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.

Estimates of the Burden of Rotavirus Disease in Malaysia

BACKGROUND

Accurate national estimates of the disease burden associated with rotavirus diarrhea are essential when considering implementation of a rotavirus vaccination program. We sought to estimate rotavirus disease-associated morbidity and mortality in Malaysia, using available sources of information.

METHODS

We analyzed national data from the Ministry of Health (Kuala Lumpur, Malaysia) to derive rates of hospitalization, clinic visits, and deaths related to acute gastroenteritis (AG) among children <5 years of age. The number of events attributable to rotavirus infection was estimated by multiplying age-stratified rates of detection of rotavirus from 2 hospital surveillance sites by national data.

RESULTS

In 1999 and 2000, an average of 13,936 children (1 in 187 children) were hospitalized annually for AG. Surveillance of visits to outpatient clinics for AG identified an average of 60,342 such visits/year between 1998 and 2000. The AG-associated mortality rate was 2.5 deaths/100,000 children. On the basis of the finding that 50% of children were hospitalized for rotavirus diarrhea, we estimated that 1 in 61 children will be hospitalized for rotavirus disease and that 1 in 37 children will seek treatment as an outpatient.

CONCLUSIONS

Among Malaysian children, there is a significant burden associated with AG- and rotavirus disease-related hospitalizations and outpatient visits, and this burden potentially could be prevented by the use of rotavirus vaccines.

Hospital‐Based Surveillance for Rotavirus Diarrhea in Children in Yangon, Myanmar

Diarrhea is a common childhood illness in Myanmar, and rotavirus is the single most important etiological agent of diarrhea. Surveillance for rotavirus diarrhea in children <5 years of age was conducted in a tertiary pediatric hospital in Yangon, Myanmar, from January 2002 through December 2003. Stool specimens obtained from children admitted to the hospital for acute diarrhea were tested for the presence of rotavirus by use of an enzyme-linked immunosorbent assay. Diarrhea was the cause of 5671 (18%) of all hospitalizations of children <5 years of age during the 2-year study period (n = 30,869). Rotavirus was identified in 923 (53%) of the 1736 stool specimens tested, and rotavirus infection was associated with approximately 10% of all hospitalizations of children. Rotavirus diarrhea most frequently occurred in children 6-17 months of age, and it was more commonly identified in boys (62% of children with rotavirus diarrhea were boys). The seasonal pattern of rotavirus disease mimicked that of diarrheal illness due to all causes, with the peak season for rotavirus disease occurring from November through February (i.e., during the cool, dry season). During the study period, 53 of the children who were hospitalized for diarrhea died. The present study confirms the importance of the etiological role that rotavirus plays in childhood diarrhea.

Epidemiological Profile and Burden of Rotavirus Diarrhea in Vietnam: 5 Years of Sentinel Hospital Surveillance, 1998–2003

For 5 years, we have conducted sentinel surveillance for rotavirus at 6 hospitals in 4 cities in Vietnam. Stool samples obtained from >10,000 children <5 years old who were admitted to the hospital with diarrhea have been screened for rotavirus. Overall, 55% of samples were positive, and there was little variability in rates of detection of rotavirus between sites (44%-62%). In Vietnam, the characteristics of rotavirus infection more closely resemble those seen in developed countries, rather than those seen in developing countries: children become infected at an older age, the percentage of stool samples in which rotavirus is detected is extremely high, and the rotavirus strains appear to be the common types, with fewer mixed infections occurring. It is estimated that 5300-6800 children <5 years old die of rotavirus infection each year in Vietnam, representing 8%-11% of all deaths in this age group (cumulative risk per child by age 5 years, 1 in 200 to 1 in 285). Additional studies are ongoing to document the economic cost of the disease and to assess the burden of both fatal cases and milder cases of disease. Study outcomes will provide information for future testing and potential use of a rotavirus vaccine.

Projected Cost‐Effectiveness of Rotavirus Vaccination for Children in Asia

BACKGROUND

New rotavirus vaccines may soon be licensed, and decisions regarding implementation of their use will likely be based on the health and economic benefits of vaccination.

METHODS

We estimated the benefits and cost-effectiveness of rotavirus vaccination in Asia by using published estimates of rotavirus disease incidence, health care expenditures, vaccine coverage rates, and vaccine efficacy.

RESULTS

Without a rotavirus vaccination program, it is estimated that 171,000 Asian children will die of rotavirus diarrhea, 1.9 million will be hospitalized, and 13.5 million will require an outpatient visit by the time the Asian birth cohort reaches 5 years of age. The medical costs associated with these events are approximately 191 million US dollars; however, the total burden would be higher with the inclusion of such societal costs as lost productivity. A universal rotavirus vaccination program could avert approximately 109,000 deaths, 1.4 million hospitalizations, and 7.7 million outpatient visits among these children.

CONCLUSIONS

A rotavirus vaccine could be cost-effective, depending on the income level of the country, the price of the vaccine, and the cost-effectiveness standard that is used. Decisions regarding implementation of vaccine use should be based not only on whether the intervention provides a cost savings but, also, on the value of preventing rotavirus disease-associated morbidity and mortality, particularly in countries with a low income level (according to 2004 World Bank criteria for the classification of countries into income groups on the basis of per capita gross national income) where the disease burden is great.

[Risk factors of death in children with diarrhea and shock admitted to the intensive care unit]

BACKGROUND

Describe clinical and epidemiological characteristics of pediatric patients diagnosed with acute diarrhea and shock, admitted to the pediatric intensive care unit, in order to compare the evolution of clinical data between the survival and non-survival groups, thereby identifying the risk factors of death.

METHODS

In the Pediatric Intensive Care Unit of the Clinical Hospital at the State University of Campinas (UNICAMP), a non-controlled, descriptive and retrospective study was carried out from February 1994 to January 1998 The epidemiological and clinical/evolution data were analyzed and the groups of those who survived (56) and did not survive (15) were compared. For continuous variables, the Chi-Square test was used and for categorical variables, the Fisher's Exact test, for values lower than five.

RESULTS

Seventy one children aged from 0.4 to 13.9 months were admitted, 15 of them died (21.2%). Low birth weight was found in 18.1% and the mean breast-feeding time was 1.1 months. The average length of stay was 5.6 days. 52/71 children needed mechanical ventilation, use of vasoactive drugs and sodium bicarbonate was necessary in 23/71 and 15/71, respectively. 93% of children were given antibiotics. The use of sodium bicarbonate, vasoactive drugs and mechanical ventilation showed an association with risk of death, but only vasoactive drugs (OR=18.56) and an age less than 3 months (OR=0.10) showed a statistically significant difference in multivariate analysis.

CONCLUSIONS

Acute diarrhea and shock occurred mainly in children under 3 months of age with a severe clinical/laboratorial condition. During clinical evolution, the high risk of death was related to the use of vasoactive drugs, a support therapy used in critical patients.

Antimicrobial resistance in developing countries. Part I: recent trends and current status

The global problem of antimicrobial resistance is particularly pressing in developing countries, where the infectious disease burden is high and cost constraints prevent the widespread application of newer, more expensive agents. Gastrointestinal, respiratory, sexually transmitted, and nosocomial infections are leading causes of disease and death in the developing world, and management of all these conditions has been critically compromised by the appearance and rapid spread of resistance. In this first part of the review, we have summarised the present state of resistance in these infections from the available data. Even though surveillance of resistance in many developing countries is suboptimal, the general picture is one of accelerating rates of resistance spurred by antimicrobial misuse and shortfalls in infection control and public health. Reservoirs for resistance may be present in healthy human and animal populations. Considerable economic and health burdens emanate from bacterial resistance, and research is needed to accurately quantify the problem and propose and evaluate practicable solutions. In part II, to be published next month, we will review potential containment strategies that could address this burgeoning problem.

Cotrimoxazole prophylaxis by HIV-infected persons in Uganda reduces morbidity and mortality among HIV-uninfected family members

BACKGROUND

The effect of cotrimoxazole prophylaxis taken by persons with HIV on community health and antimicrobial resistance is unknown.

OBJECTIVE

To assess the effect of cotrimoxazole prophylaxis taken by persons with HIV on morbidity, mortality, and antimicrobial resistance of diarrheal pathogens infecting their HIV-negative family members.

DESIGN

Prospective cohort in rural Uganda.

METHODS

A total of 879 persons with HIV and 2771 HIV-negative family members received weekly home-visits. After 5 months, persons with HIV received daily cotrimoxazole prophylaxis and households were followed for an average of 17 additional months.

FINDINGS

During the study, 224 participants with HIV (25%) and 29 household members (1%) died. Mortality among HIV-negative family members < 10 years old was 63% less during the cotrimoxazole period than before [hazard ratio, 0.37; 95% confidence interval (CI), 0.14-0.95; P = 0.04]. Malaria among family members was less common during cotrimoxazole treatment [incidence rate ratio (IRR), 0.62; CI, 0.53-0.74; P < 0.0001], as were diarrhea (IRR, 0.59; CI, 0.45-0.76; P = 0.0001), and hospitalizations (IRR, 0.57; CI, 0.36-0.92; P = 0.02). Death of a parent with HIV was associated with a threefold increase in mortality among HIV-negative children < 10 years old (hazard ratio, 2.9; CI, 1.1-8.1; P = 0.04). Of 134 bacterial isolates from family members before cotrimoxazole treatment, 89 (66%) were resistant to cotrimoxazole; of 75 recovered during cotrimoxazole treatment, 54 (72%) were resistant (P = 0.41).

INTERPRETATION

Cotrimoxazole prophylaxis taken by persons with HIV was associated with decreased morbidity and mortality among family members. Antimicrobial resistance among diarrheal pathogens infecting family members did not increase. Concerns regarding the spread of bacterial resistance should not impede implementation of cotrimoxazole programs.

Community-based surveillance: a pilot study from rural Cambodia

OBJECTIVE

This study seeks to assess the performance of a community-based surveillance system (CBSS), developed and implemented in seven rural communes in Cambodia from 2000 to 2002 to provide timely and representative information on major health problems and life events, and so permit rapid and effective control of outbreaks and communicable diseases in general.

METHODS

Lay people were trained as Village Health Volunteers (VHVs) to report suspected outbreaks, important infectious diseases, and vital events occurring in their communities to local health staff who analysed the data and gave feedback to the volunteers during their monthly meetings.

RESULTS

Over 2 years of its implementation, the system was able to detect outbreaks early, regularly monitor communicable disease trends, and to provide continuously updated information on pregnancies, births and deaths in the rural areas. In addition, the system triggered effective responses from both health staff and VHVs for disease control and prevention and in outbreaks.

CONCLUSION

A CBSS can successfully fill the gaps of the current health facility-based disease surveillance system in the rapid detection of outbreaks, in the effective monitoring of communicable diseases, and in the notification of vital events in rural Cambodia. Its replication or adaptation for use in other rural areas in Cambodia and in other developing countries is likely to be beneficial and cost-effective.

Gaps in policy-relevant information on burden of disease in children: a systematic review

BACKGROUND

Valid information about cause-specific child mortality and morbidity is an essential foundation for national and international health policy. We undertook a systematic review to investigate the geographical dispersion of and time trends in publication for policy-relevant information about children's health and to assess associations between the availability of reliable data and poverty.

METHODS

We identified data available on Jan 1, 2001, and published since 1980, for the major causes of morbidity and mortality in young children. Studies with relevant data were assessed against a set of inclusion criteria to identify those likely to provide unbiased estimates of the burden of childhood disease in the community.

FINDINGS

Only 308 information units from more than 17,000 papers identified were regarded as possible unbiased sources for estimates of childhood disease burden. The geographical distribution of these information units revealed a pattern of small well-researched populations surrounded by large areas with little available information. No reliable population-based data were identified from many of the world's poorest countries, which account for about a third of all deaths of children worldwide. The number of new studies diminished over the last 10 years investigated.

INTERPRETATION

The number of population-based studies yielding estimates of burden of childhood disease from less developed countries was low. The decreasing trend over time suggests reductions in research investment in this sphere. Data are especially sparse from the world's least developed countries with the highest child mortality. Guidelines are needed for the conduct of burden-of-disease studies together with an international research policy that gives increased emphasis to global equity and coverage so that knowledge can be generated from all regions of the world.

The use of simplified verbal autopsy in identifying causes of adult death in a predominantly rural population in Ethiopia

BACKGROUND

Information on adult mortality is essentially non-existent in Ethiopia particularly from rural areas where access to health services is limited and most deaths occur at home. This study was conducted with the aim of identifying causes of adult death in a rural population of Ethiopia using a simplified verbal autopsy instrument.

METHODS

All deaths in the age-group 15-49 years during the period of 1995-99 were taken from computerized demographic surveillance database maintained by the Butajira Rural Health Program. Data on the causes of death were collected from close relatives of the deceased persons by lay interviewers. Causes of death were diagnosed using "expert algorithm" programmed onto a computer.

RESULTS

The major causes of death were acute febrile illnesses (25.2%), liver diseases (11.3%), diarrheal diseases (11.1%), tuberculosis (9.7%) and HIV/AIDS (7.4%). Overall communicable diseases accounted for 60.8% of the deaths. The high levels of mortality from communicable diseases reflect the poor socioeconomic development of the country, and the general poor coverage of health and education services in rural Ethiopia. The tools used in this study can easily be added-on to the numerous health surveys conducted in the country.

CONCLUSION

The simplified approach to verbal autopsy diagnosis can produce useful data that can effectively guide priority health interventions in rural areas where routine information system is either very weak or non-existent.

Risk factors and mortality associated with Clostridium difficile-associated diarrhoea at a VA hospital

The objective of this study was to evaluate the risk of certain patient co-morbidities and antibiotics in the development of Clostridium difficile-associated diarrhoea (CDAD). Hospitalized patients developing CDAD during a specified period were compared with a cohort of patients, matched by age, without a diagnosis of CDAD, who were hospitalized during the same time period. Data collection included demographics, hospital ward, co-morbid conditions, antibiotics received, and mortality. Gender and age were similar in both groups. Co-morbid conditions significantly associated with the case group included cancer and COPD. The most commonly prescribed antibiotics in the case versus control group included levofloxacin, intravenous vancomycin, clindamycin, and piperacillin/tazobactam. The case group was associated with a higher mortality rate.

Equitable child health interventions: the impact of improved water and sanitation on inequalities in child mortality in Stockholm, 1878 to 1925

Today, many of the 10 million childhood deaths each year are caused by diseases of poverty--diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed.

Community Perceptions of Important Camel Diseases in Lapur Division of Turkana District, Kenya

This paper presents the results of a study conducted in Lapur Division of Turkana District, Kenya, to estimate the incidence and mortality of camel trypanosomosis using participatory methods. Four livestock camps ('adakars') were conveniently selected for the study. Four informant groups comprising 6 8 key persons were used for the participatory exercises. The camel diseases identified by the pastoralists in their order of importance according to annual incidence were: trypanosomosis (11.4%); mange (10.8%); tick infestation (7.9%); haemorrhagic septicaemia (7.7%); and non-specific diarrhoea (7.6%). Almost half (49.3%) of the camel population suffered from at least one disease over the previous year. The annual incidence and mortality rates of trypanosomosis were estimated at 15%, and 9.9%, in adult camels and 6.9% and 5.2%, in young camels, respectively. There was a seasonal occurrence of trypanosomosis, with most cases reported in the dry season. The prevalence levels of the disease reportedly declined from about 100%, in 1978 to an almost stable state of about 15% in 2002. This study revealed that camel trypanosomosis is still an important disease in Turkana District, exacting a heavy toll in terms of morbidity and mortality. The economic losses due to the disease were likely to have been great owing to the central role the camel plays in this arid district of Kenya.

A retrospective study of the diagnoses and survival of elk admitted to a large animal referral clinic

Information for veterinarians regarding diseases of farmed elk remains scarce despite an increase in the size of the industry. This retrospective study examines all (n=245) elk cases admitted to the Western College of Veterinary Medicine over an 11-year period (1991 to 2001). Age, gender, date of admission, diagnosis, and outcome were examined. Diarrhea, fractures, and other musculoskeletal problems were most common. Most (76%) cases involved elk under 1 y of age; these were more commonly diagnosed with fractures or diarrheal disease. Elk older than 1 y of age tended to be diagnosed with fractures or noninfectious diseases. Overall, the most common diagnosis was fractures, which were seen mostly as traumatic catastrophic long bone fractures. Fractures and other musculoskeletal problems occurred towards the end of summer and into the fall, while diarrhea and other infectious diseases were diagnosed in young elk in the spring and summer. The in-hospital case fatality rate was 33.5%.

Comorbidity in childhood in northern Ghana: magnitude, associated factors, and impact on mortality

BACKGROUND

It has been observed that in developing countries terminal illness in children under 5 yr of age is frequently characterized by comorbidity. This study seeks to quantify the co-occurrence of illness at the community level and investigates whether this co-occurrence increases the risk of mortality. We develop an appropriate measure of co-occurrence and investigate whether the comorbidity occurs by chance or whether it is due to shared risk factors.

METHODS

The data used for the analysis was taken from a study carried out from 1989 to 1991 in northern Ghana on children aged 2-59 months (n = 1879). Coding for diarrhoea, pneumonia, and measles was carried out using the classification system of the WHO/UNICEF strategy for the Integrated Management of Childhood Illness; malaria was confirmed by laboratory analysis. A bivariate probit analysis was conducted to quantify comorbidity. We used an additive regression model, implemented using the Generalized Estimating Equation approach, to examine the impact on mortality.

RESULTS

There is evidence of co-occurrence of diarrhoeal diseases and pneumonia, with greater comorbidity with increasing severity of disease. There is no evidence that the co-occurrence of diarrhoea with severe dehydration and severe pneumonia is characterized by a synergistic effect on mortality risk.

CONCLUSIONS

Our study has shown that it is possible to have significant co-occurrence of illness at the community level. The bivariate probit procedure was easily adopted and considered appropriate for the analysis of comorbidity. The lack of suitable datasets for a more thorough analysis of comorbidity, and for the evaluation of synergistic effects on mortality, is a major limitation.

Management of children with infection-associated persistent diarrhea

Diarrhea is the leading cause of death in children younger than 5 years of age; persistent diarrhea accounts for 30 to 50 percent of those deaths in developing countries. Malnutrition, immunosuppression, young age, and an increase in the preceding diarrhea burdens are risk factors for the development of persistent diarrhea. Although many viruses, bacteria, and parasites can produce persistent diarrhea, enteropathogenic Escherichia coli , enteroaggregative E. coli, Giardia, Cryptosporidium , and Cyclospora are the most important of these agents. With currently available tests, identifying a specific cause usually is difficult. Newer sensitive molecular tests must be used for studying the epidemiology of persistent diarrhea in children. Management includes rehydration, adequate diet, micronutrient supplementation, and antimicrobials. Persistent diarrhea seriously affects nutritional status, growth, and intellectual function. Meeting these challenges is profoundly important, particularly in developing countries.

Modeling diarrhea disease in children less than 5 years old

PURPOSE

Identification of the temporal pattern of diarrhea disease in children less than 5 years of age in Rio de Janeiro City (1995-1998) to provide support for decisions about prevention and control of the disease.

METHODS

The weekly counts of hospitalizations and deaths due to diarrhea disease were analyzed separately. An initial generalized linear model (GLM) was derived using variables related to weather and month. Displays of fitted generalized additive models (GAM) including a spline smoothed function of time suggested additional predictors that were used to obtain new models.

RESULTS

The initial models did not properly account for the observed cyclical pattern of the data. Graphical displays of the GAM model show a nonhomogeneous decline and annual cycles. Stepwise fitting of GLMs with two factors (cycle and season), and a time trend, showed that the full three-way interaction model was required. Plots of the residuals from the death model suggested a mixture of distributions while the residuals from the hospitalization model were approximately normal.

CONCLUSIONS

The same general pattern for both time series was found by graphical inspection and fitting of appropriate GLMs. This study provides some additional evidence that severe cases of diarrhea disease may be attributed to rotavirus.

Diarrhea morbidity and mortality in Mexican children: impact of rotavirus disease

AIM

To analyze changes in prevalence and seasonality of diarrhea morbidity and mortality and to evaluate the impact of rotavirus disease among Mexican children younger than 5 years old.

METHODS

Diarrhea surveillance was performed from 1990 to 2002. Rotavirus testing was performed on stool specimens from 1996 to 2002. Data were obtained from different surveillance systems considering a nationwide representation in Mexico. Diarrhea morbidity and mortality rates were analyzed against time to determine trends or seasonal patterns.

RESULTS

Improvement of surveillance for all diarrhea episodes denoted an initial morbidity increase from 1995 to 1999, followed by a decrease by 2002, without any seasonal pattern. However, from 1990 to 1995, morbidity for severe diarrhea decreased 63%. From 1996 to 2002, 62-68% of severe diarrhea episodes occurring during the fall-winter season (FWS) were rotavirus-positive compared with 6-12% in the spring-summer season (SSS). From 1990 to 2002, diarrhea mortality decreased 84%. Higher mortality rates for children younger than 1 year old coincided precisely during the FWS, annually. Both severe diarrhea episodes and diarrhea deaths denoted a changing seasonal pattern. In 1990-1991, 2 waves of increased diarrhea activity occurred. The increase in SSS was much more pronounced than that in FWS. From 1992 to 1995 for severe diarrhea and from 1993 to 2002 for diarrhea deaths, the SSS frequencies subsequently reduced, whereas the FWS peaks remained annually.

CONCLUSIONS

A significant reduction in morbidity and mortality of severe diarrhea has occurred from 1990 and 2002 in Mexican children younger than 5 years old. This is a consequence of preventive programs initiated for cholera control since 1991, which had greater impact on SSS diarrhea and limited response for FWS diarrhea, when rotavirus is mainly present. Currently rotavirus diarrhea requires new prevention strategies and specific control measures, such as a specific national vaccine program.

Impact of a standardized management protocol on mortality of children with diarrhoea: an update of risk factors for childhood death

In the developing world, diarrhoeal disease is a significant cause of childhood morbidity especially amongst severely malnourished children. As a direct result of improved acute-phase management of this group of patients, there has been a 47 per cent reduction in the death rate among severely malnourished children hospitalized at the ICDDR,B in Bangladesh. The change in the risk factors for death among children aged under 5 years presenting with diarrhoea was reassessed. The charts of 366 children under 5 years of age who were hospitalized for diarrhoeal disease in the year 1998 were retrospectively analysed. One hundred and eighty-three of these patients died and 183 of those who survived acted as controls. Univariate analysis found 12 significant risk factors on admission that impacted outcome. Only two factors, female sex and positive blood culture, remained significant in the multivariate analysis with odds ratios (95 per cent CI) of 2.05 (1.1-4.0) and 4.6 (1.7-12.4), respectively. Prior to the change in the protocol involving the management of severely malnourished children, only severe malnutrition and non-breastfeeding were found to be significant predictors of mortality.

[Clinical signs and diagnosis of a severe primary infection with BVDV subtype 1b in a dairy herd]

As a result of a BVDV infection in a herd consisting of 95 adult cattle 17 cows aborted their calves within a period of 3.5 months, one third got severe diarrhoea, 3 cows died and an increased percentage of the cattle got lochiometra after calving or abortion. The disease was diagnosed by paired serological testing of cattle with diarrhoea or abortion and post mortem examination of several aborted calves. From one foetus BVDV virus was isolated and subsequently subtyped by sequencing. Of aborting cattle, the testing results were influenced by the interval between infection and abortion. These results indicate that a primary infection with BVDV subtype 1b can cause severe clinical symptoms in a dairy herd.

Recommended guidelines for the treatment of cancer treatment-induced diarrhea

PURPOSE

To update and expand on previously published clinical practice guidelines for the treatment of cancer treatment-induced diarrhea.

METHODS

An expert multidisciplinary panel was convened to review the recent literature and discuss recommendations for updating the practice guidelines previously published by this group in the Journal of Clinical Oncology in 1998. MEDLINE searches were performed and the relevant literature published since 1998 was reviewed by all panel members. The treatment recommendations and algorithm were revised by panel consensus.

RESULTS

A recent review of early toxic deaths occurring in two National Cancer Institute-sponsored cooperative group trials of irinotecan plus high-dose fluorouracil and leucovorin for advanced colorectal cancer has led to the recognition of a life-threatening gastrointestinal syndrome and highlighted the need for vigilant monitoring and aggressive therapy for this serious complication. Loperamide remains the standard therapy for uncomplicated cases. However, the revised guidelines reflect the need for recognition of the early warning signs of complicated cases of diarrhea and the need for early and aggressive management, including the addition of antibiotics. Management of radiation-induced diarrhea is similar but may not require hospitalization, and chronic low- to intermediate-grade symptoms can be managed with continued loperamide.

CONCLUSION

With vigilant monitoring and aggressive therapy for cancer treatment-induced diarrhea, particularly in patients with early warning signs of severe complications, morbidity and mortality may be reduced.

Codelivery of a tea extract prevents morbidity and mortality associated with oral vanadate therapy in streptozotocin-induced diabetic rats

Oral administration of vanadate has a strong hypoglycemic effect but results in toxic side effects like life-threatening diarrhea. Tea is known to have potent antidiarrhea effects. We investigated the potential of suspending the vanadate in a tea decoction to reduce the diarrheatic action of vanadate. A concentrated extract of Lichee black tea was, therefore, added to sodium orthovanadate. Streptozotocin (STZ)-induced diabetic rats were orally gavaged with vanadate suspended in water or in the tea decoction, or with the tea extract alone. Blood glucose levels were assessed daily over 11 weeks with levels greater than 10 mmol/L warranting therapeutic intervention. Both the vanadate/water and vanadate/tea solutions acutely reduced blood glucose. The tea extract alone had no effect. The majority of vanadate/water-treated rats developed diarrhea and mortality rates approached 40%. Vanadate/tea-treated diabetic rats experienced no diarrhea or mortality and liver and kidney analyses (plasma ALT and creatinine, blood urea nitrogen [BUN], and urine-specific gravity) were normal. Animals treated with vanadate/tea retained blood glucose levels less than 10 mmol/L for an average of 24 consecutive days without subsequent treatments. Cataract formation was completely prevented. The mechanism of action of vanadate may have involved beta-cell stimulation because vanadate/tea-treated diabetic rats exhibited normal plasma insulin levels. In summary, because of its long-lasting effects, oral administration, and lack of side effects, vanadate/tea represents a potentially important alternative therapy for an insulin-deficient diabetic state.

[Excess mortality by diarrhea simultaneous to a cholera epidemic in Northeastern Brazil]

OBJECTIVE

To evaluate excess mortality due to infectious diarrhea without etiological diagnosis, occurring simultaneously to Vibrio cholerae circulation.

METHODS

Statistical modeling was applied to a time series of deaths ascribed to "poorly defined intestinal infections" (International Classification of Diseases -- ICD-9) and "presumably infectious diarrhea and gastroenteritis" (ICD-10), between 1980 and 1998 in the Northeast region of Brazil. The prediction of expected values was obtained after a discontinuity point. Excess mortality was calculated as the difference between observed figures and those estimated by the model.

RESULTS

Between 1992 and 1994, only 19.3% of deaths by cholera were actually notified. In 1993, the year in which the epidemic reached its peak in the area, our modeling estimated underregistration at 82.2%.

CONCLUSIONS

Results indicate substantial underregistration of cholera mortality during the epidemic in Northeastern Brazil.

Reduced case fatality among hospitalized children during a war in Guinea-Bissau: a lesson in equity

BACKGROUND

During a recent armed conflict in Guinea-Bissau, we observed a marked decline in the case fatality among hospitalized children at the only paediatric department in the country.

AIM

To analyse the causes behind the observed fall in case fatality.

MATERIAL

All children hospitalized at the only paediatric department in the capital of Guinea-Bissau. The war cohort comprised all children hospitalized during the war, which lasted from June 1998 to May 1999, and the peace cohort comprised all children hospitalized in the year preceding the war. As part of a longitudinal community study, we also registered all children being hospitalized from the Bandim Health Project's study area, including routinely collected information on socio-economic background factors.

METHODS

The war cohort was compared with the peace cohort in terms of determinants for hospital case fatality. Through information in the community register, we examined post-hospital mortality in the 2 wk after discharge as well as socio-economic differences in recruitment during the war. Hospital case fatality was estimated by odds ratios and compared by multiple logistic regression. Community mortality risk was estimated by deaths per person years.

RESULTS

The case fatality among children aged 0-14 y fell during the war (age-adjusted OR = 0.58; 95% CI: 0.50-0.68). There was a uniform reduction in case fatality among children hospitalized less than 7 d, while we observed no decline among children hospitalized longer. There were more children per bed during the war and mean hospitalization time was shorter, and post-discharge mortality also fell (mortality ratio (MR) = 0.57; 95% CI: 0.40-0.83). Adjustment for socio-economic confounders in recruitment during the war period made no difference to the estimated decline in case fatality. The decline in case fatality at the hospital was not explained by a general decline in mortality. Compared with the preceding year, the mortality ratio was 1.34 (1.20-1.51) in the Bandim Health Project's study area during the war. Adjusted for age, the decline in case fatality at the hospital was most marked for disadvantaged groups. For example, the general reduction in case fatality was 42% (95% CI: 11-63); however, children of mothers without any schooling experienced a reduction of 73% (95% CI: 27-90%), whereas the reduction was only 33% (95% CI: 14-61%) for children of mothers with school education.

CONCLUSION

The decline in case fatality could be explained neither by a general decline in childhood mortality nor by changes in recruitment or discharge policy. The decline was therefore most likely due to improved treatment as a result of better availability of drugs funded by humanitarian aid and the presence of dedicated staff, which was offered relief food as compensation. Interventions improving case management may have a proportionately larger effect for poor families.

Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles

BACKGROUND

Previous analyses derived the relative risk (RR) of dying as a result of low weight-for-age and calculated the proportion of child deaths worldwide attributable to underweight.

OBJECTIVES

The objectives were to examine whether the risk of dying because of underweight varies by cause of death and to estimate the fraction of deaths by cause attributable to underweight.

DESIGN

Data were obtained from investigators of 10 cohort studies with both weight-for-age category (<-3 SDs, -3 to <-2 SDs, -2 to <-1 SD, and >-1 SD) and cause of death information. All 10 studies contributed information on weight-for-age and risk of diarrhea, pneumonia, and all-cause mortality; however, only 6 studies contributed information on deaths because of measles, and only 3 studies contributed information on deaths because of malaria or fever. With use of weighted random effects models, we related the log mortality rate by cause and anthropometric status in each study to derive cause-specific RRs of dying because of undernutrition. Prevalences of each weight-for-age category were obtained from analyses of 310 national nutrition surveys. With use of the RR and prevalence information, we then calculated the fraction of deaths by cause attributable to undernutrition.

RESULTS

The RR of mortality because of low weight-for-age was elevated for each cause of death and for all-cause mortality. Overall, 52.5% of all deaths in young children were attributable to undernutrition, varying from 44.8% for deaths because of measles to 60.7% for deaths because of diarrhea.

CONCLUSION

A significant proportion of deaths in young children worldwide is attributable to low weight-for-age, and efforts to reduce malnutrition should be a policy priority.

Aging and infectious diseases in the developing world

Although demographic aging does not remain restricted to industrialized countries, the medical challenge arising from the aging population will be distinct in the developing world. This is particularly true with respect to infectious diseases, which have a distinct spectrum in the elderly population, as well as a greater overall relevance in the developing world. Tropical diseases have a specific presentation and epidemiology in elderly patients. Infectious diseases with a worldwide distribution impact elderly patients in the developing world in a specific manner, which is most obvious with respect to human immunodeficiency virus and tuberculosis but is also true with respect to "trivial" manifestations of infection, such as diarrhea and pneumonia. Malnutrition contributes in a major way to the immunodeficiency of elderly patients in the developing world. Poorly controlled use of antimicrobial drugs leads to multidrug-resistant microorganisms, which, together with the limited resources available for drug treatment, makes appropriate treatment of infections in elderly patients in developing countries very difficult. Infections in elderly patients will have an increasing impact on the public health and economy of developing countries.

Cost effectiveness of a latrine revision programme in Kabul, Afghanistan

INTRODUCTION

We assessed a household latrine revision intervention implemented in Kabul, Afghanistan for evidence of a reduction in diarrhoeal disease.

METHODS

A case-control design involving 1238 cases and 625 controls was used. Logistic regression modelling was performed both for children < 5 years and < or = 11 years, and the parameter estimates were later used with results from a stratified cluster sample survey. This survey used a verbal autopsy methodology to enable an estimation of the number of deaths averted over a 1-year period. A cost-effectiveness analysis using direct and indirect costs for the intervention was then conducted and the results compared with primary health care interventions identified from a Medline search.

FINDINGS

Conditional logistic regression showed that patients were less likely than controls to live in households with revised latrines (odds ratio (OR) 0.57, 95% confidence interval (CI) = 0.42-0.77 for children < 5 years, and OR 0.53, 95% = CI 0.41-0.67 for children < or = 11 years). The results from the survey of cause-specific mortality by verbal autopsy enabled estimation of the number of deaths averted over a 1-year period due to the intervention; these estimations were 235 (95% CI = 109-360) for children < 5 years and 285 (95% CI = 180-397) for children < or = 11 years. Estimates of cost effectiveness ranged from approximately US dollars 1800 to US dollars 4100 per death averted depending on age and payer perspective.

CONCLUSION

These estimates are conservative because only 1 year of effectiveness is considered, yet they compare favourably with a review of other paediatric interventions. These results are important because funding for sanitation interventions is often limited by the belief that the interventions are not cost-effective.

Randomized controlled trial of the effect of daily supplementation with zinc or multiple micronutrients on the morbidity, growth, and micronutrient status of young Peruvian children

BACKGROUND

Zinc supplements reduce childhood morbidity in populations in whom zinc deficiency is common. In such populations, deficiencies in other micronutrients may also occur.

OBJECTIVE

The objective was to determine whether the administration of other micronutrients with zinc modifies the effect of zinc supplementation on children's morbidity and physical growth.

DESIGN

Two hundred forty-six children aged 6-35 mo with persistent diarrhea were randomly assigned to 1 of 3 groups to receive a daily supplement of 10 mg Zn alone (Zn; n = 81), zinc plus vitamins and other minerals at 1-2 times recommended daily intakes (Zn+VM; n = 82), or placebo (n = 83) for approximately 6 mo after the diarrhea episode ended. Morbidity information was collected on weekdays. Weight, length, and other anthropometric indicators were measured monthly, and plasma zinc and other indicators of micronutrient status were measured at baseline and 6 mo.

RESULTS

Supplement consumption was high ( approximately 90%) in all groups, although slightly more vomiting was reported in the Zn+VM group (P < 0.0001, analysis of variance). The change in plasma zinc from baseline to 6 mo was greater in the 2 zinc groups (6.1, 27.3, and 16.2 micro g/dL in the placebo, Zn, and Zn+VM groups, respectively; P < 0.0001, analysis of variance). The Zn group had fewer episodes of diarrhea, dysentery, and respiratory illness and a lower prevalence of fever and cough than did the Zn+VM group and a lower prevalence of cough than did the placebo group (P = 0.05). No significant effects of supplementation on growth were observed.

CONCLUSION

Morbidity was greater after supplementation with zinc plus multivitamins and minerals than it was after supplementation with zinc alone.

Time series analysis of deaths due to diarrhoea in children in Rio de Janeiro, Brazil, 1980-1998

Diarrhoea is still a considerable public-health problem in developing countries, especially among children aged less than five years. The well-known relationship between seasonal variation and aetiological agents of diarrhoeal diseases helps inform the decisions about the prevention and control measures. The aim of this study was to identify the temporal patterns of deaths due to diarrhoea in children, aged less than five years, in Rio de Janeiro State from 1980 to 1998. The study analyzed data on monthly deaths due to diarrhoea; the data were supplied by the Natural Mortality Information System (NMIS, Ministry of Health of Brazil). Auto Regressive Integrated Moving Average modelling was applied to the data. Using this model, the huge decline and the winter peaks could be highlighted, and they may express the predominance of rotavirus as the aetiology of diarrhoeal deaths, suggesting that an effective vaccine is the main measure for the prevention and control of severe diarrhoea.

Diarrhoea in children: an interface between developing and developed countries

Despite much progress in the understanding of pathogenesis and of management, diarrhoeal illnesses remain one of the most important causes of global childhood mortality and morbidity. Infections account for most illnesses, with pathogens employing ingenious mechanisms to establish disease. In the developed world, an upsurge in immune-mediated gut disorders might have resulted from a disruption of normal bacterial-epithelial cross-talk and impaired maturation of the gut's immune system. Oral rehydration therapies are the mainstay of management of gastroenteritis, and their composition continues to improve. Malnutrition remains the major adverse prognostic indicator for diarrhoea-related mortality, emphasising the importance of nutrition in early management. Drugs are of little use, except for specific indications although new agents that target mechanisms of secretory diarrhoea show promise, as do probiotics. However, preventive strategies on a global scale might ultimately hold the greatest potential to reduce the burden of diarrhoeal disease. These strategies include vaccines and, most importantly, policies to address persisting inequalities between the developed and developing worlds with respect to nutrition, sanitation, and access to safe drinking water.

Capillaria philippinensis: a cause of fatal diarrhea in one of two infected Egyptian sisters

Capillaria philippinensis is an emerging infection in Egypt. Reports in children are scarce. We report here two sisters with C. philippinensis infection, aged 8 and 12 years. Their father was a fisherman and they had a habit of picking small pieces of uncooked fish to eat while their mother prepared their meals. They came from El-Menia governorate, which lies in the northern part of Upper Egypt. Most reported cases from Egypt come from this governorate and nearby areas. Both sisters had persistent profuse watery diarrhea of 12 months' duration. Their weights were below the 5th percentile for age. Both were hypoalbuminemic, but only the younger had pedal edema. Both had hypokalemia and hyponatremia. During the course of their illness they were repeatedly admitted to different hospitals and received intravenous fluids, but the correct diagnosis was not reached. Diagnosis was made by stool examination at our hospital when eggs and larvae were detected in stool samples. Although a diagnosis was promptly made, the older sister who suffered from pneumonia and septic shock unfortunately died a few days after admission. The younger sister was treated successfully with albendazole 200 mg twice daily. Diarrhea abated, pedal edema disappeared, and she started to gain weight.

Padrão temporal das internações e óbitos por diarréia em crianças, 1995 a 1998, Rio de Janeiro

OBJETIVO: Analisar o padrão temporal dos óbitos e internações, no período de 1995 a 1998, associadas à diarréia em crianças menores de cinco anos de idade para subsidiar ações específicas de prevenção e controle dessa doença. MÉTODOS: Os dados foram obtidos do Sistema de Informações sobre Mortalidade (SIM) e Sistema de Internações Hospitalares (SIH) do Ministério da Saúde. As séries mensais de internações e de óbitos por diarréia foram decompostas em componentes de tendência linear estocástica, sazonalidade determinística e irregularidades mediante a aplicação dos modelos estruturais para análise de séries temporais. RESULTADOS: Os níveis de ambas as séries apresentaram mudanças ao longo do tempo, com declínio mais perceptível na série de internações. A variação das taxas de inclinação foi constante para cada uma das séries, em média, a menos 5,3 internações por mês (p-valor <0,001) e menos um óbito por mês (p-valor <0,1), respectivamente. Na análise dos resíduos do modelo de internações, observou-se mudança no nível da tendência em janeiro de 1996. O componente sazonal de ambos os modelos foi estatisticamente significante (p-valor <0,0001), sendo maio e junho os meses com maior excesso de internações e óbitos. Os pressupostos de normalidade e de independência temporal dos resíduos não puderam ser rejeitados ao nível de 0,05. CONCLUSÕES: Os resultados sugerem a predominância da etiologia viral das diarréias moderadas e graves. Neste caso, a vacinação específica é a medida mais eficaz na prevenção e controle, sendo necessários estudos de eficácia de novas candidatas à vacina contra o rotavírus no Brasil.

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

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

Rotavirus vaccine for preventing diarrhoea

BACKGROUND

Rotaviruses cause viral gastroenteritis and result in more deaths from diarrhoea in children under 5 years of age than any other single agent, particularly in low- and middle-income countries.

OBJECTIVES

To assess rotavirus vaccines in relation to preventing rotavirus diarrhoea, death, and adverse events.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group's trial register (October 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to October 2003), EMBASE (January 1980 to October 2003), LILACS (1982 to October 2003), Biological Abstracts (January 1982 to October 2003), reference lists of articles, and contacted researchers and rotavirus vaccine manufacturers.

SELECTION CRITERIA

Randomized controlled trials comparing rotavirus vaccines to placebo, no intervention, or other rotavirus vaccines in children and adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial methodological quality, and contacted trial authors for additional information.

MAIN RESULTS

Sixty-four trials provided information on efficacy and safety of three main types of rotavirus vaccine (bovine, human, and rhesus) for 21,070 children. Different levels of efficacy were demonstrated with different vaccines varying from 22 to 89% to prevent one episode of rotavirus diarrhoea, 11 to 44% to prevent one episode of all-cause diarrhoea, and 43 to 90% to prevent one episode of severe rotavirus diarrhoea. Rhesus vaccine demonstrated a similar efficacy against one episode of rotavirus diarrhoea (37 and 44% respectively), and one episode of all-cause diarrhoea (around 15%) for trials performed in high and middle-income countries. Results on mortality and safety of the vaccines were scarce and incomplete. We noticed important heterogeneity among the pooled studies and were unable to discard a biased estimation of effect.

REVIEWER'S CONCLUSIONS

Current evidence shows that rhesus rotavirus vaccines (particularly RRV-TV) and the human rotavirus vaccine 89-12 are efficacious in preventing diarrhoea caused by rotavirus and all-cause diarrhoea. Evidence about safety, and about mortality or prevention of severe outcomes, is scarce and inconclusive. Bovine rotavirus vaccines were also efficacious, but safety data are not available. Trials of new rotavirus vaccines will hopefully improve the evidence base. Randomized controlled trials should be performed simultaneously in high-, middle-, and low-income countries.

Evaluation of flunixin meglumine as an adjunct treatment for diarrhea in dairy calves

OBJECTIVE

To assess the use of flunixin meglumine as an adjunct treatment for diarrhea in calves.

DESIGN

Clinical trial.

ANIMALS

115 calves with diarrhea that were 1 to 21 days old at enrollment.

PROCEDURE

Calves that developed diarrhea were randomly assigned to receive no flunixin meglumine (controls), a single dose of flunixin meglumine (2.2 mg/kg [1.0 mg/lb]), or 2 doses of flunixin meglumine administered 24 hours apart. Serum IgG concentration and PCV were measured prior to enrollment in the trial. Calves were evaluated daily to determine rectal temperature, fecal consistency, demeanor, and skin elasticity score. The primary analytic outcome was days of sickness (morbid-days).

RESULTS

Calves with fecal blood and treated with a single dose of flunixin meglumine had fewer morbid-days and antimicrobial treatments, compared with controls. Although not significant, calves given 2 doses of flunixin meglumine in 24 hours had fewer morbid-days than untreated control calves. Regardless of severity of diarrhea, calves without fecal blood did not benefit from the use of flunixin. For calves with fecal blood, failure of passive transfer (low serum IgG concentration) was an independent risk factor for increased morbid-days.

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment with a single dose of flunixin meglumine resulted in fewer antimicrobial treatments and morbid-days in calves with fecal blood. As observed in other studies, calves with failure of passive transfer were at high risk for poor outcomes. This emphasizes the importance of developing and implementing effective colostrum delivery programs on dairy farms.

Predicting the distribution of under-five deaths by cause in countries without adequate vital registration systems

BACKGROUND

The absence of complete vital registration and atypical nature of the locations where epidemiological studies of cause of death in children are conducted make it difficult to know the true distribution of child deaths by cause in developing countries. A credible method is needed for generating valid estimates of this distribution for countries without adequate vital registration systems.

METHODS

A systematic review was undertaken of all studies published since 1980 reporting under-5 mortality by cause. Causes of death were standardized across studies, and information was collected on the characteristics of each study and its population. A meta-regression model was used to relate these characteristics to the various proportional mortality outcomes, and predict the distribution in national populations of known characteristics. In all, 46 studies met the inclusion criteria.

RESULTS

Proportional mortality outcomes were significantly associated with region, mortality level, and exposure to malaria; coverage of measles vaccination, safe delivery care, and safe water; study year, age of children under surveillance, and method used to establish definitive cause of death. In sub-Saharan Africa and in South Asia, the predicted distribution of deaths by cause was: pneumonia (23% and 23%), malaria (24% and <1%), diarrhoea (22% and 23%), 'neonatal and other' (29% and 52%), measles (2% and 1%).

CONCLUSIONS

For countries without adequate vital registration, it is possible to estimate the proportional distribution of child deaths by cause by exploiting systematic associations between this distribution and the characteristics of the populations in which it has been studied, controlling for design features of the studies themselves.

Determinants of children's health services utilization in the Philippines

Respiratory illness and diarrhea are the two most important causes of death in children under the age of 5 in the Philippines. The government has accorded high priority to reducing the number of deaths caused by these illnesses as it attempts to reform its healthcare system. In order to re-design health systems, policy makers need to have a good understanding not only of overall health services utilization, but also of the use of public and private sectors. We used the 1998 Philippines National Demographic and Health Survey dataset to understand the service utilization patterns of children under 5 with diarrhea and/or respiratory illness. Using the Andersen Model as the conceptual framework, a nested logit regression approach was used to determine predictors of health services use, and of public vs. private use in this population. Our results indicate that maternal education and number of illnesses determine the decision to seek care. Once the decision has been made to seek care, the choice between a public or private provider is affected by the family's economic status and size of the household. Policy makers can use such information for future health planning and reform, in order to increase access to healthcare for this vulnerable population in the Philippines.

Mortality among displaced former UNITA members and their families in Angola: a retrospective cluster survey

OBJECTIVE

To measure retrospectively mortality among a previously inaccessible population of former UNITA members and their families displaced within Angola, before and after their arrival in resettlement camps after ceasefire of 4 April 2002.

DESIGN

Three stage cluster sampling for interviews. Recall period for mortality assessment was from 21 June 2001 to 15-31 August 2002.

SETTING

Eleven resettlement camps over four provinces of Angola (Bié, Cuando Cubango, Huila, and Malange) housing 149 000 former UNITA members and their families.

PARTICIPANTS

900 consenting family heads of households, or most senior household members, corresponding to an intended sample size of 4500 individuals.

MAIN OUTCOME MEASURES

Crude mortality and proportional mortality, overall and by period (monthly, and before and after arrival in camps).

RESULTS

Final sample included 6599 people. The 390 deaths reported during the recall period corresponded to an average crude mortality of 1.5/10 000/day (95% confidence interval 1.3 to 1.8), and, among children under 5 years old, to 4.1/10 000/day (3.3 to 5.2). Monthly crude mortality rose gradually to a peak in March 2002 and remained above emergency thresholds thereafter. Malnutrition was the leading cause of death (34%), followed by fever or malaria (24%) and war or violence (18%). Most war victims and people who had disappeared were women and children.

CONCLUSIONS

This population of displaced Angolans experienced global and child mortality greatly in excess of normal levels, both before and after the 2002 ceasefire. Malnutrition deaths reflect the extent of the food crisis affecting this population. Timely humanitarian assistance must be made available to all populations in such conflicts.

Dam-related effects on heart girth at birth, morbidity and growth rate from birth to 90 days of age in Swedish dairy calves

We investigated the effects of dam-related factors (such as calving performance, milk leakage, diseases, milk production, and somatic-cell count (SCC)) on heart girth at birth and the incidence risk of diarrhoea and respiratory disease during the first 90 days in Swedish dairy calves. The effects of these dam-related factors and environmental and management-related (but not dietary) factors on the calves' growth rate during the first 90 days of life also were analysed. The study used nearly 3,000 heifer calves born in 1998 on 122 farms in the south-west of Sweden. Individual health records were kept by the farmers and visiting project veterinarians. The calf's heart girth was measured at birth and weaning. We used generalised linear mixed models for the size of the calf at birth and growth rate. Variables associated with the heart girth at birth were breed, calving performance, mastitis in the dam in the last 49 days before calving, milk production and parity. Variables associated with the growth rate were breed, calving performance, disease in the calf during its first 90 days of life, heart girth at birth, and housing of calves. The effect of the dam on the relative risk of diarrhoea and/or respiratory disease in the calf was evaluated by a generalised linear mixed model with a logit link. Morbidity in the dam during late pregnancy, retained placenta and SCC were associated with the relative risk of respiratory disease in the calf. None of the explanatory variables (other then breed) was associated with the relative risk of diarrhoea.

Cryptosporidium parvum in children with diarrhea in Mulago Hospital, Kampala, Uganda

A cross-sectional case-control study (ratio = 3:1) was conducted over a 15-month period to determine the prevalence and consequences of cryptosporidiosis in hospitalized diarrheic children (0-5 years old) at Mulago Hospital in Kampala, Uganda. Cryptosporidium parvum was detected and genotyped among 2,446 children of whom 1,779 (72.7%) had diarrhea, and 667 (27.3%) were age- and sex-matched controls. Of the 1,779 children with diarrhea, 532 (29.9%) had persistent (> 14 days) diarrhea and 1,247 (70.1%) had acute diarrhea. Overall, 444 (25.0%) of the 1,779 children with diarrhea had C. parvum, compared with only 57 (8.5%) of the 667 children without diarrhea (chi2 = 80.2, P < or = 0.0001). Within this group of infected children, 72.8% were infected with genotype 1, 18.4% with genotype 2, and 4.1% with a mixture of both genotypes, and 4.1% isolates were either unclassified or C. meleagridis. The prevalence was highest during the rainy months of April to June. Of the 532 children with persistent diarrhea, 166 (31.2%) had C. parvum compared with 278 (22.3%) of the 1,247 children with acute diarrhea (chi2 = 15.8, P < or = 0.0001). There was a significant association between C. parvum and malnutrition including stunting, being underweight, and wasting. Unfavorable outcome (death or failure to resolve within 14 days) occurred in 139 (72.8%) of the 191 children with C. parvum, and in only 65.1% of the 545 without (odds ratio = 1.117, 95% confidence interval = 1.005-1.243, P = 0.05), Of the 191 children with C. parvum, 24 (12.6%) died, compared with 34 (6.2%) of the 545 without C. parvum (P = 0.005). Mortality rates were higher among children with severe dehydration and persistent diarrhea, and in stunted or underweight children infected with C. parvum. Among Ugandan children, cryptosporidiosis, which remains untreatable, is frequently associated with diarrhea and other serious and unfavorable consequences.

Talking dirty: how to save a million lives

Infectious diseases are still the number one threat to public health in developing countries. Diarrhoeal diseases alone are responsible for the deaths of at least 2 million children yearly - hygiene is paramount to resolving this problem. The function of hygienic behaviour is to prevent the transmission of the agents of infection. The most effective way of stopping infection is to stop faecal material getting into the child's environment by safe disposal of faeces and washing hands with soap once faecal material has contaminated them in the home. A review of the literature on handwashing puts it top in a list of possible interventions to prevent diarrhoea. Handwashing with soap has been calculated to save a million lives. However, few people do wash their hands with soap at these critical times. Obtaining a massive increase in handwashing worldwide requires a sea-change in thinking. Initial results from a new programme led by the World Bank, with many partner organisations, suggest that health is low on people's list of motives, rather, hands are washed to remove dirt, to rinse food off after eating, to make hands look and smell good, and as an act of motherly caring. Professional consumer and market research agencies are being used to work with the soap industry to design professional communications programmes to reach whole populations in Ghana and India. Tools and techniques for marketing handwashing and for measuring the actual impact on behaviour will be applied in new public-private handwashing programmes, which are to start up soon in Nepal, China, Peru and Senegal.