DIARRHEAL DISEASES IN THE DEVELOPING WORLD

Assessment of Determinants of Paediatric Diarrhoea Case Management Adherence in Pakistan

Worldwide, diarrhoea in children under five years of age is the second leading cause of death. Despite having high morbidity and mortality, diarrhoeal diseases can be averted by simple and cost-effective interventions. The Integrated Management of Childhood Illness (IMCI) has proposed the use of Oral Rehydration Salt (ORS) and zinc together with adequate food and fluid intake for the management of acute non-dysenteric watery diarrhoea in children. In the past, few studies examined the determinants of adherence to diarrhoea case management. Therefore, this study measured the determinants of therapeutic and dietary adherence to diarrhoea case management using the third and fourth wave of Pakistan Demographics and Health Surveys (PDHS) datasets. Data from 4068 children between 0 to 59.9 months with positive history of diarrhoea were included, while data on children with dysentery, severe dehydration, and co-morbid condition was excluded. This study reported therapeutic adherence in less than 10% of children in Pakistan, while dietary adherence was reported in 39.2% of children (37.7% in 2012–2013 and 40.7% in 2017–2018). A significant improvement in therapeutic (0.8% in 2012–2013 and 8.1% in 2017–2018) and dietary adherence (37.7% in 2012–2013 and 40.7% in 2017–2018) was reported in the 2017–2018 survey compared to the 2012–2013 survey. In general, children over the age of one year (compared to children <1 year) and of the richer/richest socioeconomic class (compared to poorest/poorer socioeconomic class) showed higher therapeutic and dietary adherence. Therapeutic and dietary adherence among diarrhoeal children can be improved by increasing the awareness and accessibility of ORS, zinc, and essential foods.

Positive Effects of a Lecithin-Based Delivery Form of Boswellia serrata Extract in Acute Diarrhea of Adult Subjects

Acute diarrhea is a frequent problem worldwide, mostly due to gastrointestinal infections or food poisoning. Boswellia serrata could be active in the treatment of acute diarrhea due to its anti-inflammatory, antispasmodic, and antimicrobial activity. In this randomized, double-blind, placebo-controlled clinical study, 49 adults with acute diarrhea were randomly allocated to receive 250 mg of a lecithin-based delivery form of Boswellia serrata (CASP) or placebo for 5 days. The time it took to become healthy with stoppage of diarrhea (primary end point) was significantly shorter in the intervention group (3.08 vs. 4.44 days: p-value < 0.0001). The probability of subjects treated with CASP to recover sooner was equal to 80.2%. A significantly lower number of stools was observed in the CASP group over time (β = −0.17, p-value < 0.0001). A significant difference was observed between the two groups for abdominal pain, nausea, and GAE (global assessment of efficacy). In conclusion, the lecithin-based delivery form of Boswellia serrata extract could be a useful addition to the treatment of acute diarrhea in adults. CASP is safe and reduces the time it takes to become healthy, the frequency of stools, the abdominal pain and nausea of subjects with acute diarrhea. Further studies are needed to confirm these promising results.

Occurrence of virulence gene signatures associated with diarrhoeagenic and non-diarrhoeagenic pathovars of Escherichia coli isolates from some selected rivers in South-Western Nigeria

BACKGROUND

Diarrhoeal diseases are attributable to unsafe water stemming from improper sanitation and hygiene and are reportedly responsible for extensive morbidity and mortality particularly among children in developed and developing countries.

METHODS

Water samples from selected rivers in Osun State, South-Western Nigeria were collected and analyzed using standard procedures. Escherichia coli isolates (n=300) were screened for 10 virulence genes using polymerase chain reaction for pathotyping.

RESULTS

While the virulence gene (VG) lt for enterotoxigenic E. coli had the highest prevalence of 45%, the enteropathogenic E. coli genes eae and bfp were detected in 6 and 4% of the isolates respectively. The VGs stx1 and stx2 specific for the enterohemorrhagic E. coli pathotypes were detected in 7 and 1% of the isolates respectively. Also, the VG eagg harboured by enteroaggregative pathotype and diffusely-adherent E. coli VG daaE were detected in 2 and 4% of the isolates respectively and enteroinvasive E. coli VG ipaH was not detected. In addition, the VGs papC for uropathogenic and ibeA for neonatal meningitis were frequently detected in 19 and 3% of isolates respectively.

CONCLUSIONS

These findings reveal the presence of diarrhoeagenic and non-diarrhoeagenic E. coli in the selected rivers and a potential public health risk as the rivers are important resources for domestic, recreational and livelihood usage by their host communities.

Epidemiological profile of rotavirus infection in the Republic of Korea: results from prospective surveillance in the Jeongeub District, 1 July 2002 through 30 June 2004

To facilitate future decisions regarding the usefulness of rotavirus vaccines in the Republic of Korea, active surveillance was conducted in a network of clinics, emergency departments, and hospitals serving Jeongeub District, Korea. Children with diarrhea underwent standard clinical evaluations, and stool specimens were collected to test for the presence of rotavirus. Parents were interviewed to collect demographic and family information. From 1 July 2002 through 30 June 2004, a total of 4106 children, representing 1 (50%) of every 2 children <5 years old in the study population, were evaluated for rotavirus diarrhea. Of the 2232 stool specimens obtained throughout the year, 460 (20.6%) were rotavirus positive; however, the monthly prevalence of rotavirus infection peaked at 49.5% in February 2004. Of the 460 rotavirus-positive stool specimens, 366 were obtained from children who visited outpatient clinics, and 94 were obtained from children who were hospitalized. By extrapolating the proportion of rotavirus-positive patients to all children with diarrhea in the surveillance system, we calculate that 882 children in Jeongeub District had rotavirus infection (which would predict that there would be 702 associated clinic visits and 180 hospitalizations). Genotyping of rotavirus strains showed that 39% of strains were type G9P[8], 24% were type G1P[8], 17% were type G3P[8], and 13% were type G2P[4]. The incidence of rotavirus diarrhea peaked at age 13-24 months, and 94% of cases occurred during the first 3 years of life. The annual incidence of all rotavirus disease-associated outcomes was 56.9 cases/1000 children <5 years old (95% confidence interval [CI], 51.9-62.2 cases/1000 children <5 years old). The incidence of rotavirus disease-associated hospitalizations was 11.6 cases/1000 children <5 years old (95% CI, 9.5-14.2 cases/1000 children <5 years old). In Korea, diarrhea is common during childhood, and the incidence of diarrhea due to rotavirus infection suggests that improved programs for the prevention and control of both rotavirus diarrhea and diarrhea due to other causes are needed.

Domestic poultry-raising practices in a Peruvian shantytown: implications for control of Campylobacter jejuni-associated diarrhea

Raising poultry at home is common in many periurban communities in low-income countries. Studies demonstrate that free-range domestic poultry increase children's risk of infection with diarrhea-causing organisms such as Campylobacter jejuni. Corralling might reduce risk, but research on the socioeconomic acceptability of corralling is lacking. To explore this issue, we studied local knowledge and practices related to poultry-raising in a Peruvian shantytown. Our objectives were to understand: (1). motives for raising domestic poultry; (2). economic and cultural factors that affect the feasibility of corralling; and (3). local perceptions about the relationship between domestic poultry and disease. During 1999-2000, we met with community health volunteers and conducted ethnographic and structured interviews with residents about poultry-raising practices. We then enrolled 12 families in a 2-month trial of corral use during which field workers made biweekly surveillance visits to each family. Most participants reported that they raise birds because home-grown poultry and eggs taste better and are more nutritious and because they enjoy living around animals. Some want to teach their children about raising animals. To prevent theft, many residents shut their birds in provisional enclosures at night, but most stated that birds are healthier, happier, and produce better meat and eggs when let loose by day. Many view bird feces in the house and yard as dirty, but few see a connection to illness. Residents consider chicks and ducklings more innocuous than adult birds and are more likely to allow them inside the house and permit children to play with them. After extensive orientation and technical assistance, participants were willing to corral birds more often. But due to perceived disadvantages, many kept birds penned only intermittently. Additional food and water costs were a significant obstacle for some. Adequate space, bird care and corral hygiene would also need to be addressed to make this intervention viable. Developing a secure, acceptable and affordable corral remains a challenge in this population.

Clinical evaluation and management of acute infectious diarrhea in adults

Acute infectious diarrhea is a major global health problem. Issues for the developed and developing regions of the world differ. Awareness of disease pathophysiology and epidemiology are essential, however, for clinical evaluation and management. The immense human and economic burden imposed by acute diarrhea illness can be addressed only by thoughtful strategies aimed at prevention as well as cost-efficient evaluation and treatment.

To boil or not: drinking water for children in a periurban barrio

Boiling water, or other water purification methods, are common recommendations of health promoters in developing countries to improve the quality of drinking water in an attempt to decrease the incidence of childhood diarrhea. Health education programs frequently employ an approach based on knowledge deficits to promote this practice. However, there has been little published about water purification practices or associated variables such as knowledge deficits. We interviewed 266 randomly selected child caregivers about water purification in a poor periurban district of Santo Domingo, Dominican Republic. Though most reported that they provided purified drinking water for their children when they were babies, only half of the children five years of age and under were regularly drinking purified water at the time of the study. Only one knowledge variable remained significantly related to purifying drinking water in the final multivariate model. Other factors that remained in the final model were level of maternal education, endorsing being too tired to boil water and a global measure of social support. Several other hypothesized variables were not related to purifying water. Knowledge deficits may play only a limited role in determining this prevention practice. Further work is required to better identify key factors to improve this practice and hence guide health promotion efforts.

Acute diarrhea: a practical review

This review provides a practical, simple, and logical approach to the diagnosis and management of patients with acute infectious diarrhea, one of the most common diagnoses in clinical practice. Diarrhea in the immunocompromised host, traveler's diarrhea, and diarrhea in the hospitalized patient are also discussed. Most episodes of acute diarrhea are self-limited, and investigations should be performed only if the results will influence management and outcome. After an adequate history and physical examination, the clinician should be able to classify the acute diarrheal illness, assess the severity, and determine whether investigations are needed. Most patients do not require specific therapy. Therapy should mainly be directed at preventing dehydration. Various home remedies frequently suffice in mild, self-limited diarrhea. However, in large-volume, dehydrating diarrhea, oral rehydration solutions should be used, as they are formulated to stimulate sodium and water absorption. Antidiarrheal agents can be useful in reducing the number of bowel movements and diminishing the magnitude of fluid loss. The most useful agents are opiate derivatives and bismuth subsalicylate. Antibiotic therapy is not required in most patients with acute diarrheal disorders. Guidelines for their use are presented.

Effectiveness of an Indonesian model for rapid training of Guatemalan health workers in diarrhea case management

The aim of this study was to assess the effectiveness of a newly developed method for rapid tiered training of health workers in improving community health worker knowledge and case management skills. The interactive "Kader" method, developed in West Java, Indonesia, was compared with traditional didactic training in a prospective trial with rural health workers ("Tecnicos") and village health promoters ("Promotores") for the Public Health Department in the state of Alta Verapaz, Guatemala. Twenty-five tecnicos received one day of training concerning diarrhea and dehydration. One group was trained using the interactive Kader method of Indonesia; the other with didactic methods. A sample of these tecnicos then trained 49 randomized promotores utilizing the same training method with which they were trained. The tecnicos and promotores in each group completed a case-based pre-test and post-test before and after their training sessions. Both tecnicos and promotores trained using the Kader tiered training approach demonstrated significantly greater improvement in their ability to correctly diagnose and recommend treatment for diarrhea of varying type and severity. Non-significant differences favoring the experimental groups were found in the tecnicos' and promotores' general knowledge regarding diarrhea prevention practices, signs of dehydration and preparation of oral rehydration solution. This pilot study suggests that the Kader method for rapid tiered training of health workers has applicability to the populations of other developing nations and can be recommended for large scale implementation and evaluation in the training of public health workers, village health promoters and families in Guatemala.