing problem scores were an adjusted 2.5 (95% CI: 0.1, 4.9; p = .04) and 3.1 (95% CI: 1.1, 5.2; p = .003) units higher among children with moderate diarrhea with vomiting and high cough with fever rates, respectively. High cough with fever and high fever rates were associated with increased CBCL somatic complaints and anxious/depressed scores, respectively. WBC >10,000/mm³ was associated with both internalizing problem and YSR withdrawn/depressed scores. There were no associations with externalizing behavior problems. Whether or not decreasing the burden of common infections results in improved neurobehavioral outcomes warrants further investigation.

Prevalence of diarrheal disease and associated factors among under-five children in flood-prone settlements of Northwest Ethiopia: A cross-sectional community-based study

BACKGROUND

Diarrheal illnesses are a long-standing public health problem in developing countries due to numerous sanitation issues and a lack of safe drinking water. Floods exacerbate public health issues by spreading water-borne infectious diseases such as diarrhea through the destruction of sanitation facilities and contamination of drinking water. There has been a shortage of studies regarding the magnitude of diarrheal disease in flood-prone areas. Therefore, this research aimed to evaluate the prevalence of diarrheal disease and its predictors among under-five children living in flood-prone localities in the south Gondar zone of Northwest Ethiopia.

METHOD

A community-based cross-sectional research was carried out in flood-prone villages of the Fogera and Libokemkem districts from March 17 to March 30, 2021. Purposive and systematic sampling techniques were used to select six kebeles and 717 study units, respectively. Structured and pretested questionnaires were used to collect the data. A multivariable analysis was performed to determine the predictors of diarrheal disease, with P-value <0.05 used as the cut-off point to declare the association.

RESULT

The prevalence of a diarrheal disease among under-five children was 29.0%. The regular cleaning of the compound [AOR: 2.13; 95% CI (1.25, 3.62)], source of drinking water [AOR: 2.36; 95% CI: (1.26, 4.41)], animal access to water storage site [AOR: 3.04; 95% CI: (1.76, 5.24)], vector around food storage sites [AOR: 9.13; 95% CI: (4.06, 20.52)], use of leftover food [AOR: 4.31; 95% CI: (2.64, 7.04)], and fecal contamination of water [AOR: 12.56; 95% CI: (6.83, 23.20)] remained to have a significant association with diarrheal diseases.

CONCLUSION

The present study found that the prevalence of the diarrheal disease among under-five children was high. Routine compound cleaning, the source of drinking water, animal access to a water storage site, vectors near food storage sites, consumption of leftover food, and fecal contamination of water were significant predictors of diarrheal disease. Therefore, it is advised to provide improved water sources, encourage routine cleaning of the living area, and offer health education about water, hygiene, and sanitation.

Evaluation of the kitchen microbiome and food safety behaviors of predominantly low-income families

Bacterial pathogens in the domestic environment present a risk to residents, particularly among susceptible populations. However, the impact of consumer demographic characteristics and food handling methods on kitchen microbiomes is not fully understood. The domestic kitchen bacterial communities of ten predominantly low-income families in Houston, TX, were assessed in conjunction with a cross-sectional food safety survey to evaluate differences in household and surface-specific microbiomes and bacterial foodborne pathogen presence. Three kitchen surfaces within each household, including the sink drain, the refrigerator handle, and the counter, were environmentally sampled and metataxonomically evaluated via targeted 16S rRNA sequencing. Disposable dish sponges were also acquired and examined. Results indicated that alpha diversity did not vary by the households, sampling locations, or demographic characteristics evaluated. Significant differences in beta diversity were observed among the bacterial communities of five pairs of households and between refrigerator handle and disposable dish sponge microbiomes. A total of 89 unique bacterial foodborne pathogens were identified across surface types. Each household contained at least one contaminated surface, and the most common bacterial foodborne pathogens identified were Escherichia coli, Staphylococcus aureus, and Klebsiella pneumoniae. All parents reported washing their hands before meal preparation, washing fresh fruits and vegetables, and washing cutting boards with soap after use to prepare raw animal proteins. Gaps in food safety behaviors identified included a lack of serious concern for food contamination with germs and inappropriate handwashing, food handling, and cleaning behaviors. The number of unique bacterial foodborne pathogens identified within households was significantly higher among households whose respondent parent reported that they did not consider food contamination with germs to be a serious food safety problem (median: 41.0 species) compared to households whose respondent parent did consider food contamination to be a serious food safety problem (median: 3.0 species; p value = 0.0218). These results demonstrate that domestic kitchen taxonomic abundance profiles vary according to household and surface type. Data suggest that low-income consumers may be at risk of foodborne pathogen exposure from contaminated home kitchen surfaces, and that food safety attitudes may directly contribute to this hazard.

Water, Sanitation, and Hygiene (WASH) Practices and Outreach Services in Settlements for Rohingya Population in Cox's Bazar, Bangladesh, 2018-2021

(1) Background: This study aimed to investigate the existing water, sanitation, and hygiene (WASH) policy and practice of the study population and strengthen the evidence base by documenting changes in the WASH policy and practice over 3 years of the Rohingya refugee humanitarian crisis, Cox's Bazar, Bangladesh. (2) Methods: A cross-sectional surveillance design was followed; the sampling of the study population included the Rohingya refugee population and neighborhood host nationals who required hospitalization soon after seeking care and enrolled into the diarrheal disease surveillance in diarrhea-treatment centers. Throughout the study period of 3 years, a total of 4550 hospitalized individuals constituted the study participants. (3) Results: Among the hospitalized Rohingya refugee population; the use of public tap water increased significantly from 38.5% in year 1 to 91% in year 3. The use of deep tube well water significantly changed from 31.3% to 8.2%, and the use of shallow tube well water reduced significantly from 25.8% to 0.4%. Households using water seal latrine were 13.3% in year 1 and increased significantly to 31.7% in year 3. ORS consumption at home changed significantly from 61.5% in the first year to 82.1% in third year. Multivariable analysis demonstrated patients' age groups at 5 to 14 years, and 15 years and more, drinking non-tube well water, soap use after using toilet, use of non-sanitary toilet facility, father's and mother's lack of schooling, and some and severe dehydration were significantly associated with the Rohingya refugee population enrolled into the diarrheal disease surveillance. (4) Conclusion: The findings indicate significant advances in WASH service delivery as well as outreach activities by aid agencies for the Rohingya refugee population living in settlements.

Occurrence of Diarrheal Disease among Under-Five Children and Associated Sociodemographic and Household Environmental Factors: An Investigation Based on National Family Health Survey-4 in Rural India

Diarrheal disease is a significant public health problem leading to mortality and morbidity among children aged 0-59 months in rural India. Therefore, the rationale of this study was to identify the sociodemographic and environmental predictors associated with diarrhea among under-five children in rural India. A total of 188,521 living children (0-59 months) were studied from the National Family Health Survey-4, (NFHS-4) 2015-2016. Bivariate and binary logistic regression models were carried out from the available NFHS-4 data for selected sociodemographic and environmental predictors to identify the relationship of occurrence of diarrhea using STATA 13.1. In rural India, children aged 12-23 months, 24-35 months, 36-47 months, and 48-59 months were significantly improbable to suffer diarrheal disease. Children of the female sex, as well as children of scheduled tribes (ST) and other backward classes (OBC), were less likely to experience diarrhea. The disease was more likely to occur among children of scheduled castes (SC); Muslim or other religions; children belonging to central, eastern, and western regions; children with low birth weight; as well as children with improper stool disposal and rudimentary roof materials. In the rural parts of India, sociodemographic and household environmental factors were most influential. Effective community education; improved handwashing practices; pure water supply; and proper waste disposal, including building and utilizing latrines, would help reduce the burden of diarrheal disease in children.

Associations Between Eight Earth Observation-Derived Climate Variables and Enteropathogen Infection: An Independent Participant Data Meta-Analysis of Surveillance Studies With Broad Spectrum Nucleic Acid Diagnostics

Diarrheal disease, still a major cause of childhood illness, is caused by numerous, diverse infectious microorganisms, which are differentially sensitive to environmental conditions. Enteropathogen-specific impacts of climate remain underexplored. Results from 15 studies that diagnosed enteropathogens in 64,788 stool samples from 20,760 children in 19 countries were combined. Infection status for 10 common enteropathogens-adenovirus, astrovirus, norovirus, rotavirus, sapovirus, Campylobacter, ETEC, Shigella, Cryptosporidium and Giardia-was matched by date with hydrometeorological variables from a global Earth observation dataset-precipitation and runoff volume, humidity, soil moisture, solar radiation, air pressure, temperature, and wind speed. Models were fitted for each pathogen, accounting for lags, nonlinearity, confounders, and threshold effects. Different variables showed complex, non-linear associations with infection risk varying in magnitude and direction depending on pathogen species. Rotavirus infection decreased markedly following increasing 7-day average temperatures-a relative risk of 0.76 (95% confidence interval: 0.69-0.85) above 28°C-while ETEC risk increased by almost half, 1.43 (1.36-1.50), in the 20-35°C range. Risk for all pathogens was highest following soil moistures in the upper range. Humidity was associated with increases in bacterial infections and decreases in most viral infections. Several virus species' risk increased following lower-than-average rainfall, while rotavirus and ETEC increased with heavier runoff. Temperature, soil moisture, and humidity are particularly influential parameters across all enteropathogens, likely impacting pathogen survival outside the host. Precipitation and runoff have divergent associations with different enteric viruses. These effects may engender shifts in the relative burden of diarrhea-causing agents as the global climate changes.

Narrative Review of Primary Preventive Interventions against Water-Borne Diseases: Scientific Evidence of Health-EDRM in Contexts with Inadequate Safe Drinking Water

Waterborne diseases account for 1.5 million deaths a year globally, particularly affecting children in low-income households in subtropical areas. It is one of the most enduring and economically devastating biological hazards in our society today. The World Health Organization Health Emergency and Disaster Risk Management (health-EDRM) Framework highlights the importance of primary prevention against biological hazards across all levels of society. The framework encourages multi-sectoral coordination and lessons sharing for community risk resilience. A narrative review, conducted in March 2021, identified 88 English-language articles published between January 2000 and March 2021 examining water, sanitation, and hygiene primary prevention interventions against waterborne diseases in resource-poor settings. The literature identified eight main interventions implemented at personal, household and community levels. The strength of evidence, the enabling factors, barriers, co-benefits, and alternative measures were reviewed for each intervention. There is an array of evidence available across each intervention, with strong evidence supporting the effectiveness of water treatment and safe household water storage. Studies show that at personal and household levels, interventions are effective when applied together. Furthermore, water and waste management will have a compounding impact on vector-borne diseases. Mitigation against waterborne diseases require coordinated, multi-sectoral governance, such as building sanitation infrastructure and streamlined waste management. The review showed research gaps relating to evidence-based alternative interventions for resource-poor settings and showed discrepancies in definitions of various interventions amongst research institutions, creating challenges in the direct comparison of results across studies.

A site assessment tool for inpatient controlled human infection models for enteric disease pathogens

The use of the controlled human infection model to facilitate product development and to advance understanding of host-pathogen interactions is of increasing interest. While administering a virulent (or infective) organism to a susceptible host necessitates an ongoing evaluation of safety and ethical considerations, a central theme in conducting these studies in a safe and ethical manner that yields actionable data is their conduct in facilities well-suited to address their unique attributes. To that end, we have developed a framework for evaluating potential sites in which to conduct inpatient enteric controlled human infection model to ensure consistency and increase the likelihood of success.

Antidiarrheal and antispasmodic activities of Trillium govanianum rhizomes extract: involvement of calcium channel blockade

The antidiarrheal effect of methanolic extract of Trillium govanianum Wall. ex D. Don (Melanthiaceae alt. Trilliaceae) was studied at doses of 12.5, 25, and 50 mg/kg in different animal models of diarrhea including castor oil (6 mL/kg), magnesium sulfate (2 gm/kg), sodium picosulfate (2 mL/kg) and lactitol (0.25 mL/kg). The antispasmodic effect of T. govanianum was studied on isolated rabbit's jejunum, using acetylcholine as tissue stabiliser and verapamil as calcium channel blocker. T. govanianum attenuated the diarrhea by producing a significant decrease in the number and weight of stool, and an increase in stool latency time. T. govanianum completely inhibited both spontaneous as well as high potassium induced contractions of isolated rabbit's jejunum, which was analogous to verapamil. Moreover, T. govanianum produced a right shift in calcium concentration response curve, confirming its calcium channel blocking activity. These findings provide scientific ground to its medicinal use in diarrhea and gut spasms.

Diarrheal pathogens trigger rapid evolution of the guanylate cyclase-C signaling axis in bats

The pathogenesis of infectious diarrheal diseases is largely attributed to enterotoxins that cause dehydration by disrupting intestinal water absorption. We investigated patterns of genetic variation in mammalian guanylate cyclase-C (GC-C), an intestinal receptor targeted by bacterially encoded heat-stable enterotoxins (STa), to determine how host species adapt in response to diarrheal infections. Our phylogenetic and functional analysis of GC-C supports long-standing evolutionary conflict with diarrheal bacteria in primates and bats, with highly variable susceptibility to STa across species. In bats, we further show that GC-C diversification has sparked compensatory mutations in the endogenous uroguanylin ligand, suggesting an unusual scenario of pathogen-driven evolution of an entire signaling axis. Together, these findings suggest that conflicts with diarrheal pathogens have had far-reaching impacts on the evolution of mammalian gut physiology.

Effectiveness of rotavirus vaccine in the prevention of diarrhoeal diseases among children under age five years in Kavango East and West Regions, Namibia

Background

Diarrheal diseases due to rotavirus infection contribute greatly to morbidity and mortality rates of babies and young children in many developing countries. This public health concern can effectively be reduced by the use of the rotavirus vaccine, though there is an anecdotal evidence indicating that despite introduction of the vaccine the number of cases of diarrhoea diseases are still high in Namibia, particularly in Kavango east and west regions.

Objective

This study evaluated the effectiveness of the rotavirus vaccine in preventing diarrhoea cases among children under age five years in Kavango regions.

Methods

The study employed a quasiexperimental design comparing diarrhoea cases before (2010-2013) and after (2014-2017) introduction of the rotavirus vaccine among children under age five years. Data were extracted from District Health Information System version 2 and analysed by using one way analysis of covariance.

Results

Before introduction of the rotavirus vaccine, there were 14 500 diarrhoea cases, which is 1.6% rate of infection. After introduction of the rotavirus vaccine, there were 14 400 diarrhoea cases, which is 1.58% rate of infection. This is supported by the effect size (partial eta²) of 0.01%, which is very small. The trend of diarrhoea cases after rotavirus vaccine introduction fluctuated with no major decline of diarrhoea cases.

Conclusions

The study concluded that rotavirus vaccine is less effective in preventing diarrhoea diseases among children under age five years in the Kavango regions. Further research is needed to substantiate these findings as other factors can contribute to fluctuation of diarrhoea cases.

Wa-1 Equine-Like G3P[8] Rotavirus from a Child with Diarrhea in Colombia

Rotavirus A (RVA) has been considered the main cause of diarrheal disease in children under five years in emergency services in both developed and developing countries. RVA belongs to the Reoviridae family, which comprises 11 segments of double-stranded RNA (dsRNA) as a genomic constellation that encodes for six structural and five to six nonstructural proteins. RVA has been classified in a binary system with Gx[Px] based on the spike protein (VP4) and the major outer capsid glycoprotein (VP7), respectively. The emerging equine-like G3P[8] DS-1-like strains reported worldwide in humans have arisen an important concern. Here, we carry out the complete genome characterization of a previously reported G3P[8] strain in order to recognize the genetic diversity of RVA circulating among infants in Colombia. A near-full genome phylogenetic analysis was done, confirming the presence of the novel equine-like G3P[8] with a Wa-like backbone for the first time in Colombia. This study demonstrated the importance of surveillance of emerging viruses in the Colombian population; furthermore, additional studies must focus on the understanding of the spread and transmission dynamic of this important RVA strain in different areas of the country.

Evolving Epidemiology of Reported Giardiasis Cases in the United States, 1995-2016

BACKGROUND

Giardiasis is the most common intestinal parasitic disease of humans identified in the United States (US) and an important waterborne disease. In the United States, giardiasis has been variably reportable since 1992 and was made a nationally notifiable disease in 2002. Our objective was to describe the epidemiology of US giardiasis cases from 1995 through 2016 using National Notifiable Diseases Surveillance System data.

METHODS

Negative binomial regression models were used to compare incidence rates by age group (0-4, 5-9, 10-19, 20-29, 30-39, 40-49, 50-64, and ≥ 65 years) during 3 time periods (1995-2001, 2002-2010, and 2011-2016).

RESULTS

During 1995-2016, the average number of reported cases was 19 781 per year (range, 14 623-27 778 cases). The annual incidence of reported giardiasis in the United States decreased across all age groups. This decrease differs by age group and sex and may reflect either changes in surveillance methods (eg, changes to case definitions or reporting practices) or changes in exposure. Incidence rates in males and older age groups did not decrease to the same extent as rates in females and children.

CONCLUSIONS

Trends suggest that differences in exposures by sex and age group are important to the epidemiology of giardiasis. Further investigation into the risk factors of populations with higher rates of giardiasis will support prevention and control efforts.

Feeding Practices and Associated Factors During Diarrheal Disease Among Children Aged Less Than Five Years: Evidence from the Ethiopian Demographic and Health Survey 2016

Purpose

Diarrhea is a common childhood illness and one of the leading causes of death in young children globally. In Ethiopia, a significant number of deaths and hospitalizations in under-five children are related to diarrheal diseases. Inappropriate feeding during diarrhea leads to a double burden of diarrhea recurrence and malnutrition among children. However, empirical evidence is limited in Ethiopia. Thus, this study was aimed to assess feeding practices and associated factors during diarrheal disease among children aged less than five years in Ethiopia.

Patients and Methods

The study used the Ethiopian Demographic and Health Survey (EDHS) 2016 data. A two-stage stratified sampling technique was applied to identify 917 under five years children. Generalized linear mixed model analyses were computed, and a P value of less than 0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were used to identify statistically significant factors with feeding practices.

Results

The majority (92.5%) of mothers were married. Out of the participants, (54.1%) of children were male; 55.6% of them were in the age group of 6–23 months. The appropriate feeding practices for children aged less than five years who had diarrhea was 15.4% (95% CI: 13.7%-18.2%). Mothers aged 25–34 years (AOR: 0.6, 95% CI: 0.4–0.9), agricultural occupation of mothers (AOR: 2.2, 95% CI: 1.3–3.6), mothers attended four and more antenatal visit (AOR: 2.3, 95% CI: 1.3–4.32) and mothers who had a postnatal checkup within two months of birth (AOR: 1.9, 95% CI: 1.1–3.2) were factors statistically associated with child feeding practices during diarrhea.

Conclusion

Less than one-fifth of under-five children practiced appropriate feeding during diarrheal disease. Working in agriculture and attending antenatal care and postnatal checkup within two months were positively influencing feeding practice. Therefore, the government of Ethiopia needs to strengthen the existing maternal and child health services.

The Relationship Between Demographic, Socioeconomic, and Health-Related Parameters and the Impact of COVID-19 on 24 Regions in India: Exploratory Cross-Sectional Study

BACKGROUND

The impact of the COVID-19 pandemic has varied widely across nations and even in different regions of the same nation. Some of this variability may be due to the interplay of pre-existing demographic, socioeconomic, and health-related factors in a given population.

OBJECTIVE

The aim of this study was to examine the statistical associations between the statewise prevalence, mortality rate, and case fatality rate of COVID-19 in 24 regions in India (23 states and Delhi), as well as key demographic, socioeconomic, and health-related indices.

METHODS

Data on disease prevalence, crude mortality, and case fatality were obtained from statistics provided by the Government of India for 24 regions, as of June 30, 2020. The relationship between these parameters and the demographic, socioeconomic, and health-related indices of the regions under study was examined using both bivariate and multivariate analyses.

RESULTS

COVID-19 prevalence was negatively associated with male-to-female sex ratio (defined as the number of females per 1000 male population) and positively associated with the presence of an international airport in a particular state. The crude mortality rate for COVID-19 was negatively associated with sex ratio and the statewise burden of diarrheal disease, and positively associated with the statewise burden of ischemic heart disease. Multivariate analyses demonstrated that the COVID-19 crude mortality rate was significantly and negatively associated with sex ratio.

CONCLUSIONS

These results suggest that the transmission and impact of COVID-19 in a given population may be influenced by a number of variables, with demographic factors showing the most consistent association.

Lack of Safe Drinking Water for Lake Chapala Basin Communities in Mexico Inhibits Progress toward Sustainable Development Goals 3 and 6

BACKGROUND

Access to safe, affordable and accessible drinking water is a human right and foundational to the third and sixth World Health Organization's Sustainable Development Goals (SDGs). Unsafe drinking water is a risk factor for chronic and enteric diseases. Both chronic kidney disease (CKD) and diarrheal disease are highly prevalent in the Lake Chapala basin, Jalisco, Mexico, suggesting disparities in factors leading to successful achievement of these two SDGs.

METHODS

This study aimed to assess progress towards SDG three and six in the Lake Chapala basin. Qualitative, quantitative, and geospatial data were collected between May and August of 2019 from three towns within the municipalities of Poncitlán and Chapala.

RESULTS

Ninety-nine households participated in this study. Water sampling analyses determined 81.18% of samples from water jugs (garrafones) and 70.05% of samples from tap water were contaminated with total coliform bacteria, often including E. coli. Additionally, 32% of garrafón samples and 61.9% of tap water samples had detectable levels of arsenic. Approximately 97.94% of respondents stated that they believe clean water is a human right, but 78.57% feel the Mexican government does not do enough to make this a reality.

CONCLUSIONS

This mixed methods approach highlights water quality as a serious issue in communities around Lake Chapala, and demonstrates inadequate drinking water as a key hazard, potentially perpetuating the high disease burden of both CKD and enteric disease in the region.

Associations between Household-Level Exposures and All-Cause Diarrhea and Pathogen-Specific Enteric Infections in Children Enrolled in Five Sentinel Surveillance Studies

Diarrheal disease remains a major cause of childhood mortality and morbidity causing poor health and economic outcomes. In low-resource settings, young children are exposed to numerous risk factors for enteric pathogen transmission within their dwellings, though the relative importance of different transmission pathways varies by pathogen species. The objective of this analysis was to model associations between five household-level risk factors-water, sanitation, flooring, caregiver education, and crowding-and infection status for endemic enteric pathogens in children in five surveillance studies. Data were combined from 22 sites in which a total of 58,000 stool samples were tested for 16 specific enteropathogens using qPCR. Risk ratios for pathogen- and taxon-specific infection status were modeled using generalized linear models along with hazard ratios for all-cause diarrhea in proportional hazard models, with the five household-level variables as primary exposures adjusting for covariates. Improved drinking water sources conferred a 17% reduction in diarrhea risk; however, the direction of its association with particular pathogens was inconsistent. Improved sanitation was associated with a 9% reduction in diarrhea risk with protective effects across pathogen species and taxa of around 10-20% risk reduction. A 9% reduction in diarrhea risk was observed in subjects with covered floors, which were also associated with decreases in risk for zoonotic enteropathogens. Caregiver education and household crowding showed more modest, inconclusive results. Combining data from diverse sites, this analysis quantified associations between five household-level exposures on risk of specific enteric infections, effects which differed by pathogen species but were broadly consistent with hypothesized transmission mechanisms. Such estimates may be used within expanded water, sanitation, and hygiene (WASH) programs to target interventions to the particular pathogen profiles of individual communities and prioritize resources.

Biomimetic Gut Model Systems for Development of Targeted Microbial Solutions for Enhancing Warfighter Health and Performance

The human gut microbiome plays a vital role in both health and disease states and as a mediator of cognitive and physical performance. Despite major advances in our understanding of the role of gut microbes in host physiology, mechanisms underlying human-microbiome dynamics have yet to be fully elucidated.

The human gut microbiome plays a vital role in both health and disease states and as a mediator of cognitive and physical performance. Despite major advances in our understanding of the role of gut microbes in host physiology, mechanisms underlying human-microbiome dynamics have yet to be fully elucidated. This knowledge gap represents a major hurdle to the development of targeted gut microbiome solutions influencing human health and performance outcomes. The microbiome as it relates to warfighter health and performance is of interest to the Department of Defense (DoD) with the development of interventions impacting gut microbiome resiliency among its top research priorities. While technological advancements are enabling the development of experimental model systems that facilitate mechanistic insights underpinning human health, disease, and performance, translatability to human outcomes is still questionable. This review discusses some of the drivers influencing the DoD’s interest in the warfighter gut microbiome and describes current in vitro gut model systems supporting direct microbial-host interactions.

Distantly Related Rotaviruses in Common Shrews, Germany, 2004-2014

We screened samples from common shrews (Sorex araneus) collected in Germany during 2004–2014 and identified 3 genetically divergent rotaviruses. Virus protein 6 sequence similarities to prototype rotaviruses were low (64.5% rotavirus A, 50.1% rotavirus C [tentative species K], 48.2% rotavirus H [tentative species L]). Shrew-associated rotaviruses might have zoonotic potential.

Diarrheal disease and associated behavioural factors among food handlers in Addis Ababa, Ethiopia

Introduction: Diarrheal diseases are threat everywhere, but its frequency and impact are more severe in developing countries. Diarrhea occurs world-wide and causes 4% of all deaths and 5% of health loss to disability. In 2016, it was the eighth leading cause of mortality. Moreover, data from the World Health Organization indicated that diarrheal diseases are causes for an estimated 2 million deaths annually. Therefore, this study aimed to assess diarrheal diseases and associated behavioural factors. Method: An institution based cross-sectional study was conducted. A stratified random sampling method was employed to select 1050 study participants. Participants were interviewed using structured questionnaire. To analysis the data, binary logistic regression and multivariable logistic regression analysis was conducted. Results: The two weeks prevalence of diarrhea was found to be 3.4%. Further, 1.6%, 10.5%, 10.7% and 9% of the food handlers had acute watery diarrhea, cough, an infection of runny nose and incidence of any fever respectively. Regular hand washing after toilet (AOR = 0.13 with 95% CI: 0.024, 0.72), using toilet while wearing protective clothes/gown (AOR = 5.39 with 95% CI; 1.59, 18.32), habit of eating raw beef and raw vegetables (AOR = 6.27 with 95% CI: 1.89–20.78), type of toilet (AOR = 4.07 with 95% CI: 0.29–6.67 were associated significantly with diarrhea. Conclusion: This assessment proved to be an essential activity for reduction of community diarrheal diseases, as a significant number of food handlers had diarrhea. Good sanitation, hygiene practice and a healthy lifestyle behavior can prevent diarrhea. A strong political commitment with appropriate budgetary allocation is essential for the control of diarrheal diseases.

An Extended-Spectrum Beta-Lactamase-Producing Hybrid Shiga-Toxigenic and Enterotoxigenic Escherichia coli Strain Isolated from a Piglet with Diarrheal Disease in Northeast China

Shiga-toxigenic Escherichia coli (STEC) and enterotoxigenic E. coli (ETEC) can cause diarrhea in piglets. This is the first report and complete genome sequence of an extended-spectrum β-lactamase-producing hybrid STEC/ETEC strain isolated from a piglet with diarrhea on a swine farm in China. We investigated the virulence genes and phylogenetic diversity with publicly available E. coli genomes. Both E. coli strains S17-13 and S17-20 harbored multiple virulence genes, mainly including stx2e and eastA genes. Other important virulence genes (estIa, estIb, fedABCDEF, and hlyABCD) were located in the plasmid p1713-1 of S17-13, which could be transferred from E. coli S17-13 to S17-20 by conjugation. The presence of virulence genes associated with different pathogroups (STEC or ETEC) confirmed the hybrid status of E. coli strain S17-13. Phylogenetic analysis showed that STEC/ETEC S17-13, STEC S17-20, avian pathogenic E. coli (APEC) O78, and APEC ACN001 are located in the same evolutionary branch, indicating that they may originate from a common ancestor. It is crucial to understand the phylogeny of pathogenic bacteria to evaluate how they have evolved and to monitor the emergence of potential new pathogens. The emergence of novel hybrid E. coli strains presents a new public health risk. More attention must be paid to these hybrid pathogens during typing and epidemiological surveillance of E. coli infections, which challenges the traditional diagnostics of E. coli infections.

Disparities in Shigellosis Incidence by Census Tract Poverty, Crowding, and Race/Ethnicity in the United States, FoodNet, 2004-2014

Background

Shigella causes an estimated 500000 enteric illnesses in the United States annually, but the association with socioeconomic factors is unclear.

Methods

We examined possible epidemiologic associations between shigellosis and poverty using 2004–2014 Foodborne Diseases Active Surveillance Network (FoodNet) data. Shigella cases (n = 21246) were geocoded, linked to Census tract data from the American Community Survey, and categorized into 4 poverty and 4 crowding strata. For each stratum, we calculated incidence by sex, age, race/ethnicity, and FoodNet site. Using negative binomial regression, we estimated incidence rate ratios (IRRs) comparing the highest to lowest stratum.

Results

Annual FoodNet Shigella incidence per 100000 population was higher among children <5 years old (19.0), blacks (7.2), and Hispanics (5.6) and was associated with Census tract poverty (incidence rate ratio [IRR], 3.6; 95% confidence interval [CI], 3.5–3.8) and household crowding (IRR, 1.8; 95% CI, 1.7–1.9). The association with poverty was strongest among children and persisted regardless of sex, race/ethnicity, or geographic location. After controlling for demographic variables, the association between shigellosis and poverty remained significant (IRR, 2.3; 95% CI, 2.0–2.6).

Conclusions

In the United States, Shigella infections are epidemiologically associated with poverty, and increased incidence rates are observed among young children, blacks, and Hispanics.

Pathogen-Specific Impacts of the 2011-2012 La Niña-Associated Floods on Enteric Infections in the MAL-ED Peru Cohort: A Comparative Interrupted Time Series Analysis

Extreme floods pose multiple direct and indirect health risks. These risks include contamination of water, food, and the environment, often causing outbreaks of diarrheal disease. Evidence regarding the effects of flooding on individual diarrhea-causing pathogens is limited, but is urgently needed in order to plan and implement interventions and prioritize resources before climate-related disasters strike. This study applied a causal inference approach to data from a multisite study that deployed broadly inclusive diagnostics for numerous high-burden common enteropathogens. Relative risks (RRs) of infection with each pathogen during a flooding disaster that occurred at one of the sites-Loreto, Peru-were calculated from generalized linear models using a comparative interrupted time series framework with the other sites as a comparison group and adjusting for background seasonality. During the early period of the flood, increased risk of heat-stable enterotoxigenic E. coli (ST-ETEC) was identified (RR = 1.73 [1.10, 2.71]) along with a decreased risk of enteric adenovirus (RR = 0.36 [0.23, 0.58]). During the later period of the flood, sharp increases in the risk of rotavirus (RR = 5.30 [2.70, 10.40]) and sapovirus (RR = 2.47 [1.79, 3.41]) were observed, in addition to increases in transmission of Shigella spp. (RR = 2.86 [1.81, 4.52]) and Campylobacter spp. (RR = 1.41 (1.01, 1.07). Genotype-specific exploratory analysis reveals that the rise in rotavirus transmission during the flood was likely due to the introduction of a locally atypical, non-vaccine (G2P[4]) strain of the virus. Policy-makers should target interventions towards these pathogens-including vaccines as they become available-in settings where vulnerability to flooding is high as part of disaster preparedness strategies, while investments in radical, transformative, community-wide, and locally-tailored water and sanitation interventions are also needed.

Mothers' Handwashing Knowledge as a Predictor of Diarrheal Disease Among Under-Five Children Visiting Pediatric Ward in University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2019

Background

Diarrheal disease is one of the leading causes of mortality and morbidity among under-five children in the world and often results from contaminated food and water. The aim of this study was to assess the prevalence of diarrheal disease among under-five children visiting the pediatric ward in University of Gondar Comprehensive Specialized Hospital and its association with their mothers’ handwashing knowledge.

Methods

An institutional-based cross-sectional study was conducted from May to July 2019 among under-five children visiting the pediatric ward in University of Gondar Comprehensive Specialized Hospital. An interviewer-administered questionnaire was used to collect the data. Chart review was undertaken using a data abstraction form. A simple random sampling technique was used to select the study participants. Data were entered using Epi Info version 7 and analyzed using STATA version 14.0. A binary logistic regression analysis was employed between dependent and independent variables to determine association. The statistical significance was declared at P<0.05.

Results

In this study, the prevalence of diarrheal disease among under-five children visiting the pediatric ward in University of Gondar Comprehensive Specialized Hospital was 30.09% (95% CI: (26%, 35%)). Age of mothers (AOR=3.72, 95% CI: (1.67, 8.28)), mothers’ educational status (AOR=0.44, 95% CI: (0.23, 0.80)), malnutrition (AOR=6.72, 95% CI: (3.44, 13.11)), and maternal knowledge of handwashing (AOR=0.49, 95% CI: (0.27, 0.90)) were factors associated with diarrheal disease among under-five children.

Conclusion

The prevalence of diarrheal disease was higher in the current study, which is a major public health concern. Age of mothers, malnutrition, and mothers’ handwashing knowledge and educational status were significantly associated with diarrheal disease of under-five children. In order to reduce diarrheal disease and improve child health, attention should be given to improving mothers’ educational status and knowledge regarding handwashing.

Multistate Outbreaks of Foodborne Illness in the United States Associated With Fresh Produce From 2010 to 2017

In the United States, the consumption of fresh fruits and vegetables has increased during recent years as consumers seek to make healthier lifestyle choices. However, the number of outbreaks associated with fresh produce that involve cases in more than one state (multistate) has increased concomitantly. As the distance along the farm-to-fork continuum has lengthened over time, there are also more opportunities for fresh produce contamination with bacterial pathogens before it reaches the consumer. This review provides an overview of the three bacterial pathogens (i.e., pathogenic Escherichia coli, Listeria monocytogenes, and Salmonella enterica) associated with multistate fresh produce outbreaks that occurred between 2010 and 2017 in the U.S. Possible routes of fresh produce contamination, including pre- and post-harvest, are summarized and outcomes of selected outbreaks within this timeframe are highlighted. Eighty-five multistate outbreaks linked to fresh produce with a confirmed etiology occurred from 2010 to 2017. Cross-contamination within the distribution chain and poor agricultural practices, along with the production of sprouts and importation of fresh produce were frequently implicated contributors to these events. The evolution of the food supply chain in the U.S. necessitates an examination of multistate outbreaks to shed light on factors that increase the scale of these events.

Antibiotic therapy in acute gastroenteritis: a single-center retrospective cohort study

Background:

Acute gastroenteritis (AGE) is a common reason for emergency department visits and hospitalizations. The role of antibiotics in AGE is unclear, as the current literature shows only a minor impact on the duration of symptoms and the overall clinical course. Our goal was to assess whether antibiotic therapy in patients with AGE affects the length of hospital stay (LOS).

Methods:

In a retrospective study, we evaluated 479 patients admitted to the hospital with a diagnosis of AGE. The study compared the 219 patients (46%) treated with antibiotics to the remainder treated with supportive therapy. The diagnosis of AGE was made either clinically or based on imaging findings. The primary outcome of this study was to compare the LOS in days between both groups.

Results:

Patients treated with antibiotics had a similar LOS to those treated with supportive therapy (2.62 vs. 2.66 days, P=0.77). Patients with presumed sepsis had a higher likelihood of receiving antibiotics compared to those without presumed sepsis (risk ratio 1.49, 62.5% vs. 41.95%; P<0.001). In this subgroup, patients who received antibiotics had a slightly shorter LOS than those who received only supportive therapy, but the difference was not statistically significant (2.09 vs. 2.54 days, P=0.69).

Conclusion:

We found no difference in the LOS for hospitalized patients with AGE treated with antibiotics when compared to supportive therapy. This calls into question the role of antibiotics in the management of AGE.

Effects of Claudin-1 on the Action of Clostridium perfringens Enterotoxin in Caco-2 Cells

Clostridium perfringens enterotoxin (CPE) contributes to diarrhea and an often-lethal enterotoxemia. CPE action starts when it binds to claudin receptors, forming a small complex (90 kDa). Six small complexes then oligomerize to create prepores, followed by insertion of beta-hairpins from CPE to form beta-barrel pores named CH-1 or CH-2. Of the ~27 members of the human claudin protein family, only some bind CPE. However, both receptor claudins and the nonreceptor claudin-1 (CLDN-1) are associated with the small and CH-1/CH-2 CPE complexes. Therefore, this study evaluated whether claudin-1 affects CPE action by generating a CLDN-1 null mutant in Caco-2 cells using CRISPR-Cas9. Compared to wild-type Caco-2 cells, paracellular permeability of the CLDN-1 mutant was significantly enhanced, suggesting that claudin-1 may reduce CPE absorption during enterotoxemia. The CLDN-1 mutant was also markedly more sensitive than wild-type Caco-2 cells to apically-applied CPE. The mechanism behind this increased sensitivity involved higher CPE binding by the CLDN-1 mutant vs. wild-type Caco-2 cells, which led to more CH-1/CH-2 complex formation. However, the CH-1/CH-2 complexes formed by the CLDN-1 mutant were less stable or trypsin resistant than those of wild-type cells. These results indicate that, although a nonreceptor, CLDN-1 positively and negatively influences CPE action.

Mass Gatherings and Diarrheal Disease Transmission Among Rural Communities in Coastal Ecuador

Mass gatherings exacerbate infectious disease risks by creating crowded, high-contact conditions and straining the capacity of local infrastructure. While mass gatherings have been extensively studied in the context of epidemic disease transmission, the role of gatherings in incidence of high-burden, endemic infections has not been previously studied. Here, we examine diarrheal incidence among 17 communities in Esmeraldas, Ecuador, in relation to recurrent gatherings characterized using ethnographic data collected during and after the epidemiologic surveillance period (2004-2007). Using distributed-lag generalized estimating equations, adjusted for seasonality, trend, and heavy rainfall events, we found significant increases in diarrhea risk in host villages, peaking 2 weeks after an event's conclusion (incidence rate ratio, 1.21; confidence interval, adjusted for false coverage rate of ≤0.05: 1.02, 1.43). Stratified analysis revealed heightened risks associated with events where crowding and travel were most likely (2-week-lag incidence rate ratio, 1.51; confidence interval, adjusted for false coverage rate of ≤0.05: 1.09, 2.10). Our findings suggest that community-scale mass gatherings might play an important role in endemic diarrheal disease transmission and could be an important focus for interventions to improve community health in low-resource settings.

Correlation of sonographic inferior vena cava and aorta diameter ratio with dehydration in Nigerian children

Background

Accurate assessment of the degree of dehydration is essential in the management and fluid therapy of dehydrated children. The invasiveness of central venous pressure limits its routine clinical use. Fortunately, some studies have suggested that ultrasonographic measurement of inferior vena cava (IVC) diameter: aorta diameter ratio (IADR) is an objective method of assessing intravascular volume.

Objectives

To determine the clinical usefulness of ultrasound measurement of IADR in assessment of children with dehydration.

Methodology

This was a cross-sectional study which compared dehydrated children to age- and sex-matched euvolemic healthy children as controls. The maximum anteroposterior diameter of the abdominal aorta (at peak systole) and maximum IVC diameter (in expiration) were measured.

Results

A total of 120 subjects and 120 controls were evaluated. The mean age was 21.73 ± 20.89 months for subjects and 21.19 ± 22.13 months for control. The mean IADR for children with mild, moderate, and severe dehydration was 0.75 ± 0.07, 0.55 ± 0.07, and 0.33 ± 0.05, respectively. The mean IADR for controls was 0.99 ± 0.06. IADR had an inverse relationship with the degree of dehydration in the subjects. A cut-off point of 0.86, with a sensitivity and specificity of 96.7% in predicting dehydration, was derived, with the sensitivity and specificity increasing with increasing level of dehydration.

Conclusion

IADR is sensitive and specific for assessing moderate and severe dehydration in Nigerian children.

Cost of Caregivers for Treating Hospitalized Diarrheal Patients in Bangladesh

INTRODUCTION

Diarrheal diseases are a global public health problem and one of the leading causes of mortality, morbidity and economic loss. The objective of the study is to estimate the economic cost of caregivers and cost distribution per diarrheal episodes in Bangladesh.

METHODS

This was a cross-sectional hospital-based study conducted in public hospitals in Bangladesh. A total of 801 diarrheal patients were randomly selected and interviewed during January to December 2015. Simple descriptive statistics including frequencies, percentage, mean with 95% CI and median are presented.

RESULTS

The overall average cost of caregivers was BDT 2243 (US$ 28.58) while only BDT 259 (US$ 3.29) was spent as out of pocket payments. Caregivers mostly spent money (US$ 1.63) for food, lodging, utility bills, and other lump sum costs followed by the transportation costs (US$ 1.57). The caregivers spent more (US$ 44.45) when they accompanied the patients who were admitted in inpatients care and almost 3.6 times higher than for out-patients care (US$ 12.42).

CONCLUSIONS

The study delivers an empirical evidence to the health-care programmers and policy makers about the economic cost of caregivers during diarrheal treatment care, which should be accounted for in designing future diarrheal prevention programme.

Experience and Future Perceived Risk of Floods and Diarrheal Disease in Urban Poor Communities in Accra, Ghana

Diarrheal disease is a critical health condition in urban areas of developing countries due to increasing urbanization and its associated problems of sanitation and poor access to good drinking water. Increasing floods in cities have been linked to the risk of diarrheal disease. There are few studies that specifically link flooding with diarrhea diseases. This may be due to the fact that secondary data mainly hospital recorded cases, and not individual cases at the household level are used. Furthermore, of the few papers that consider the flood-diarrheal diseases nexus, none have considered risk perceptions in general, and more specifically, whether households that have experienced floods which resulted in a reported case of diarrhea, have higher perceived risks of future occurrences of the two phenomena compared to households that had different experiences. Yet, this is critical for the development of interventions that seek to increase protective behaviors and reduce the risk of contracting diarrhea. We surveyed 401 households in some selected urban poor communities in Accra, the capital of Ghana. Results show that households that experienced floods which resulted in a reported case of diarrhea, have higher perceived risk of future occurrence of the two phenomena compared to other households. We recommend public education that reduces the risk of exposure to flood and diarrhea through flood mitigation measures, including the construction of drains in communities and educating communities on good sanitation.

Diffusion of Handwashing Knowledge and Water Treatment Practices From Mothers in an Antenatal Hygiene Promotion Program to Nonpregnant Friends and Relatives, Machinga District, Malawi

Access to safe drinking water and improved hygiene are essential for preventing diarrheal diseases in low- and middle-income countries. Integrating water treatment and hygiene products into antenatal clinic care can motivate water treatment and handwashing among pregnant women. Free water hygiene kits (water storage containers, sodium hypochlorite water treatment solution, and soap) and refills of water treatment solution and soap were integrated into antenatal care and delivery services in Machinga District, Malawi, resulting in improved water treatment and hygiene practices in the home and increased maternal health service use. To determine whether water treatment and hygiene practices diffused from maternal health program participants to friends and relatives households in the same communities, we assessed the practices of 106 nonpregnant friends and relatives of these new mothers at baseline and 1-year follow-up. At follow-up, friends and relatives were more likely than at baseline to have water treatment products observable in the home (33.3% vs. 1.2%, p < 0.00001) and detectable free chlorine residual in their water, confirming water treatment (35.7% vs. 1.4%; p < 0.00001). Qualitative data from in-depth interviews also suggested that program participants helped motivate adoption of water treatment and hygiene behaviors among their friends and relatives.

Where Children Play: Young Child Exposure to Environmental Hazards during Play in Public Areas in a Transitioning Internally Displaced Persons Community in Haiti

Globally, gastrointestinal (GI) infections by enteric pathogens are the second-leading cause of morbidity and mortality in children under five years of age (≤5 years). While GI pathogen exposure in households has been rigorously examined, there is little data about young children's exposure in public domains. Moreover, public areas in low-income settings are often used for other waste disposal practices in addition to human feces, such as trash dumping in areas near households. If young children play in public domains, they might be exposed to interrelated and highly concentrated microbial, chemical, and physical hazards. This study performed structured observations at 36 public areas in an internally displaced persons community that has transitioned into a formal settlement in Haiti. We documented how often young children played in public areas and quantified behaviors that might lead to illness and injury. Children ≤5 years played at all public sites, which included infants who played at 47% of sites. Children touched and mouthed plastic, metal and glass trash, food and other objects from the ground, ate soil (geophagia) and drank surface water. They also touched latrines, animals, animal feces and open drainage canals. Hand-to-mouth contact was one of the most common behaviors observed and the rate of contact significantly differed among developmental stages (infants: 18/h, toddlers: 11/h and young children: 9/h), providing evidence that children could ingest trace amounts of animal/human feces on hands that may contain GI pathogens. These findings demonstrate that water, sanitation and hygiene interventions could be more effective if they consider exposure risks to feces in public domains. Furthermore, this research highlights the need for waste-related interventions to address the broader set of civil conditions that create unsafe, toxic and contaminated public environments where young children play.

Risk factors for sporadic Giardia infection in the USA: a case-control study in Colorado and Minnesota

Giardia duodenalis is the most common intestinal parasite of humans in the USA, but the risk factors for sporadic (non-outbreak) giardiasis are not well described. The Centers for Disease Control and Prevention and the Colorado and Minnesota public health departments conducted a case-control study to assess risk factors for sporadic giardiasis in the USA. Cases (N = 199) were patients with non-outbreak-associated laboratory-confirmed Giardia infection in Colorado and Minnesota, and controls (N = 381) were matched by age and site. Identified risk factors included international travel (aOR = 13.9; 95% CI 4.9-39.8), drinking water from a river, lake, stream, or spring (aOR = 6.5; 95% CI 2.0-20.6), swimming in a natural body of water (aOR = 3.3; 95% CI 1.5-7.0), male-male sexual behaviour (aOR = 45.7; 95% CI 5.8-362.0), having contact with children in diapers (aOR = 1.6; 95% CI 1.01-2.6), taking antibiotics (aOR = 2.5; 95% CI 1.2-5.0) and having a chronic gastrointestinal condition (aOR = 1.8; 95% CI 1.1-3.0). Eating raw produce was inversely associated with infection (aOR = 0.2; 95% CI 0.1-0.7). Our results highlight the diversity of risk factors for sporadic giardiasis and the importance of non-international-travel-associated risk factors, particularly those involving person-to-person transmission. Prevention measures should focus on reducing risks associated with diaper handling, sexual contact, swimming in untreated water, and drinking untreated water.

Association between Precipitation and Diarrheal Disease in Mozambique

Diarrheal diseases are a leading cause of morbidity and mortality in Africa. Although research documents the magnitude and pattern of diarrheal diseases are associated with weather in particular locations, there is limited quantification of this association in sub-Saharan Africa and no studies conducted in Mozambique. Our study aimed to determine whether variation in diarrheal disease was associated with precipitation in Mozambique. In secondary analyses we investigated the associations between temperature and diarrheal disease. We obtained weekly time series data for weather and diarrheal disease aggregated at the administrative district level for 1997–2014. Weather data include modeled estimates of precipitation and temperature. Diarrheal disease counts are confirmed clinical episodes reported to the Mozambique Ministry of Health (n = 7,315,738). We estimated the association between disease counts and precipitation, defined as the number of wet days (precipitation > 1 mm) per week, for the entire country and for Mozambique’s four regions. We conducted time series regression analyses using an unconstrained distributed lag Poisson model adjusted for time, maximum temperature, and district. Temperature was similarly estimated with adjusted covariates. Using a four-week lag, chosen a priori, precipitation was associated with diarrheal disease. One additional wet day per week was associated with a 1.86% (95% CI: 1.05–2.67%), 1.37% (95% CI: 0.70–2.04%), 2.09% (95% CI: 1.01–3.18%), and 0.63% (95% CI: 0.11–1.14%) increase in diarrheal disease in Mozambique’s northern, central, southern, and coastal regions, respectively. Our study indicates a strong association between diarrheal disease and precipitation. Diarrheal disease prevention efforts should target areas forecast to experience increased rainfall. The burden of diarrheal disease may increase with increased precipitation associated with climate change, unless additional health system interventions are undertaken.

Comprehensive Analysis of Prevalence, Epidemiologic Characteristics, and Clinical Characteristics of Monoinfection and Coinfection in Diarrheal Diseases in Children in Tanzania

The role of interactions between intestinal pathogens in diarrheal disease is uncertain. From August 2010 to July 2011, we collected stool samples from 723 children admitted with diarrhea (cases) to 3 major hospitals in Dar es Salaam, Tanzania, and from 564 nondiarrheic children (controls). We analyzed the samples for 17 pathogens and assessed interactions between coinfections in additive and multiplicative models. At least one pathogen was detected in 86.9% of the cases and 62.8%, of the controls. Prevalence of coinfections was 58.1% in cases and 40.4% in controls. Rotavirus, norovirus genogroup II, Cryptosporidium, and Shigella species/enteroinvasive Escherichia coli were significantly associated with diarrhea both as monoinfections and as coinfections. In the multiplicative interaction model, we found 2 significant positive interactions: rotavirus + Giardia (odds ratio (OR) = 23.91, 95% confidence interval (CI): 1.21, 470.14) and norovirus GII + enteroaggregative E. coli (OR = 3.06, 95% CI: 1.17, 7.98). One significant negative interaction was found between norovirus GII + typical enteropathogenic E. coli (OR = 0.09, 95% CI: 0.01, 0.95). In multivariate analysis, risk factors for death were presence of blood in stool and severe dehydration. In conclusion, coinfections are frequent, and the pathogenicity of each organism appears to be enhanced by some coinfections and weakened by others. Severity of diarrhea was not affected by coinfections.

Presentation matters: Buffers, packaging, and delivery devices for new, oral enteric vaccines for infants

Oral administration of vaccines is simpler and more acceptable than injection via needle and syringe, particularly for infants (Fig. 1) This route is promising for new vaccines in development against enterotoxigenic Escherichia coli (ETEC) and Shigella that cause childhood diarrhea with devastating consequences in low-resource countries. However, vaccine antigens and adjuvants given orally need buffering against the degradative effects of low stomach pH, and the type and volume of antacid buffer require special attention for infants. In addition, container/closure systems must be compatible with vaccine formulations, protect against water and gas transfer, and have minimal impact on the cold chain. Health care workers in demanding low-resource settings need an administration device that is easy to use, yet will accurately measure and safely deliver the correct vaccine dose. Developers must consider manufacturing capabilities, and immunization program managers want affordable vaccines. As new combination enteric vaccine candidates advance into clinical evaluation, features of the final vaccine presentation-liquid or dry format, diluent, buffer, primary and secondary packaging, and administration device-should be taken into account early in product development to achieve the greatest possible impact for the vaccine.

The economic impact of childhood acute gastroenteritis on Malawian families and the healthcare system

OBJECTIVES

This prospective cohort study sought to estimate health system and household costs for episodes of diarrhoeal illness in Malawi.

SETTING

Data were collected in two Malawian settings: a rural health centre in Chilumba and an urban tertiary care hospital in Blantyre.

PARTICIPANTS

Children under 5 years of age presenting with diarrhoeal disease between 1 January 2013 and 21 November 2014 were eligible for inclusion. Illnesses attributed to other underlying causes were excluded, as were illnesses commencing more than 2 weeks prior to presentation. Complete data were collected on 514 cases at both the time of the initial visit to the participating healthcare facility and 6 weeks after discharge.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the total cost of an episode of illness. Costs to the health system were gathered from chart review (drugs and diagnostics) and actual hospital expenditure (staff and facility costs). Household costs, including lost income, were obtained by interview with the parents/guardians of patients.

RESULTS

Total costs in 2014 US$ for rural inpatient, rural outpatient, urban inpatient and urban outpatient were $65.33, $8.89, $60.23 and $14.51, respectively (excluding lost income). Mean household contributions to these costs were 15.8%, 9.8%, 21.3% and 50.6%.

CONCLUSION

This study found significant financial burden from childhood diarrhoeal disease to the healthcare system and to households. The latter face the risk of consequent impoverishment, as the study demonstrates how the costs of seeking treatment bring the income of the majority of families in all income strata below the national poverty line in the month of illness.

Generating and Maintaining Transgenic Cryptosporidium parvum Parasites

The apicomplexan parasite Cryptosporidium is a leading cause of diarrheal disease and an important contributor to overall global child mortality. We currently lack effective treatment and immune prophylaxis. Recent advances now permit genetic modification of this important pathogen. We expect this to produce rapid advances in fundamental as well as translational research on cryptosporidiosis. Here we outline genetic engineering for Cryptosporidium in sufficient detail to establish transfection in any laboratory that requires access to this key technology. This chapter details the conceptual design consideration, as well as the experimental steps required to transfect, select, and isolate transgenic parasites. We also provide detail on key in vitro and in vivo assays to detect, validate, and quantify genetically modified Cryptosporidium parasites. © 2017 by John Wiley & Sons, Inc.

Socioeconomic Determinants of Cipro-floxacin-Resistant Shigella Infections in Bangladeshi Children

Background:

Shigella species (spp.) are a leading cause of moderate to severe diarrhea in children worldwide. The recent emergence of quinolone-resistant Shigella spp. gives cause for concern, and South Asia has been identified as a reservoir for global spread. The influence of socioeconomic status on antimicrobial resistance in developing countries, such as those in South Asia, remains unknown.

Methods:

We used data collected from 2009 to 2014 from a hospital specializing in the treatment of diarrhea in Dhaka, Bangladesh, to determine the relationship between ciprofloxacin-resistant Shigella spp. isolates and measures of socioeconomic status in Bangladeshi children less than 5 years of age.

Results:

We found 2.7% (230/8,672) of children who presented with diarrhea had Shigella spp. isolated from their stool, and 50% (115/230) had resistance to ciprofloxacin. Using multivariable logistic regression analysis, we found that children from families where the father's income was in the highest quintile had significantly higher odds of having ciprofloxacin-resistant Shigella spp. compared to children in the lowest quintile (OR = 6.1, CI 1.9-19). Factors protective against the development of resistance included access to improved sanitation (OR = 0.27, CI 0.11-0.7), and improved water sources (OR = 0.48, CI 0.25-0.92). We did not find a relationship between ciprofloxacin resistance and other proxies for socioeconomic status, including the presence of animals in the home, nutritional status, paternal education level, and the number of family members in the home.

Conclusions:

Although the associations between wealth and antimicrobial resistance are not fully understood, possible explanations include increased access and use of antibiotics, greater access to healthcare facilities and thus resistant pathogens, or greater consumption of commercially produced foods prepared with antibiotics.

Norovirus in Latin America: Systematic Review and Meta-analysis

BACKGROUND

Noroviruses are increasingly recognized as a major cause of sporadic and epidemic acute gastroenteritis (AGE). Although there have been multiple studies published on norovirus epidemiology in Latin America, no comprehensive assessment of the role of norovirus has been conducted in the region. We aim to estimate the role of norovirus in the Latin American region through a systematic review and meta-analysis of the existing literature.

METHODS

We carried out a literature search in MEDLINE, SciELO and LILACS. We included papers that provided information on the prevalence or incidence of norovirus (including seroprevalence studies and outbreaks), with a recruitment and/or follow-up period of at least 12 months and where the diagnosis of norovirus was confirmed by reverse transcription polymerase chain reaction. The data were pooled for meta-analysis to estimate the prevalence of norovirus AGE and norovirus asymptomatic infection with 95% confidence intervals (CIs).

RESULTS

Thirty-eight studies were included in the review. Overall, the prevalence of norovirus among AGE cases was 15% (95% CI: 13-18). By location, it was 15% in the community (95% CI: 11%-21%), 14% in outpatient settings (95% CI: 10%-19%) and 16% in hospital locations (95% CI: 12%-21%). The prevalence of norovirus among asymptomatic subjects was 8% (95% CI: 4-13). Norovirus GII.4 strains were associated with 37%-100% of norovirus AGE cases, but only 7% of norovirus asymptomatic detections.

CONCLUSIONS

Noroviruses are associated with almost 1 out of every 6 hospitalizations because of acute diarrhea in children younger than 5 years of age in Latin America.

Diarrheal Diseases and Climate Change in Cambodia

The DRIP-SWICCH (Developing Research and Innovative Policies Specific to the Water-related Impacts of Climate Change on Health) project aimed to increase the resilience of Cambodian communities to the health risks posed by climate change-related impacts on water. This article follows a review of climate change and water-related diseases in Cambodia and presents the results of a time series analysis of monthly weather and diarrheal disease data for 11 provinces. In addition, correlations of diarrheal disease incidence with selected demographic, socioeconomic, and water and sanitation indicators are described, with results suggesting education and literacy may be most protective against disease. The potential impact of climate change on the burden of diarrheal disease in Cambodia is considered, along with the implications of these findings for health systems adaptation.

Risk Factors for Sustained Cholera Transmission, Juba County, South Sudan, 2014

We conducted a case–control study to identify risk factors for the 2014 cholera outbreak in Juba County, South Sudan. Illness was associated with traveling or eating away from home; treating drinking water and receiving oral cholera vaccination were protective. Oral cholera vaccination should be used to complement cholera prevention efforts.

Characterization of a multicomponent live, attenuated Shigella flexneri vaccine

Shigella flexneri is a leading cause of diarrheal disease in children under five in developing countries. There is currently no licensed vaccine and broad spectrum protection requires coverage of multiple serotypes. The live attenuated vaccines CVD 1213 and CVD 1215 were derived from two prominent S. flexneri serotypes: S. flexneri 3a and S. flexneri 6. To provide broad-spectrum immunity, they could be combined with CVD 1208S, a S. flexneri 2a strain that demonstrated promising results in phase I and II clinical trials. Each strain contains a mutation in the guaBA operon. These vaccine candidates were tested in vitro and in vivo and were found to be auxotrophic for guanine and defective in intracellular replication, but capable of inducing cytokine production from both epithelial cells and macrophages. Both strains were attenuated for virulence in the guinea pig Serény test and induced robust serotype-specific antibody responses following immunization. Each strain induced homologous serotype protection against challenge and a mixed inoculum of the three S. flexneri vaccines conferred protection against all three virulent wild-type strains. These data support the use of CVD 1213, CVD 1215 and CVD 1208S in a multivalent vaccine to confer broad protection against disease caused by Shigella flexneri.