Breastfeeding and the risk of life-threatening enterotoxigenic Escherichia coli diarrhea in Bangladeshi infants and children

OBJECTIVE

To assess the relationship between breastfeeding and the risk of life-threatening enterotoxigenic Escherichia coli (ETEC) diarrhea among Bangladeshi infants and young children <36 months of age.

DESIGN

Case-control study.

SETTING

A rural Bangladesh community.

PARTICIPANTS

A total of 168 cases with clinically severe ETEC diarrhea detected in a treatment center-based surveillance system during 1985 to 1986 and 3679 controls selected in three surveys of the same community during the same calendar interval.

OUTCOMES

Cases and controls were compared for the frequency of antecedent breastfeeding patterns.

RESULTS

Compared with other feeding modes, exclusive breastfeeding of infants was associated with significant protection against severe ETEC diarrhea (relative risk [RR] = 0.51; 95% confidence interval [CI]: 0.28,0.96). However, during the second and third years of life, the risk of this outcome was similar in both breastfed and nonbreastfed children (RR = 0.98; 95% CI: 0.45,2.12), and no significant overall protective association between breastfeeding and severe ETEC diarrhea was evident during the first 3 years of life (RR = 0.86; 95% CI: 0.43,1. 74).

CONCLUSIONS

Exclusive breastfeeding appeared to protect infants against severe ETEC diarrhea, but breastfeeding was not associated with protection after infancy, nor was it associated with a major overall reduction of severe ETEC disease during the first 3 years of life. Although not diminishing the importance of breastfeeding, our findings suggest that other interventions, such as immunization and education about proper food hygiene, may also be required in efforts to prevent this major pediatric disease.

Waterborne diseases of bacterial origin in relation to quality of water in a suburb of Uttar Pradesh

Waterborne disorders of bacterial origin, e.g. typhoid, bacillary dysentery and diarrhea are one of the major global health problems, especially in developing countries like India. The prevalence of these diseases is largely dependent on the quality of water consumed by people. The quality of water in India is still below the WHO recommendation of zero fecal coliform/100 ml of water. The present study was conducted in a suburb of Aligarh District of U.P. (India). A total of 1270 persons were selected by paying home visits and followed up for a period of one year. The study revealed that morbidity was higher in standpost group, i.e., 88.3% while in piped water group it was 51.8%. The average episode of typhoid for both source of water was one while dysentery had 3 average episodes. The average episodes of diarrhea was 4 in stand post and 3 in piped water group. In standpost group the majority of people, (87.6%) were using unsatisfactory water as compared to 74.4% for piped water supply. The frequency of typhoid was 1.4% bacillary dysentery 3.4% and diarrhea 7.7%. The occurrence of waterborne disorders of bacterial origin was common for typhoid in the 5-12 years age group bacillary dysentery for the 1-5 years, and diarrhea for the 0-5 years age group. The morbidity rate in standpost group was comparatively higher, i.e., 79.6%. The frequency for the standpost group and piped water group for different diseases were, typhoid 1.1% and 0.7%, bacillary dysentery 2.7% and 2.2%, and diarrhea 6.1% and 5.1%, respectively.

Malnutrition, cell-mediated immune deficiency and acute upper respiratory infections in rural Bangladeshi children

A community-based longitudinal study conducted in rural Bangladesh investigated the association between nutritional status, cell-mediated immune status and acute upper respiratory infections (URI). A total of 696 children aged 0-59 months was followed prospectively for 1 y yielding 183,865 child-days' observation. Trained field workers visited each child every 4th d and collected morbidity data on symptoms suggesting URI (cough, fever, nasal discharge) for the preceding 3 d by recall. On the day of visit they examined each child reporting cough and/or fever to record the temperature, presence of nasal discharge, rate of respiration and presence of chest indrawing. Anthropometry for all children was conducted monthly. Cell-mediated immune competence was assessed by a multiple antigen skin test at baseline and thereafter every 3 months. The incidence of URI was 5.3 episodes per child-year observed. Approximately three-quarters of the study children were below -2 Z-score weight for age and height for age, and a quarter below -2 Z-score weight for height. During different test periods 9-21% of the study children did not respond to any of the test antigens. In a regression model children < -2 Z-score for weight for height had 16% [odds ratio (OR) 1.16, 95% confidence interval (CI) 1.03-1.31, p = 0.01] higher risk of developing URI. Anergic children had 20% higher risk (OR 1.20, CI 1.05-1.38, p = 0.009) of URI than immunocompetent children. The study demonstrated that wasting and depressed cell-mediated immunity (CMI), but not stunting, were associated with the incidence of URI among rural Bangladeshi children.

Acute respiratory infections in children: a community-based longitudinal study in rural Bangladesh

A community-based logitudinal study conducted in Matlab, a rural area in Bangladesh, investigated acute respiratory infections (ARI) among children. A cohort of 696 children under 5 years of age was followed for 1 year yielding 183,865 child-days of observation. Trained field workers visited the study children every fourth day. Data on symptoms suggesting ARI, such as fever, cough, and nasal discharge, were collected for the preceding 3 days by recall. To determine the type and severity of ARI, the field workers conducted physical examinations (temperature, rate of respiration, and chest indrawing) of children reporting cough and/or fever. The overall incidence of ARI was 5.5 episodes per child-year observed; the prevalence was 35.4 per hundred days observed. Most of the episodes (96 per cent) were upper respiratory infections (URI). The incidence of acute lower respiratory infections (ALRI) was 0.23 per child per year. The incidence of URI was highest in 18-23-month-old children, followed by infants 6-11 months old. The highest incidence of ALRI was observed in 0-5-month-old infants followed by 12-17-month-old children. Among 559 children who were followed for 6 months or longer, about 9 per cent did not suffer any URI episode and about 16 per cent suffered one or more ALRI episodes. About 46 per cent of URI and 65 per cent of ALRI episodes lasted 15 days or more. The incidence rates of URI were higher during the monsoon and pre-winter periods, and that of ALRI at the end of the monsoon and during the pre-winter periods. Sociodemographic variables were not associated with the incidence of URI or ALRI. The study documents ARI to be a major cause of morbidity among rural Bangladeshi children.

Acute lower respiratory infections in rural Bangladeshi children: patterns of treatment and identification of barriers

A study conducted in rural Bangladesh examined the patterns of health seeking behavior, mothers' recognition of symptoms, the perceived causes and barriers to timely treatment of acute lower respiratory infections (ALRI). A total of 194 children under 5 years of age suffering from ALRI in an intensive maternal child health and family planning area was prospectively followed. About 62% of the mothers sought allopathic treatment for their children within 24 hours of case detection. No treatment of any kind was sought in 45 (23.2%) cases. Most of the mothers could recognize the different symptoms of ALRI. Cold was reported as the most common cause of ALRI. No significant difference was observed in the reported symptoms or perceived cause of the disease between those who sought no treatment and those who sought allopathic, homeopathic, spiritual or combined treatments. Failure to recognize severity followed by work loss were the most common reasons identified for not seeking any medical care. Whether or not a mother sought allopathic treatment was not associated with the child's age, sex, mother's age, mother's education, duration of illness, birth order, housing type or distance from the health center. The study indicates the potential value of giving parents clear guidelines on recognition of severity of symptoms of ALRI and motivating them to seek treatment quickly when these symptoms present. Health service providers should be aware of the heavy work loads which rural women have and the severe time constraints which deter them from seeking timely treatment from the appropriate sources.

Antimicrobial resistance in organisms causing diarrheal disease

Antimicrobial resistance is becoming increasingly important in the treatment of enteric infections, particularly those due to Shigella, Vibrio cholerae, enterotoxigenic Escherichia coli (associated with traveler's diarrhea), and Salmonella typhi. The rate of antimicrobial resistance is highest in the developing world, where the use of antimicrobial drugs is relatively unrestricted. Of greatest immediate concern is the need for an effective, inexpensive antimicrobial that can be used safely as treatment for small children with dysentery due to Shigella, primarily Shigella dysenteriae type 1.

Association between nutritional status, cell-mediated immune status and acute lower respiratory infections in Bangladeshi children

OBJECTIVE

To investigate the association between nutritional status, cell-mediated immune status and the incidence of acute lower respiratory infections (ALRI).

DESIGN

Community-based longitudinal study.

SETTING

Three villages in rural Bangladesh at Matlab.

SUBJECT

696 children aged 0-59 months were followed up for a year.

METHODS

Trained field workers visited all children every fourth day and collected morbidity data for the preceding three days by recall. To determine the type and severity of respiratory infections, the field workers physically examined each child reporting a cough. Anthropometric status was determined monthly and cell-mediated immune status by skin tests was assessed at the beginning of the study and thereafter every 3 months.

RESULTS

The incidence of ALRI was 23 episodes per 100 child-years. A total of 73-78% of the children were below -2 z score weight for age, 15-30% were below - 2 z score weight for height, and 68-76% were below -2 z score height for age. In logistic regression models, malnutrition as assessed by weight-for-height status [odds ratio (OR) 0.66, 95% confidence interval (CI) 0.45-0.96, P = 0.03] or weight-for-age status (OR 0.64, 95% CI 0.45-0.92, P = 0.02) was significant predictor of ALRI. Anergic children had a higher risk of ALRI which approached to be statistically significant (OR 1.81, 95% CI 0.92-3.55, P = 0.08).

CONCLUSIONS

Improvement of nutritional and cell-mediated immune status in rural Bangladeshi children should reduce the incidence of ALRI.

The effects of health services utilization on the recovery from dysentery

A community-based programme for the treatment of dysentery in children under five years of age was implemented in Matlab, Bangladesh. Dysentery cases, identified at home, were referred to a sub-center for standard treatment with nalidixic acid. To assess the response to this intervention, a one year survey was carried out in 1990. The incidence of dysentery in this age group was 7 per cent. Isolation of Shigella species was 27 per cent (47/177) and was strongly associated with the frequency of stools (chi2 for trend, P = 0.001). S. flexneri accounted for 81 per cent of the isolates. Only 45 per cent of the cases were actually taken to the sub-center, 27 per cent went to traditional healers and 23 per cent used private allopathic services. Less than 40 per cent of the shigellosis cases received the suggested standard treatment. The overall recovery rate at 7 days, based arbitrarily on the number and type of stools, was 62 per cent and quite homogeneous among the types of services used. Neither the presence of Shigella isolates nor the type of treatment were associated with a higher recovery rate. We concluded that a systematic treatment of dysentery patients should be more selective on shigellosis.

Field trial of inactivated oral cholera vaccines in Bangladesh: results from 5 years of follow-up

To determine the protective efficacy (PE) of three doses of oral B subunit-killed whole cell (BS-WC) or killed whole cell-only (WC) vaccines against cholera, a clinical trial was conducted among 62285 children over 2 years and adult women in rural Bangladesh. During 5 years of follow-up, there were 144 cases of cholera in the BS-WC group (PE = 49%; P < 0.001), 150 in the WC group (PE = 47%; P < 0.001), and 283 in the K12 group. Protection by each vaccine was evident only during the first three years of follow-up; long-term protection of young children was observed only against classical but not El Tor cholera; 3-year protection against both cholera biotypes occurred among older persons, but at a higher level against classical cholera.

Rheumatic heart disease in India

A cross-sectional study was carried out in rural areas of Jawan Block, District Aligarh, Uttar Pradesh, India, covering a total population of 3760 drawn from 11 villages. The total number of confirmed cases of rheumatic heart disease was 24 with a prevalence rate of 6.4 per 1000 of the general rural population. The prevalence of rheumatic heart disease increased with age until the age of 25 years. Females were more prone to rheumatic heart disease compared to males. Socio-economic class had a direct impact on the occurrence of rheumatic heart disease.

Impaired immune response to natural infection as a correlate of vaccine failure in a field trial of killed oral cholera vaccines

In a field trial carried out in 1985 in Matlab, Bangladesh, the authors evaluated whether subjects who developed Vibrio cholerae 01 infections during the first year after earlier receipt of B subunit-killed whole cell (BS-WC) or killed whole cell-only (WC) oral cholera vaccines exhibited deficient serum vibriocidal immune responses to these infections. After severe V. cholerae 01 infections (n = 70) in subjects > 5 years of age, the age group in which both vaccines were efficacious, a 6.5 geometric mean-fold rise of serum vibriocidal antibodies was observed among vaccinees, compared with an 18.6 geometric mean-fold rise in placebo-recipients (p < 0.01). Depressions of serum vibriocidal responses among vaccinees were even more marked after asymptomatic infections (n = 30): a 1.1 geometric mean-fold rise in vaccinees versus a 5.9 geometric mean-fold rise in placebo-recipients (p < 0.01). The authors conclude that subjects who failed to be protected by BS-WC and WC, despite being in the age group for which these vaccines were protective, exhibited poor immune responses even to the vigorous stimulus of natural infection. These findings raise the possibility that immune hyporesponsiveness may limit the potential efficacy attainable by cholera vaccines in populations with endemic cholera.

A study of nosocomial infection in relation to different host factors in an Indian teaching hospital

Out of a total of 422 patients studied, 164 (38.8%) developed nosocomial infection. The rate was higher (41.6%) in males than in females (34.7%). A rising trend of infection was observed with age, maximum (69.6%) being in the above 60 age group. Nosocomial infection rate was inversely proportional to the socio-economic status of the patient. At the same time some underlying diseases in the patients influenced the rate of infection to a great extent, eg infection rates in patients with anaemia (53.7%), diabetes mellitus (85.2%), hypertension (82.0%) and obesity (51.5%) were much more than in patients with no such underlying disease (17.5%).

Monitoring of auto exhaust pollution by roadside plants

The changing levels of SO2 and Pb in the air and vegetation, along ten road transections of Lucknow city (having varying traffic densities) have been investigated, with a view to authenticate a possible correlation between SO2 and Pb concentration in air and sulphate and lead accumulation in the foliage of avenue trees. The study showed that the road transection at Alambagh (traffic density 4835 for 2 h) revealed the highest level of pollutants (SO2, 202 µg m(-3); SPM, 1080 µg m(-3); and lead, 2.96 µg m(-3), 2 h average) in air, as well as in the foliage of plants, whereas the road stretches with less traffic density correspondingly showed lower levels of pollutants. Pb and sulphate in leaves were found to be positively correlated with Pb and SO2 pollution in the air. Results suggest that Dalbergia sissoo and Calotropis procera are the ideal plant species to monitor as indications of Pb and SO2, respectively, in the air.

Growth response and element accumulation in Beta vulgaris L. raised in fly-ash-amended soils

: Fly-ash disposal is a major problem in and around coal-fired power plants. Although the fly-ash contains several essential minerals, its application in agricultural practices is uncommon in India as elsewhere. The present study was undertaken to elucidate the possibility of fly-ash application to agricultural soils to improve crop yields. Three different amounts of fly-ash (2, 4 and 8% w/w) were mixed with soil in 1 m(2) plots and seeds of Beta vulgaris were sown in these soil-amended plots. Plants and soils were sampled at 20, 40, 60 and finally at 80 days (each had five replicates) and analysed with respect to plant growth and yield and the concentration of the elements both in under- and above-ground parts. The data were subjected to two-way analysis of variance and Duncan's multiple range test.The results revealed that fly-ash application, particularly in higher amounts (4 and 8% w/w) increased the pH and conductivity of the soils to undesirable levels, however, the appliction of low amounts favoured plant growth and improved yields. Although the elements, viz. Cd, Cu, Fe, Mn, Ni and Pb accumulated in larger quantities in plants grown in fly-ash-amended soils than the control, their levels remained well below the threshold limit and, thus, are suitable for human consumption at the lowest fly-ash application rate. The increase in the sugar content at the low flyash application rate in beet root, the second most important crop for sugar extraction, enhances the possible use/application of fly-ash in tested amounts, in improving crop yields.

Isolation of Vibrio cholerae O139 synonym Bengal from the aquatic environment in Bangladesh: implications for disease transmission

Currently, Bangladesh is experiencing an epidemic of acute watery diarrhea caused by Vibrio cholerae O139. Surface waters were collected and cultured for vibrious following enrichment. Twelve percent (11 of 92) of samples yielded V. cholerae O139, and all of them were positive for cholera toxin. The data suggest that V. cholerae O139 is easily culturable from surface water samples.

A clinical-epidemiological study of hypertension in rural population of Jawan Block, Distt, Aligarh (UP) India

A cross-sectional study was carried out in rural areas of Jawan Block District Aligarh, Uttar Pradesh, India covering a total population of 3760 drawn from 11 villages. The total number of confirmed hypertensives was 59 with a prevalence rate of 15.7 per 1000 of the general rural population. The prevalence of hypertension gradually increased with increase in age. Males were more prone to develop hypertension as compared to females. Obesity, social class and occupation had a direct impact on hypertension.

Breast-feeding and the risk of life-threatening rotavirus diarrhea: prevention or postponement?

PURPOSE

To assess the relationship between breast-feeding and the risk of life-threatening rotavirus diarrhea among Bangladeshi infants and children younger than 24 months of age.

DESIGN

Case-control study.

SETTING

A rural Bangladesh community.

PARTICIPANTS

One hundred two cases with clinically severe rotavirus diarrhea detected in a treatment center-based surveillance system during 1985 and 1986, and 2587 controls selected in three surveys of the same community during the same calendar interval.

OUTCOMES

Cases and controls were compared for the frequency of antecedent breast-feeding patterns.

RESULTS

Compared with other feeding modes, exclusive breast-feeding of infants was associated with significant protection against severe rotavirus diarrhea (relative risk (RR) = 0.10; 95% confidence interval [CI] = 0.03, 0.34). However, during the second year of life, the risk of this outcome was higher in breast-fed than in non-breast-fed children (RR = 2.85; 95% CI = 0.37, 21.71), and no overall protection was associated with breast-feeding during the first 2 years of life (RR = 2.61; 95% CI = 0.62, 11.02).

CONCLUSIONS

Although exclusive breast-feeding appeared to protect infants against severe rotavirus diarrhea, breast-feeding per se conferred no overall protection during the first 2 years of life, suggesting that breast-feeding temporarily postponed rather than prevented this outcome. While not detracting from efforts to promote breast-feeding to alleviate the burden of diarrhea due to nonrotaviral enteropathogens, our findings cast doubt on whether such efforts will impact on the problem of severe rotavirus diarrhea.