Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

Global, regional, and national progress towards the 2030 global nutrition targets and forecasts to 2050: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

The six global nutrition targets (GNTs) related to low birthweight, exclusive breastfeeding, child growth (ie, wasting, stunting, and overweight), and anaemia among females of reproductive age were chosen by the World Health Assembly in 2012 as key indicators of maternal and child health, but there has yet to be a comprehensive report on progress for the period 2012 to 2021. We aimed to evaluate levels, trends, and observed-to-expected progress in prevalence and attributable burden from 2012 to 2021, with prevalence projections to 2050, in 204 countries and territories.

METHODS

The prevalence and attributable burden of each target indicator were estimated by age group, sex, and year in 204 countries and territories from 2012 to 2021 in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, the most comprehensive assessment of causes of death, disability, and risk factors to date. Country-specific relative performance to date was evaluated with a Bayesian meta-regression model that compares prevalence to expected values based on Socio-demographic Index (SDI), a composite indicator of societal development status. Target progress was forecasted from 2021 up to 2050 by modelling past trends with meta-regression using a combination of key quantities and then extrapolating future projections of those quantities.

FINDINGS

In 2021, a few countries had already met some of the GNTs: five for exclusive breastfeeding, four for stunting, 96 for child wasting, and three for child overweight, and none met the target for low birthweight or anaemia in females of reproductive age. Since 2012, the annualised rates of change (ARC) in the prevalence of child overweight increased in 201 countries and territories and ARC in the prevalence of anaemia in females of reproductive age decreased considerably in 26 countries. Between 2012 and 2021, SDI was strongly associated with indicator prevalence, apart from exclusive breastfeeding (|r-|=0·46-0·86). Many countries in sub-Saharan Africa had a decrease in the prevalence of multiple indicators that was more rapid than expected on the basis of SDI (the differences between observed and expected ARCs for child stunting and wasting were -0·5% and -1·3%, respectively). The ARC in the attributable burden of low birthweight, child stunting, and child wasting decreased faster than the ARC of the prevalence for each in most low-income and middle-income countries. In 2030, we project that 94 countries will meet one of the six targets, 21 countries will meet two targets, and 89 countries will not meet any targets. We project that seven countries will meet the target for exclusive breastfeeding, 28 for child stunting, and 101 for child wasting, and no countries will meet the targets for low birthweight, child overweight, and anaemia. In 2050, we project that seven additional countries will meet the target for exclusive breastfeeding, five for low birthweight, 96 for child stunting, nine for child wasting, and one for child overweight, and no countries are projected to meet the anaemia target.

INTERPRETATION

Based on current levels and past trends, few GNTs will be met by 2030. Major reductions in attributable burden for exclusive breastfeeding and anthropometric indicators should be recognised as huge scientific and policy successes, but the comparative lack of progress in reducing the prevalence of each, along with stagnant anaemia in women of reproductive age and widespread increases in child overweight, suggests a tenuous status quo. Continued investment in preventive and treatment efforts for acute childhood illness is crucial to prevent backsliding. Parallel development of effective treatments, along with commitment to multisectoral, long-term policies to address the determinants and causes of suboptimal nutrition, are sorely needed to gain ground.

FUNDING

Bill & Melinda Gates Foundation.

The Association Between Exclusive Breastfeeding and Diarrhoea Morbidity in Infants Aged 0-6 Months: A Rapid Review and Meta-Analysis

Diarrhoea remains a major cause of mortality among children under five, despite global efforts to reduce childhood morbidity and mortality. Exclusive breastfeeding (EBF) has been recognised as an effective and cost-effective intervention to reduce diarrhoeal disease burden in infants. This rapid review and meta-analysis aimed to assess the association of EBF on diarrhoea morbidity in early childhood, a critical period for growth and development, while addressing existing gaps by employing standardised definitions of EBF. A systematic search was conducted in Medline, Scopus, Embase, and Web of Science databases for studies published between 2010 and 2024. Seventeen studies met inclusion criteria and underwent quality assessment using the Joanna Briggs Institute (JBI) critical appraisal tool. Data from the identified studies were extracted, and a meta-analysis was conducted using random effects models to calculate the pooled effect size, with odds ratios (OR) and 95% confidence intervals (CI). This review found that EBF significantly reduces the risk of diarrhoeal diseases in infants under 6 months of age across diverse geographical regions and study designs. The meta-analysis of the association between exclusive breastfeeding and diarrhoea in infants aged 0-6 months resulted in a pooled OR of 0.57 (95% CI: 0.51, 0.63; I² = 57.66%). These findings underscore the critical role of promoting and supporting EBF as a pivotal public health strategy to enhance early childhood health outcomes and contribute to achieving global child health goals.

Challenges and lessons learned during the switching of rotavirus vaccine from Rotarix to Rotavac in Zambia

INTRODUCTION

Active Rotavirus diarrhea surveillance has been ongoing in Zambia at three dedicated sentinel sites since 2007, focusing on hospitalized children under five years of age. During 2021 and 2022, many African countries, including Zambia, experienced a severe shortage of rotavirus vaccines. This vaccine shortage resulted in many children who were eligible for vaccination remaining unvaccinated. Consequently, these children were exposed to a higher risk of severe acute gastroenteritis.

METHODS

To ascertain the impact of rotavirus vaccine stock-out and switch in Zambia, a comprehensive desk review was conducted focusing on the switch of the vaccine from Rotarix to Rotavac and the change of the Rotavac formulation. This review encompassed all children under five years of age recruited at the surveillance sites between 2017 and 2023 and the country's comparison of national administrative and WUENIC 2023 rotavirus vaccine coverage rate estimates for 2014 to 2023. March 2022 to April 2023 was defined as the Rotarix vaccine stock-out period. Hospitalization trends, demographic and clinical data, and rotavirus confirmed ELISA results were analyzed.

RESULTS

Following the introduction of rotavirus vaccine, the number of fully vaccinated children increased steadily over the years, reaching 4.73 million in 2023. However, 2.63 million children missed vaccination between 2016 and 2023. The administrative and WUENIC 2023 estimates for rotavirus coverage rates were the same during the period under review. Hospitalized diarrhea cases and rotavirus positivity rates remained essentially the same during the in-stock and stock-out periods of rotavirus vaccine. However, mortality rates increased three-fold during the vaccine stock-out period.

CONCLUSION

The impact of the Rotarix vaccine era was reversed due to the global supply chain disruptions, leading to missed vaccinations, increased diarrhea-related hospitalizations, and higher infant mortality in Zambia. The COVID-19 pandemic may also have further disrupted the vaccination sessions, further impacting rotavirus vaccination. Rotarix shortages likely contributed to rising rotavirus cases. There is an urgent need to completely replace the old under-5 vaccination card with a revised one to improve documentation for new rotavirus vaccines.

Comparing the Power of Low vs High-Precision Methods for Measuring E. coli in Drinking Water in Low-Resource Settings

Methods to measure Escherichia coli concentrations in water vary in precision, complexity, and cost. Low-precision methods are more affordable, faster, and simpler to implement in low-resource settings but may reduce statistical power. We compared the statistical power of low- and high-precision methods using data from UNICEF's Multiple Indicator Cluster Surveys across 11 low-income regions, and from a birth cohort study in Ecuador. Both data sets included continuous E. coli concentrations from high-precision methods, which we categorized to emulate low-precision methods outcomes. Using logistic regression, we modeled associations between water quality and two dichotomous outcomes: water treatment (treated/untreated) and water storage (stored/not stored). We compared the sample size needed to reach 80% power for detecting statistically significant differences between these groups. Power was calculated using a bootstrap-based algorithm. Compared to continuous measures, categorizing E. coli concentrations required 10-90% larger sample sizes in treatment models and about 10% in storage models, except in regions with good water quality, where similar or lower sample sizes were sufficient. Our findings indicate that low-precision methods can reliably infer associations between water practices and water quality but often require larger sample sizes, highlighting a trade-off between cost and statistical power in resource-limited settings.

Association between dietary index for gut microbiota and diarrhea among US adults: a cross-sectional analysis of NHANES 2005-2010

Objectives

Growing attention has been paid to the relationship between the gut microbiota and diarrhea. A recently proposed Dietary Index for Gut Microbiota (DI-GM) reflects the overall dietary quality as it pertains to gut microbiota diversity. However, evidence regarding the association between DI-GM and diarrhea is still lacking. This study aims to investigate the association between DI-GM and the risk of diarrhea.

Methods

A total of 15,590 adults (≥20 years old) from National Health and Nutrition Examination Survey (NHANES) 2005-2010 were included in this analysis. Diarrhea was defined by self-reported common Bristol Stool Form Scale (BSFS) type 6 or 7, or more than three bowel movements per day. DI-GM comprises 14 food/nutrient components known to be associated with gut microbiota. A higher score indicates a more favorable diet for the gut microbiota. Multivariable logistic regression was used to evaluate the association between DI-GM and diarrhea, with subgroup and sensitivity analyses performed to confirm robustness.

Results

After adjusting for age, gender, race, physical activity, chronic diseases, and other confounders, each 1-point increase in DI-GM was associated with a 5% reduction in diarrhea risk (adjusted OR = 0.95, 95% CI: 0.91-0.98, p = 0.005). Compared with those who had a DI-GM score of 0-3, individuals with a DI-GM score ≥ 6 demonstrated a significantly lower risk of diarrhea (OR = 0.77, 95% CI: 0.65-0.91, p = 0.002). Subgroup and sensitivity analyses further supported this negative association. Notably, the "beneficial component" was found to have a more pronounced effect on reducing diarrhea risk.

Conclusion

Based on a large representative population, our findings suggest that a higher DI-GM score is significantly associated with a lower risk of diarrhea, underscoring the importance of overall dietary patterns in maintaining gut function and homeostasis.

Global burden of diarrhea disease in the older adult and its attributable risk factors from 1990 to 2021: a comprehensive analysis from the global burden of disease study 2021

Introduction

Diarrhea disease among the older adult is an underappreciated global health issue despite its substantial burden. This study provides a comprehensive analysis of the epidemiological trends of diarrhea in individuals over 65 years, examining incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) from 1990 to 2021.

Methods

Utilizing data from the Global Burden of Diseases (GBD) 2021, this cross-sectional study assesses the older adult population across 204 countries and territories. The analysis includes metrics such as incidence, prevalence, mortality, DALYs, and estimated annual percentage changes (EAPCs), stratified by region, country, age, sex, and Sociodemographic Index (SDI).

Results

A nearly 200% increase in incidence and prevalence was observed worldwide, with the highest rise in those over 95 years. Mortality and DALYs have declined, especially in the 65-69 age group. High SDI regions showed the largest increase in incidence rates and are the only areas with increasing mortality and DALYs trends. Unsafe water sources emerged as the primary risk factor for diarrhea-related deaths among the older adult.

Discussion

The burden of diarrhea in the older adult has significantly increased, particularly in high-income regions, warranting targeted interventions. The positive correlation between EAPC and the Human Development Index underscores the need for improved water safety to mitigate the disease burden. This study's findings are crucial for shaping public health strategies and informing policy decisions regarding the older adult population.

Identifying risk factors for vomiting during diarrhea: A secondary analysis of a randomized trial of zinc supplementation

OBJECTIVES

Supplemental zinc during acute diarrhea reduces illness duration but also increases vomiting. In a recent trial, we found that children receiving lower daily doses of zinc (5 mg or 10 mg vs. 20 mg) had lower rates of vomiting with comparable stool output and duration of diarrhea. We performed a secondary analysis to identify sociodemographic and clinical factors associated with vomiting in children with acute diarrhea.

METHODS

We performed a secondary data analysis of 4500 children aged 6-59 months with an acute episode of diarrhea (<72 h before enrollment) in a randomized, double-blind controlled trial in India and Tanzania. To identify clinically important risk factors for overall, regimen-related, and regimen-unrelated vomiting, we created log-binomial models with relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

The trial enrolled 4500 children, of whom 1203 (26.7%) had any vomiting. After adjusting for multiple demographic and clinical characteristics, the presence of dehydration (RR: 1.45, 95% CI: 1.10-1.92), being underweight (RR: 1.22, 95% CI: 1.05-1.41), receipt of the rotavirus vaccine (RR: 1.89, 95% CI: 1.69-2.12), and household wealth above the median (RR: 1.17, 95% CI: 1.07-1.29) were factors associated with an increased risk of vomiting. Rotavirus vaccine receipt was nearly 100% concordant with the study site of Tanzania. Older age and lower zinc dosing were associated with a lower risk of vomiting.

CONCLUSIONS

Young, underweight, or dehydrated children are more likely to have concurrent vomiting with zinc supplementation. Identification of these factors may allow providers to better monitor such children, thus reducing the chances of recurrent dehydration or inadequate dietary intake.

Risk factors of CVDs among residents of resource-limited rural settings. Preliminary findings based on a cross-sectional study, Ghana

BACKGROUNDS

Cardiovascular disease (CVD) risk factors lead to morbidity and mortality among adults globally. In Ghana, there is a lack of coordinated efforts at all levels of healthcare service to prevent risk factors of cardiovascular disease (CVD). This study assessed cardiovascular disease risk factors among residents of resource-limited rural settings.

METHODS

This descriptive cross-sectional design is the first phase of a two-year community-level study aimed at implementing an intervention to reduce CVD risk in a rural community in Ghana. The study population included 379 people living in the Avenui community. We conducted a nurse-led door-to-door visit, screened for CVD risk, provided health education, and collected data using an adapted questionnaire. The data were analyzed using SPSS. Categorical data were expressed as frequencies and proportions, and the Chi-Square test of associations. A multivariable logistic regression analysis with a backward elimination method was used to examine the association of the risk factors with the risk of developing CVD.

RESULTS

The CVD risk among participants was categorized as 'very high' (35.4%), high (55.4%), and low or moderate (9.2%). There was a positive correlation between lifestyle (r = 0.126, p-value < 0.05), stress (r = 0.114, p-value < 0.05), blood sugar level (r = 0.102, p-value < 0.05) inflammation and pain (r = 0.109, p-value < 0.05), and high blood pressure (r = 0.268, p-value < 0.01) with history of CVD. CVD high risk was significantly associated with marital status (p-value = 0.001), employment status (p-value = 0.001), perception of personal health (p-value = 0.045), lifestyle (p-value = 0.034), knowledge of peripheral arterial disease (p-value = 0.018), and knowledge on deep vein thrombosis and pulmonary embolism (p-value = 0.002). The backward multiple logistic regression model was significant (78.912, p-value < 0.001) with a non-significant Hosmer and Lemeshow Test (2.145, p-value = 0.976) and a Cox & Snell R Square and Nagelkerke R Square of 0.393 and 0.619, respectively. The significant predictors of a 'very high' CVD risk include marital status being single (p-value = 0.001), those that exercise only two (2) times a week (p-value = 0.001) employment status being part-time worker (p-value = 0.015), poor perception of overall personal health (p-value < 0.001), and those listening to the radio (p-value = 0.024).

CONCLUSION

The risk factors associated with CVD were identified to be multiple and interacted variable among rural community dwellers. These factors included marital status, exercise, employment, perception of health, and listening to the radio. We recommend implementing primary prevention strategies that involve adopting a comprehensive assessment and management of the risk factors of CVD in Ghana.

Global, regional, and national incidence and mortality for enteric infections from 1990 to 2019

BACKGROUND

Enteric infections are among the most common infectious diseases. The aim of this article was to track the global trends in morbidity and mortality from enteric infections in 204 countries or territories from 1990 to 2019.

METHODS

Data were obtained from the Global Burden of Disease 2019 study. Average annual percentage changes (AAPCs) in age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) were calculated to quantify trends in enteric infections. Age-period-cohort models were used to estimate the annual percentage changes from 0 to 4 to 80 - 84 years (local drifts), period and cohort effects between 1990 and 2019 in different socio-demographic index (SDI) regions.

RESULTS

In 2019, there were 6.59 billion incident cases of enteric infections, and caused 1,748,251 deaths worldwide. From 1990 to 2019, the trend in the global ASIR of enteric infections was relatively stable, but that of ASMR declined (AAPC=-3.30, 95% confidence interval [CI]: -3.54 to -3.07), and global mortality decreased in all age groups. Meanwhile, decreasing trends in ASMR were observed in 173 countries/territories (P < 0.05), particularly in North Macedonia and Kazakhstan. The low and low-middle SDI areas showed decreasing trends in ASIR and ASMR for enteric infections. However, an increasing trend was observed in high SDI regions, especially among older people aged over 60 years.

CONCLUSIONS

The global incidence of enteric infections did not change significantly between 1990 and 2019, but the mortality showed a significantly downward trend. The global burden of enteric infections remains serious in children under 5 years and in low and low-middle SDI regions.

Trends in epidemiological characteristics and etiologies of diarrheal disease in children under five: an ecological study based on Global Burden of Disease study 2021

Background

Diarrhea remains a significant health threat to children under five years of age. The study aims to systematically elucidate the global burden of diarrhea in children, providing scientific insights for effective prevention and control strategies.

Methods

The data from the Global Burden of Disease (GBD) 2021 study was analyzed to assess the trends in incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of diarrhea in children under five years across the globe, 21 geographical region, and 204 countries and territories, stratified by age group, sex, and socio-demographic index (SDI) levels. The trend of the disease burden for childhood diarrhea from 1990 to 2021 was described and estimated using the average annual percent change (AAPC), and a Bayesian age-period-cohort (BAPC) model was employed to predict the future burden of diarrhea in children.

Results

From 1990 to 2021, there was a significant decline in the global burden of diarrhea among children under five years of age. The AAPC for incidence (-4092.18, 95% confidence interval [CI]: -4224.60 to -3959.76), prevalence (-70.98, 95% CI: -72.67 to -69.28), mortality (-6.89, 95% CI: -6.95 to -6.83), and DALYs rate (-621.79, 95% CI: -627.20 to -616.38) of diarrhea in children all showed a marked downward trend. Diarrheal incidence (r = -0.782, P < 0.001), prevalence (r = -0.777, P < 0.001), mortality (r = -0.908, P < 0.001), and DALYs rate (r = -0.904, P < 0.001) were negatively correlated with the SDI. Between 2022 and 2035, the global incidence, prevalence, and mortality rates of diarrhea in children under five years are projected to continue declining. The leading causes of diarrheal mortality in children include wasting, underweight, and non-exclusive breastfeeding. Rotavirus remains the predominant pathogen associated with diarrhea-related mortality rate and DALY rate.

Conclusion

Although the global burden of diarrhea in children under five has steadily declined, it remains a significant health threat. Rotavirus is the leading pathogen, highlighting the importance of expanding rotavirus vaccination. Additionally, improving nutritional status, increasing exclusive breastfeeding rates, and enhancing access to sanitation and clean drinking water are crucial measures that, when widely implemented, can effectively reduce the health risks posed by diarrhea in children.

Aetiology of diarrhoea in children aged zero to nine years in low- and middle-income countries: A systematic review

Background

While diarrhoeal disease remains a leading cause of death in children aged <5 years in low- and middle-income countries (LMICs), it also poses significant health risks for older children, underscoring the importance of our study focusing on children aged <10 years. In this systematic review, we assessed common diarrhoea aetiologies in children aged <10 years in LMICs.

Methods

We identified relevant articles in PubMed, Embase, and Web of Science using pre-defined search criteria. We included case series and case-control studies of children aged <10 years with non-bloody, bloody, acute, persistent, and chronic diarrhoea. Articles that evaluated two or more diarrhoea pathogens in LMICs conducted between 1 January 1990 and 31 July 2020 were eligible for inclusion. We stratified combined data from case series and case-control studies by age and World Health Organization (WHO) regions.

Results

76 studies published between 1990-2020 were eligible for inclusion. Among these, eight were case-control studies. 56 papers focused only on children aged <5 years, while 20 also included children aged ≥5 years. The most common viral pathogens among <5 years old children were rotavirus, norovirus, adenovirus, and astrovirus. Bacterial pathogens included Escherichia coli, Salmonella enterica, Shigella species, and Campylobacter species, while parasitic pathogens included Cryptosporidium, Giardia, and Entamoeba species. Rotavirus was the most common viral pathogen among children across all age groups and every WHO region. Escherichia coli was prevalent in all age groups and was responsible for most diarrhoea cases in the African Region. Among parasitic pathogens, Entamoeba species and Giardia were prevalent in children aged three to five years, with the former a major cause of diarrhoea in the Eastern Mediterranean Region. Similarly, in children aged six to 10 years, bacterial pathogens, including Escherichia coli, Salmonella, and Shigella, suggest a continued significance of these pathogens beyond the age of five. Common viral pathogens for this group were rotavirus, norovirus, and sapovirus, although the number of studies for this age group is limited.

Conclusions

Escherichia coli, rotavirus, and Entamoeba species were the most common pathogens responsible for diarrhoea in children aged <5 years in LMICs. Future research should focus on characterising the pathogens responsible for causing diarrhoea in children aged six to 10 years stratified by geographic area of residence, i.e. WHO region and urban vs rural. Case-control or cohort studies covering a full 12-month period to account for seasonality are needed for a more accurate picture of diarrhoea aetiology among children.

Registration

PROSPERO (CRD42020204005).

Molecular survey of certain protozoan agents that cause diarrhea in children in Sudan

Introduction

Diarrhea is a significant health problem in the Third World. Identification of the pathogen that causes diarrhea is vital for measures to prevent and control this disease. There are also very few reports of diarrhea in Sudan. Our study aimed to determine the Prevalence of specific protozoan pathogens ( Entamoeba histolytica, Cryptosporidium parvum., and Giardia spp) in children in Khartoum, Sudan.

Methods

We conducted a cross-sectional survey among children under five years of age hospitalized with acute diarrhea between April and December 2014. Diarrheal stool samples were collected, and E. histolytica, C. parvum, and Giardia spp were examined using multiplex real-time PCR.

Results

Four hundred and thirty-seven children with acute diarrhea were included in this study; the higher prevalence of diarrhea was in the age ≤ 2 years old (403, 92.2%), >2-≤4 years (32, 7.3%), and >4-<5 years (2, 0.5%). The male-to-female ratio in this study was 1:1.7. Infection with intestinal parasite was found in 155 (35.5%) cases, and co-infection was detected in 16 (3.7%) cases. Giardia spp (18.8%) and C. parvum (15.8%) were the most frequently identified parasites, followed by E. histolytica (0.9). The parasite infection rate was highest and lowest in the under 2-year-old group 143 (35.5%) and the 2-4-year-old group 12 (37.5%). The infection rate was higher in boys 104 (37.7%) than in girls 51 (31.7%). The number of positive cases was higher in the rainy season (August to December) 143 (37.4%), corresponding with that in the dry Season (April to June) 12 (21.8%).

Discussion

Our present study demonstrated the high prevalence of Giardia spp and C. parvum in children with diarrhea in the Khartoum region and the usefulness of the multiplex real-time method in disclosing pathogenic protozoal agents. Our result highlighted the necessity of developing intervention measurement and control strategies to deal with childhood parasitic diarrhea in this region.

Multilevel factors drive child exposure to enteric pathogens in animal feces: A qualitative study in northwestern coastal Ecuador

Exposure to animal feces and associated enteric pathogens poses significant risks to child health. However, public health strategies to mitigate enteric infections among children largely aim to reduce exposure to human feces, overlooking transmission pathways related to animal feces. In this study we examine if and how children are exposed to enteric pathogens in animal feces in northwestern coastal Ecuador. We conducted qualitative interviews with mothers of children aged 10-18 months that owned (n = 32) and did not own (n = 26) animals in urban and rural communities. Using thematic analysis, we identified community, household, and child behavioral factors that influence exposure. We also compared child exposure by household animal ownership. Our findings revealed myriad opportunities for young children to be exposed to enteric pathogens in many locations and from multiple animal sources, regardless of household animal ownership. Animal feces management practices (AFM) used by mothers, such as rinsing feces into ditches and throwing feces into surrounding areas, may increase environmental contamination outside their homes and in their communities. Unsafe AFM practices were similar to unsafe child feces management practices reported in other studies, including practices related to defecation location, feces removal and disposal, environmental contamination cleaning, and handwashing. Findings suggest that animal feces may contaminate the environment along similar pathways as human feces. Identification and incorporation of safe AFM practices, similar to those developed for child feces management, would 1) mitigate child exposure to enteric pathogens by reducing animal feces contamination in domestic and public spaces; and 2) enable an integrated approach to address enteric pathogen exposure pathways related to animal and child feces.

The development and validation of a survey to measure fecal-oral child exposure to zoonotic enteropathogens: The FECEZ Enteropathogens Index

Child exposure to animal feces and associated enteropathogens contribute to a significant burden of disease in low- and middle-income countries. However, there are no standardized, validated survey-based approaches to enable accurate assessment of child exposure to zoonotic enteropathogens. We developed and validated a survey-based measure of exposure, the fecal-oral child exposure to zoonotic enteropathogens Index (the FECEZ Enteropathogens Index). First, we identified critical attributes of child exposure through in-depth interviews (IDIs) in Ecuador among individuals who care for animals (n = 29) and mothers of children under two years old (n = 58), and through a systematic review of existing exposure measures. Second, based on these findings, we developed a 105-question survey and administered it to 297 mothers with children under age five. Third, we refined the survey, using principal component analysis to determine the optimal number of components. The final index consisted of 34 items across two sub-domains: the child Environment and child Behavior. Lastly, we compared index scores to two commonly used, unvalidated measures of child exposure-maternal reported household animal ownership and presence of animal feces. Using the FECEZ Enteropathogens Index revealed varying degrees of exposure in our study population, with only two children having no exposure. In contrast, if we had used animal ownership or the presence of animal feces as a measure of exposure, 44% and 33% of children would have been classified as having no exposure, respectively. These common binary exposure measures may be inadequate because they do not provide sufficient information to identify the relative risk of zoonotic pathogen exposure. The FECEZ Enteropathogens Index overcomes this limitation, advancing our ability to assess exposure by quantifying the multiple components of child exposure to zoonotic enteropathogens with higher resolution. Additional testing and evaluation of the index is needed to ensure its reliability, validity, and cross-cultural equivalence in other contexts.

Identification of Enteric Pathogen Reservoirs and Transmission Pathways Associated with Short Childhood Stature in the Kolkata Indian Site of the Global Enteric Multicenter Study

Age-stratified path analyses modeled associations between enteric pathogen reservoirs, transmission pathways and height-for-age z-scores (HAZ) to identify determinants of childhood growth in the Kolkata, India site of the Global Enteric Multicenter Study (GEMS). Models tested direct associations of potential pathogen reservoirs with HAZ at 60-day follow-up in separate moderate and severe diarrhea (MSD) case and control cohorts or indirectly when mediated by enteric infections. In the MSD cohort, rotavirus and typical EPEC (tEPEC) infections among children 0-11 months of age and ST-ETEC infections among children 12-23 months of age were associated with lower HAZ. Handwashing after defecating and before cooking reduced impaired growth through reductions in rotavirus and tEPEC infections. Water storage increased rotavirus and ST-ETEC infection risks, resulting in increased impaired growth, but was reduced with reported child feces disposal. The GII norovirus variant was inversely associated with HAZ among children 12-59 months of age in the control cohort. Reported handwashing before the handling of children reduced GII infections and impaired growth. Boiling water and the disposal of children's feces mediated by stored water were positively associated with HAZ. The targeting of pathogen-specific reservoirs and transmission pathways may more effectively improve childhood linear growth in South Asian urban communities.

Global burden of enteric infections related foodborne diseases, 1990-2021: findings from the Global Burden of Disease Study 2021

Background

Understanding the global burden of enteric infections is crucial for prioritizing control strategies for foodborne and waterborne diseases. This study aimed to assess the global burden of enteric infections in 2021 and identify risk factors from One Health aspects.

Methods

Leveraging the Global Burden of Disease (GBD) 2021 database, the incidence, disability-adjusted life years (DALYs), and deaths of enteric infections and the subtypes were estimated, including diarrheal diseases, typhoid and paratyphoid fever, invasive non-typhoidal Salmonella (iNTS) infections, and other intestinal infectious diseases. The estimates were quantified by absolute number, age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR) and age-standardized DALY rate with 95% uncertainty intervals (UIs). Thirteen pathogens and three risk factors associated with diarrheal diseases were analyzed.

Results

In 2021, the global age-standardized DALY rate of enteric infections was 1020.15 per 100,000 popultion (95% UI: 822.70-1259.39 per 100,000 population) with an estimated annual percentage change (EAPC) of -4.11% (95% confidence interval: -4.31% to -3.90%) in 1990-2021. A larger burden was observed in regions with lower Socio-demographic index (SDI) levels. Diarrheal disease was the most serious subtype with Western Sub-Saharan Africa exhibiting the highest age-standardized DALY rate (2769.81 per 100,000 population, 95% UI: 1976.80-3674.41 per 100,000 population). Children under 5 and adults over 65 years suffered more from diarrheal diseases with the former experiencing the highest global age-standardized DALY rate (9382.46 per 100,000 population, 95% UI: 6771.76-13,075.12 per 100,000 population). Rotavirus remained the leading cause of diarrheal diseases despite a cross-year decline in the observed age-standardized DALY rate. Unsafe water, sanitation, and handwashing contributed most to the disease burden.

Conclusion

The reduced burden of enteric infections suggested the effectiveness of previous control strategies; however, more efforts should be made in vulnerable regions and populations through a One Health approach.

High-resolution mapping of essential maternal and child health service coverage in Nigeria: a machine learning approach

BACKGROUND

National-level coverage estimates of maternal and child health (MCH) services mask district-level and community-level geographical inequities. The purpose of this study is to estimate grid-level coverage of essential MCH services in Nigeria using machine learning techniques.

METHODS

Essential MCH services in this study included antenatal care, facility-based delivery, childhood vaccinations and treatments of childhood illnesses. We estimated generalised additive models (GAMs) and gradient boosting regressions (GB) for each essential MCH service using data from five national representative cross-sectional surveys in Nigeria from 2003 to 2018 and geospatial socioeconomic, environmental and physical characteristics. Using the best-performed model for each service, we map predicted coverage at 1 km2 and 5 km2 spatial resolutions in urban and rural areas, respectively.

RESULTS

GAMs consistently outperformed GB models across a range of essential MCH services, demonstrating low systematic prediction errors. High-resolution maps revealed stark geographic disparities in MCH service coverage, especially between rural and urban areas and among different states and service types. Temporal trends indicated an overall increase in MCH service coverage from 2003 to 2018, although with variations by service type and location. Priority areas with lower coverage of both maternal and vaccination services were identified, mostly located in the northern parts of Nigeria.

CONCLUSION

High-resolution spatial estimates can guide geographic prioritisation and help develop better strategies for implementation plans, allowing limited resources to be targeted to areas with lower coverage of essential MCH services.

Multiplex PCR for bacterial, viral and protozoal pathogens in persistent diarrhoea or persistent abdominal pain in Côte d'Ivoire, Mali and Nepal

In contrast to acute diarrhoea, the aetiology of persistent digestive disorders (≥ 14 days) is poorly understood in low-resource settings and conventional diagnostic approaches lack accuracy. In this multi-country study, we compared multiplex real-time PCR for enteric bacterial, parasitic and viral pathogens in stool samples from symptomatic patients and matched asymptomatic controls in Côte d'Ivoire, Mali and Nepal. Among 1826 stool samples, the prevalence of most pathogens was highest in Mali, being up to threefold higher than in Côte d'Ivoire and up to tenfold higher than in Nepal. In all settings, the most prevalent bacteria were EAEC (13.0-39.9%) and Campylobacter spp. (3.9-35.3%). Giardia intestinalis was the predominant intestinal protozoon (2.9-20.5%), and adenovirus 40/41 was the most frequently observed viral pathogen (6.3-25.1%). Significantly different prevalences between symptomatic and asymptomatic individuals were observed for Campylobacter, EIEC and ETEC in the two African sites, and for norovirus in Nepal. Multiple species pathogen infection was common in Côte d'Ivoire and Mali, but rarely found in Nepal. We observed that molecular testing detected multiple enteric pathogens and showed low discriminatory accuracy to distinguish between symptomatic and asymptomatic individuals. Yet, multiplex PCR allowed for direct comparison between different countries and revealed considerable setting-specificity.

The Planetary Child Health & Enterics Observatory (Plan-EO): A protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

BACKGROUND

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

METHODS

The Planetary Child Health & Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

DISCUSSION

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making and disseminating rigorously obtained, generalizable disease burden estimates. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available for download to the research and stakeholder communities. These can then be used as inputs to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

STUDY REGISTRATION

PROSPERO protocol #CRD42023384709.

What drives poor quality of care for child diarrhea? Experimental evidence from India

Most health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades. Using randomized experiments in India, we estimated the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider's financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing, whereas stock-outs and financial incentives explain only 6 and 5%, respectively.

Spatial-temporal evolution of overweight and obesity among Chinese adolescents from 2016 to 2020

This study examines the spatial-temporal evolution of overweight and obesity among Chinese adolescents aged 14-17. Data from five national surveys conducted between 2016 and 2020 were analyzed to determine distribution patterns and trends. Results showed that overweight and obesity exhibit spatial clustering, with greater severity in the north and less severity in the south. The issue has spread from the northeast to the southwest of Mainland China. Using a local autocorrelation model, the regions were divided into a northern disease cold spot area (Inner Mongolia) and a southern disease hot spot area (Guangxi). Over the past five years, overweight rates among Chinese adolescents have not been effectively curbed, but obesity has shown some success in control and reversal until 2019. Future efforts should focus on the spatial-temporal pattern of disease spread, targeting hotspot areas and abnormal values for regional synergy and precise prevention and control.

The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

Background

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

Methods

The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

Discussion

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

Study registration

PROSPERO protocol #CRD42023384709.

The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

Background

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

Methods

The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

Discussion

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

Study registration

PROSPERO protocol #CRD42023384709.

A mathematical, classical stratification modeling approach to disentangling the impact of weather on infectious diseases: A case study using spatio-temporally disaggregated Campylobacter surveillance data for England and Wales

Disentangling the impact of the weather on transmission of infectious diseases is crucial for health protection, preparedness and prevention. Because weather factors are co-incidental and partly correlated, we have used geography to separate out the impact of individual weather parameters on other seasonal variables using campylobacteriosis as a case study. Campylobacter infections are found worldwide and are the most common bacterial food-borne disease in developed countries, where they exhibit consistent but country specific seasonality. We developed a novel conditional incidence method, based on classical stratification, exploiting the long term, high-resolution, linkage of approximately one-million campylobacteriosis cases over 20 years in England and Wales with local meteorological datasets from diagnostic laboratory locations. The predicted incidence of campylobacteriosis increased by 1 case per million people for every 5° (Celsius) increase in temperature within the range of 8°-15°. Limited association was observed outside that range. There were strong associations with day-length. Cases tended to increase with relative humidity in the region of 75-80%, while the associations with rainfall and wind-speed were weaker. The approach is able to examine multiple factors and model how complex trends arise, e.g. the consistent steep increase in campylobacteriosis in England and Wales in May-June and its spatial variability. This transparent and straightforward approach leads to accurate predictions without relying on regression models and/or postulating specific parameterisations. A key output of the analysis is a thoroughly phenomenological description of the incidence of the disease conditional on specific local weather factors. The study can be crucially important to infer the elusive mechanism of transmission of campylobacteriosis; for instance, by simulating the conditional incidence for a postulated mechanism and compare it with the phenomenological patterns as benchmark. The findings challenge the assumption, commonly made in statistical models, that the transformed mean rate of infection for diseases like campylobacteriosis is a mere additive and combination of the environmental variables.

Mapping the global, regional, and national burden of diarrheal diseases attributable to unsafe water

Background

Diarrheal diseases are major contributors to deaths. Data on global and country-specific levels and trends of diarrheal diseases resulting from unsafe water are essential for policymakers to allocate resources.

Aims

This study aimed to describe the global, regional, and national spatiotemporal burden of diarrheal diseases resulting from unsafe water exposure.

Methods

According to the Global Burden of Disease (GBD) 2019 dataset, deaths, disability-adjusted life years (DALYs) of diarrheal diseases, and their age-standardized rates (ASRs) were analyzed by age and sex in 204 countries and territories. Moreover, the average annual percentage change (AAPC) was estimated by a log-linear regression model to reflect the time trend. The association between ASR of diarrheal diseases due to unsafe water and socio-demographic index (SDI) levels was also analyzed.

Results

From 1990 to 2019, the number of deaths and DALYs of diarrheal diseases resulting from unsafe water decreased by 50 and 59%, respectively. Moreover, the ASR of deaths and DALYs also decreased during the study period, with AAPCs of -3.69 (95% CI [95% confidence interval]: -3.91 to -3.47) and - 3.66 (95% CI: -3.8 to -3.52), respectively. High diarrheal diseases resulting from unsafe water occurred mainly in low SDI regions and Africa. Males exhibited greater diarrheal deaths attributable to unsafe water than females, which was contrary to the condition in terms of DALYs. The age-specific burden of diarrheal deaths attributable to unsafe water is concentrated in children younger than 5 years. The AAPCs of the ASR of both deaths and DALYs showed a strong negative correlation with the SDI levels.

Conclusion

The current study indicated that the global burden of unsafe water exposure-related diarrheal diseases decreased from 1990 to 2019 and varied significantly according to age, sex, and geographical location. Effective health promotion and health communication strategies and policies should be adopted to prevent and control diarrheal diseases resulting from unsafe water exposure.

Vaccine value profile for Shigella

Shigella is the leading bacterial cause of diarrhoea and the second leading cause of diarrhoeal mortality among all ages. It also exhibits increasing levels of antibiotic resistance. The greatest burden is among children under five in low- and middle-income countries (LMICs). As such, a priority strategic goal of the World Health Organization (WHO) is the development of a safe, effective and affordable vaccine to reduce morbidity and mortality from Shigella-attributable dysentery and diarrhea, including long term outcomes associated with chronic inflammation and growth faltering, in children under 5 years of age in LMICs. In addition, a safe and effective Shigella vaccine is of potential interest to travellers and military both to prevent acute disease and rarer, long-term sequelae. An effective Shigella vaccine is also anticipated to reduce antibiotic use and thereby help diminish further emergence of enteric pathogens resistant to antimicrobials. The most advanced vaccine candidates are multivalent, parenteral formulations in Phase 2 and Phase 3 clinical studies. They rely on O-antigen-polysaccharide protein conjugate technologies or, alternatively, outer membrane vesicles expressing penta-acylated lipopolysaccharide that has been detoxified. Other parenteral and oral formulations, many delivering a broader array of Shigella antigens, are at earlier stages of clinical development. These formulations are being assessed in alignment with the WHO Preferred Product Characteristics, which call for a 1 to 2 dose primary immunization series given during the first 12 months of life, ideally starting at 6 months of age. This 'Vaccine Value Profile' (VVP) for Shigella is intended to provide a high-level, holistic assessment of the information and data that are currently available to inform the potential public health, economic and societal value of pipeline vaccines and vaccine-like products. This VVP was developed by a working group of subject matter experts from academia, non-profit organizations, government agencies and multi-lateral organizations. All contributors have extensive expertise on various elements of the Shigella VVP and collectively aimed to identify current research and knowledge gaps. The VVP was developed using only existing and publicly available information.

The unfinished agenda of communicable diseases among children and adolescents before the COVID-19 pandemic, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

Communicable disease control has long been a focus of global health policy. There have been substantial reductions in the burden and mortality of communicable diseases among children younger than 5 years, but we know less about this burden in older children and adolescents, and it is unclear whether current programmes and policies remain aligned with targets for intervention. This knowledge is especially important for policy and programmes in the context of the COVID-19 pandemic. We aimed to use the Global Burden of Disease (GBD) Study 2019 to systematically characterise the burden of communicable diseases across childhood and adolescence.

METHODS

In this systematic analysis of the GBD study from 1990 to 2019, all communicable diseases and their manifestations as modelled within GBD 2019 were included, categorised as 16 subgroups of common diseases or presentations. Data were reported for absolute count, prevalence, and incidence across measures of cause-specific mortality (deaths and years of life lost), disability (years lived with disability [YLDs]), and disease burden (disability-adjusted life-years [DALYs]) for children and adolescents aged 0-24 years. Data were reported across the Socio-demographic Index (SDI) and across time (1990-2019), and for 204 countries and territories. For HIV, we reported the mortality-to-incidence ratio (MIR) as a measure of health system performance.

FINDINGS

In 2019, there were 3·0 million deaths and 30·0 million years of healthy life lost to disability (as measured by YLDs), corresponding to 288·4 million DALYs from communicable diseases among children and adolescents globally (57·3% of total communicable disease burden across all ages). Over time, there has been a shift in communicable disease burden from young children to older children and adolescents (largely driven by the considerable reductions in children younger than 5 years and slower progress elsewhere), although children younger than 5 years still accounted for most of the communicable disease burden in 2019. Disease burden and mortality were predominantly in low-SDI settings, with high and high-middle SDI settings also having an appreciable burden of communicable disease morbidity (4·0 million YLDs in 2019 alone). Three cause groups (enteric infections, lower-respiratory-tract infections, and malaria) accounted for 59·8% of the global communicable disease burden in children and adolescents, with tuberculosis and HIV both emerging as important causes during adolescence. HIV was the only cause for which disease burden increased over time, particularly in children and adolescents older than 5 years, and especially in females. Excess MIRs for HIV were observed for males aged 15-19 years in low-SDI settings.

INTERPRETATION

Our analysis supports continued policy focus on enteric infections and lower-respiratory-tract infections, with orientation to children younger than 5 years in settings of low socioeconomic development. However, efforts should also be targeted to other conditions, particularly HIV, given its increased burden in older children and adolescents. Older children and adolescents also experience a large burden of communicable disease, further highlighting the need for efforts to extend beyond the first 5 years of life. Our analysis also identified substantial morbidity caused by communicable diseases affecting child and adolescent health across the world.

FUNDING

The Australian National Health and Medical Research Council Centre for Research Excellence for Driving Investment in Global Adolescent Health and the Bill & Melinda Gates Foundation.

Determinants, inequalities, and spatial patterns of diarrhea in the Peruvian under-five population: findings from nationally representative survey data

Objective

To determine the associated factors, decompose the socioeconomic inequalities, and analyze the spatial distribution of childhood diarrhea in Peru.

Methods

A cross-sectional analytical study was conducted using data from the National Demographic and Family Health Survey 2021. The dependent variable was the presence of diarrhea in the last two weeks. Three types of analysis were performed: (i) to evaluate the associated factors, generalized linear models of the Poisson family with logarithmic link were applied and prevalence ratios with their 95% confidence intervals were reported; (ii) for the analysis of inequalities, a decomposition of the Erreygers concentration index was performed using a generalized linear model; and (ii) a spatial autocorrelation analysis, hot spot analysis and cluster and outlier analysis were performed.

Results

A total of 18,871 children under 5 years of age were included. The prevalence of diarrhea in this population was 10.0%. Determinants such as being aged 0-23 months, being male, belonging to the poorest, poorer and rich wealth index, and residing in the Highlands and Jungle increased the probability of presenting diarrhea. In the decomposition analysis, diarrhea had a pro-poor orientation, with the greatest contributors were age 0-23 months, belonging to the poorest and poorer wealth indexes, and residing in the Highlands and Jungle. Spatial analysis showed that the highest concentrations and occurrence of this event were observed in departments of the Highlands and Jungle.

Conclusion

Government institutions seeking to reduce the numbers and burden of childhood diarrhea should focus their strategies on promoting hygiene measures and improving access to water and sanitation services, especially in poor populations living in the Peruvian Highlands and Jungle.

Risk factors for acute diarrhoea in children between 0 and 23 months of age in a peri-urban district of Pakistan: a matched case-control study

BACKGROUND

Diarrhoea is a leading cause of preventable childhood morbidity and mortality worldwide. Unfortunately, Pakistan has the third-highest burden of diarrhoea-related deaths in children <5 y of age. Therefore we aimed to evaluate factors associated with diarrhoea among Pakistani children.

METHODS

A retrospective 1:2 matched case-control study nested in a baseline cross-sectional survey was conducted from October to December 2018 in Taluka Kotri, a two-thirds urban locality in the Jamshoro district. Children between the ages of 0 and 23 months with a history of diarrhoea in the 2 weeks preceding the survey were labelled as cases. Age-matched controls were children without symptoms of diarrhoea. Univariate and multivariable conditional logistic regression was performed to identify diarrhoea-related factors.

RESULTS

A total of 1558 cases were matched with 3116 controls. Factors significantly associated with lower odds of diarrhoea in the multivariate analysis included increasing maternal age (odds ratio [OR] 0.78 [95% confidence interval {CI} 0.67 to 0.90]), breastfeeding (OR 0.77 [95% CI 0.66 to 0.90]), higher paternal education (OR 0.79 [95% CI 0.65 to 0.97]) and belonging to the rich (OR 0.66 [95% CI 0.54 to 0.80]) and richest quintiles (OR 0.54 [95% CI 0.44 to 0.66]).

CONCLUSIONS

This study identifies risk factors associated with diarrhoea in children <23 months of age, including younger maternal age, higher paternal education, not breastfeeding and poverty, which has implications for developing preventive programs and strategies that target populations with a higher risk of diarrhoea.

The Full Impact of Rotavirus Vaccines in Africa Has Yet to Be Realized

Africa bears the brunt of diarrheal mortality globally. Rotavirus vaccination rates are high across the continent and demonstrate impact on diarrheal disease reduction. Nevertheless, there is room for significant improvement in managing rotavirus vaccine coverage, in access to recognized public services such as appropriate medical care, including oral rehydration therapy and improved water and sanitation.

Molecular Prevalence of Diarrheal Pathogens in Children with Acute Diarrhea in Southeastern Gabon

Diarrheal diseases are a major cause of morbidity and mortality in infants and young children, particularly in sub-Saharan countries. In Gabon, there are few data on the prevalence of diarrheal pathogens in children. The aim of this study was to assess the prevalence of diarrheal pathogens in children with diarrhea in southeastern Gabon. Stool samples (n = 284) from Gabonese children 0 to 15 years of age with acute diarrhea were analyzed using polymerase chain reaction targeting 17 diarrheal pathogens. At least one pathogen was detected in 75.7% of samples (n = 215). Coinfection with multiple pathogens was observed in 44.7% of patients (n = 127). Diarrheagenic Escherichia coli was the most commonly detected pathogen (30.6%, n = 87), followed by adenovirus (26.4%, n = 75), rotavirus (16.9%, n = 48), Shigella sp. (16.5%, n = 47), Giardia duodenalis (14.4%, n = 41), norovirus GII (7.0%, n = 20), sapovirus (5.6%, n = 16), Salmonella enterica (4.9%, n = 14), astrovirus (4.6%, n = 13), Campylobacter jejuni/coli (4.6%, n = 13), bocavirus (2.8%, n = 8), and norovirus GI (2.8%, n = 8). Our study provides useful information on the possible causes of diarrheal diseases affecting children in southeastern Gabon. A similar study with a control group of healthy children is needed to assess the burden of the disease attributed to each pathogen.

Spatiotemporal variation in risk of Shigella infection in childhood: a global risk mapping and prediction model using individual participant data

BACKGROUND

Diarrhoeal disease is a leading cause of childhood illness and death globally, and Shigella is a major aetiological contributor for which a vaccine might soon be available. The primary objective of this study was to model the spatiotemporal variation in paediatric Shigella infection and map its predicted prevalence across low-income and middle-income countries (LMICs).

METHODS

Individual participant data for Shigella positivity in stool samples were sourced from multiple LMIC-based studies of children aged 59 months or younger. Covariates included household-level and participant-level factors ascertained by study investigators and environmental and hydrometeorological variables extracted from various data products at georeferenced child locations. Multivariate models were fitted and prevalence predictions obtained by syndrome and age stratum.

FINDINGS

20 studies from 23 countries (including locations in Central America and South America, sub-Saharan Africa, and south and southeast Asia) contributed 66 563 sample results. Age, symptom status, and study design contributed most to model performance followed by temperature, wind speed, relative humidity, and soil moisture. Probability of Shigella infection exceeded 20% when both precipitation and soil moisture were above average and had a 43% peak in uncomplicated diarrhoea cases at 33°C temperatures, above which it decreased. Compared with unimproved sanitation, improved sanitation decreased the odds of Shigella infection by 19% (odds ratio [OR]=0·81 [95% CI 0·76-0·86]) and open defecation decreased them by 18% (OR=0·82 [0·76-0·88]).

INTERPRETATION

The distribution of Shigella is more sensitive to climatological factors, such as temperature, than previously recognised. Conditions in much of sub-Saharan Africa are particularly propitious for Shigella transmission, although hotspots also occur in South America and Central America, the Ganges-Brahmaputra Delta, and the island of New Guinea. These findings can inform prioritisation of populations for future vaccine trials and campaigns.

FUNDING

NASA, National Institutes of Health-The National Institute of Allergy and Infectious Diseases, and Bill & Melinda Gates Foundation.

Hygiene Practices and Early Childhood Development in the East Asia-Pacific Region: A Cross-Sectional Analysis

Poor hygiene might be a risk factor for early childhood development (ECD). This study investigated the associations of three hygiene practices ('wash hands before a meal,' 'wash hands after going to the toilet,' and 'brush teeth'), separately and combined, with ECD. Six thousand six hundred ninety-seven children (4 [0.8] years) from the East Asia-Pacific Early Child Development Scales validation study were included in this cross-sectional analysis. The hygiene variables were recoded to have comparable values as 'always,' 'sometimes,' and 'never.' These variables were then grouped to create combined categories. The binary outcome variables, poor ECD, were defined as a score < age-specific 25th centile. Modified Poisson regression models were used to analyse the associations. Data collection was performed between 2012 and 2014, and the analyses were conducted in April 2022. Compared with children who 'always' washed their hands before a meal, those who did it 'sometimes' (Prevalence Ratio [PR]: 1.30 [95% CI: 1.16-1.46]) or 'never' (PR: 1.35 [1.18-1.55]) had a higher likelihood of poorer overall development. Comparable results were identified for the other two hygiene practices and the other four domain-specific outcomes (p < 0.05). Compared with children who always followed the three hygiene practices, the likelihood of poor overall ECD increased as the combined hygiene practice decreased among children with poor hygiene practices (PRnever: 1.67 [1.40-2.00]; PRrarely: 1.49 [1.30-1.71]; PRsometimes: 1.30 [1.14-1.49]). Children who did not always follow good hygiene practices had a higher likelihood of poor ECD independently of sociodemographic factors. Considering these findings, future hygiene practice interventions and trials should consider including ECD outcomes.

Escherichia coli Contamination of Water for Human Consumption and Its Associated Factors in Peru: A Cross-Sectional Study

The objective of the study was to determine the factors associated with the presence of Escherichia coli contamination in water supplies for human consumption in Peru. A secondary analysis of the Food and Nutrition Surveillance by Life Stages survey (VIANEV) of 2017-2018 was performed. The presence of E. coli contamination in the water samples for human consumption of the households evaluated was defined as a dependent variable. A supply was considered contaminated when there was at least 1 colony-forming unit of E. coli in 100 mL of water for human consumption. Data from 886 participants were analyzed. It was found that 25.2% of household water supply sources for human consumption had E. coli at the time of sampling. Water reservoirs such as buckets or other containers (adjusted prevalence ratio [aPR]: 1.15; 95% confidence interval [CI]: 1.18-1.93), households belonging to a poor wealth quintile (aPR: 1.82; 95% CI: 1.01-3.25), residing in a rural area (aPR: 1.36; 95% CI: 1.01-1.83), and having a low human development index (aPR: 2.12; 95% CI: 1.15-3.91) were more likely to contain E. coli in water supplies for human consumption. However, households with chlorine concentrations of 0.5 mg/L or more in water (aPR: 0.20; 95% CI: 0.11-0.33) and with household members with a higher education (aPR: 0.67; 95% CI: 0.45-0.99) were less likely to contain E. coli in drinking-water supplies. From 2017 to 2018, one in four Peruvians had contamination by E. coli in the water supply to their homes, which was associated with sociodemographic factors, management, and water treatment.

Viral metagenomics of the gut virome of diarrheal children with Rotavirus A infection

Diarrhea is a leading cause of morbidity and mortality in children worldwide and represents a major dysbiosis event. Rotavirus has been recognized as a global leading pathogen of diarrhea. This study is aimed at investigating differences in the gut virome between diarrheal children and healthy controls. In 2018, 76 diarrheal fecal samples and 27 healthy fecal samples in Shanghai and 40 diarrheal fecal samples and 19 healthy fecal samples in Taizhou were collected to investigate the composition of the gut virome. Viral metagenomic analyses revealed that the alpha diversity of the diarrheal virome was not significantly different from that of the healthy virome, and the beta diversity had a significant difference between diarrheal and healthy children. The diarrheal virome was mainly dominated by the families Adenoviridae, Astroviridae, Caliciviridae, and Picornaviridae. Meanwhile, the healthy virome also contains phages, including Microviridae and Caudovirales. The high prevalence of diverse enteric viruses in all samples and the little abundance of Microviridae and Caudovirales in diarrheal groups were identified. The study introduced a general overview of the gut virome in diarrheal children, revealed the compositional differences in the gut viral community compared to healthy controls, and provided a reference for efficient treatments and prevention of virus-infectious diarrhea in children.

There is urgent need to treat atherosclerotic cardiovascular disease risk earlier, more intensively, and with greater precision: A review of current practice and recommendations for improved effectiveness

Atherosclerotic cardiovascular disease (ASCVD) is epidemic throughout the world and is etiologic for such acute cardiovascular events as myocardial infarction, ischemic stroke, unstable angina, and death. ASCVD also impacts risk for dementia, chronic kidney disease peripheral arterial disease and mobility, impaired sexual response, and a host of other visceral impairments that adversely impact the quality and rate of progression of aging. The relationship between low-density lipoprotein cholesterol (LDL-C) and risk for ASCVD is one of the most highly established and investigated issues in the entirety of modern medicine. Elevated LDL-C is a necessary condition for atherogenesis induction. Basic scientific investigation, prospective longitudinal cohorts, and randomized clinical trials have all validated this association. Yet despite the enormous number of clinical trials which support the need for reducing the burden of atherogenic lipoprotein in blood, the percentage of high and very high-risk patients who achieve risk stratified LDL-C target reductions is low and has remained low for the last thirty years. Atherosclerosis is a preventable disease. As clinicians, the time has come for us to take primordial and primary prevention more serously. Despite a plethora of therapeutic approaches, the large majority of patients at risk for ASCVD are poorly or inadequately treated, leaving them vulnerable to disease progression, acute cardiovascular events, and poor aging due to loss of function in multiple visceral organs. Herein we discuss the need to greatly intensify efforts to reduce risk, decrease disease burden, and provide more comprehensive and earlier risk assessment to optimally prevent ASCVD and its complications. Evidence is presented to support that treatment should aim for far lower goals in cholesterol management, should take into account many more factors than commonly employed today and should begin significantly earlier in life.

Household Factors of Foodborne Diarrhea in Children under Five in Two Districts of Maputo, Mozambique

Household factors involved in the disease of diarrhea are multifaceted. This study aimed to explore and describe the household factors affecting foodborne diarrhea in children younger than 5 years old using structured questionnaire data based on quantitative tools. The sample size was calculated based on a binomial distribution. A total of 300 children, together with their caregivers, participated, and the data were descriptively and mathematically analyzed using Epi Info modelling. The caregivers were mostly female and included 93.3% rural and 84% urban dwellers of ages between 18 and 38, who were single but living with someone. Of the children who were under six months of age, 23.3% in rural areas and 16.6% in urban areas had diarrhea, while of the children between 12 and 23 months of age, 36.6% in urban areas and 30% in rural areas had diarrhea. The relatives had similar symptoms before the child became ill, with 12.6% of relatives in rural areas and 13.3% in urban areas reporting this. Before receiving medical assistance, 51.3% of children in rural areas and 16% of children in urban areas were treated with traditional medication. Water was not treated before drinking in 48% of rural cases and 45.3% of urban cases. A total of 24.6% of infants in urban areas and 12.6% of infants in rural areas used a bottle for feeding. The factors affecting foodborne diarrhea were the use of traditional medication in rural areas, bottle feeding in urban areas and untreated water used for drinking in both areas.

Gut bacterial extracellular vesicles: important players in regulating intestinal microenvironment

Intestinal microenvironment dysbiosis is one of the major causes of diseases, such as obesity, diabetes, inflammatory bowel disease, and colon cancer. Microbiota-based strategies have excellent clinical potential in the treatment of repetitive and refractory diseases; however, the underlying regulatory mechanisms remain elusive. Identification of the internal regulatory mechanism of the gut microbiome and the interaction mechanisms involving bacteria-host is essential to achieve precise control of the gut microbiome and obtain effective clinical data. Gut bacteria-derived extracellular vesicles (GBEVs) are lipid bilayer nanoparticles secreted by the gut microbiota and are considered key players in bacteria-bacteria and bacteria-host communication. This review focusses on the role of GBEVs in gut microbiota interactions and bacteria-host communication, and the potential clinical applications of GBEVs.

Maintaining Momentum for Rotavirus Immunization in Africa during the COVID-19 Era: Report of the 13th African Rotavirus Symposium

The 13th African Rotavirus Symposium was held as a virtual event hosted by the University of Nairobi, Kenya and The Kenya Paediatric Association on 3rd and 4th November 2021. This biennial event organized under the auspices of the African Rotavirus Network shapes the agenda for rotavirus research and prevention on the continent, attracting key international and regional opinion leaders, researchers, and public health scientists. The African Rotavirus Network is a regional network of institutions initially established in 1999, and now encompassing much of the diarrheal disease and rotavirus related research in Africa, in collaboration with the World Health Organization African Regional Office (WHO-AFRO), Ministries of Health, and other partners. Surges in SARS-CoV2 variants and concomitant travel restrictions limited the meeting to a webinar platform with invited scientific presentations and scientific presentations from selected abstracts. The scientific program covered updates on burden of diarrheal diseases including rotavirus, the genomic characterization of rotavirus strains pre- and post-rotavirus vaccine introduction, and data from clinical evaluation of new rotavirus vaccines in Africa. Finally, 42 of the 54 African countries have fully introduced rotavirus vaccination at the time of the meeting, including the two recently WHO pre-qualified vaccines from India. Nonetheless, the full benefit of rotavirus vaccination is yet to be realized in Africa where approximately 80% of the global burden of rotavirus mortality exists.

Acceptability measures of water, sanitation and hygiene interventions in low- and middle-income countries, a systematic review

BACKGROUND

Inadequate access to water, sanitation, and hygiene (WASH) is an environmental risk factor for poor health outcomes globally, particularly for children in low- and middle-income countries (LMIC). Despite technological advancements, many interventions aimed at improving WASH access return less than optimal results on long term impact, efficacy and sustainability. Research focus in the 'WASH sector' has recently expanded from investigating 'which interventions work' to 'how they are best implemented'. The 'acceptability' of an intervention is a key component of implementation that can influence initial uptake and sustained use. Acceptability assessments are increasingly common for health interventions in clinical settings. A broad scale assessment of how acceptability has been measured in the WASH sector, however, has not yet been conducted.

METHODS/PRINCIPAL FINDINGS

We conducted a systematic literature review of intervention studies published between 1990 and 2021 that evaluated the acceptability of WASH interventions in LMIC settings. Using an implementation science approach, focused outcomes included how acceptability was measured and defined, and the timing of acceptability assessment. We conducted quality assessment for all included studies using the Cochrane Risk of Bias tool for randomised studies, and the Newcastle-Ottawa Scale for non-randomised studies. Of the 1238 records; 36 studies were included for the analysis, 22 of which were non-randomized interventions and 16 randomized or cluster-randomized trials. We found that among the 36 studies, four explicitly defined their acceptability measure, and six used a behavioural framework to inform their acceptability study design. There were few acceptability evaluations in schools and healthcare facilities. While all studies reported measuring WASH acceptability, the measures were often not comparable or described.

CONCLUSIONS

As focus in WASH research shifts towards implementation, a consistent approach to including, defining, and measuring acceptability is needed.

Hunger and its associated factors in the western Brazilian Amazon: a population-based study

BACKGROUND

Hunger affects millions of people worldwide. In the current pandemic scenario of coronavirus Brazil has experienced an epidemic peak of hunger, amplifying existing prepandemic vulnerabilities, mainly in the North Region of the country. The aim of the present study was to investigate the prevalence of food insecurity and its associated factors in homes with children under 5 years of age in an urban area of a municipality of the western Brazilian Amazon.

METHODS

A household survey was conducted with a probabilistic sample of 557 children and their families. Food insecurity (FI) was determined using the Brazilian Food Insecurity Scale. Associations between variables were analyzed based on the prevalence ratio (PR) and respective 95% confidence intervals (CI) calculated through multiple Poisson regression analysis. Variables with a P value < 0.05 after adjustments were considered significantly associated with the outcome.

RESULTS

A prevalence of 76.5% (CI 1.36-2.67) food insecurity was found among the families in the study; 42.9% had moderate (CI 1.31-2.83) and severe (CI 1.10-1.83) food insecurity. Moderate and severe FI was associated with low family income (P = 0.00), participation in governmental income transfer programs (P = 0.01), and heads of household with less than 7 years of schooling (P = 0.02). Moreover, substantial frequencies of height deficit and being overweight were found among the children.

CONCLUSIONS

The high prevalence of hunger and food insecurity and its associated factors reflects the context of geographic isolation and social exclusion in which these families live, suggesting that a substantial portion of the population under 5 years of age had experienced episodes of hunger in the 90 days prior to the survey. The prevalence of height deficit and being overweight among the children reveals a scenario of epidemiological/nutritional polarization, requiring the formulation of specific public policies for this population.

Using Open-Access Data to Explore Relations between Urban Landscapes and Diarrhoeal Diseases in Côte d’Ivoire

Unlike water and sanitation infrastructures or socio-economic indicators, landscape features are seldomly considered as predictors of diarrhoea. In contexts of rapid urbanisation and changes in the physical environment, urban planners and public health managers could benefit from a deeper understanding of the relationship between landscape patterns and health outcomes. We conducted an ecological analysis based on a large ensemble of open-access data to identify specific landscape features associated with diarrhoea. Designed as a proof-of-concept study, our research focused on Côte d’Ivoire. This analysis aimed to (i) build a framework strictly based on open-access data and open-source software to investigate diarrhoea risk factors originating from the physical environment and (ii) understand whether different types and forms of urban settlements are associated with different prevalence rates of diarrhoea. We advanced landscape patterns as variables of exposure and tested their association with the prevalence of diarrhoea among children under the age of five years through multiple regression models. A specific urban landscape pattern was significantly associated with diarrhoea. We conclude that, while the improvement of water, sanitation, and hygiene infrastructures is crucial to prevent diarrhoeal diseases, the health benefits of such improvements may be hampered if the overall physical environment remains precarious.

Impact of integrated water, sanitation, hygiene, health and nutritional interventions on diarrhoea disease epidemiology and microbial quality of water in a resource-constrained setting in Kenya: A controlled intervention study

Objectives

We assessed the impact of water, hygiene and sanitation (WASH), maternal, new‐born and child health (MNCH), nutrition and early childhood development (ECD) on diarrhoea and microbial quality of water in a resource‐constrained rural setting in Kenya.

Methods

Through a controlled intervention study, we tested faecal and water samples collected from both the intervention and control sites before and after the interventions using microbiological, immunological and molecular assays to determine the prevalence of diarrhoeagenic agents and microbial quality of water. Data from the hospital registers were used to estimate all‐cause diarrhoea prevalence.

Results

After the interventions, we observed a 58.2% (95% CI: 39.4–75.3) decline in all‐cause diarrhoea in the intervention site versus a 22.2% (95% CI: 5.9–49.4) reduction of the same in the control site. Besides rotavirus and pathogenic Escherichia coli, the rate of isolation of other diarrhoea‐causing bacteria declined substantially in the intervention site. The microbial quality of community and household water improved considerably in both the intervention (81.9%; 95% CI: 74.5%–87.8%) and control (72.5%; 95% CI: 64.2%–80.5%) sites with the relative improvements in the intervention site being slightly larger.

Conclusions

The integrated WASH, MNCH, nutrition and ECD interventions resulted in notable decline in all‐cause diarrhoea and improvements in water quality in the rural resource‐limited population in Kenya. This indicates a direct public health impact of the interventions and provides early evidence for public health policy makers to support the sustained implementation of these interventions.

Case fatality risk of diarrhoeal pathogens: a systematic review and meta-analysis

BACKGROUND

Estimates of the relative contribution of different pathogens to all-cause diarrhoea mortality are needed to inform global diarrhoea burden models and prioritize interventions. We aimed to investigate and estimate heterogeneity in the case fatality risk (CFR) of different diarrhoeal pathogens.

METHODS

We conducted a systematic review and meta-analysis of studies that reported cases and deaths for 15 enteric pathogens published between 1990 and 2019. The primary outcome was the pathogen-specific CFR stratified by age group, country-specific under-5 mortality rate, setting, study year and rotavirus vaccine introduction status. We developed fixed-effects and multilevel mixed-effects logistic regression models to estimate the pooled CFR overall and for each pathogen, controlling for potential predictors of heterogeneity.

RESULTS

A total of 416 studies met review criteria and were included in the analysis. The overall crude CFR for all pathogens was 0.65%, but there was considerable heterogeneity between and within studies. The overall CFR estimated from a random-effects model was 0.04% (95% CI: 0.026%-0.062%), whereas the pathogen-specific CFR estimates ranged from 0% to 2.7%. When pathogens were included as predictors of the CFR in the overall model, the highest and lowest odds ratios were found for enteropathogenic Escherichia coli (EPEC) [odds ratio (OR) = 3.0, 95% CI: 1.28-7.07] and rotavirus (OR = 0.23, 95% CI: 0.13-0.39), respectively.

CONCLUSION

We provide comprehensive estimates of the CFR across different diarrhoeal pathogens and highlight pathogens for which more studies are needed. The results motivate the need for diarrhoeal interventions and could help prioritize pathogens for vaccine development.

Royal Jelly Protected against Dextran-Sulfate-Sodium-Induced Colitis by Improving the Colonic Mucosal Barrier and Gut Microbiota

Royal jelly (RJ) is a natural bee product that contains a variety of biologically active ingredients and has antitumor, antiallergic, antibacterial and immune-regulating effects. Inflammatory bowel disease (IBD) is a chronic inflammatory disease of the intestine that can cause abdominal pain and diarrhea. With this study, we aimed to explore the protective effect of RJ on DSS-induced colitis in mice. The physiochemical parameters (water, protein, 10-hydroxy-2-decenoic acid, total sugar, starch, ash and acidity) of the RJ samples used in this study met the requirements of the international and Chinese national standards. Treatment with RJ improved symptoms and colonic cell apoptosis and decreased intestinal permeability by increasing the expression of tight-junction protein, goblet cells and their secretion mucin, MUC2, in DSS-induced ulcerative colitis mice. RJ also reduced the expression of proinflammatory cytokine IL-6 and increased the expression of anti-inflammatory cytokine IL-10 and sIgA. DSS resulted in an increase in the relative abundance of Parabacteroides, Erysipelotrichaceae, Proteobacteria (Gammaproteobacteria, Enterobacteriales and Enterobacteriaceae) and Escherichia Shigella in the colon and a decrease in the relative abundance of Muribaculum. In the RJ treatment group, the relative abundance of the above intestinal flora was improved by treatment with 2.0 g/kg RJ. These results suggested that RJ alleviated DSS-induced colitis by improving the colonic mucosal barrier.

Exploring the effect of the primary care health workers number on infectious diarrhea morbidity and where the health resources should go

We aimed to explore the association between the number of primary healthcare workers and infectious diarrhea morbidity at community levels and to provide evidence-based implications for optimizing primary healthcare manpower resource allocations. We collected annual infectious diarrhea morbidity and relevant data of 4321 communities in Sichuan Province, China, from 2017 to 2019. Global and local Moran’s I were calculated to detect the spatial clustering of infectious diarrhea morbidity and to identify areas where increased primary healthcare manpower resources should be allocated. The spatial lag fixed effects panel data model was adopted to explore the association between the number of primary healthcare workers per 1000 residents and infectious diarrhea morbidity. Significantly high–high and low–low clusters of infectious diarrhea cases were found to be mainly distributed in underdeveloped and developed areas during the studied period years, respectively. The infectious diarrhea morbidity was found to be statistically negatively associated with the number of primary healthcare workers per 1000 residents with a coefficient of − 0.172, indicating that a 0.172 reduction of infectious diarrhea morbidity (1/10,000) was associated with doubled amounts of primary healthcare workers per 1000 residents. Our findings highlighted the role of primary healthcare in the process of infectious diarrhea prevention and control, and implied that constant efforts should be addressed to facilitate infectious diarrhea prevention and control, especially in the underdeveloped areas.