Factors associated with rotavirus diarrhoea in children living in a socially diverse urban centre in Brazil

Study design and rationale for the PAASIM project: a matched cohort study on urban water supply improvements and infant enteric pathogen infection, gut microbiome development and health in Mozambique

INTRODUCTION

Despite clear linkages between provision of clean water and improvements in child health, limited information exists about the health impacts of large water infrastructure improvements in low-income settings. Billions of dollars are spent annually to improve urban water supply, and rigorous evaluation of these improvements, especially targeting informal settlements, is critical to guide policy and investment strategies. Objective measures of infection and exposure to pathogens, and measures of gut function, are needed to understand the effectiveness and impact of water supply improvements.

METHODS AND ANALYSIS

In the PAASIM study, we examine the impact of water system improvements on acute and chronic health outcomes in children in a low-income urban area of Beira, Mozambique, comprising 62 sub-neighbourhoods and ~26 300 households. This prospective matched cohort study follows 548 mother-child dyads from late pregnancy through 12 months of age. Primary outcomes include measures of enteric pathogen infections, gut microbiome composition and source drinking water microbiological quality, measured at the child's 12-month visit. Additional outcomes include diarrhoea prevalence, child growth, previous enteric pathogen exposure, child mortality and various measures of water access and quality. Our analyses will compare (1) subjects living in sub-neighbourhoods with the improved water to those living in sub-neighbourhoods without these improvements; and (2) subjects with household water connections on their premises to those without such a connection. This study will provide critical information to understand how to optimise investments for improving child health, filling the information gap about the impact of piped water provision to low-income urban households, using novel gastrointestinal disease outcomes.

ETHICS AND DISSEMINATION

This study was approved by the Emory University Institutional Review Board and the National Bio-Ethics Committee for Health in Mozambique. The pre-analysis plan is published on the Open Science Framework platform (https://osf.io/4rkn6/). Results will be shared with relevant stakeholders locally, and through publications.

Etiology and risk factors for diarrheal disease amongst rural and peri-urban populations in Cambodia, 2012-2018

Diarrheal diseases are a leading cause of mortality and morbidity, disproportionally affecting persons residing in low and middle-income countries. Accessing high-resolution surveillance data to understand community-level etiology and risk remains challenging, particularly in remote and resource limited populations. A multi-year prospective cohort study was conducted in two rural and two peri-urban villages in Cambodia from 2012 to 2018 to describe the epidemiology and etiology of acute diarrheal diseases within the population. Suspected diarrheal episodes among participants were self-reported or detected via routine weekly household visits. Fresh stool and fecal swabs were tested, and acute-illness and follow-up participant questionnaires collected. Of 5027 enrolled participants, 1450 (28.8%) reported at least one diarrheal incident. A total of 4266 individual diarrhea case events were recorded. Diarrhea incidence rate was calculated to be 281.5 persons per 1000 population per year, with an event rate of 664.3 individual diarrhea events occurring per 1000 population per year. Pathogenic Escherichia coli, Aeromonas spp., and Plesiomonas shigelloides were the most prevalent bacterial infections identified. Hookworm and Strongyloides stercoralis were the predominant helminth species, while Blastocystis hominis and Giardia lamblia were the predominant protozoan species found. Norovirus genotype 2 was the predominant virus identified. Mixed infections of two or more pathogens were detected in 36.2% of positive cases. Risk analyses identified unemployed status increased diarrhea risk by 63% (HR = 1.63 [95% CI 1.46, 1.83]). Individuals without access to protected water sources or sanitation facilities were 59% (HR = 1.59 [95% CI 1.49, 1.69]) and 19% (HR = 1.19 [95% CI 1.12, 1.28]) greater risk of contracting diarrhea, respectively. Patient-level surveillance data captured in this long-term study has generated a unique spatiotemporal profile of diarrheal disease in Cambodia. Understanding etiologies, together with associated epidemiological and community-level risk, provides valuable public health insight to support effective planning and delivery of appropriate local population-targeted interventions.

Epidemiology and pre-vaccine burden of rotavirus diarrhea in Democratic Republic of Congo (DRC): Results of sentinel surveillance, 2009-2019

INTRODUCTION

Since August 2009, the Democratic Republic of Congo (DRC) has implemented sentinel site surveillance for rotavirus gastroenteritis. Limited hospital studies have been carried out, in DRC, describing the epidemiology of rotavirus diarrhea before rotavirus vaccine introduction in October 2019. This analysis describes the epidemiology of rotavirus gastroenteritis and characteristics of circulating viral strains from 2009 to 2019.

MATERIALS AND METHODS

We analyzed demographic and clinic data collected from children < 5 years old enrolled at three rotavirus sentinel surveillance sites in DRC during 2009-2019, prior to rotavirus vaccine introduction in 2019. Data have been described and presented as mean ± standard deviation for quantitative variables with normal distribution, or as median with an interquartile range [Q1-Q3] for quantitative variables with non-normal distribution, or as absolute value with percentage for qualitative variables.

RESULTS

Between August 2009 and December 2019, 4,928 children < 5 years old were admitted to sentinel surveillance sites for gastroenteritis in the DRC; the rotavirus positivity rate was 60 %. There was a slight male gender predominance (56 %), and the majority of children (79 %) were 0-11 months of age. Every year, the incidence was highest between May and September corresponding to the dry and cool season. Genotyping was performed for 50 % of confirmed rotavirus cases. The most common G genotypes were G1 (39 %) and G2 (24 %) and most common P genotypes were P[6] (49 %) and P[8] (37 %). The most common G-P genotype combinations were G1P[8] (22 %), G2P[6] (16 %) and G1P[6] (14 %). Genotype distribution varied by site, age group, and year.

CONCLUSION

From 2009 to 2019, rotavirus-associated gastroenteritis represented a significant burden among DRC children under 5 who were admitted to sentinel sites. G1P[8] was the most commonly identified genotype. Continued monitoring after the introduction of rotavirus vaccine will be essential to monitor any changes in epidemiology.

Diversity of Rotavirus Strains among Children with Acute Diarrhea in Karachi, Pakistan

One of the common viral pathogens in infectious diarrhea is Rotavirus; in developing countries, it is a primary cause of deaths in children less than five years of age. This study was planned to find out the etiologic agents of acute watery diarrhea. In this study, 1465 stool samples were analyzed with the symptoms of acute diarrhea. Demographic data analysis showed no. of episodes of diarrhea, vomiting, and fever. All samples were checked by ELISA technique for the presence of Rotavirus circulating strains. More than 6% patients were found to be positive with Rotavirus. Common Rotavirus genotypes, including G2P4, G2P6, G3P4, G8P4, G8P6, G9P4, and G10P4, were detected in patients through RT-PCR. This study concluded that detection of rotavirus strain diversity and management of diarrheal patients may identify assortment of emerging strains and reduce emergence of antimicrobial resistance and repeated episodes of diarrhea, which may also help to avoid and manage the essential nutrients lost leading to malnutrition and stunted growth, as well as to reduce high mortality rate in young children less than five years.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection

BACKGROUND

Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation.

OBJECTIVES

To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

No direct correlation between rotavirus diarrhea and breast feeding: A meta-analysis

BACKGROUND

Some studies indicated that children with exclusive breast feeding had a reduction in the prevalence of rotavirus diarrhea, while some others held the opposite views. In this study, we aimed to systematically find the associations between rotavirus diarrhea and breast feeding.

METHODS

A literature search up to June 2016 in electronic literature databases, including PubMed and Embase, was performed. The Newcastle-Ottawa Scale was used to conduct the quality assessment of all the selected studies. Statistical analyses were performed using the R package version 3.12 (R Foundation for Statistical Computing, Beijing1, China, meta package), and odds ratio (OR) and 95% confidence interval (CI) were used to assess the strength of the association. The heterogeneity was assessed by Cochran's Q-statistic and I² test, and the sensitivity analysis was performed by trimming one study at a time.

RESULTS

A total of 17 articles, which included 10,841 participants, were investigated in the present meta-analysis. There was no significant difference between the case group and control group (OR, 0.59 95% CI 0.33-1.07) in the meta-analysis of exclusive breast feeding, and no significant difference was found between the case group and the control group (OR, 0.86; 95% CI 0.63-1.16) in the meta-analysis of breast feeding. No significant difference was found between the case group and control group (OR, 0.78 95% CI 0.59-1.04) for all quantitative data.

CONCLUSIONS

There may be no direct correlation between rotavirus diarrhea and breast feeding.

Effects of acupuncture on the urinary metabolome of spontaneously hypertensive rats

BACKGROUND

The mechanism of action underlying the putative effects of acupuncture in essential hypertension remains unknown but neuronal mechanisms have been explored most extensively to date. We aimed to explore the effects of manual acupuncture (MA) with manual stimulation on blood pressure (BP) and urine metabolites in the spontaneously hypertensive rat (SHR) model of hypertension.

METHODS

After adaptive feeding (with a standard laboratory diet and distilled water) for 1 week, five normotensive Wistar Kyoto (WKY) rats with normal BP formed the control group. Ten SHRs were randomised into two groups (n=5 each), one of which received MA at ST9 for a total of 14 days (SHR+MA group). The other (SHR group) and the WKY control group underwent needle insertion without manual stimulation. BP was measured pre- and post-acupuncture in all groups and urinary metabolic profiles were investigated using metabonomics methods based on ¹H nuclear magnetic resonance (NMR) spectroscopy coupled with principal component analysis, partial least squares discriminant analysis, and orthogonal to partial least squares discriminant analysis.

RESULTS

A total of 46 metabolites were clearly separated in the urine by ¹H NMR. Loading plots showed significant changes in urinary metabolite contents after acupuncture treatment as well as significant differences between SHR and WKY rats. Acupuncture at ST9 in SHRs increased urine metabolites including α-ketoglutaric acid, N-acetyl glutamic acid, and betaine. Furthermore, systolic and diastolic BP, mean arterial pressure and heart rate were significantly reduced after acupuncture.

CONCLUSIONS

Acupuncture may decrease BP in SHRs by improving the metabolic disorder associated with hypertension.

Factors associated with nutritional outcomes in the mother–child dyad: a population-based cross-sectional study

Objective

To estimate factors associated with double burden of nutritional outcomes in the mother–child dyad at the household level (child stunting and/or maternal overweight).

Design

Cross-sectional study using the Brazilian Demographic and Health Survey. Nutritional outcomes were: mother with normal weight and child with normal height; overweight mother and child with normal height; mother with normal weight and short-stature child; and overweight mother and child with short stature (double burden). The child was classified as short when height-for-ageZ-score was <−2 and the mother as overweight when BMI was ≥25·00 kg/m2. Socio-economic status, environment, social vulnerability, maternal characteristics and the child’s food intake were the exposure factors. The hierarchical approach for multinomial logistic regression modelling was used to assess the associations.

Setting

National Demographic and Health Survey of Children and Women conducted in Brazil, 2006–2007.

Subjects

Mother–child dyads (n3676).

Results

After adjustments, lower maternal educational level (OR=3·53; 95 % CI 1·33, 9·33) and inadequate household (non-masonry house; OR=2·54; 95 % CI 1·39, 4·66) were associated with the double burden of malnutrition. Mother’s short stature (OR=3·41; 95 % CI 1·76, 6·61), child’s vegetable intake on less than or equal to 4 d/week (OR=2·21; 95 % CI 1·03, 4·75) and inadequate household (non-masonry house; OR=2·29; 95 % CI 1·36, 3·87) were associated with child’s short stature. The lack of breast-feeding (OR=2·00; 95 % CI 1·07, 3·72) was associated with maternal overweight.

Conclusions

The present findings contribute to establishing strategies promoting health and healthy diets, by considering the growth deficit and overweight/obesity concomitantly.

Impact of rainfall on diarrheal disease risk associated with unimproved water and sanitation

Diarrheal disease remains a leading cause of morbidity in areas with limited access to safe water and sanitation. As water and sanitation interventions continue to be implemented, it will be important to understand the ecological context in which they can prevent diarrhea. We conducted six serial case control studies in Ecuador to estimate the risk of diarrhea from unimproved water and sanitation and the potential for effect modification by rainfall. Unimproved water source and unimproved sanitation increased the adjusted odds of diarrhea (odds ratio [OR] = 3.6, 95% confidence interval [95% CI] = 1.7-7.8 and OR = 1.7, 95% CI = 1.2-2.5, respectively). The OR associated with an unimproved water source was highest after maximum rainfall (OR = 6.8, 95% CI = 1.9-24.5), whereas the OR associated with unimproved sanitation was highest after minimal rainfall (OR = 2.9, 95% CI = 1.3-6.6). Our finding that use of safe water sources and improved sanitation facilities are most protective under opposing rainfall conditions highlights the need for integrated interventions to reduce the burden of diarrheal disease.

Characteristics of diarrheal illnesses in non-breast fed infants attending a large urban diarrheal disease hospital in Bangladesh

Background

Lack of breast feeding is associated with higher morbidity and case-fatality from both bacterial and viral etiologic diarrheas. However, there is very limited data on the characteristics of non–breastfed infants attending hospital with diarrheal illnesses caused by common bacterial and viral pathogens. Our objective was to assess the impact of lack of breast feeding on diarrheal illnesses in infants living in urban Bangladesh.

Methods

We extracted data of infants (0–11 months) for analyses from the data archive of Diarrheal Disease Surveillance System (DDSS) of the Dhaka Hospital of icddr,b for the period 2008–2011.

Results

The prevalence of breastfeeding in infants attending the hospital with diarrhea reduced from 31% in 2008 to 17% in 2011, with corresponding increase in the prevalence of non-breastfed (chi square for trend <0.001). Among breastfed infants, the incidence of rotavirus infections was higher (43%) among the 0–5 months age group than infants aged 9–11 months (18%). On the other hand, among non-breastfed infants, the incidence of rotavirus infections was much higher (82%) among 9–11 months old infants compared to those in 0–5 months age group (57%) (chi square for trend <0.001). Very similar trends were also observed in the incidence of cholera and ETEC diarrheas among different age groups of breastfed and non-breastfed infants (chi square for trend 0.020 and 0.001 respectively). However, for shigellosis, the statistical difference remained unchanged among both the groups (chi square for trend 0.240).

Conclusion and Significance

We observed protective role of breastfeeding in infantile diarrhea caused by the major viral and common bacterial agents. These findings underscore the importance of promotion and expansion of breastfeeding campaigns in Bangladesh and elsewhere.