Mutations in SPINT2 cause a syndromic form of congenital sodium diarrhea

Autosomal-recessive congenital sodium diarrhea (CSD) is characterized by perinatal onset of a persistent watery diarrhea with nonproportionally high fecal sodium excretion. Defective jejunal brush-border Na(+)/H(+) exchange has been reported in three sporadic patients, but the molecular basis of the disease has not been elucidated. We reviewed data from a large cohort of CSD patients (n = 24) and distinguished CSD associated with choanal or anal atresia, hypertelorism, and corneal erosions--i.e., a syndromic form of CSD--occurring in ten families from an isolated form--i.e., classic CSD--presenting in seven families. Patients from both groups have a high risk of mortality due to immediate electrolyte imbalances and complications from long-term parenteral nutrition in the first years of life, but survivors can eventually adapt to partial or complete enteral nutrition. A genome-wide SNP scan was applied and identified a homozygous c.593-1G-->A splicing mutation in SPINT2, encoding a Kunitz-type serine-protease inhibitor, in one extended kindred with syndromic CSD. The same mutation and four distinct, homozygous or compound heterozygous mutations (p.Y163C, c.1A-->T, c.337+2T-->C, c.553+2T-->A) were identified in all syndromic patients. No SPINT2 mutations were found in classic-CSD patients. SPINT2 mutations were associated with loss of protein synthesis or failure to inhibit the serine protease trypsin in vitro. We delineate syndromic CSD as a distinct disease entity caused by SPINT2 loss-of-function mutations. SPINT2 mutations might lead to an excess of yet unknown serine protease activity in affected tissues.

[Family practice in a rural environment in the west of France (1908-1920): chronicle of mortality]

This paper reports about a manuscript from Doctor Pelletier who accounted the causes of death rate in a village of the Vendée: pneumopathy, typhoid, diarrhoea linked to unhealthiness provoked by stagnant waters.

[Hospital-acquired clostridium difficile-associated diarrhea]

Clostridium difficile-associated diarrhea (CDAD) is common among hospital-acquired bacterial diarrhea, its mortality and morbidity show an increasing trend in recent years. Improper antimicrobial drug use is one of the key reasons. Adequate hand hygiene of healthcare workers, thorough disinfection of hospital environment, and appropriate isolation of patients are effective measures to prevent the outbreak of hospital-aquired CDAD.

Infectious diseases and vaccine sciences: strategic directions

Despite substantial progress, infectious diseases remain important causes of ill-health and premature deaths in Bangladesh. Bangladesh has experienced a > 90% reduction in the incidence of deaths due to childhood diarrhoea over the last 25 years. Further reductions can be achieved through the introduction of effective vaccines against rotavirus and improvements in home hygiene, quality of drinking-water, and clinical case management, including appropriate use of oral rehydration solution and zinc. Pneumonia is now the leading cause of childhood deaths in Bangladesh, and the pneumonia-specific child mortality is largely unchanged over the last 25 years. Reductions in mortality due to pneumonia can be achieved through the introduction of protein conjugate vaccines against Haemophilus influenza type b and Streptococcus pneumoniae, improvements in case management, including efforts to prevent delays in providing appropriate treatment, and the wider use of zinc. Tuberculosis is responsible for an estimated 70,000 deaths each year in Bangladesh. Although services for directly-observed therapy have expanded markedly, improved case finding and involvement of private practitioners will be important to reduce the burden of disease.

Renal damage and death in weaned mice after oral infection with Shiga toxin 2-producing Escherichia coli strains

Enterohaemorrhagic Escherichia coli (EHEC) O157:H7 infections are considered a public health problem in both developed and developing countries because of their increasing incidence and the severity of clinical presentation. Approximately 10% of infected patients develop complications such as haemolytic uraemic syndrome (HUS) characterized by acute renal failure, thrombocytopenia and haemolytic anaemia. The precise sequence of events leading to HUS is still understood incompletely. Because of the lack of a reproducible small animal model for EHEC infections, in vivo studies examining EHEC-host early interactions are limited and insufficient. The aim of this study was to characterize the weaned BALB/c mouse as a model of E. coli O157:H7 infection. In this paper we report that human Shiga toxin 2 (Stx2)-producing EHEC strains can adhere to the intestinal epithelium of weaned BALB/c mice, and produce local damage which leads to systemic disease and death in a percentage of infected mice. The lethality of the EHEC strain is closely age-dependent, and is related to the bacterial ability to colonize intestine and to produce Stx2. It can be concluded that the weaned BALB/c mouse can be used as a small animal model to study host early responses, and the role of bacterial pathogenic factors in the induction of systemic disease, thus providing a useful tool for the evaluation of therapeutic or vaccine approaches.

Oral zinc for treating diarrhoea in children

BACKGROUND

Diarrhoea causes around two million child deaths annually. Zinc supplementation could help reduce the duration and severity of diarrhoea, and is recommended by the World Health Organization and UNICEF.

OBJECTIVES

To evaluate oral zinc supplementation for treating children with acute or persistent diarrhoea.

SEARCH STRATEGY

In November 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE, LILACS, CINAHL, mRCT, and reference lists. We also contacted researchers.

SELECTION CRITERIA

Randomized controlled trials comparing oral zinc supplementation (>/= 5 mg/day for any duration) with placebo in children aged one month to five years with acute or persistent diarrhoea, including dysentery.

DATA COLLECTION AND ANALYSIS

Both authors assessed trial eligibility and methodological quality, extracted and analysed data, and drafted the review. Diarrhoea duration and severity were the primary outcomes. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses (using the fixed- or random-effects model) and assessed heterogeneity.

MAIN RESULTS

Eighteen trials enrolling 6165 participants met our inclusion criteria. In acute diarrhoea, zinc resulted in a shorter diarrhoea duration (MD -12.27 h, 95% CI -23.02 to -1.52 h; 2741 children, 9 trials), and less diarrhoea at day three (RR 0.69, 95% CI 0.59 to 0.81; 1073 children, 2 trials), day five (RR 0.55, 95% CI 0.32 to 0.95; 346 children, 2 trials), and day seven (RR 0.71, 95% CI 0.52 to 0.98; 4087 children, 7 trials). The four trials (1458 children) that reported on diarrhoea severity used different units and time points, and the effect of zinc was less clear. Subgroup analyses by age (trials with only children aged less than six months) showed no benefit with zinc. Subgroup analyses by nutritional status, geographical region, background zinc deficiency, zinc type, and study setting did not affect the results' significance. Zinc also reduced the duration of persistent diarrhoea (MD -15.84 h, 95% CI -25.43 to -6.24 h; 529 children, 5 trials). Few trials reported on severity, and results were inconsistent. No trial reported serious adverse events, but vomiting was more common in zinc-treated children with acute diarrhoea (RR 1.71, 95% 1.27 to 2.30; 4727 children, 8 trials).

AUTHORS' CONCLUSIONS

In areas where diarrhoea is an important cause of child mortality, research evidence shows zinc is clearly of benefit in children aged six months or more.

Predictors of severe illness in children under age five with concomitant infection with pneumonia and diarrhea at a large hospital in Dhaka, Bangladesh

We compared the socio-demographic and clinical outcomes as predictors in severely ill hospitalized under-five diarrheal children with and without pneumonia. We studied 496 under-five children with diarrhea admitted to the Special Care Ward (SCW) of Dhaka Hospital of International Center for Diarrheal Disease Research, Bangladesh from 1999 to 2004. Children with pneumonia, in addition to their diarrhea, constituted the study group (cases), and those who did not have pneumonia constituted the comparison (control) group. The individual predictors of pneumonia in children were a history of cough (OR 2.19, 95% CI 1.30-3.72, p=0.002), fever (OR 1.73, 95% CI 1.19-2.53, p=0.003), and rapid breathing (OR 2.45, 95% CI 1.49-4.03, p<0.001). Hypothermia (6% vs 2%; p=0.02), hyponatremia (41% vs 27%; p=0.003) and dehydrating diarrhea (81% vs 69%, p=0.003) were more frequent in control children. On logistic regression analyses, the case fatality among children with pneumonia was nearly two times (OR, 1.88 CI, 1.12-3.15, p= 0.02) than that of controls. Formulation of guidelines and implementation of a more comprehensive approach to managing pneumonia among severely ill diarrheal children is necessary to reduce childhood deaths in Bangladesh.

Microbial toxins and diarrhoeal diseases: introduction and overview

Without question, diarrhoeal diseases constitute one of the greatest causes of morbidity and death on a global scale. To an increasingly recognized extent, they are caused by an expanding array of microbial products or "toxins'. The symposium focuses on microbial products that alter normal bowel function either by augmenting secretory pathways or by selectively destroying mucosal cells or pathways, thus leading to an imbalance in the concert of normal absorptive function that results in diarrhoea. An understanding of normal intestinal physiology is thus the key to unraveling the specific actions of microbial toxins. In many instances, the microbial toxins are themselves providing unique pharmacological tools with which to dissect normal intestinal function. Specifically, families of enterotoxins are reviewed that appear to cause secretion through the recognized second messengers of cyclic AMP and cyclic GMP as well as cyclic nucleotide-independent and calcium-dependent pathways. Potential "third messengers' such as the protein kinases, through which one or more of the second messengers may act, are also considered. We examine cytotoxins that alter the orchestrated function of specialized regions of intact intestinal mucosa by selectively impeding or killing certain cells, so leading to small intestinal or colonic pathology and contributing to diarrhoea. We also consider a wide range of recognized bacterial and parasitic agents and their enterotoxic products. In some instances, these toxins may strikingly resemble our own endogenous humoral regulators or hormones. At this point, the possible roles of viruses or other transmissible genome products in this area await further clarification. Finally, we examine pharmacological and immunological approaches to attacking the toxins themselves or the deranged physiology they cause, in order to approach the control of the potentially devastating diseases of diarrhoea.

Comparison of the pathogenicity in three different Korean canine parvovirus 2 (CPV-2) isolates

Canine parvovirus type 2 (CPV-2) is a major pathogen inducing acute hemorrhagic gastroenteritis in dogs. Despite the identification of numerous CPV-2 variants (from CPV-2a to CPV-2c), the pathogenic differences among the CPV-2 variants in dogs have not been evaluated. The aim of this study was to compare the pathogenicity of CPV-2 variants (CPV-2a-I, CPV-2a-V and CPV-2b) isolated mainly from Korea. We evaluated the pathogenicity of three different CPV-2 variants, by performing clinical, hematological, serological and histopathological examinations after experimentally inoculating three types of CPV-2 variants into young puppies. We found that the overall pathogenicity of the CPV-2a variants (CPV-2a-I and 2a-V) was severer compared to the CPV-2b variant. In addition, there was no significant difference in pathogenicity between the two CPV-2a variants. Our findings indicate that there are differences in the pathogenicity of CPV-2 variants in dogs, which may be useful to understand the different pathobiology of the CPV-2 variants.

Does age affect the response to zinc therapy for diarrhoea in Bangladeshi infants?

The benefit of zinc for the treatment of diarrhoea in a cluster-randomized trial of children, aged 3-59 months, living in rural Bangladesh was previously reported. Here, the benefits of zinc stratified by age--3-5 months, 6-11 months, and 12-59 months--are reported. Although the sample sizes in the stratified groups were too small to detect statistical significance in the 3-5-month and 6-11-month age-groups, the trends suggest that there may be a benefit of zinc for the treatment of diarrhoea on the duration of diarrhoea and on subsequent morbidity and mortality. Additional research is needed to better understand the effect of zinc for the treatment of diarrhoea among infants aged less than six months.

Effect of HIV/AIDS and malaria on the context for introduction of zinc treatment and low-osmolarity ORS for childhood diarrhoea

Diarrhoea was estimated to account for 18% of the estimated 10.6 million deaths of children aged less than five years annually in 2003. Two--Africa and South-East Asia--of the six regions of the World Health Organization accounted for approximately 40% and 31% of these deaths respectively, or almost three-quarters of the global annual deaths of children aged less than five years attributable to diarrhoea. Much of the effort to roll out low-osmolarity oral rehydration solution (ORS) and supplementation of zinc for the management of diarrhoea accordingly is being devoted to sub-Saharan Africa and to South and South-East Asia. A number of significant differences exist in diarrhoea-treatment behaviours and challenges of the public-health systems between Africa and Asia. The differences in rates of ORS use are the most common indicator of treatment of diarrhoea and vary dramatically by and within region and may significantly influence the roll-out strategy for zinc and low-osmolarity ORS. The prevalence of HIV/AIDS and the endemicity of malaria also differ greatly between regions; both the diseases consume the attention and financial commitment of public-health programmes in regions where rates are high. This paper examined how these differences could affect the context for the introduction of zinc and low-osmolarity ORS at various levels, including the process of policy dialogue with local decision-makers, questions to be addressed in formative research, implementation approaches, and strategies for behaviour-change communication and training of health workers.

Increased mortality in the year following discharge from a paediatric ward in Bissau, Guinea-Bissau

BACKGROUND

Few studies in developing countries have examined posthospital mortality and little is known about the magnitude of posthospital mortality and risk factors for long-term survival. A better understanding of the determinants of posthospital mortality could help improve discharge policies and interventions with implications for overall childhood mortality.

STUDY POPULATION

In the period from 1991 to 1996 all paediatric admissions coming from the Bandim Health Project's area were registered at the National Hospital in Bissau, Guinea-Bissau. Posthospitalization information from a population-based surveillance system was available for 4153 admissions contributed by 3373 individuals having between 1 and 8 admissions during the period. Three thousand six hundred forty seven (3647) admissions by 2950 children resulted in live discharges. Postdischarge mortality included all deaths during 1 year following live discharge.

RESULTS

Among the 221 children who died during the first year after discharge, 170 died in the community and 51 children died during a subsequent hospitalization; thirty-eight died on the day of discharge and almost one third had died within the first 2 weeks. The overall in-hospital and 12-month posthospital mortality was 20%. Compared to the mortality level in the community and controlled for other determinants of childhood mortality, children discharged from hospital had 12 times higher risk of dying during the first 2 weeks after discharge. The mortality rate ratio (MR) was 6.2 (95% confidence interval 3.8-10.2) times higher when we excluded those who died at the day of discharge. For the period 30-91 days after discharge the MR ratio was 3.7 (2.5-5.5), and in the period 3-6 months after discharge, the risk estimate was still 2.5 (1.6-3.9) times higher than community mortality. In a multivariate analysis, the all-dominating risk factor was discharge status as 'fled' in the sense of nonmedical discharge, the MRs being 18.6 (9.5-36.6) in the first 2 weeks after discharge and 4.0 (2.0-8.3) in the remaining part of the first year. Other significant risk factors for postdischarge mortality included ethnic group, housing quality and maternal education, and were similar to risk factors for community mortality. The same diagnoses that had high acute mortality, including anaemia, diarrhoea and 'other', were also associated with high postdischarge mortality.

CONCLUSION

There was a marked increase in mortality after hospitalization, the effect being particularly strong for children who fled the hospital. Improved discharge and follow-up policies might have an important impact on survival after paediatric hospitalization. Studies on the effect of focused intervention at discharge are needed.

Severity of Clostridium difficile-associated diarrhea in solid organ transplant patients

Clostridium difficile-associated diarrhea (CDAD) has a wide spectrum of disease severity. Studies have implicated immunosuppressants as a risk factor for severe disease. We hypothesized that solid organ transplant (SOT) patients with CDAD would be at greater risk for severe disease because of their profound immunosuppression. Adult SOT patients with CDAD seen at Duke University Medical Center between 1999 and 2003 were compared with a reference group of non-transplant patients with CDAD. The primary outcome was the development of complicated colitis defined as death, intensive care unit admission, or urgent colectomy within 30 days of diagnosis. A secondary outcome was relapse within 60 days. Eighty transplant and 86 non-transplant cases were reviewed. There was no significant difference in the development of complicated colitis (13.8% vs. 7.0%) or relapse rates (6.2% vs. 7.0%) between the 2 groups. In the entire sample, 18.5% of patients receiving corticosteroids unrelated to transplantation relapsed as compared with 4.5% not receiving corticosteroids (risk ratio 4.3, P=0.02). In conclusion, no significant difference was found in severity of CDAD between SOT patients and non-transplant patients. Exposure to corticosteroids was significantly associated with an increased risk of relapse and may warrant a longer treatment course.

A review of changing episode definitions and their effects on estimates of diarrhoeal morbidity

This paper describes how the methodology used for measuring diarrhoeal morbidity has changed over time and assesses how differences in episode definition have affected estimates of diarrhoeal morbidity among children aged less than five years. The episode definition used in 73 studies included in three previously-published literature reviews was identified. In earlier work, a method was developed that adjusts morbidity estimates to take account of differences in episode definition. This adjustment method was applied to the studies identified in these three literature reviews. Episode definitions were better documented and were more consistent in studies published after 1980. Adjusting morbidity estimates to account for definitional differences did not substantially alter the reviews' conclusions. Diarrhoeal surveillance has steadily improved since 1980, with methodology becoming more consistent between studies and better documented. Although episode definitions have changed over time, the morbidity estimates derived in the three reviews appear robust to these changes.

Centers for Disease Control and Prevention (CDC). Baseline data from the Nyando Integrated Child Health and Education Project--Kenya, 2007

Approximately 10 million children aged <5 years die each year in developing countries. The leading infectious causes of these deaths include acute respiratory infections, diarrhea, measles, and malaria; malnutrition contributes to approximately 50% of these deaths. To address multiple conditions that contribute to mortality, child-survival programs require effective interventions and implementation strategies. To assess the effectiveness of multiple interventions, CDC has joined with partners to create the Nyando Integrated Child Health and Education (NICHE) project to combine several proven approaches to child survival in an impoverished rural district of western Kenya. During March-April 2007, CDC began the NICHE project with a baseline survey. This report summarizes preliminary data from that survey, which determined that 1) 86.1% of surveyed households were in the poorest Kenya socioeconomic quintile and 2) among children aged 6-35 months, 21.5% had experienced an acute respiratory infection and 9.1% had experienced diarrhea in the preceding 24 hours, 28.0% had chronic malnutrition, 66.2% had anemia, and 19.8% had a positive malaria smear. Comprehensive interventions will be needed to improve living conditions and reduce the risk for death before age 5 years among children in this population.

Clostridium difficile: emergence of hypervirulence and fluoroquinolone resistance

Clostridium difficile is a well-known cause of sporadic and healthcare-associated diarrhea. Multihospital outbreaks due to a single strain and outbreaks associated with antibiotic selective pressure, especially clindamycin, have been well documented. Severe cases and fatalities from C. difficile are uncommon. The recent global emergence of a hypervirulent strain containing binary toxin (Toxinotype III ribotype 027), with or without deletion in a regulatory gene (tcdC gene), together with high-level resistance to third generation fluoroquinolones, has been associated with increased morbidity and mortality. Although the defective regulatory gene locus is associated with increased toxin production in vitro, the in vivo significance of this mutation and of the binary toxin remains undefined. To date, treatment strategies have not evolved in response to the emergence of this hypervirulaent strain. We provide a critical, quantitative summary of the evolving clinical and molecular epidemiology of C. difficile along with implications relevant to future treatment strategies.

Rotavirus mortality confirmed by etiologic identification in Venezuelan children with diarrhea

BACKGROUND

Hospital-based studies to determine the etiology of deaths from diarrhea are scarce. In this study, we specifically analyzed deaths due to rotavirus to assess the rotavirus impact on diarrhea mortality.

METHODS

To determine the rotavirus proportion contributing to mortality due to diarrhea, we analyzed data obtained from a hospital-based mortality surveillance, conducted over 7 years, in the Ciudad Hospitalaria Dr. Enrique Tejera, Valencia, Venezuela. Rotavirus was identified in stool samples collected from children who died of diarrhea, by a confirmatory ELISA and/or reverse transcription polymerase chain reaction.

RESULTS

Our results show that rotavirus (21%; 21/100) is the leading cause of death due to diarrhea among children <5 years of age; rotavirus also has an important impact (2%; 21/1336) on deaths from all causes in this age group. Shigella spp. (19%; 13/69) was the second most important cause of death, followed by calicivirus (6%; 3/53). Furthermore, this study documents a seasonal pattern in the deaths due to rotavirus (odds ratio 3.28; 95% confidence interval 1.13-9.76).

CONCLUSIONS

For Venezuela, it is estimated that approximately 300 children <5 years of age die of rotavirus each year, which means that 1 in 1800 children die by the age of 5. Rotavirus was found to be the main cause of death due to diarrhea, which supports previous estimations. This is the first study to present data of cause-specific mortality due to diarrhea based on hospital surveillance of diarrhea etiologies.

Diarrheal diseases in the history of public health

While the public health threat of HIV/AIDS in developing countries has drawn increasing attention from the international community for more than two decades, other health problems such as diarrheal diseases continue to contribute to higher morbidity and mortality rates in much of the developing world. This literature review is an account of both the history and current risks associated with diarrheal diseases.

Hospitalizations and deaths from diarrhea and rotavirus among children <5 years of age in the United States, 1993-2003

Recently a new rotavirus vaccine was licensed in the United States and recommended for universal immunization of American children. The impact of the vaccine on a decrease in hospitalizations will take several years to assess and will be based on the availability of good baseline data on the disease. We used the largest US hospital discharge database available, the Healthcare Cost and Utilization Project (HCUP), to study national rates, trends, and risk factors for diarrhea- and rotavirus-associated hospitalizations and deaths among children <5 years of age, to establish a baseline against which vaccine implementation can be measured. Rotavirus remained the most important cause of pediatric diarrhea throughout the study period (1993-2003). When the data were extrapolated to the US population, rotavirus was estimated to be the cause of approximately 60,000 hospitalizations and 37 deaths annually. Black infants had a significantly higher risk of being hospitalized with and dying from rotavirus disease early in life, compared with white infants (risk ratio [RR] for hospitalization by 12 months of age was 2.4, with a 95% confidence interval [CI] of 1.2-4.7; RR for death was 2.0, with a 95% CI of 1.7-2.5). Such racial differences in age and risk of rotavirus-associated hospitalization and death highlight the importance of timely and early rotavirus immunization of minority children. The HCUP database serves as a sensitive and robust data source for monitoring the impact of a rotavirus-immunization program in the United States.

Impact of zinc supplementation on subsequent morbidity and growth in Bangladeshi children with persistent diarrhoea

This study was conducted to explore whether supplementation of zinc to children during persistent diarrhoea has any subsequent effect on morbidity and growth. A prospective follow-up study was conducted among children, aged 3-24 months, with persistent diarrhoea, who participated earlier in a double-blind randomized placebo-controlled trial. During persistent diarrhoea, children were randomly allocated to receive either zinc in multivitamin syrup or only multivitamin syrup for two weeks. After recovering from diarrhoea, 76 children in the multi-vitamin syrup and 78 children in the zinc plus multivitamin syrup group were followed up for subsequent morbidity and growth. Weekly morbidity and two-weekly anthropometric data were collected for the subsequent 12 weeks. Data showed that episodes and duration of diarrhoea were reduced by 38% and 44% respectively with supplementation of zinc. There was no significant difference in the incidence or duration of respiratory tract infection between the zinc-supplemented and the non-supplemented group. Improved linear growth was observed in underweight children (weight-for-age <70% of the National Center for Health Statistics standard) who received zinc compared to those who did not receive.

Evaluation of endotoxaemia in the prognosis and treatment of scouring merino lambs

This study looked at measurement of endotoxaemia as a tool in determining prognosis and probable response to treatment in scouring lambs. One hundred eighty-three lambs in the first 15-20 days of life, from eight Merino sheep farms located in the region of La Serena, south-west Spain, were used in this experiment. Scouring and normal/control lambs were selected following a clinical examination, the scouring group was further divided into subgroups, specifically those that did or did not survive 72 h following treatment. At the time of the clinical examination, faecal and blood samples were taken. Faecal culture and commercial faecal antigen tests for detection of enteropathogens in faeces and serum endotoxin measurement using chromogenic lymulus amoebocyte lysate (LAL) were carried out. Scouring lambs received 0.07 mg/kg liveweight halofuginone once a day for 3 days, a single oral dose of 0.20 mg/kg liveweight of spectinomycin and oral rehydration fluid. The pathogens isolated were Cryptosporidium spp. and Escherichia coli. The case fatality rate was 51% in the scouring lambs. Postmortem findings were consistent with enterotoxigenic E. coli infection. The concentration of endotoxin was 0.18 +/- 0.12 ng/ml in the control group, 0.35 +/- 0.17 ng/ml in the surviving lambs and 0.46 +/- 0.14 ng/ml in the non-surviving lambs. Significant differences between groups were found. Case fatality rate of the scouring lambs with endotoxaemia below 0.30 ng/ml was 0%, while it was 100% above 0.50 ng/ml. These results may be utilized as a prognostic indicator in lambs affected by E. coli and Cryptosporidium that will help aid in decision-making as to whether to treat a lamb or not based on its chances of survival.

Effect of daily low dose of vitamin A compared with single high dose on morbidity and mortality of hospitalized mainly malnourished children in senegal: a randomized controlled clinical trial

BACKGROUND

In vitamin A-deficient populations, children hospitalized with infections and/or malnutrition are at particular risk of developing severe vitamin A (VA) deficiency. High-dose VA supplements are recommended as part of the treatment but results on its effect on recovery from morbidity and on prevention from nosocomial morbidity are conflicting.

OBJECTIVE

We aimed to assess the effect of a single high dose and daily low dose of VA on hospitalized malnourished children's morbidity.

DESIGN

We carried out a double-blind, randomized trial in 604 and 610 Senegalese hospitalized children. The first mentioned batch received a high-dose VA supplement (200,000 IU) on admission, the second a daily low-dose VA supplement (5000 IU per day) during hospitalization. Children were followed up until discharged. Data on all-cause morbidity were collected daily.

RESULTS

Survival analysis showed that the incidence of respiratory disease was significantly lower in the low-dose group than in the high-dose group, hazard ratios (HR): 0.26, 95% CI: 0.07-0.92. The duration of respiratory infection was also significantly lower in the low-dose group than in the high-dose group (HR of cure: 1.41, 95% CI: 1.05-1.89). Duration and incidence of diarrhoea were not significantly different between treatment groups. In children with oedema on admission, mortality was significantly lower in the low-dose group (Adjusted odds ratio: 0.21; 95% CI: 0.05-0.99).

CONCLUSIONS

Daily low dose of VA compared with single high dose significantly reduced duration and incidence of respiratory infection but not of diarrhoea in hospitalized children.

The effect of nutritional support on weight gain of HIV-infected children with prolonged diarrhoea

AIM

To examine the effect on growth and immunity of enhanced calorie and protein provision to HIV-infected children presenting with prolonged diarrhoea.

METHODS

A total of 169 HIV-infected children aged 6-36 months with diarrhoea for 7 days or more were randomly assigned to either standard nutrition support for children with prolonged diarrhoea or an enhanced diet started during hospitalisation and continued after discharge. The change in weight between enrolment and 8, 14 and 26 weeks and changes in plasma HIV-RNA and CD4 cell count at 8 and 26 weeks were estimated.

RESULTS

Children receiving enhanced nutrition achieved significantly more weight gain (p < 0.001) between enrolment and 8 weeks than children on the standard diet (median increase in weight-for-age standard deviation score +1.02 vs. +0.01). After 8 weeks median weight velocity was normal and similar in both groups. The change in median CD4 count was similar in both groups. The 26-week mortality rate was high in both groups (standard support: 22%, enhanced support: 29%).

CONCLUSIONS

Nutrition support of children with advanced HIV infection and prolonged diarrhoea resulted in significant and sustained weight gain, but did not improve CD4 counts or survival. These results support integrated nutrition interventions for HIV-infected children.

[The etiological, clinical and prognosis of diarrhea occurs during AIDS in to hospital in Bamako]

Its was a descriptive survey achieved in the service of the infectious and tropical illnesses of the teaching hospital of the "Point G" from 31 December 2002 to 30 June 2004 was about the analysis of 76 files. Its goal was to determine the clinical, etiological and prognostic aspects, of the diarrhea during the AIDS. The oral-pharyngeal candidiasis (50%), the deshydratation (60,5%), the fever (67,5%) and the thinning (77,6%) were associated to the diarrhoea frequently. Cholera syndrome was (52.6%), dysenteric syndrome was (36.8%) and the diarrhea syndrome was (10.5%). According to the etiological aspect, the parasites were founded in 51,3 % of cases, bacteria 9,2 % of cases, and fungus 5,3%. Any pathogen hasn't been founded in 34,2% of cases. Cyptosporidium parvum (15,8 %), and Isospora Belli (11,8%) was the most common parasites founded, but some unusual pathogens as: Entamoeba hystolitica, Trichomonas intestinalis , Giardia intestinalis , Shistosoma mansoni , Dicrococelium dendriticum, Trichostrongylus were present . The most common bacteria were Escherichia coli 5,3%. The fungus family was represented by Candida albicans . The lethality rate was 46,1%.

CONCLUSION

The etiology of diarrhea occurs during aids is variable and include opportunistic and non opportunistic. The fatality rate remains incised because the delay of care and the poverty of the patients.

Chronic enteropathy: clinical aspects

Diarrheal disease is a major cause of childhood morbidity and mortality worldwide. Chronic enteropathy with subsequent persistent diarrhea and associated vicious cycles of malnutrition, increased gut permeability and secondary immunodeficiency are particularly devastating in the childhood population. The major causes of chronic enteropathy differ significantly between developed countries and developing countries. In developed countries, infectious and postinfectious diarrhea as well as abnormalities in immune response including celiac disease, food-induced allergic enteropathy and idiopathic inflammatory bowel disease account for most cases of chronic enteropathy. In developing countries, syndromic persistent diarrhea associated with malnutrition and secondary immunodeficiency due to human immunodeficiency virus (HIV) infection predominate as the major causes of chronic enteropathy. These latter two causes account for a disproportionate share of the more than 2.5 million deaths of children under 5 years of age due to diarrhea each year worldwide. From a practical perspective, diagnostic evaluation of chronic enteropathy in developing countries is often limited to identifying potential causative enteropathogens and antimicrobial treatment. Proper management with an emphasis on fluid homeostasis and protocolized nutritional therapy and rehabilitation is essential to successful treatment of syndromic persistent diarrhea.

Autologous peripheral blood stem cell transplantation for severe multiple sclerosis

We describe the results of a clinical trial to evaluate the feasibility and toxicity of autologous hematopoietic stem cell transplantation (auto-HSCT) for patients with progressive multiple sclerosis (MS). Fifteen patients (all patients with secondary progressive MS) were enrolled. The median expanded disability status scale (EDSS) score at baseline was 6.0 (range, 4.5-7.5). Peripheral blood stem cells were obtained by leukapheresis after mobilization with granulocyte colony-stimulating factor. In 9 patients, CD34+ cell selection was performed with a CliniMACS cell selection system, and 6 patients accepted infusion of unmodified peripheral blood stem cells. The modified BEAM (carmustine, teniposide, cytarabine, and melphalan) was the sole conditioning regimen used. The adverse effects included infections, mucositis, transient hepatotoxicity, and diarrhea. Three patients had flares of neurologic deterioration during mobilization, 8 patients had the same manifestation during transplantation, and 2 patients had similar flares within 3 months of transplantation. Six patients experienced continuous neurologic improvement after transplantation, 5 patients experienced neurologic progression, and 4 patients had stabilization of their disease. The confirmed progression-free rate was 63.8% at 49 months. The results of lymphocyte purging were no better than for no purging. Auto-HSCT proved to be safe and beneficial for some MS patients. Further studies are needed to establish the merit of this procedure for MS patients.

Molecular characterization of rotavirus gastroenteritis strains, Iraqi Kurdistan

Of 260 children with acute diarrhea in Erbil, Iraqi Kurdistan, 96 (37%) were infected with rotavirus. Reverse transcription-polymerase chain reaction identified G1, G4, G2, G9, P[8], P[6], and P[4] as the most common genotypes. Eight G/P combinations were found, but P[8]G1 and P[4]G2 accounted for >50% of the strains.

Mortality rates in conflict zones in Karen, Karenni, and Mon states in eastern Burma

OBJECTIVES

To estimate mortality rates for populations living in civil war zones in Karen, Karenni, and Mon states of eastern Burma.

METHODS

Indigenous mobile health workers providing care in conflict zones in Karen, Karenni, and Mon areas of eastern Burma conducted cluster sample surveys interviewing heads of households during 3-month time periods in 2002 and 2003 to collect demographic and mortality data.

RESULTS

In 2002 health workers completed 1290 household surveys comprising 7496 individuals. In 2003, 1609 households with 9083 members were surveyed. Estimates of vital statistics were as follows: infant mortality rate: 135 (95% CI: 96-181) and 122 (95% CI: 70-175) per 1000 live births; under-five mortality rate: 291 (95% CI: 238-348) and 276 (95% CI: 190-361) per 1000 live births; crude mortality rate: 25 (95% CI: 21-29) and 21 (95% CI: 15-27) per 1000 persons per year.

CONCLUSIONS

Populations living in conflict zones in eastern Burma experience high mortality rates. The use of indigenous mobile health workers provides one means of measuring health status among populations that would normally be inaccessible due to ongoing conflict.

National and sub-national under-five mortality profiles in Peru: a basis for informed policy decisions

Background

Information on profiles for under-five causes of death is important to guide choice of child-survival interventions. Global level data have been published, but information at country level is scarce. We aimed at defining national and departmental trends and profiles of under-five mortality in Peru from 1996 through 2000.

Methods

We used the Ministry of Health registered under-five mortality data. For correction of under-registration, a model life-table that fitted the age distribution of the population and of registered deaths was identified for each year. The mortality rates corresponding to these model life-tables were then assigned to each department in each particular year. Cumulative reduction in under-five mortality rate in the 1996–2000 period was estimated calculating the annual reduction slope for each department. Departmental level mortality profiles were constructed. Differences in mortality profiles and in mortality reduction between coastal, andean and jungle regions were also assessed.

Results

At country level, only 4 causes (pneumonia, diarrhoea, neonatal diseases and injuries) accounted for 68% of all deaths in 1996, and for 62% in 2000. There was 32.7% of under-five death reduction from 1996 to 2000. Diarrhoea and pneumonia deaths decreased by 84.5% and 41.8%, respectively, mainly in the andean region, whereas deaths due to neonatal causes and injuries decreased by 37.2% and 21.7%. For 1996–2000 period, the andean, coast and jungle regions accounted for 52.4%, 33.1% and 14.4% of deaths, respectively. These regions represent 41.0%, 46.4% and 12.6% of under-five population. Both diarrhoea and pneumonia constitute 30.6% of under-five deaths in the andean region. As a proportion, neonatal deaths remained stable in the country from 1996 to 2000, accounting for about 30% of under-five deaths, whereas injuries and "other" causes, including congenital anomalies, increased by about 5%.

Conclusion

Under-five mortality declined substantially in all departments from 1996 to 2000, which is explained mostly by reduction in diarrhoea and pneumonia deaths, particularly in the andean region. There is the need to emphasize interventions to reduce neonatal deaths and emerging causes of death such as injuries and congenital anomalies.

Diarrheal epidemics in Dhaka, Bangladesh, during three consecutive floods: 1988, 1998, and 2004

We examined demographic, microbiologic, and clinical data from patients presenting during 1988, 1998, and 2004 flood-associated diarrheal epidemics at a diarrhea treatment hospital in Dhaka, Bangladesh. Compared with non-flood periods, individuals presenting during flood-associated epidemics were older, more severely dehydrated, and of lower socioeconomic status. During flood-associated epidemics, Vibrio cholerae was the most commonly identified cause of diarrhea, and the only diarrheal pathogen whose incidence proportionally increased in each epidemic compared with seasonally matched periods. Rotavirus was the second most frequently identified flood-associated pathogen, although the proportion of cases caused by rotavirus infection decreased during floods compared with matched periods. Other causes of diarrhea did not proportionally change, although more patients per day presented with enterotoxigenic Escherichia coli, Shigella, and Salmonella species-associated diarrhea during floods compared with matched periods. Our findings suggest that cholera is the predominant cause of flood-associated diarrheal epidemics in Dhaka, but that other organisms spread by the fecal-oral route also contribute.

Diarrheal epidemics in Dhaka, Bangladesh, during three consecutive floods: 1988, 1998, and 2004

We examined demographic, microbiologic, and clinical data from patients presenting during 1988, 1998, and 2004 flood-associated diarrheal epidemics at a diarrhea treatment hospital in Dhaka, Bangladesh. Compared with non-flood periods, individuals presenting during flood-associated epidemics were older, more severely dehydrated, and of lower socioeconomic status. During flood-associated epidemics, Vibrio cholerae was the most commonly identified cause of diarrhea, and the only diarrheal pathogen whose incidence proportionally increased in each epidemic compared with seasonally matched periods. Rotavirus was the second most frequently identified flood-associated pathogen, although the proportion of cases caused by rotavirus infection decreased during floods compared with matched periods. Other causes of diarrhea did not proportionally change, although more patients per day presented with enterotoxigenic Escherichia coli, Shigella, and Salmonella species-associated diarrhea during floods compared with matched periods. Our findings suggest that cholera is the predominant cause of flood-associated diarrheal epidemics in Dhaka, but that other organisms spread by the fecal-oral route also contribute.

Rotavirus and severe childhood diarrhea

Studies published between 1986 and 1999 indicated that rotavirus causes ≈22% (range 17%–28%) of childhood diarrhea hospitalizations. From 2000 to 2004, this proportion increased to 39% (range 29%–45%). Application of this proportion to the recent World Health Organization estimates of diarrhea-related childhood deaths gave an estimated 611,000 (range 454,000–705,000) rotavirus-related deaths.

Comorbidities and mortality among children hospitalized with diarrheal disease in an area of high prevalence of human immunodeficiency virus infection

PURPOSE

To describe the profile of comorbidities in children admitted with diarrhea to an urban hospital with high human immunodeficiency virus (HIV) prevalence in South Africa and to examine the contribution of comorbidities to inpatient mortality.

METHODS

Data from a retrospective random sample of 319 children were extracted and analyzed from a total of 1145 children hospitalized for diarrhea in 2001. We used multiple logistic regression models to determine the independent effects of HIV infection, malnutrition, pneumonia and bacteremia on inpatient mortality.

RESULTS

Overall 68% of the diarrheal admissions were classified as HIV-infected and 61% were classified as malnourished, with 53% having evidence of both. HIV infection was strongly associated with malnutrition, pneumonia and bacteremia. Inpatient mortality was 14% [95% confidence interval (CI), 11-19%]. Mortality was higher among HIV-infected than among uninfected children [crude odds ratio (OR), 6.0; 95% CI 2.1-17.0]. History of low birth weight, previous admission, malnutrition, HIV infection, pneumonia, bacteremia, low hemoglobin, total white blood cell count and serum albumin were significant predictors of mortality in univariate analyses. After adjustment, severe malnutrition (OR 2.1; 95% CI 1.0-4.9), bacteremia (OR 2.9; 95% CI 1.2-7.2) and pneumonia (OR 3.9; 95% CI 1.3-12.0) remained independent predictors of mortality, whereas the association between HIV infection and mortality was significantly diminished (OR 4.0; 95% CI 0.8-18.1).

CONCLUSION

In a setting of high HIV prevalence, malnutrition, bacteremia and pneumonia contribute independently to death in children hospitalized with diarrheal disease.

Estimating the causes of 4 million neonatal deaths in the year 2000

BACKGROUND

Information on cause-of-death is lacking for 98% of the world's 4 million neonatal deaths that occur in countries with inadequate vital registration (VR). Our aim was to estimate, by country for the year 2000, the distribution of neonatal deaths across programme-relevant causes including: asphyxia, preterm birth, congenital abnormalities, sepsis/pneumonia, neonatal tetanus, diarrhoea, and 'other'.

METHODS

Two sources of neonatal cause-of-death data were examined: VR datasets for countries with high coverage (>90%), and published and unpublished studies identified through systematic searches. Multinomial regression was used to model the distribution of neonatal deaths. A VR-based model was used to estimate the distribution of causes of death for 37 low-mortality countries without national data. A study-based model was applied to obtain estimates for 111 high-mortality countries. Uncertainty estimates were derived using the jackknife approach.

RESULTS

Data from 44 countries with VR (96 797 neonatal deaths) and from 56 studies (29 countries, 13 685 neonatal deaths) met inclusion criteria. The distribution of reported causes of death varied substantially between countries and across studies. Based on 193 countries, the major causes of neonatal death globally were estimated to be infections (sepsis/pneumonia, tetanus, and diarrhoea, 35%), preterm birth (28%), and asphyxia (23%). Regional variation is important. Substantial uncertainty surrounds these estimates.

CONCLUSIONS

This exercise highlights the lack of reliable cause-of-death data in the settings in which most neonatal deaths occur. Complex statistical models are not a panacea. Representative data with comparable case definitions and consistent hierarchical cause-of-death attribution are required.

Defining episodes of diarrhoea: results from a three-country study in Sub-Saharan Africa

The study was conducted to assess the effect of definition of episode on diarrhoeal morbidity and to develop a means of adjusting estimates of morbidity for the definition of episode used. This paper reports on a cohort study of 374 children, aged 9-32 months, in three African countries, which recorded frequency and consistency of stool over a seven-month period. Different definitions of episode were applied to these data to assess their effect on annualized diarrhoeal morbidity. Adjustment factors were then derived that corrected morbidity for non-standard definitions of episode. Applying non-standard definitions of episode gave estimates of an annualized number of episodes between 38% and 137% of the internationally-accepted definition. Researchers should be encouraged to use the standard definition of episode of diarrhoea and to use appropriate field protocols. Where this is not possible, correction factors should be applied, particularly where estimates of diarrhoeal morbidity are pooled in systematic reviews.

New rotavirus vaccines protect against diarrhoea in children

Rotavirus is the leading cause of diarrhoea in young children worldwide, and is responsible for over half a million deaths and 2 million hospitalisations each year

The burden of rotavirus diarrhea in Khanh Hoa Province, Vietnam: baseline assessment for a rotavirus vaccine trial

BACKGROUND

In Vietnam, rotavirus is seen as a priority disease because studies have demonstrated that >50% of children hospitalized for treatment of diarrhea have rotavirus as the pathogen. To anticipate the availability of new vaccines, we have examined our field area in Nha Trang, Khanh Hoa Province, Vietnam, as a potential site to conduct a field trial of a future rotavirus vaccine.

METHODS

Data from a population census, incidence rates of diarrhea from a previous cholera vaccine trial and hospitalization rates from computerized records collected from the 2 main hospitals in the province were reviewed to estimate the burden of rotavirus-related diarrhea that might be expected during a field trial of a rotavirus vaccine.

RESULTS

For a birth cohort of approximately 5000 children, we would expect approximately 2500 clinic visits and 650-850 hospitalizations for treatment of diarrhea, of which approximately 375-425 would be attributable to rotavirus. For the Vietnamese birth cohort of 1,639,000 children, these numbers translate into approximately 820,000 clinic visits, 122,000-140,000 hospitalizations and 2900-5400 deaths annually attributable to rotavirus-related diarrhea.

CONCLUSIONS

Vietnam is an early adaptor of new vaccines, has high national coverage rates (>85%) for childhood immunization and receives international donor support for the introduction of new vaccines. We found the epidemiologic features of rotavirus in rural Vietnam to be more similar to those of rotavirus in a developed country than to those of rotavirus in India or Bangladesh.

Health Care Costs of Diarrheal Disease and Estimates of the Cost‐Effectiveness of Rotavirus Vaccination in Vietnam

BACKGROUND

Rotavirus disease causes a significant health and economic burden worldwide. Several rotavirus vaccines may soon be available for use. A country's decision to introduce these vaccines will depend on its rotavirus disease burden, on the cost of the vaccine, and on the results of an economic assessment of the cost and effectiveness of a rotavirus vaccination program.

METHODS

Data on medical and nonmedical direct costs and indirect costs were established in Khanh Hoa Province, Vietnam, and extrapolated to national estimates on the basis of the birth cohort in 2004. The main outcome measures were economic burden and cost-effectiveness ratio (United States dollars per disability-adjusted life-year averted and dollars per life saved) of vaccination.

RESULTS

The disease burden is equivalent to an economic burden of an estimated 3.1 million US dollars in medical direct costs, 685,000 US dollars in nonmedical direct costs, and 1.5 million US dollars in indirect costs. From a societal perspective, treatment of rotavirus disease costs an estimated 5.3 million US dollars per year. From the health care system perspective, universal vaccination of infants at a cost of < or = 7.26 US dollars/vaccine dose would be a cost-effective public health intervention, according to the World Bank cost-effectiveness standard for low-income countries (140 US dollars/disability-adjusted life-year).

CONCLUSIONS

Vaccination can effectively reduce the disease burden and health care costs of rotavirus-specific diarrhea in Vietnam.

Neonatal foal diarrhea

Diarrhea is a significant cause of morbidity and mortality in the neonatal foal. Numerous noninfectious and infectious agents are responsible for enterocolitis and enteritis. This article provides an overview of the differential diagnoses for neonatal diarrhea and general and specific guidelines for therapy.

Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhoea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial

OBJECTIVE

To compare the effect on prevalence of diarrhoea and mortality of household based treatment of drinking water with flocculant-disinfectant, sodium hypochlorite, and standard practices in areas with turbid water source in Africa.

DESIGN

Cluster randomised controlled trial over 20 weeks.

SETTING

Family compounds, each containing several houses, in rural western Kenya.

PARTICIPANTS

6650 people in 605 family compounds.

INTERVENTION

Water treatment: flocculant-disinfectant, sodium hypochlorite, and usual practice (control).

MAIN OUTCOME MEASURES

Prevalence of diarrhoea and all cause mortality. Escherichia coli concentration, free residual chlorine concentration, and turbidity in household drinking water as surrogates for effectiveness of water treatment.

RESULTS

In children < 2 years old, compared with those in the control compounds, the absolute difference in prevalence of diarrhoea was -25% in the flocculant-disinfectant arm (95% confidence interval -40 to -5) and -17% in the sodium hypochlorite arm (-34 to 4). In all age groups compared with control, the absolute difference in prevalence was -19% in the flocculant-disinfectant arm (-34 to -2) and -26% in the sodium hypochlorite arm (-39 to -9). There were significantly fewer deaths in the intervention compounds than in the control compounds (relative risk of death 0.58, P = 0.036). Fourteen per cent of water samples from control compounds had E coli concentrations < 1 CFU/100 ml compared with 82% in flocculant-disinfectant and 78% in sodium hypochlorite compounds. The mean turbidity of drinking water was 8 nephelometric turbidity units (NTU) in flocculant-disinfectant households, compared with 55 NTU in the two other compounds (P < 0.001).

CONCLUSIONS

In areas of turbid water, flocculant-disinfectant was associated with a significant reduction in diarrhoea among children < 2 years. This health benefit, combined with a significant reduction in turbidity, suggests that the flocculant-disinfectant is well suited to areas with highly contaminated and turbid water.

Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhoea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial

OBJECTIVE

To compare the effect on prevalence of diarrhoea and mortality of household based treatment of drinking water with flocculant-disinfectant, sodium hypochlorite, and standard practices in areas with turbid water source in Africa.

DESIGN

Cluster randomised controlled trial over 20 weeks.

SETTING

Family compounds, each containing several houses, in rural western Kenya.

PARTICIPANTS

6650 people in 605 family compounds.

INTERVENTION

Water treatment: flocculant-disinfectant, sodium hypochlorite, and usual practice (control).

MAIN OUTCOME MEASURES

Prevalence of diarrhoea and all cause mortality. Escherichia coli concentration, free residual chlorine concentration, and turbidity in household drinking water as surrogates for effectiveness of water treatment.

RESULTS

In children < 2 years old, compared with those in the control compounds, the absolute difference in prevalence of diarrhoea was -25% in the flocculant-disinfectant arm (95% confidence interval -40 to -5) and -17% in the sodium hypochlorite arm (-34 to 4). In all age groups compared with control, the absolute difference in prevalence was -19% in the flocculant-disinfectant arm (-34 to -2) and -26% in the sodium hypochlorite arm (-39 to -9). There were significantly fewer deaths in the intervention compounds than in the control compounds (relative risk of death 0.58, P = 0.036). Fourteen per cent of water samples from control compounds had E coli concentrations < 1 CFU/100 ml compared with 82% in flocculant-disinfectant and 78% in sodium hypochlorite compounds. The mean turbidity of drinking water was 8 nephelometric turbidity units (NTU) in flocculant-disinfectant households, compared with 55 NTU in the two other compounds (P < 0.001).

CONCLUSIONS

In areas of turbid water, flocculant-disinfectant was associated with a significant reduction in diarrhoea among children < 2 years. This health benefit, combined with a significant reduction in turbidity, suggests that the flocculant-disinfectant is well suited to areas with highly contaminated and turbid water.