Etiology of diarrhea requiring hospitalization in Bangladesh by quantitative PCR, 2014-2018

Enteroaggregative Escherichia coli in mid-Norway: A prospective, case control study

BACKGROUND

The use of molecular methods has led to increased detection of Enteroaggregative Escherichia coli (EAEC) in faecal samples. Studies have yielded conflicting results regarding the clinical relevance of this finding. The objective of this study was to investigate the prevalence of EAEC in faecal samples from patients with diarrhoea and healthy controls and describe characteristics of EAEC positive persons.

METHODS

From March 1st, 2017 to February 28th, 2019, we investigated all consecutive faecal samples from patients with diarrhoea received at the laboratory and collected faecal samples from randomly invited healthy controls from mid-Norway. Real-time multiplex PCR was used for detection of bacterial, viral, and parasitic pathogens. We registered sex, age, urban versus non-urban residency, and travel history for all participants. Statistical analyses were performed with Pearson chi-squared test, Kruskal-Wallis test, and Mann-Whitney U test.

RESULTS

We identified EAEC in 440 of 9487 (4.6%) patients with diarrhoea and 8 of 375 (2.2%) healthy controls. The EAEC prevalence was 19.1% among those with diarrhoea and recent foreign travel and 2.2% in those without travel history independent of diarrhoea. Concomitant pathogens were detected in 64.3% of EAEC-positive patients with diarrhoea. The median age was 28.5 in those with EAEC-positive diarrhoea and 38 in those with EAEC-negative diarrhoea (p <0.01). In patients with diarrhoea, travel was reported in 72% of those with EAEC and concomitant pathogens, and 54% and 12% in those with only EAEC and no EAEC, respectively (p <0.01).

CONCLUSIONS

EAEC was a common detection, particularly in patients with diarrhoea and recent international travel, and was found together with other intestinal pathogens in the majority of cases. Our results suggest that domestically acquired EAEC is not associated with diarrhoea. Patients with EAEC-positive diarrhoea and concomitant pathogens were young and often reported recent travel history compared to other patients with diarrhoea.

Effect of infant viral respiratory disease on childhood asthma in a non-industrialized setting

BACKGROUND

There are limited data from non-industrialized settings on the effects of early life viral respiratory disease on childhood respiratory illness. We followed a birth cohort in tropical Ecuador to understand how early viral respiratory disease, in the context of exposures affecting airway inflammation including ascariasis, affect wheezing illness, asthma, and rhinoconjunctivitis in later childhood.

METHODS

A surveillance cohort nested within a birth cohort was monitored for respiratory infections during the first 2 years in rural Ecuador and followed for 8 years for the development of wheeze and rhinoconjunctivitis. Nasal swabs were examined for viruses by polymerase chain reaction and respiratory symptom data on recent wheeze and rhinoconjunctivitis were collected by periodic questionnaires at 3, 5, and 8 years. Stools from pregnant mothers and periodically from children aged 2 years were examined microscopically for soil-transmitted helminths. Atopy was measured by allergen skin prick testing at 2 years. Spirometry, fractional exhaled nitric oxide measurement, and nasal washes were performed at 8 years. Associations between clinically significant respiratory disease (CSRD) and wheezing or rhinoconjunctivitis at 3, 5, and 8 years were estimated using multivariable logistic regression.

RESULTS

Four hundred and twenty six children were followed of which 67.7% had at least one CSRD episode; 12% had respiratory syncytial virus (RSV)+CSRD and 36% had rhinovirus (RHV)+CSRD. All-cause CSRD was associated with increased wheeze at 3 (OR 2.33 [95% confidence intervals (CI) 1.23-4.40]) and 5 (OR: 2.12 [95% CI 1.12-4.01]) years. RHV+CSRD was more strongly associated with wheeze at 3 years in STH-infected (STH-infected [OR 13.41, 95% CI 1.56-115.64] vs. uninfected [OR 1.68, 95% CI 0.73-3.84]) and SPT+ (SPT+ [OR 9.42, 95% CI 1.88-47.15] versus SPT- [OR 1.92, 95% CI 0.84-4.38]) children. No associations were observed between CSRD and rhinoconjunctivitis.

DISCUSSION

CSRD was significantly associated with childhood wheeze with stronger associations observed for RHV+CSRD in SPT+ and STH-infected children.

Derivation and External Validation of a Clinical Prediction Model for Viral Diarrhea Etiology in Bangladesh

Background

Antibiotics are commonly overused for diarrheal illness in many low- and middle-income countries, partly due to a lack of diagnostics to identify viral cases, in which antibiotics are not beneficial. This study aimed to develop clinical prediction models to predict risk of viral-only diarrhea across all ages, using routinely collected demographic and clinical variables.

Methods

We used a derivation dataset from 10 hospitals across Bangladesh and a separate validation dataset from the icddr,b Dhaka Hospital. The primary outcome was viral-only etiology determined by stool quantitative polymerase chain reaction. Multivariable logistic regression models were fit and externally validated; discrimination was quantified using area under the receiver operating characteristic curve (AUC) and calibration assessed using calibration plots.

Results

Viral-only diarrhea was common in all age groups (<1 year, 41.4%; 18-55 years, 17.7%). A forward stepwise model had AUC of 0.82 (95% confidence interval [CI], .80-.84) while a simplified model with age, abdominal pain, and bloody stool had AUC of 0.81 (95% CI, .78-.82). In external validation, the models performed adequately although less robustly (AUC, 0.72 [95% CI, .70-.74]).

Conclusions

Prediction models consisting of 3 routinely collected variables can accurately predict viral-only diarrhea in patients of all ages in Bangladesh and may help support efforts to reduce inappropriate antibiotic use.

Outbreak of diarrheal diseases causes mortality in different geographical locations of Bangladesh during the 2021 COVID-19 era

Objectives

Diarrhea is a major public health problem in low- and middle-income countries, including Bangladesh. Of the different spectrums of diarrheal diseases, cholera occurs every year, causing outbreaks and epidemics following a biannual seasonal pattern. Due to the COVID-19 pandemic, hospitalization for diarrheal diseases decreased in 2020 compared to the previous years. However, in 2021, massive outbreaks occurred in different geographical locations of the country. We described that an outbreak of diarrheal diseases causes mortality in different geographical locations in Bangladesh.

Method

In this study, we present a report of diarrhea outbreaks that were reported in 2018-2021 in different parts of Bangladesh, and data have been captured from different sources such as print and electronic media as well as from a nationwide surveillance system.

Results

Among these locations, districts of Barisal Division, Kishorganj, Noakhali, Gopalganj, Bandarban, and Chattogram were the major hotspots of the outbreaks where high morbidity due to acute watery diarrhea and even mortality, which is usually low in Bangladesh, were recorded.

Conclusion

Early detection and prevention and strengthening of the surveillance system are needed to combat the diarrheal upsurge, take immediate control, and adopt preventive strategies.

A comparative study on the Antihyperlipidemic and antibacterial potency of the shoot and flower extracts of Melastoma malabathricum Linn's

Background

Atherosclerosis is arteries’ thickening and stiffening condition manifested due to plaque formation by oxidized-LDL of abundant and deranged lipid metabolism. Traditionally, Melastoma malabathricum Linn (MM) leaves are used for anti-diabetics, abdominal problems, and high blood pressure. The current experiment unveils the potency of ethanol, acetone, and water MM extracts as antibacterial agents and alternative medicine during hyperlipidemic conditions.

Methods

A high cholesterol diet (HCD-2500 mg/kg) was provided with regular feeds for 3 weeks to induce hyperlipidemic mice. Afterward, comparing weight with Group-A (normal control), the hyperlipidemic mice were classified into five groups: Group-B (hyperlipidemic control), Group-C (MFA-500 mg/kg), Group-D (MSE-250 mg/kg), Group-E (MSE-500 mg/kg), and Group-F (ATOVAT-20 mg/kg). And the dosages were given orally for 28 days according to their body weight. Fasting blood was collected at the end of treatment, and serum was taken to test lipid profiling and liver enzymes.

Results

The body mass had waxed significantly (P < 0.001) in all the groups compared with Group-A. Subsequently, orally administered different doses where group-D and group-E demonstrated magnificent anti-hyperlipidemic potency (P < 0.001) compared with group-B. During treatment, rapid upward body mass was tardy in group-E (P < 0.001). However, the liver enzyme expression such as AST, ALT, and ALP was elevated (P < 0.001) in Group-F, they were significantly lessened (P < 0.001, P < 0.01) in Groups-C, D, and E, which indicates these extracts have significant anti-liver damaging potency. Alongside the antibacterial activity of MSE-1500 μg/disc, it exhibited the greatest (16.50 mm) zone of inhibition against Shigella dysenteriae.

Conclusion

However, in our current experiment, depending on the derived data, we can elicit that the Melastoma malabathricum shoot ethanolic (MSE) extract is a potential resource for developing alternative medicine to manage the hyperlipidemic condition.

Aetiology and incidence of diarrhoea requiring hospitalisation in children under 5 years of age in 28 low-income and middle-income countries: findings from the Global Pediatric Diarrhea Surveillance network

INTRODUCTION

Diarrhoea remains a leading cause of child morbidity and mortality. Systematically collected and analysed data on the aetiology of hospitalised diarrhoea in low-income and middle-income countries are needed to prioritise interventions.

METHODS

We established the Global Pediatric Diarrhea Surveillance network, in which children under 5 years hospitalised with diarrhoea were enrolled at 33 sentinel surveillance hospitals in 28 low-income and middle-income countries. Randomly selected stool specimens were tested by quantitative PCR for 16 causes of diarrhoea. We estimated pathogen-specific attributable burdens of diarrhoeal hospitalisations and deaths. We incorporated country-level incidence to estimate the number of pathogen-specific deaths on a global scale.

RESULTS

During 2017-2018, 29 502 diarrhoea hospitalisations were enrolled, of which 5465 were randomly selected and tested. Rotavirus was the leading cause of diarrhoea requiring hospitalisation (attributable fraction (AF) 33.3%; 95% CI 27.7 to 40.3), followed by Shigella (9.7%; 95% CI 7.7 to 11.6), norovirus (6.5%; 95% CI 5.4 to 7.6) and adenovirus 40/41 (5.5%; 95% CI 4.4 to 6.7). Rotavirus was the leading cause of hospitalised diarrhoea in all regions except the Americas, where the leading aetiologies were Shigella (19.2%; 95% CI 11.4 to 28.1) and norovirus (22.2%; 95% CI 17.5 to 27.9) in Central and South America, respectively. The proportion of hospitalisations attributable to rotavirus was approximately 50% lower in sites that had introduced rotavirus vaccine (AF 20.8%; 95% CI 18.0 to 24.1) compared with sites that had not (42.1%; 95% CI 33.2 to 53.4). Globally, we estimated 208 009 annual rotavirus-attributable deaths (95% CI 169 561 to 259 216), 62 853 Shigella-attributable deaths (95% CI 48 656 to 78 805), 36 922 adenovirus 40/41-attributable deaths (95% CI 28 469 to 46 672) and 35 914 norovirus-attributable deaths (95% CI 27 258 to 46 516).

CONCLUSIONS

Despite the substantial impact of rotavirus vaccine introduction, rotavirus remained the leading cause of paediatric diarrhoea hospitalisations. Improving the efficacy and coverage of rotavirus vaccination and prioritising interventions against Shigella, norovirus and adenovirus could further reduce diarrhoea morbidity and mortality.

Characteristics of Rotavirus, ETEC, and Vibrio Cholerae Among Under 2-year Children Attending an Urban Diarrheal Disease Hospital in Bangladesh

Background

Information on comparative clinical and host characteristics of under-2 children with watery diarrhea caused by rotavirus, Enterotoxigenic Escherichia coli (ETEC), and Vibrio cholerae as single pathogens is lacking. We sought to investigate the sociodemographic, clinical, and host characteristics of under-2 children hospitalized due to these pathogens.

Methodology

We conducted a hospital-based case-control study using the icddr,b Diarrheal Diseases Surveillance System. Children of either sex, <2 years with diarrhea, who attended the hospital during 2014 to 2018, constituted the study population. Stool specimens having a single pathogen like rotavirus, ETEC, or Vibrio cholerae constituted the cases and stool specimens having no detectable common enteropathogens comprised the controls. Multinomial logistic regression analysis was done where control was the reference group.

Results

A total of 14 889 patients were enrolled, 6939 of whom were under-2 children, and 5245 (76%) constituted our study population. Among them 48% (n = 2532), 3% (n = 148) and 1% (n = 49) had rotavirus, ETEC, and Vibrio cholera, respectively. A control group (diarrhea without these 3 or Shigella, Salmonella, Aeromonas) accounted for 48% (n = 2516). In multinomial regression model, children with rotavirus (adjusted odds ratio [aOR], 1.36; 95% confidence interval [95% CI], 1.19-1.55) less often presented with dehydrating diarrhea compared to those with ETEC (aOR, 1.54; 95% CI, 1.05-2.26) and cholera (aOR, 2.25; 95% CI, 1.11-4.57). Rotavirus diarrhea was associated (aOR, 1.25; 95% CI, 1.07-1.46) with those who received antimicrobials prior to hospital admission and protectively associated with drinking tap water (aOR, 0.84; 95% CI, 0.73-0.95); however, ETEC diarrhea had protective association (aOR, 0.62; 95% CI, 0.43-0.92) with children who received antimicrobials prior to hospital admission and was associated with drinking tap water (aOR, 1.78; 95% CI, 1.19-2.66). Use of intravenous fluid was associated with cholera (aOR, 10.36; 95% CI, 4.85-22.16) and had protective association with rotavirus episodes (aOR, 0.64; 95% CI, 0.45-0.91).

Conclusions

Clinical presentations and host characteristics of rotavirus, ETEC, and Vibrio cholerae diarrhea differed from each other and the information may be helpful for clinicians for better understanding and proper management of these children.

Enterotoxigenic Escherichia coli (ETEC) vaccines: Priority activities to enable product development, licensure, and global access

Diarrhoeal disease attributable to enterotoxigenic Escherichia coli (ETEC) causes substantial morbidity and mortality predominantly in paediatric populations in low- and middle-income countries. In addition to acute illness, there is an increasing appreciation of the long-term consequences of enteric infections, including ETEC, on childhood growth and development. Provision of potable water and sanitation and appropriate clinical care for acute illness are critical to reduce the ETEC burden. However, these interventions are not always practical and may not achieve equitable and sustainable coverage. Vaccination may be the most cost-effective and equitable means of primary prevention; however, additional data are needed to accelerate the investment and guide the decision-making process for ETEC vaccines. First, to understand and quantify the ETEC disease burden, additional data are needed on the association between ETEC infection and physical and cognitive stunting as well as delayed educational attainment. Furthermore, the role of inappropriate or inadequate antibiotic treatment of ETEC-attributable diarrhoea may contribute to the development of antimicrobial resistance (AMR) and needs further elucidation. An ETEC vaccine that mitigates acute diarrhoeal illness and minimizes the longer-term disease manifestations could have significant public health impact and be a cost-effective countermeasure. Herein we review the ETEC vaccine pipeline, led by candidates compatible with the general parameters of the Preferred Product Characteristics (PPC) recently developed by the World Health Organization. Additionally, we have developed an ETEC Vaccine Development Strategy to provide a framework to underpin priority activities for researchers, funders and vaccine manufacturers, with the goal of addressing globally unmet data needs in the areas of research, product development, and policy, as well as commercialization and delivery. The strategy also aims to guide prioritization and co-ordination of the priority activities needed to minimize the timeline to licensure and use of ETEC vaccines, especially in in low- and middle-income countries, where they are most urgently needed.

Fecal Microbiota Transplantation: The Evolving Risk Landscape

Fecal microbiota transplantation (FMT) has been recommended in clinical guidelines for the treatment of recurrent Clostridioides difficile infection (CDI). However, it is considered investigational by most regulatory agencies. As the adoption of FMT has increased from a small group of CDI experts alone to more widespread use, there has been a corresponding increase in concern regarding potential risk. FMT is largely considered a safe procedure although risks described range from mild gastrointestinal symptoms to serious infection. Currently, there is variability in how "FMT" is characterized specifically regarding testing approach, which, in turn, impacts the risk profile. This has been highlighted by the rare cases of multidrug-resistant organisms, Shiga toxin-producing Escherichia and enteropathogenic E. coli, recently reported, where these organisms were not screened. These cases have prompted additional screening mandates from the US Food and Drug Administration (FDA), which has maintained its policy of enforcement discretion for the use of FMT for CDI not responding to standard therapy. Here, we examine the evolving risk landscape of FMT.