Comparison of 1-week and 2-week recall periods for caregiver-reported diarrhoeal illness in children, using nationally representative household surveys

Animal Handling Practice Among Rural Households in Northwest Ethiopia Increases the Risk of Childhood Diarrhea and Exposure to Pathogens From Animal Sources

Background

In Ethiopia, domestic animals and their feces are not properly contained. However, the risk of exposure to zoonotic pathogens is not well documented. This study was conducted to assess animal handling practices and the risk of childhood diarrhea among rural households in northwest Ethiopia.

Methods

This study was done among 403 randomly selected households. Information on animal handling was collected using a questionnaire and spot-check observation. The occurrence of childhood diarrhea in 14 days prior to the survey was assessed based on the reports of female head of households. Multivariable binary logistic regression analysis was performed to identify the association between animal handling practices and childhood diarrhea.

Results

All the female head of households had contact with animal feces when preparing fuel disks and plastering the house components with animal dung. Domestic animals shared a corral within the living space of the humans in 20% of the households. Animals entered the human living quarters and accessed foods in 32% of the households. Moreover, 24% of the children aged 24 to 59 months had diarrhea in a 2-week period prior to the survey. Childhood diarrhea was associated with domestic animals sharing the same house as humans (AOR: 3.3, 95% CI: 1.3, 8.6), presence of animal excreta in child playing areas (AOR: 2.4, 95% CI: 1.2, 4.6), contact of domestic animals with stored foods (AOR: 3.5, 95% CI: 2.0, 5.9), trapped dirt under fingernails of female heads (AOR: 3.7, 95% CI: 1.9, 7.5), open defecation (AOR: 3.24, 95% CI: 1.8, 5.9), and unprotected sources (AOR: 4.2, 95% CI: 1.1, 15.3).

Conclusion

Domestic animals and their excreta are not hygienically contained in the area. Animal handling practices including their excreta and the hygiene behavior of female head of households (eg, handwashing and food handling practices) should be improved to prevent childhood diarrhea.

Patterns of antibiotic use for acute respiratory infections in under-three-year-old children in India: A cross-sectional study

Background

Despite its mostly viral etiology, antibiotics are frequently used to treat acute respiratory infections (ARIs) in children. India is one of the largest global consumers of antibiotics and has one of the highest rates of resistance to antimicrobial treatments. However, the epidemiology of antibiotic treatment among young children in India is poorly understood.

Methods

Using nationally representative household survey data from the Indian National Family Health Surveys (NFHS) conducted between 2015 and 2016 and 2019 and 2021, we estimated the prevalence of antibiotic use among 17 472 children under the age of three who reported ARI symptoms within two weeks before their mothers were interviewed. To assess the factors associated with antibiotic use for the treatment of ARI symptoms, we used multivariable logistic regression models that included sociodemographic, child-related, household, and health care related characteristics, with results reported on the prevalence difference (PD) scale.

Results

We estimated that 18.7% (95% CI = 17.8-19.6) of under-three-year-old (U3) children who exhibited ARI symptoms in the two weeks prior to the survey were given antibiotics as a treatment. The highest prevalence was observed in the southern and northern geographic zones of India. Furthermore, multivariable regression models indicated that children with greater access to health services were more likely to receive antibiotics for ARI treatment, regardless of the type of health care facility (public, private or pharmacy/unregulated). Additionally, the prevalence of antibiotic consumption was higher among children from families with religious affiliations other than Muslim and Hindu backgrounds (i.e. Christian, Sikh, Buddhist/neo-Buddhist, Jain, Jewish, Parsi, no religion and other) (PD = 11.7 (95% CI = 6.3-16.7)) compared to Hindu families and among mothers with a secondary or higher education (PD = 5.8 (95% CI = 1.7-9.9)) compared to mothers lacking formal education.

Conclusions

Our findings provide an important baseline for monitoring the use of antibiotics for the treatment of acute respiratory infections, and for designing interventions to mitigate potential misuse among young children in India.

Effectiveness of a home-environmental intervention package and an early child development intervention on child health and development in high-altitude rural communities in the Peruvian Andes: a cluster-randomised controlled trial

BACKGROUND

Unsafe drinking water, poor sanitation and hygiene, exposure to household air pollution and low cognitive and socio-emotional stimulation are risk factors affecting children in low- and middle-income countries. We implemented an integrated home-environmental intervention package (IHIP), comprising a kitchen sink, hygiene education and a certified improved biomass cookstove, and an early child development (ECD) programme to improve children´s health and developmental outcomes in the rural high-altitude Andes of Peru.

METHODS

We conducted a one-year cluster-randomised controlled trial among 317 children < 36 months divided into 4 arms (IHIP + ECD, IHIP, ECD, and Control) and 40 clusters (10 clusters per arm). ECD status (socio-emotional, fine and gross motor, communication, cognitive skills, and an overall performance) measured with the Peruvian Infant Development Scale and the occurrence of self-reported child diarrhoea from caretakers were primary outcomes. Secondary outcomes included the occurrence of acute respiratory infections and the presence of thermo-tolerant faecal bacteria in drinking water. The trial was powered to compare each intervention against its control arm but it did not allow pairwise comparisons among the four arms. Primary analysis followed the intention-to-treat principle. For the statistical analysis, we employed generalised estimating equation models with robust standard errors and an independent correlation structure.

RESULTS

We obtained ECD information from 101 children who received the ECD intervention (individually and combined with IHIP) and 102 controls. Children who received the ECD intervention performed better in all the domains compared to controls. We found differences in the overall performance (64 vs. 39%, odd ratio (OR): 2.8; 95% confidence interval (CI): 1.6-4.9) and the cognitive domain (62 vs 46%, OR: 1.9; 95% CI: 1.1-3.5). Data analysis of child morbidity included 154 children who received the IHIP intervention (individually and combined with ECD) and 156 controls. We recorded 110,666 child-days of information on diarrhoea morbidity and observed 1.3 mean episodes per child-year in the children who received the IHIP intervention and 1.1 episodes in the controls. This corresponded to an incidence risk ratio of 1.2 (95% CI: 0.8-1.7).

CONCLUSIONS

Child stimulation improved developmental status in children, but there was no health benefit associated with the home-environmental intervention. Limited year-round access to running water at home and the possible contamination of drinking water after boiling were two potential factors linked to the lack of effect of the home-environmental intervention. Potential interactions between ECD and home-environmental interventions need to be further investigated.

TRIAL REGISTRATION

ISRCTN, ISRCTN-26548981. Registered 15 January 2018-Retrospectively registered, https://doi.org/10.1186/ISRCTN26548981 .

Water, Sanitation, and Hygiene Service Ladders and Childhood Diarrhea in Haramaya Demographic and Health Surveillance Site, Eastern Ethiopia

BACKGROUND

The WHO/UNICEF Joint Monitoring Program (JMP) service ladders are worldwide indicators for monitoring drinking water, sanitation, and hygiene elements of the sustainable development goal targets. However, evidence on how the prevalence of childhood diarrhea looks across the service ladders is limited. This study aimed to assess the relationship between WASH service ladders and the prevalence of childhood diarrhea in Haramaya Demographic and Health Surveillance site, Eastern Ethiopia.

METHODS

A cross-sectional study using a structured questionnaire, observational checklist, and water quality analysis was conducted on 535 households with children under 5 years of age. Poisson regression with a robust error variance estimator was used to investigate the relationship between dependent and independent variables.

RESULTS

The prevalence of diarrhea among under-five children in the surveillance site was 24.8% (95% CI: 22.3-27.6). The regression model revealed that water and sanitation service ladders were associated with childhood diarrhea. Childhood diarrhea was found to be 73% (APR = 0.27; 95% CI: 0.12-0.57) less common in families with a basic water service ladder than in households with a surface water service ladder. In addition, children in households with basic sanitation services had 83% (APR = 0.17; 95% CI: 0.05-0.56) lower diarrhea prevalence than children in households where open defecation was practiced.

CONCLUSION

The present study found that childhood diarrhea differed considerably among WASH service levels and continues to be a serious health problem at the surveillance site. This study also shows that much work is needed to improve WASH services.

Antibiotic use for acute respiratory infections among under-5 children in Bangladesh: a population-based survey

Introduction

Despite acute respiratory infections (ARIs) being the single largest reason for antibiotic use in under-5 children in Bangladesh, the prevalence of antibiotic use in the community for an ARI episode and factors associated with antibiotic use in this age group are unknown.

Methods

We analysed nationally representative, population-based, household survey data from the Bangladesh Demographic and Health Survey 2014 to determine the prevalence of antibiotic use in the community for ARI in under-5 children. Using a causal graph and multivariable logistical regression, we then identified and determined the sociodemographic and antibiotic source factors significantly associated with the use of antibiotics for an episode of ARI.

Results

We analysed data for 2 144 children aged <5 years with symptoms of ARI from 17 300 households. In our sample, 829 children (39%) received antibiotics for their ARI episode (95% CI 35.4% to 42.0%). Under-5 children from rural households were 60% (adjusted OR (aOR): 1.6; 95% CI 1.2 to 2.1) more likely to receive antibiotics compared with those from urban households, largely driven by prescriptions from unqualified or traditional practitioners. Private health facilities were 50% (aOR: 0.5; 95% CI 0.3 to 0.7) less likely to be sources of antibiotics compared with public health facilities and non-governmental organisations. Age of children, sex of children or household wealth had no impact on use of antibiotics.

Conclusion

In this first nationally representative analysis of antibiotic use in under-5 children in Bangladesh, we found almost 40% of children received antibiotics for an ARI episode. The significant prevalence of antibiotic exposure in under-5 children supports the need for coordinated policy interventions and implementation of clinical practice guidelines at point of care to minimise the adverse effects attributed to antibiotic overuse.

Study design, rationale and methods of the Revitalising Informal Settlements and their Environments (RISE) study: a cluster randomised controlled trial to evaluate environmental and human health impacts of a water-sensitive intervention in informal settlements in Indonesia and Fiji

INTRODUCTION

Increasing urban populations have led to the growth of informal settlements, with contaminated environments linked to poor human health through a range of interlinked pathways. Here, we describe the design and methods for the Revitalising Informal Settlements and their Environments (RISE) study, a transdisciplinary randomised trial evaluating impacts of an intervention to upgrade urban informal settlements in two Asia-Pacific countries.

METHODS AND ANALYSIS

RISE is a cluster randomised controlled trial among 12 settlements in Makassar, Indonesia, and 12 in Suva, Fiji. Six settlements in each country have been randomised to receive the intervention at the outset; the remainder will serve as controls and be offered intervention delivery after trial completion. The intervention involves a water-sensitive approach, delivering site-specific, modular, decentralised infrastructure primarily aimed at improving health by decreasing exposure to environmental faecal contamination. Consenting households within each informal settlement site have been enrolled, with longitudinal assessment to involve health and well-being surveys, and human and environmental sampling. Primary outcomes will be evaluated in children under 5 years of age and include prevalence and diversity of gastrointestinal pathogens, abundance and diversity of antimicrobial resistance (AMR) genes in gastrointestinal microorganisms and markers of gastrointestinal inflammation. Diverse secondary outcomes include changes in microbial contamination; abundance and diversity of pathogens and AMR genes in environmental samples; impacts on ecological biodiversity and microclimates; mosquito vector abundance; anthropometric assessments, nutrition markers and systemic inflammation in children; caregiver-reported and self-reported health symptoms and healthcare utilisation; and measures of individual and community psychological, emotional and economic well-being. The study aims to provide proof-of-concept evidence to inform policies on upgrading of informal settlements to improve environments and human health and well-being.

ETHICS

Study protocols have been approved by ethics boards at Monash University, Fiji National University and Hasanuddin University.

TRIAL REGISTRATION NUMBER

ACTRN12618000633280; Pre-results.

Survey data and human computation for improved flu tracking

While digital trace data from sources like search engines hold enormous potential for tracking and understanding human behavior, these streams of data lack information about the actual experiences of those individuals generating the data. Moreover, most current methods ignore or under-utilize human processing capabilities that allow humans to solve problems not yet solvable by computers (human computation). We demonstrate how behavioral research, linking digital and real-world behavior, along with human computation, can be utilized to improve the performance of studies using digital data streams. This study looks at the use of search data to track prevalence of Influenza-Like Illness (ILI). We build a behavioral model of flu search based on survey data linked to users' online browsing data. We then utilize human computation for classifying search strings. Leveraging these resources, we construct a tracking model of ILI prevalence that outperforms strong historical benchmarks using only a limited stream of search data and lends itself to tracking ILI in smaller geographic units. While this paper only addresses searches related to ILI, the method we describe has potential for tracking a broad set of phenomena in near real-time.

Nutritional Status Among School-Age Children of Bangladeshi Tea Garden Workers

BACKGROUND

While considerable progress has been made in reducing undernutrition in Bangladesh, regional disparities are known to exist, and certain population subgroups may lag behind.

OBJECTIVE

To characterize nutritional status among school-age children in a historically marginalized population of Bangladesh.

METHODS

We conducted a cross-sectional assessment of children attending 14 nongovernmental organization-operated schools serving the tea estate population in Kulaura Upazila, Sylhet Division. We randomly selected 168 children from a population of 418 whose parents attended school-organized Parent-Teacher Association meetings. Parents provided consent and data on household food consumption in the past week, foods consumed by children in the past 24 hours, and household food insecurity. We drew venous blood from assenting children for the analysis of hemoglobin and plasma retinol, C-reactive protein, and α₁-acid glycoprotein. Children were classified as stunted, underweight, or thin based on comparisons with the World Health Organization standards for height-for-age, weight-for-age, or body mass index-for-age, respectively.

RESULTS

Food insecurity was highly prevalent, with ∼85% of households affected. Roughly half of children had low dietary diversity. Prevalence estimates for stunting, underweight, and thinness were 32%, 50%, and 49%, respectively. Approximately 60% of children had a hemoglobin concentration <11 g/dL. The mean (±SD) plasma retinol concentration was 0.79 μmol/L (±0.23 μmol/L), with 34% deficient using a 0.70 μmol/L cutoff.

CONCLUSIONS

A heightened focus on tracking progress in underserved populations and appropriately targeted programming will be critical as Bangladesh seeks to accelerate progress toward global development goals for nutrition.

The impact of delayed treatment of uncomplicated P. falciparum malaria on progression to severe malaria: A systematic review and a pooled multicentre individual-patient meta-analysis

BACKGROUND

Delay in receiving treatment for uncomplicated malaria (UM) is often reported to increase the risk of developing severe malaria (SM), but access to treatment remains low in most high-burden areas. Understanding the contribution of treatment delay on progression to severe disease is critical to determine how quickly patients need to receive treatment and to quantify the impact of widely implemented treatment interventions, such as 'test-and-treat' policies administered by community health workers (CHWs). We conducted a pooled individual-participant meta-analysis to estimate the association between treatment delay and presenting with SM.

METHODS AND FINDINGS

A search using Ovid MEDLINE and Embase was initially conducted to identify studies on severe Plasmodium falciparum malaria that included information on treatment delay, such as fever duration (inception to 22nd September 2017). Studies identified included 5 case-control and 8 other observational clinical studies of SM and UM cases. Risk of bias was assessed using the Newcastle-Ottawa scale, and all studies were ranked as 'Good', scoring ≥7/10. Individual-patient data (IPD) were pooled from 13 studies of 3,989 (94.1% aged <15 years) SM patients and 5,780 (79.6% aged <15 years) UM cases in Benin, Malaysia, Mozambique, Tanzania, The Gambia, Uganda, Yemen, and Zambia. Definitions of SM were standardised across studies to compare treatment delay in patients with UM and different SM phenotypes using age-adjusted mixed-effects regression. The odds of any SM phenotype were significantly higher in children with longer delays between initial symptoms and arrival at the health facility (odds ratio [OR] = 1.33, 95% CI: 1.07-1.64 for a delay of >24 hours versus ≤24 hours; p = 0.009). Reported illness duration was a strong predictor of presenting with severe malarial anaemia (SMA) in children, with an OR of 2.79 (95% CI:1.92-4.06; p < 0.001) for a delay of 2-3 days and 5.46 (95% CI: 3.49-8.53; p < 0.001) for a delay of >7 days, compared with receiving treatment within 24 hours from symptom onset. We estimate that 42.8% of childhood SMA cases and 48.5% of adult SMA cases in the study areas would have been averted if all individuals were able to access treatment within the first day of symptom onset, if the association is fully causal. In studies specifically recording onset of nonsevere symptoms, long treatment delay was moderately associated with other SM phenotypes (OR [95% CI] >3 to ≤4 days versus ≤24 hours: cerebral malaria [CM] = 2.42 [1.24-4.72], p = 0.01; respiratory distress syndrome [RDS] = 4.09 [1.70-9.82], p = 0.002). In addition to unmeasured confounding, which is commonly present in observational studies, a key limitation is that many severe cases and deaths occur outside healthcare facilities in endemic countries, where the effect of delayed or no treatment is difficult to quantify.

CONCLUSIONS

Our results quantify the relationship between rapid access to treatment and reduced risk of severe disease, which was particularly strong for SMA. There was some evidence to suggest that progression to other severe phenotypes may also be prevented by prompt treatment, though the association was not as strong, which may be explained by potential selection bias, sample size issues, or a difference in underlying pathology. These findings may help assess the impact of interventions that improve access to treatment.

Water, sanitation, and hygiene risk factors of acute diarrhea among children under five years in the Gaza Strip

This cross-sectional community household-based study aims to evaluate the water, sanitation, and hygiene facilities in the Gaza Strip and to investigate their associations with the occurrence of acute diarrhea among children under five years. A survey using a structured questionnaire was conducted on 1,857 households with an child under five years from August 2017 to June 2018. About 69.7% of heads of households reported a diarrheal episode among their children during the two months preceding the survey. Multivariable logistic regression showed that sewage water observed around the households was associated with an increased risk of acute diarrhea (AOR = 2.45; P &lt; 0.001; 95% CI: 1.83–3.27). Nevertheless, the allocation of a special water tank for desalinated drinking water at home (AOR = 0.3; P = 0.02; 95% CI: 0.1–0.8), the connection of households to a closed sewerage system (AOR = 0.56; P &lt; 0.001; 95% CI: 0.43–0.73), and handwashing practices before and after eating (AOR = 0.42; P = 0.003; 95% CI: 0.24–0.74 and AOR = 0.50; P = 0.03; 95% CI: 0.26–0.94, respectively), as well as using desalinated water sources for drinking purposes, were inversely associated with the incidence of acute diarrhea among children under five. Further improvements in the existing sewerage system and the intensification of sanitation and hygiene promotion programs at the household levels may reduce the risk of acute diarrhea among children under five years in the Gaza Strip.